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Echo Boards > Systolic function and Aortic valve > Flashcards

Systolic function and Aortic valve Flashcards

1
Q

measures of systolic function

A

fractional shortening nml >30

fractional area change nml >50
ejection fraction >55
SV and CO
Dp/dt
V of circumferential shortening
End systolic elastance
preload recruitable stroke work
strain rate
tissue doppler peak systolic velocity

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2
Q

Fraction indices

A

all are (Diastolic - systolic) / diastolic

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3
Q

Qp/Qs

A

SVpa/SVlvot, helps to determine shunt

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4
Q

Inward radial motion of normal , hypokinetic, akinetic, dyskenitic function

A

normal - greater than 30%
hypokinetic - 10-30 %
Akinetic less than 10%
dyskinetic - paradoxical systolic motion

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5
Q

Dp/Dt

A

slope of LV pressure rise from 4-36 mmHg, need MR jet, measured at 1 and 3 m/s
Normal is 1610 +/- 290 mmHg/sec (around 1300 min)

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6
Q

velocity of circumferential shortening

A

FS with ET in denominator

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7
Q

end systolic elastance

A

Load Independent. Slope of PV loop at end systole points. Steeper slope is better systolic function

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8
Q

preload recruitable stroke work

A

Stroke work is the area under curve of PV loop. If this is plotted as function of end diastolic volume
Steeper slope is better systolic function

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9
Q

preload adjusted max power

A

Stroke work/EDV^2 or
stroke work/ EDA^(3/2)
load independent

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10
Q

tissue doppler peak systolic velocity

A

faster s’ is better systolic function, no normal values to be tested on
influenced by tethering and translation

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11
Q

strain rate

A

Strain is dimensionless, and change in length produced by application of stress
strain rate is strain/time
Translation and angle independent but limited by noise
load independent

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12
Q

Aortic root size

A

normally less than 4 cm in adult

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13
Q

Basic views of Aortic valve

A

ME AV SAX, LAX
Deep TG LAX
TG LAX
ME 5 chamber

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14
Q

AI acute vs chronic

A

acute- stroke work preserved, elevated end diastolic pressure
chronic - compensates by dilating and lower end diastolic pressure, larger stroke volumes. Eventually sarcomeres stretch too far and causes decompensation
Intervene before it becomes too dilated and decreased SV

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15
Q

Severity of AI

A

Jet height : LVOT diameter
mod 25-64%
Jet area : LVOT area
mod 5-59%
Jet depth
mod tip of AL
VC
greater than 6mm severe
Slope of jet decay
greater than 3 m/s severe
PHT
mod 200-500 ms, affected by diastolic function
Flow reversal in Aorta

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16
Q

3 things determine prognosis in AI.

A

LV dysfunction
LV dilation
Asc Ao dilation- sinus best predictor (normal 25-31mm)

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17
Q

High risk AI patients

A

symptomatic
Reduced EF
end systolic diameter indexed >25mm/m2 (81 vs 34% survival at 10 years)

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18
Q

Low risk group Marfan syndrome for AI

A

Indexed sinus / predicted sinus diameter that is less than 1.3 or less than 5% change annually

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19
Q

When to replace valve

A

symptomatic or
asymptomatic with severe chronic AR, or chronic AR with root dilation

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20
Q

Types of AI classes

A

type 1 a- 1 d is normal cusp motion
type 2 - cusp prolapse, common
type 3 - cusp restriction

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21
Q

Aortic stenosis assessment

A

peak velocity - mod 3-3.9 m/s
mean grad - 30-49 mmHg
max grad - 40-69 mmHg
DVI mod 0.25-0.5 independent of patient size, stroke volume (TVI LVOT/TVI AV) or ( A valve/ A LVOT)
AVA mod 1-1.5 cm2
Indexed AVA mod 0.6-0.85 cm2/m2

If mean gradient is high then you are done

If low, need to see if there is low flow and use cont eq or DVI

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22
Q

Modified gorlin equation

A

Shows how you can have low gradient but still have aortic stenosis

AVA = CO/ Peak grad

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23
Q

continuity equation

A

flow in equals flow out
can use Vpeak or VTI

24
Q

psuedoaortic stenosis

A

not enough stroke volume to pop valve open.

25
Q

peak instantaneous vs peak to peak gradient

A

peak instantaneous > p 2 p gradient
Echo is instantaneous, p2p is cardiac cath

26
Q

In 3d en face view of mitral valve where is LAA and interatrial septum

A

LAA screen left, IAS screen right

27
Q

Right heart views

A

4 C - FAC , Septal and post/ant leaflet
RV I/O
TG SAX
TG RV inflow
Deep TG RV outflow
Asc AO SAX
Ao Arch SAX
ME bicaval and modified bicaval

28
Q

Innominate vein

A

can be recognized on right hand side of aortic arch in upper esophageal aortic arch short axis view

29
Q

RVSP calculation

A

4Vtr^2 + RAP
Estimate pulmonic pressure assuming no pulmonic valve stenosis

30
Q

RV function assessment

A

more qualitative than LV
highly compliant, low resistance, sensitive to loading conditions

20% of post CPB failure due to RV

31
Q

RV failure

A

can occur just by opening pericardium
2-3% of patients after heart transplant and 20-30% after LVAD

retrograde cardioplegia doesnt protect because of thebesian veins draining into RV and not sinus.
PVR increases after CPB

32
Q

parameters of RV function

A

FAC >35% (mean 49)
EF >45%
TAPSE >15-17 mm (mean 23)
IVA = 1.4 +/- 0.5 m/s (mean 3.7) most load independent for RV
TV S’ <10 abnormal
strain >-20

33
Q

Isovolumic acceleration

A

Peak velocity seen before s’ on tissue doppler / time it takes to reach peak

Should be somewhere around 2-3 m/s

load independent!

34
Q

RV volume overload

A

flattening of septum at end diastole to left hand side

usually from PI, ASD, TR

35
Q

eccentricity index

A

vertical dimension / horizontal dimension

Index >1 = RV dysfunction

36
Q

RV pressure overload

A

Shifts to left during end systole
RVH thickness >5mm

37
Q

Mcconell sign

A

apex moves but base does not indicates PE

38
Q

RV inflow outlfow leaftlets seen

A

Posterior on lateral side and a/s on medial side

39
Q

Tricuspid Regurgitation

A

Functional TR (normal leaflets) from annular dilation, pap muscle dysfunction, pressure/vol overload, PA cath

structural TR ( abnormal leaflets)
from rheumatic dz, myxomatous dz, ebsteins, carcinoid, endocarditis

Jet area mod 5-10 cm2
vena contracta >7 severe
hepatic flow reversal severe
jet density = more volume

40
Q

Rheumatic dz

A

most common cause of TS but less likely than TR , most commonly affects MV alone but can affect MV, AV and TV

41
Q

Ebsteins anomaly

A

Large sail like anterior leaflet, TV funnel shaped and apically displaced p/s leaflets
Associated with secundum ASD and SVT (WPW)

42
Q

carcinoid syndrome

A

releases serotonin, bradykinin , histamine, prostaglandin

RV valves damaged , thickened, fibrosed. Usually MAO protect LV (PFO can facilitate passage)

can cause both TR and TS but TR more common

43
Q

CVP and HV waveform timing

A

x descent which matches s wave on HV

y descent which matches d wave on HV

A and V waves match

44
Q

Tricuspid stenosis

A

rare, but most commonly from rhuematic dz. Also from carcinoid or congenital

Normal Peak velocity 30-70 cm/sec
190/PHT
mean gradient >5 mmHg severe but dependent on HR and flow

45
Q

Pulmonic valve

A

Hard to visualize
Has anterior , right and left cusps
valve leaflet closest to aortic valve is either left or right, farthest away from AV is anterior cusp

46
Q

Pulmonic insufficiency

A

Mild PI is normal
Significant PI usually congenital but can be caused by carcinoid, endocarditis, pHTN, myxomatous dz, radiation

measured with jet area, width and holodiastolic flow reversal in main pa

Early PI velocity used for PA mean pressure

Late pi velocity used for pa diastolic pressure

47
Q

pulmonic stenosis

A

usually congenital
measured by peak and mean gradients

seen in TOF ( subpulmonic)

Hemodynamic goal includes maintaining aortic diastolic pressure. RVH and elevated RV pressure leads to coronary perfusion during diastole only. Does not drop o2 demand

Pts frequently arrest

48
Q

RV differences from LV

A

TV septal leaflet more apically placed than MV Anterior leaflet
moderator band
presence of TV
presence of trabeculations
absence of two well defined pap muscles

49
Q

RV MPI

A

(IVRT + IVCT) / ET , lower is better

Also can use TR signal time - PA signal time / PA signal time

with PWD < 0.43 normal
with TDI < 0.54 normal

50
Q

RV dp/dt

A

12/time it takes TR jet to go from 1- 2 m/s.
Affected by loading conditions
<400 mmHg/s is abnormal
Innacurate with severe TR

51
Q

Things to look for assessing right heart function

A

CVP+CI
position of IAS
TR?
Geometry
Free wall motion and FAC
RIMP

52
Q

grading of endocardical thickening

A

grade 1 normal movement with thickening <30%
grade 2 slightly decreased movement with 10-30% thickening
grade 3 severe hypokinesis with <10% thickening
grade 4 akinesis with no thickening
grade 5 dyskinesis

53
Q

How to calculate LVEDP using AR CWD

A

Using modified bernouli equation of the late AI velocity
AoDP-LVEDP=4 Vailate^2

54
Q

how and when to measure aortic annulus and root

A

aortic annulus - mid systole inner edge to inner edge
all other measurements end diastole from leading edge to leading edge in perpendicular plane to long axis of aorta.

55
Q

what is leading edge to leading edge in aorta

A

includes anterior wall but not posterior wall

Echo Boards (11 decks)

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