Set 3 Flashcards
Which is the most accurate method of calculating the mitral valve area?
A. Using M-mode echocardiography to determine the E-F slope
B. Performing 2D planimetry of the mitral orifice in the short axis view
C. Using the Doppler pressure halftime
B. Performing 2D planimetry of the mitral orifice in the short axis view is the most accurate way to measure the mitral orifice, provided that:
- There is no echo dropout
- The beam is perpendicular to the leaflets and is directed at the leaflet tips
- The highest frequency transducer and the lowest gain settings possible are used
If the question is which is the EASIER method, then the answer is using Doppler pressure half time
A 55 year old female complains of increasing dyspnea on exertion for 3 months. Her physical examination reveals jugular venous distention, ascites, and a pericardial knock. What is the most likely clinical diagnosis?
This patient may have constrictive pericarditis
The dyspnea, ascites, and jugular venous distention could all result from a restriction to diastolic filling.
A pericardial knock (loud 3rd heart sound) is a classic physical finding associated with constriction
What is the normal mitral valve area?
The normal mitral valve measures 4-5 cm squared in area and is therefore smaller than the tricuspid
What valve areas are associated with mild, moderate, and severe mitral stenosis?
The valve areas associated with mitral stenosis are:
Mild = > 1.5 cm2
Moderate = 1.0 to 1.5 cm2
Severe = < 1 cm2
What are the main echocardiographic findings associated with chronic mitral regurgitation?
Mild chronic mitral regurgitation may yield normal echocardiographic findings.
Moderate to severe chronic mitral regurgitation usually causes left atrial enlargement, as well as left ventricular dilatation and hypercontractility. Mitral deformities such as thickened leaflets, prolapse, or stenosis may also be present
What are the main echocardiographic findings associated with acute mitral regurgitation?
In patients with acute mitral regurgitation echocardiographic abnormalities such as valvular vegetations, torn chordae tendinae, and flail or partial flail mitral leaflets are often found
If the mitral regurgitation is ischemic in origin, the echocardiogram may show regional wall motion abnormalities when the patient is at rest
A 32 year old female complains of fatigue and her chest X-ray reveals cardiomegaly. An echocardiogram is ordered. Right atrial and ventricular enlargement appears on the echocardiogram. Additionally, there is a flattened interventricular septum, M-mode findings of pulmonic valve mid systolic closure, and an absent A-wave
Identify the cardiac abnormality consistent with these findings
These echocardiographic findings are consistent with pulmonary hypertension
A microcavitation (saline contrast) study should be performed to rule out an atrial level shunt as the cause of this pulmonary hypertension
How is mitral regurgitation quantified by color flow Doppler imaging?
Color flow Doppler imaging (which is similar to pulsed Doppler scanning) “maps” the area of regurgitant flow
Unlike the pulsed Doppler approach, color flow imaging shows the regurgitant jet within a single cardiac cycle. The larger the size of the jet, the more severe the regurgitation.
In determining the severity of mitral regurgitation, the examiner must take into account the total size, length, duration, width of the jet, as well as the patients blood pressure
How does mitral regurgitation affect the atria?
Mitral regurgitation can cause left atrial enlargement. The degree of such enlargement is usually proportional to the severity of regurgitation. Trivial or mild regurgitation rarely results in atrial enlargement
How does chronic mitral regurgitation affect the ventricles?
Mild mitral regurgitation has no noticeable effect on either ventricle.
Moderate to severe chronic mitral regurgitation results in volume overload of the left ventricle. In the absence of systolic dysfunction, the ventricle becomes dilated, and its walls become hypercontractile.
Severe chronic mitral regurgitation can also cause increased pulmonary pressures and right ventricular dilatation and hypertrophy
What are the primary M-mode findings associated with mitral valve prolapse?
As documented by M-mode, mitral valve prolapse is defined as posterior displacement of the mitral leaflets during systole. This displacement can be either holosystolic or mid to late systolic.
The prolapsing leaflet should extend more than 2-3 mm below a line connecting the echocardiographic C-D (closure and opening) points
What are the primary 2D echocardiographic findings associated with mitral valve prolapse?
As documented by 2D echocardiography, mitral valve prolapse is defined as systolic displacement of one or both mitral leaflets into the left atrium in the parasternal or apical long axis views.
Why should you refrain from diagnosing mitral valve prolapse in the presence of a large pericardial effusion?
Diagnosing mitral valve prolapse in patients with a large pericardial effusion is more of a problem with M-mode than 2D echocardiography.
During late systole, when the entire heart moves in a posterior direction within the effusion, posterior movement of the mitral valve may be falsely interpreted as prolapse.
Why should you refrain from diagnosing mitral valve prolapse from the apical four chamber view?
Because the mitral annulus is saddle shaped, even normal mitral leaflets appear to prolapse into the left atrium when seen from the apical four chamber viewpoint. The other apical views can be used to diagnose MVP
Will rupture of a few mitral chordae tendinae cause any serious clinical problems?
Rupture of a few chordae tendinae rarely results in loss of leaflet support, so significant mitral regurgitation does not usually occur. Chordal rupture is typically seen in patients with coronary artery disease or bacterial endocarditis
In what clinical setting is chordal rupture a potential source of diagnostic confusion?
In patients being evaluated for endocarditis, ruptured chordae tendinae may be difficult to distinguish from a vegetative valvular mass. If available, a previous echocardiogram is helpful for comparison
Will a flail mitral leaflet cause significant hemodynamic problems? What symptoms will a patient with this condition probably present?
A flail mitral leaflet results in severe, acute mitral regurgitation. Because the left atrium does not have time to adapt to the increased hemodynamic volume, the left atrial pressure rises sharply, and patients often present with pulmonary edema.
Symptoms of acute pulmonary edema include sudden breathlessness
Which of the two mitral papillary muscles has a higher incidence of rupture? Why?
The posteromedial papillary muscle has a higher rate of rupture than the anterolateral one.
The posteromedial papillary muscle receives its blood supply from a single coronary artery (the right coronary artery)
The anterolateral papillary muscle receives a dual blood supply, from both the circumflex and the left anterior descending arteries.
Patients with calcifications or fibrosis of the mitral annulus commonly have mitral regurgitation. If the anatomy of the mitral leaflets is normal, what causes this regurgitation?
The mitral regurgitation is probably caused by the fact that the annulus is now “fixed” and is therefore unable to adapt to left ventricular/atrial changes.
Normally, the mitral annulus is a flexible fibrous ring, whose shape changes to reflect alterations in the left ventricular geometry throughout the cardiac cycle.
A 22 year old male complains of chest pain following exercise. An echocardiogram displays concentric left ventricular hypertrophy (2.5 cm) and a small LV cavity size. Systolic motion of the mitral leaflet (SAM) and pericardial effusion are NOT observed. What is the most likely diagnosis for this patient?
The findings of concentric left ventricular hypertrophy and a small LV cavity size is diagnostic of hypertrophic cardiomyopathy
What additional noninvasive tests may help in diagnosing a patient with hypertrophic cardiomyopathy?
In order to identify the presence or absence of an obstructive component, an amyl nitrite or Valsalva challenge should be performed while the left ventricular outflow tract is interrogated by continuous wave Doppler
In patients with mitral stenosis, how does mitral regurgitation affect the peak flow velocity?
In patients with mitral stenosis, mild mitral regurgitation has no effect on the peak flow velocity.
Moderate to severe regurgitation causes volume overload of the left ventricle and an increase in the mitral diastolic flow velocity.
Does mitral regurgitation affect the pressure half time method of calculating the mitral valve area?
Mild to moderate mitral regurgitation does not affect the pressure half time method of calculating the mitral valve area. Whereas the peak mitral flow velocity may increase, the relationship between the peak and the slope remains constant.
Severe mitral regurgitation, with large increase in peak mitral flow velocity, may invalidate the pressure half time method
Describe the normal aortic valve anatomy
The aortic valve is comprised of 3 cup shaped leaflets: the right, left, and non coronary leaflets.
Behind each leaflet, the aortic wall dilates to form a sinus of Valsalva. The left and right coronary arteries originate from the sinuses of the left and right aortic valve leaflets, respectively
Why is the aortic valve so resistant to regurgitation?
Compared to the mitral leaflets, the aortic leaflets are unsupported. Nevertheless, they are partly surrounded by the hearts of fibrous skeleton, which strengthens the aortic annulus. Because the leaflets are cup-shaped and their edges overlap (supporting each other), the normal aortic valve is very resistant to regurgitation
What is the normal area of the aortic valve?
The normal area of the aortic valve ranges from 3.0 to 4.0 cm2
What is the normal gradient across the aortic valve during systole?
The normal gradient across the aortic valve during systole is 2 to 4 mmHg in adults
What is the normal aortic valve flow velocity?
The normal aortic valve flow velocity is 1.4 m/sec, with a range of 0.9 to 1.8 m/sec.
In children, the normal aortic valve flow velocity is slightly higher at 1.5 m/sec
Name the branches of the aortic arch starting with the one closest to the aortic valve
Starting at the top of the transverse arch closest to the aorta is the innominate (right brachiocephalic artery), then the left common carotid artery, and finally the left subclavian artery
What are the primary M-mode findings associated with aortic valvular stenosis?
The M-mode findings associated with aortic valvular stenosis are:
Multiple reverberant echoes during systole and diastole, owing to thickening of the valve leaflets, decreased separation of the valve leaflets, left ventricular hypertrophy
What are the primary 2D echocardiographic findings associated with aortic valvular stenosis?
Thickening of the aortic leaflets with decreased leaflet mobility
Left ventricular hypertrophy
Occasional post stenotic dilation of the aorta
A 38 year old male is sent to the echocardiography lab for evaluation after complaining of severe dyspnea on exertion for 2 months. M-mode findings include a dilated left ventricle, increased E point to septal separation (EPSS) B-notch on the mitral valve and overall hypocontractile left ventricular wall motion.
What type of cardiac abnormality do these findings suggest?
The M-mode findings of a dilated left ventricle identify a patient with dilated cardiomyopathy
What is the best noninvasive method for quantifying aortic valve stenosis?
The best noninvasive method for quantifying aortic valve stenosis is to use the continuity of flow equation to calculate the area of the aortic valve
How does the aortic valve area correlate with the degree of stenosis?
Mild = > 1.5 cm2
Moderate = 1.5 to 1.0 cm2
Severe = < 1.0 cm2
