Set 4 Flashcards
How does aortic stenosis affect the ventricles?
Aortic stenosis causes pressure overload of the left ventricle. The ventricle responds to this overload (increased wall stress) by becoming hypertrophied.
Over time, the pressure overload may cause left ventricular dilatation and decreased contractility. The right ventricle is not usually affected.
After a chest X-ray revealed cardiomegaly, a 58 year old female with a primary complaint of increasing dyspnea on exertion is sent for an echocardiogram.
The echocardiogram demonstrates left ventricular hypertrophy with a “bright” myocardial appearance, left atrial enlargement, and a small pericardial effusion.
What is this patients most likely cardiac diagnosis?
Left ventricular hypertrophy with a “bright” myocardium, left atrial enlargement, and a small pericardial effusion are echocardiographic findings most consistent with a diagnosis of:
Infiltrative (restrictive) cardiomyopathy
Which of the following methods is the most accurate means of calculating the aortic valve area?
- M-mode measurement of the aortic leaflet separation
- 2D planimetry of the aortic area in the short axis view
- Doppler calculation of the continuity of flow calculation
Of these 3 methods, Doppler calculation of the continuity of flow equation is the most accurate means of determining the aortic valve area.
Measurement of the aortic leaflet separation does not determine the aortic valve area or indicate what the third aortic leaflet is doing.
In most patients, planimetric calculation of the aortic valve area is impossible from the chest wall orientation because of multiple reverberations from the calcified/fibrotic leaflets
A 56 year old female visits her doctor with the complaint of shortness of breath. Upon physical examination, a low frequency diastolic (rumbling) murmur is detected. The patient denies any history of rheumatic fever. What 3 cardiac abnormalities might be present in this patient?
- Mitral stenosis (or tricuspid stenosis). Even with no known history, she may have had rheumatic fever as a child and now has rheumatic heart disease.
- Left atrial myxomas mimic mitral stenosis with regard to both physical findings and symptoms.
- Aortic regurgitation. If the aortic regurgitation jet hits the mitral valve anterior leaflet, the MV’s opening can be restricted. As a result, a “rumbling” diastolic murmur (Austin Flint), rather than the typical “blowing” AR diastolic murmur will be heard
2D echocardiography of a 58 year old man with a systolic murmur reveals the following findings:
– Concentric left ventricular hypertrophy
– Mild to moderate thickening of the aortic leaflets, with decreased valvular opening
– Systolic doming of the aortic leaflets on the parasternal long axis views
What is the most likely diagnosis?
The most likely diagnosis is a stenosis of a congenital bicuspid aortic valve.
Thickened leaflets and concentric hypertrophy may also be seen in patients with degenerative aortic valve stenosis, but systolic doming in the parasternal long axis view is typical of a bicuspid aortic valve.
Define aortic valve sclerosis
Aortic valve sclerosis denotes hardening and fibrosis of the aortic leaflets.
This condition does not produce a significant gradient, but it may cause a systolic murmur or some degree of regurgitation
Define aortic valve stenosis
Aortic valve stenosis denotes narrowing of the aortic leaflets or outflow tract
This condition is different from sclerosis, in that stenosis implies the presence of a hemodynamic gradient
What are the primary 2D echocardiographic findings associated with congenital bicuspid aortic valve stenosis?
Typical findings associated with congenital bicuspid aortic valve stenosis are:
– Concentric left ventricular hypertrophy
– Mild to moderate thickening of the aortic leaflets
– Systolic doming of the leaflets in the parasternal long axis view
In a 2D echocardiographic study, what would be the major difference between the findings associated with degenerative aortic valve stenosis and those associated with rheumatic aortic valve stenosis?
Although the aortic valve might present a similar appearance in both cases, rheumatic heart disease is almost always accompanied by coexisting mitral stenosis
What is Takayasu’s arteritis?
Fibrosis of the aortic arch and descending aorta. This disease occurs more frequently in young women from Asia and Africa.
Also called aortic arch syndrome
In a patient with Takayasu’s arteritis, what would you look for on the echocardiogram?
You would look for supravalvular aortic stenosis. In the most severe forms of this disease multiple coarctations may occur throughout the aortic arch system.
How does aortic regurgitation affect the stenotic aortic valve gradient as assessed by Doppler examination?
Mild aortic regurgitation has no effect on the aortic valve gradient.
Moderate or severe aortic regurgitation causes the existing gradient to increase because of volume overload on the left ventricle.
How does aortic regurgitation affect the aortic valve area, as calculated by the continuity of flow equation?
Aortic regurgitation does not affect the aortic valve area, as calculated by the continuity of flow equation, because the velocities for V1 and V2 increase equally
What are the main echocardiographic findings associated with chronic aortic regurgitation?
Patients with mild chronic aortic regurgitation may have slight aortic valve thickening and an otherwise normal echocardiogram.
Those with moderate to severe chronic aortic regurgitation present with early left ventricular dilatation and hypercontractility, and late in the disease process impairment of ventricular function.
What are the main echocardiographic findings associated with acute aortic regurgitation?
Patients with mild acute aortic regurgitation may have a fairly normal echocardiogram.
Those with moderate to severe acute aortic regurgitation have hypercontractile left ventricles, left ventricular dilatation, and occasional premature closure of the mitral valve owing to increased end diastolic pressure. These patients usually have some pathological aortic condition such as vegetations, prolapse, dissection, or trauma
How is aortic 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 jet the more severe the regurgitation.
In determining the severity of aortic regurgitation, the examiner must take into account the total size, length, duration, and width of the jet as well as the patients BP
A 31 year old male with a history of uncontrolled systemic hypertension enters the emergency room with severe chest pain that he describes as “ripping”. What is a likely cardiac diagnosis for this patient?
Although this patient may be experiencing a myocardial infarction, the history of age, hypertension, and “ripping” chest pain indicate the possibility of an aortic dissection
Which noninvasive examination would be useful to confirm the diagnosis of aortic dissection?
In many places chest CT is the preferred test as it’s fast and has better sensitivity over transesophageal echocardiography. TTE is not sensitive or specific
How does aortic regurgitation affect the ventricles?
Mild aortic regurgitation does not affect the left ventricle
In contrast, moderate to severe aortic regurgitation results in left ventricular dilatation because of volume overload. In such cases, left ventricular contractility is hyperdynamic. The left ventricle continues to dilate until decompression sets in and ventricular function decreases.
What is the most common congenital cause of aortic regurgitation?
Bicuspid aortic valve is the most common congenital cause of aortic regurgitation
What is another word used to describe diastolic flow reversal in the descending aorta?
Another word used to describe diastolic flow reversal in the descending aorta is retrograde
Retrograde refers to any flow that is moving the opposite of the normal antegrade direction
How is diastolic flow reversal used to quantitate aortic regurgitation?
Patients with mild aortic regurgitation will usually NOT have diastolic flow reversal in the descending aorta.
Patients with severe aortic regurgitation will usually have holodiastolic flow reversal in the descending aorta or even in the abdominal aorta.
Name 3 classic M-mode findings associated with aortic regurgitation.
Classic M-mode findings associated with aortic regurgitation (AR) include:
- Diastolic fluttering of the aortic leaflet
- Diastolic fluttering of the interventricular septum
- Dilatation and hypercontractility of the left ventricle (alternatively, hypocontractility may be present if left ventricular decompensation is involved)
- Mitral valve preclosure (in severe acute AR)
In aortic valve endocarditis, what symptoms are patients likely to present with?
Symptoms of aortic valve endocarditis include:
- Fever
- Chills/night sweats
- Diastolic murmur
- Tachycardia
- Dyspnea on exertion or at rest
What is the most common cause of a flail aortic leaflet?
The most common cause of a flail aortic leaflet is endocarditis.
A less common cause is trauma
Define Marfan syndrome
Marfan syndrome is a connective tissue disease characterized by increased joint flexibility and elongation of the long bones. Ocular lens problems and cardiac abnormalities are often present
How does Marfan syndrome affect the aortic valve? How does it affect the mitral valve?
Cardiac manifestations of Marfan syndrome includes ascending aortic dilatation and mitral valve prolapse
Depending on the severity of the disease, varying degrees of aortic or mitral regurgitation may be present.
Aortic dissections may also occur
Describe the anatomy of the tricuspid valve, including the name and location of each leaflet.
The tricuspid valve is located between the right atrium and the right ventricle
It has 3 leaflets: the anterior, posterior, and medial (septal) leaflets
These names reflect the leaflets anatomic relationships to the right ventricle.
The medial (septal) leaflet is connected to the septal wall. Its insertion is located closer to the cardiac apex than that of the anterior mitral leaflet.
Name the 3 classic M-mode findings associated with tricuspid stenosis
- A decreased E-F slope
- A reduced early diastolic amplitude
- Multiple reverberant echoes during diastole
Describe the most common 2D echocardiographic findings associated with tricuspid stenosis
- Thickening and tethering (doming) of the tricuspid leaflets
- Decreased leaflet mobility during diastole
- Mitral stenosis
What is the normal flow velocity (mean value and range) through the tricuspid valve?
The normal flow velocity through the tricuspid valve is a mean of 0.6 m/sec with a range of 0.4 to 0.8 m/sec
Describe the changes in the Doppler spectral trace associated with tricuspid stenosis
In tricuspid stenosis, changes in the Doppler spectral trace include:
- An increase in flow velocity
- An increase in flow turbulence (as detected by pulsed or color flow Doppler)
- A decrease in the rate of drop off for the early diastolic flow (pressure half time)
