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DMST 253 Adult Echocardiography 1 > Module 7: LV diastolic function > Flashcards

Module 7: LV diastolic function Flashcards

1
Q

What is diastole?

A

Phase of the heart cycle where the chambers relax and fill with blood

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2
Q

What is the time interval for diastole?

A

Interval from AV closure to MV closure

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3
Q

What does relaxation mean?

A

Relaxation of the ventricule

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3
Q

What does relaxation mean? Including IVRT and early phase of ventricular filling

A

Relaxation of the ventricular filling

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4
Q

What does compliance mean for Diastole?

A

Change in volume/ change in pressure (DV/DP) in the LV during diastole

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5
Q

What is the inverse to stiffness?

A

Compliance

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6
Q

A complaint ventricle is able to do what?

A

Increase its volume without increasing its pressure significantly
Think of the balloon - easily stretch

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7
Q

What is the inverse of compliance?

A

Stiffness

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8
Q

What is stiffness?

A

Change in pressure/ Change in volume in the LV during diastole

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9
Q

A stiff ventricle has a disproportionate increase in what?

A

Pressure for a relatively small increase in volume

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10
Q

What is filling pressure? What does it include?

A

Includes LV EDP (LV end diastolic pressure) and mean LA pressure

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11
Q

What is LV EDP? 2

A
  1. Left ventricular end diastolic pressure
  2. Reflects LV pressure after filling is complete
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12
Q

Where is LV EDP located on the MV doppler wave?

A

After the MV doppler “A” wave

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13
Q

What is Mean LAP?

A

Average pressure during the LV filling period

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14
Q

What does LV filling pressures include? 2

A
  1. LV end diastolic pressure (LVEDP)
  2. Mean LA pressure (LAP)
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15
Q

What does this image represent?

A

LV filling pressures

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16
Q

What is normal diastolic function?

A

Means that the LV can fill to an adequate volume to ensure forward stroke volume at low filling pressures during rest or exercise

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17
Q

What is diastolic dysfunction (DDfxn)?

A

Increasing stiffness of the LV means that the LV can fill to ensure a normal forward volume, but only when the filling pressures increase to abnormal levels

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18
Q

What causes Diastolic dysfunctions? 5

A
  1. Aging
  2. Hypertension
  3. DM
  4. Renal dysfunction
  5. Infiltrative diseases
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19
Q

How does aging affect diastolic dysfunction?

A

As we age, our stiffness increases and compliance decreases

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20
Q

How does hypertension affect diastolic dysfunction?

A

Causes high afterload which may lead to Left ventricle LVH, which leads to decrease in compliance

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21
Q

What is the only treatment for diastolic dysfunction?

A

Exercise is the only treatment which directly alters diastolic function

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22
Q

What other s/s of diastolic dysfunction might be treated with exercise? 4

A
  1. Hypertension
  2. Obesity
  3. Sodium intake
  4. Smoking may also be treated
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23
Q

A program of aerobic ______ training can __________ the ___________ function of the heart and can be very helpful in _________ _____________. In fact, an ________ program is the only treatment that has been demonstrated to improve the quality of life in patients with Diastolic dysfunction

A
  1. Exercise
  2. Improve
  3. Diastolic
  4. Diastolic dysfunction
  5. Exercise
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24
Q

Diastolic dysfunction has been previously described as an increased filling pressures, are they the same thing?

A

No

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25
Q

Elevated filling pressure is a consequence of what?

A

Diastolic dysfunction

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26
Q

Why is elevated filling pressure a consequence of diastolic dysfunction?

A

When the LV loses its ability to relax and becomes more stiff, then the filling pressures rise to maintain flow

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27
Q

What is Normal LV filling?

A

LV fills at low pressures because the myocardium is compliant

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28
Q

In a normal filling LV what would happen if the LV was stiff what would happen to the filling pressure?

A

It would rise above normal

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29
Q

What does this image demonstrate?

A

LV normal filling.

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30
Q

What are some factors that affect filling? 2

A
  1. Chamber compliance
  2. Extrinsic factors
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31
Q

What are some chamber compliance factors that affect filling in the LV? 3

A
  1. Hypertrophy/ infiltrative disease
  2. LV muscle remodeling (post Myocardial infarction scar tissue)
  3. Normal change with aging (fibrotic changes in the LV stiffness as we age)
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32
Q

What are some extrinsic factors that affect filling?

A

Pericardial stiffness

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33
Q

What are some factors that specifically affect early diastolic filling? 3

A
  1. Volume load (preload)
  2. Hyper/Hypovolemia
  3. Excessive mitral regurgitation (increases the volume of blood moving past the MV)
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34
Q

What are some conditions that specifically affect late diastolic filling? 5

A
  1. Cardiac rhythm
  2. Atrial contractile function
  3. Increased LV EDP
  4. HR
  5. Ventricular diastolic function
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35
Q

As we get older (_____) or if we are under _____ with diseases stated on the previous slide, the LV muscle becomes _____ __________ during diastole

A
  1. > 60 years
  2. 60
  3. Less compliant
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36
Q

During impaired LV filling what happens in the early filling stage? 3

A
  1. LV does not expand as quickly
  2. LV/LA pressure gradient is reduced which reduces the E wave peak velocity
  3. Leads to lower velocity E wave and relatively higher velocity A wave
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37
Q

What are the four phases of diastole?

A
  1. IVRT
  2. Early phase
  3. Diastasis
  4. Late phase
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38
Q

During the IVRT phase of Diastole: There is no change in ventricle volume but pressure in ventricle is __________

A

Falling

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39
Q

During the early phase of diastole: ________ filling of the LV

A

Rapid

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40
Q

During diastasis of diastole: Pressure ___________ between LV and LA

A

Equalize

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41
Q

What happens during the late phase of diastole?

A

Atria contract and push the rest through “atrial kick”

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42
Q

During IVRT what happens to the valves?

A

They are all closed

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43
Q

During IVRT what is the pressure?

A

Rapidly falling

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44
Q

What is IVRT?

A

Period between AV closure and MV opening

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45
Q

What is the volume like during IVRT?

A

Constant

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46
Q

What is IVRT influenced by?

A
  1. conduction abnormalities or conduction mechanics
  2. Loading conditions (preload and LAP)
  3. Age
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47
Q

What is Normal IVRT?

A

50-100ms

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48
Q

What is the timing of Early/ rapid filling?

A

Period between V opening and diastasis

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49
Q

What is the valves like during early/ rapid filling?

A

AV valves open

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50
Q

What is the pressure during Early/ rapid filling? 3

A
  1. LV pressure low
  2. Ventricle has “elastic recoil”
  3. Blood is effectively “sucked” from LA to LV
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51
Q

What is the volume during the early filling phase?

A

Increasing

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52
Q

During the early- rapid filling stage LA/LV PG begins to fall resulting in what? what is this called?

A
  1. Slowdown of blood entering the LV
  2. Deceleration time
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53
Q

Rapid filling is influenced by what? 3

A
  1. Rate of LV relaxation
  2. Chamber compliance
  3. LAP
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54
Q

How much filling is done during the early/ rapid filling phase?

A

70%

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55
Q

What is the normal DT for the early filling phase?

A

160- 220ms

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56
Q

What is the time for diastasis?

A

Between early and late filling

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57
Q

What is the valves like during diastasis?

A

MV hovering barely open

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58
Q

What is the pressure like during diastasis?

A
  1. LV/LA pressure almost equal, LV pressure increasing as it fills
  2. LAP decreasing as it empties
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59
Q

What is the LV volume during diastasis?

A

Small amount of blood may flow due to inertia

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60
Q

What is the diastasis length determined by? 2

A

HR
1. Slow = long diastasis
2. Fast: Short/ absent diastasis

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61
Q

What is the time of atrial contraction? ( on ecg)

A

After P wave on ECG

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62
Q

What is the valves like during atrial contraction?

A

MV opens more again due to atrial contraction

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63
Q

What is the pressure like during atrial contraction?

A

Once the LV is full, it’s pressure will rise aboev the LAP and the MV will close

64
Q

The atrial contraction phase will be absent with what?

A

Atrial fibrillation

65
Q

What is the LV volume increase during atrial contraction?

A

30% of diastolic filling

66
Q

What does this image demonstrate?

A

Normal MV inflow valves

67
Q

What is the normal MV E velocity?

A

0.8 - 1.3 m/s

68
Q

What is the normal MV value for DT?

A

160-220 ms

69
Q

What is the normal E/A value for MV inflow?

A

0.8 - 2.0

70
Q

Most of the LA filling from the PV occurs during when?

A

Systole while the atrium is relaxing

71
Q

When the LA fills from the PVs during systole, what does this lead to?

A

1.an S wave which is higher than the D wave

72
Q

Younger adults may have a ______ ________ LV with high suction and higher _

A
  1. Super relaxing
  2. D
73
Q

Atrial reversal can be found near what?

A

The P wave

74
Q

The MV annuli moves__________ as the the ventricle fills

A

downward

75
Q

What are the normal TDI values for med and lat?

A
  1. Med >7cm/sec
  2. Lat >10cm/sec
76
Q

Normal TDI velocities in young adults may be has high as what? Why?

A
  1. 30cm/s
  2. The young and more athletic you are, you can expect higher velocity TDI because your heart is more efficient
77
Q

A healthy TDI resembles a mirror image of what?

A

MV inflow

78
Q

What is grade 1 diastolic dysfunction also called

A
  1. Mild diastolic dysfunction
  2. Impaired relaxation
79
Q

When does grade 1 DD happen?

A

Early stages of diadtole, the LV relaxation becomes impaired

80
Q

How can we measure Grade 1 DD?

A

We can measure this by measuring the annular velocity during diastole (TDI)

81
Q

For grade 1DD what should E’ look like? What about TDI?

A
  1. E’ should be low
  2. TDI is reduced
82
Q

What does abnormal TDI values?

A

Med <7cm/s
Lat <10cm/s

83
Q

What does this image demonstrate?

A

Grade 1 DD

84
Q

If the relaxation is impaired, how will this affect LV?

A

The LV will take a longer time to fill

85
Q

How does the MV E wave deceleration time look during Grade 1 DD?

A
  1. Longer MV E wave deceleration time
  2. DT > 220ms
86
Q

Grade 1 DD is common with what demographic of people?

A

Ages >60 years

87
Q

During Grade 1 DD LV filling is now more dependent on what?

A

Atrial Filling than early filling

88
Q

Why is LV filling more dependent on atial filling than early filling? 3

A
  1. Increased A wave
  2. Decreased E wave velocity <50 cm/sec
  3. Reduced E/A ratio <0.8
89
Q

How does the IVRT appear during grade 1 DD?

A
  1. It will be increased
  2. > 100ms
90
Q

When LV pressures increase, it takes longer for the LV pressure to do what during grade 1 DD?

A

It takes longerfor the LV pressure to dip below the LA pressure

91
Q

During Grade 1 DD does the patient show any signs or symtoms? 2

A
  1. Usually not
  2. Possible SOB
92
Q

As DD worsens, the LV becomes ______ __________

A

Less compliant

93
Q

As DD worsens the LV becomes less compliant which leads to what?

A

Pressure increase in the LV when it is filling (and its volume is increase)

94
Q

What is pseudonormaliztion?

A

The process of becoming pseudonormal, such as: A change in the waves on an electrocardiogram whereby abnormal or unusual waves become closer to normal-looking but not necessarily for the reasons that would produce a truly normal wave.

95
Q

What does this image demonstrate?

A

A grade 2/ modified diastolic dysfunction.
Note the E/A, also look at the E and A wave

96
Q

What is another name for grade 2 diastolic dysfunction?

A

Pseudo normalization phase

97
Q

What is a way to reveal a pseudonormal waveform?

A

Get the patient to do a Valsalva maneuver for 10 seconds

98
Q

Why does doing a valsalva reveal a pseudonormal waveform?

A
  1. Reduces E velocity
  2. Peak E velocity should reducec >50% if pseudonormal
99
Q

What does this image demonstrate?

A

The effect of valsalva revealing a pseudonormal waveform.
note the reduced e velocity, it reduced more then 50%

100
Q

For a grade 2 DD with __ ______ ________, the mv opens earlier, decreasing the IVRT <50ms

A

LA pressure increased

101
Q

What does this image demonstrate?

A

How with LA pressure increase, the MV opens earlier, decreasing the IVRT <50ms

102
Q

What is the L wave?

A

When LA pressure increases, we may see flow across the MV during diastasis

103
Q

When do we see the L wave?

A

Seen in lower heart rates and with LVH (LV hypertrophy)

104
Q

Why do we do not see much flow during diastasis?

A

Because the pressures are equal

105
Q

What does this image demonstrate?

A

The “L” wave

106
Q

With grade 2 DD, increased LA pressure leads to what?

A
  1. PV failing to fill well during systole
  2. S<D
  3. Once MV opens, the LA is “vented” and will accept most flow from the PVs
107
Q

What does this image demonstrate?

A

Grade 2 DD

108
Q

During grade 2 DD, increased LA pressure leads to what? 4

A
  1. Pressure backing up into the PVs (PV>lungs>RT heart)
  2. Increased RVSP (TR jet) > 35mmHg
  3. TR jet >2.8 m/s
  4. More severe DD (mod/sev)
109
Q

For increased LA pressure during grade 2 DD what does the LA look like? and what is it prone to?

A

LA is thin walled, and prone to dilation

110
Q

During increased LA pressure grade 2 DD, the LA thin wall is a result of what? What is the LA volume index after?

A

LA remodeling, >34ml/m^2

111
Q

What kind of symptoms does patients exhibit during grade 2 DD?

A

May have SOB at lower levels of activity compared to grade 1 DD

112
Q

What are some grade 3 DD symptoms?3

A
  1. LV becomes less and less compliant increasing the pressure very quickly when the volume increases
  2. Quick equilibrium in pressure/ abrupt filling
  3. Quick, sharp MV E wave short decel time <150ms
113
Q

What is the E/A for grade 3 DD?

A

> 2.0

114
Q

What does this image demonstrate?

A
  1. Grade 3 DD
  2. Very high LV filling pressure and LA pressure and its functions
115
Q

What is other names for grade 3 DD? 2

A
  1. Severe diastolic dysfunction
  2. Restrictive filling phase
116
Q

For grade 3 DD what might your patient show? 3

A
  1. Dyspnea with minimal exertion
  2. Reduced exercise tolerance
  3. Pedal or abdominal edema
117
Q

In order to analyze DD, we look at what? 5

A
  1. MV inflow - by pulsed wave (E/A ratio)
  2. E prime values (tissue doppler)
  3. Averaged E/e’ ratio
  4. LA volume index
  5. TR jet velocity (RVSP)
118
Q

What are the 4 values we look at for LV DD?

A
  1. Average E/e’
  2. Septal E’ velocity and lateral E’ velocity
  3. TR velocity
  4. LA volume index
119
Q

What is the E/e’ value for LV DD?

A

> 14

120
Q

What is the Septal E’ and Lateral E’ velocity?

A

Septal <7cm/s
lateral <10cm/s

121
Q

For normal diastolic function, how much of the criteria is met?

A

0-1 positive

122
Q

For intermediate DD, how much of the criteria is met?

A

2 positive

123
Q

For DD how much criteria is met?

A

3 or 4 positive

124
Q

What does the Mitral shape look during grade 0 normal? And what is E/a?

A
125
Q

What does Grade 1 MV inflow look like? And what does the E/a ratio?

A
126
Q

What does Grade 2 DD MV inflow look like? And what is the E/a

A
127
Q

What does grade 3 DD MV inflow look like?

A
128
Q

What does TDI look like for normal?

A
129
Q

What does TDI look like for grade 1

A
130
Q

What does grade 2 DD TDI look like?

A
131
Q

What does grade 3 DD TDI look like?

A
132
Q

What is the numerical values for grade 0 DD

A
  1. E/A >0.8
  2. e’>8cm/s
  3. E/e’ <8
133
Q

What is the numerical values for grade 1?

A
  1. E/A <0.8
  2. e’<8cm/s
  3. E/e’ <8
134
Q

What is the numerical values for grade 2?

A
  1. E/A >0.8
  2. e’<8cm/s
  3. E/e’ 8-15
135
Q

What is the numerical values for grade 3?

A
  1. E/A >2
  2. e’<8cm/s
  3. E/e’ >15
136
Q

What are some factors affecting diastolic measurements?

A
  1. HR
  2. Rhythm
  3. Preload
  4. LV systolic function
  5. Aortic insufficiency
  6. Age
137
Q

How does HR affect diastolic measurements?

A

IVRT shortens, E/A fuse with tachycardia

138
Q

How does Rhythm affect diastolic measurements?

A

A- Fib/PVC make sure to measure 3-5 beats and average the measurements

139
Q

How does preload affect diastolic measurements?

A

Artificially increases the E wave height (mitral regurg)

140
Q

How does LV systolic function affect diastolic measurements?

A

Abnormal contraction = abnormal relaxation

141
Q

How does aortic insufficiency affect diastolic measurements?

A

AI jets typically blow across the AMVL, often making it impossible to assess the MV inflow waveform

142
Q

During _____ _________ the E and A wave may be fused

A

Sinus tachycardia

143
Q

During sinus tachycardia the A wave may be what?

A

Falsely elevated

144
Q

During tachycardia, we may not be able to cearly discern what?

A

The E and A wave

145
Q

Aortic insufficiency jets typically blow across the _____, often making it impossible to assess the ____ ______ _______

A
  1. AMVL
  2. MV inflow waveform
146
Q

When there is MV inflow with AI, we can still assess DD using what?

A
  1. E/e’
  2. TR peak velocity
  3. LA volume
147
Q

What are some MV inflow tips?

A
  1. AMVL is longer and larger than the PMVL, the LV fills laterally and posteriorly. Tilt posteriorly and bring SV out a bit laterally
  2. Bring SV closer to annulus
  3. Measure the strongest signal
  4. TDI SV should be placed at the annulus, not in the IAS and IVS (watch for a few beats)
148
Q

What are some 2D changes with DD?

A

Hypertension

149
Q

For 2D changes with DD, hypertension is a high afterload condition leading to what?

A

Increased LV muscle mass and thickness

150
Q

What is the biggest cause of diastolic dysfunction? why?

A

Hypertension, a thicker LV muscle is a stiffer and less compliant muscle

151
Q

What are three things that usually accompany diastolic dysfunction?

A
  1. LVH
  2. LAE
  3. Increased LV mass
152
Q

Increased LAEDP and LAP will dilate what?

A

LA

153
Q

The LA is only ____ thick and dilates easily with an increase in what?

A
  1. 2-3 mm
  2. pressure within the chamber
154
Q

What is abnormal LA volume?

A

> 34 ml/m^2

155
Q

What are some less common DD parameters?

A
  1. IVRT
  2. DT
  3. Aortic regurg
  4. RV diastolic dysfunction
156
Q

What are some RV diastolic dysfunction parameters?

A
  1. TV inflow
  2. E/e’
  3. Hepatic vein flow
157
Q

When we measure AR where do we measure?

A

MV A wave duration at MV annulus and compare it to PV A reversal wave duration

DMST 253 Adult Echocardiography 1 (27 decks)

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