TEE Flashcards
1
Q
Normal Systolic LVID
A
Men: 32.4 +/- 3.7 mm
Women: 28.2 +/- 3.3 mm
2
Q
Normal Diastolic LVID
A
Men: 50.2 +/- 4.1 mm
Women: 45 +/- 3.6 mm
3
Q
Normal LVEDV
A
Men: 74 mL/m^2
Women: 61 mL/m^2
4
Q
Normal LVESV
A
Men: 31 mL/m^2
Women: 24 mL/m^2
5
Q
Relative Wall Thickness
A
(2 x PWT)/LVIDd
6
Q
Concentric hypertrophy
A
RWT >0.42
7
Q
Eccentric hypertrophy
A
RWT <0.42
8
Q
Ejection Fraction
A
(EDV - ESV)/EDV
9
Q
RV free wall thickness
A
End-diastole
<0.5 cm
10
Q
RV dimensions
A
RVD1 (TV annulus): 2-2.8 cm
RVD2 (mid-ventricle): 2.7-3.3 cm
RVD3 (long axis): 7.1-7.9 cm
11
Q
LA dimension
A
Men: 3-4 cm
Women: 2.7-3.8 cm
Volume: <34 mL/m^2
12
Q
RA volume
A
Men: 25 +/- 7 mL/m^2
Women: 21 +/- 6 mL/m^2
13
Q
Aortic Regurgitation
When to replace valve?
A
- Severe, symptomatic AR
- Asymptomatic patients with
- Dilated heart (EDD >70 mm)
- Decreased EF (<55%)
- Dilated aortic root (>50-55 mm)
14
Q
Aortic Regurgitation
Pressure Half Time (PHT)
A
Mild: >500 ms
Moderate: 200-500 ms
Severe: <200 ms
15
Q
Aortic Regurgitation
Deceleration Slope
A
Mild: <2 m/s
Moderate: 2-3 m/s
Severe: >3 m/s
16
Q
Aortic Regurgitation
Descending Aorta Flow Reversal
A
Mild: Early brief
Moderate: Intermediate
Severe: Holodiastolic
17
Q
Aortic Regurgitation
Vena Contracta width
A
Mild: <3 mm
Moderate: 3-6 mm
Severe: >6 mm
18
Q
Aortic Regurgitation
AR Jet/LVOT width
A
Mild: <25%
Moderate: 25-64%
Severe: >64%
19
Q
Aortic Regurgitation
Regurgitant Volume
A
Mild: <30 mL
Moderate: 30-59 mL
Severe: >59 mL
20
Q
Aortic Regurgitation
Regurgitant Fraction
A
Mild: 20-30%
Moderate: 30-49%
Severe: >49%
21
Q
Aortic Regurgitation
EROA
A
Mild: <0.1 cm^2
Moderate: 0.1-0.29 cm^2
Severe: >0.29 cm^2
22
Q
Aortic Stenosis
Modified Gorlin Equation
A
AVA = CO / MG^(1/2) AVA = CO / PG
23
Q
Aortic Stenosis
Peak Velocity
A
Aortic Sclerosis: = 2.5 m/s
Mild: 2.6-2.9 m/s
Moderate: 3-4 m/s
Severe: >4 m/s
24
Q
Aortic Stenosis
Mean Gradient
A
Mild: <20 mmHg
Moderate: 20-40 mmHg
Severe: >40 mmHg
25
Aortic Stenosis
| AVA
Mild: >1.5 cm^2
Moderate: 1-1.5 cm^2
Severe: <1 cm^2
26
Aortic Stenosis
| Indexed AVA
Mild: >0.85 cm^2/m^2
Moderate: 0.6-0.85 cm^2/m^2
Severe: <0.6 cm^2/m^2
27
```
Aortic Stenosis
Velocity Ratio (Dimensionless Index)
```
Mild: > 0.5
Moderate: 0.25-0.5
Severe: <0.25
28
LV Fractional Shortening
(LVEDd - LVESd) / LVEDd
| Normal >25%
29
LV Fractional Area Change
(EDA - ESA) / EDA
| Normal >40-45%
30
Ejection Fraction
(EDV - ESV) / EDV
| Normal >55%
31
Simplified Bernoulli's Equation
P = 4v^2
32
Dp/Dt
32/Dt
Normal >1200 mmHg/s
Abnormal <800 mmHg/s
Independent of afterload, dependent on preload
33
Velocity of Circumferential Shortening (VCF)
FS/LVET
| Normal 1.09 +/- 0.3 circ/s
34
End Systolic Elastance
- Plot series of end-systolic points under various loading conditions
- Steeper slope = better systolic function
- Load independent
35
Preload-Recruitable Stroke Work
- Stroke work = area under pressure-volume loop
- Plot stroke work as function of end-diastolic volume
- Steeper slope = better systolic function
- Load independent
36
Preload Adjusted Max Power
=Stroke Work / (EDV)^2
=Stroke Work / (EDA)^(3/2)
-Load independent
37
Systolic Mitral Annular Velocity (Sm)
- S' velocity lateral annulus
- Normal >8 cm/s
- Abnormal <5 cm/s
38
Strain Rate
= (v1-v2) / x
Dimensionless
Exempt from influence of translation
Load independent
39
Load Independent Measures of Systolic Function
- End-systolic elastance
- Preload recruitable stroke work
- Preload adjusted max power
- Strain rate
40
MAPSE
Normal 12 +/- 2 mm
| Abnormal <8 mm
41
Myocardial Performance Index (MPI)
(ICT + IRT) / ET
Normal 0.39 +/- 0.05
Abnormal >0.5
42
Mitral valve annulus diameter
ME long axis view
Mid-diastole
29 +/- 4 mm
43
Mitral Regurgitation
| Ajet/Aatria
Mild: <20%
Moderate: 20-40%
Severe: >40%
44
Mitral Regurgitation
| Vena Contracta
Mild: <3 mm
Moderate: 3-6.9 mm
Severe: >7 mm
45
Mitral Regurgitation
| MR Jet Area
Mild: <4 cm^3
Moderate: 4-10 cm^3
Severe: >10 cm^3
46
Mitral Regurgitation
| Pulmonary Vein Flow
Mild: Normal
Moderate: Blunted S
Severe: S reversal
47
```
Mitral Regurgitation
Regurgitant Fraction (RF)
```
RF = RV / SV(MV)
Mild: <30%
Moderate: 30-49%
Severe: >50%
48
```
Mitral Regurgitation
Regurgitant Volume (RV)
```
```
RV = SV(MVinflow) - SV(LVOT)
RV = EROA / VTI(MR)
Mild: <30 cc
Moderate: 30-59 cc
Severe: >60 cc
```
49
Mitral Regurgitation
| EROA
```
EROA = RV / VTI(MR)
EROA(PISA) = Q(MRPisa) / V(MRpeak)
Mild: < 0.2 cm^2
Moderate: 0.2-0.39 cm^2
Severe: >0.4 cm^2
```
50
Mitral Regurgitation
| CWD Strength
Mild: Faint
Moderate: Moderate, partial
Severe: Very dense, holosystolic
51
Mitral Regurgitation
| PISA Radius
*If Valias = 40 and V(MRpeak) ~500 cm/s*
Mild: <4 mm
Moderate: 4-10 mm
Severe: >10 mm
52
SAM Risk Factors
- LV EDD <45 mm
- Aortomitral angle <120
- C-sept distance <25 mm
- AL/PL <1.3 (valve closed)
- Basal septum >15 mm
- LVOT <2 cm
- AL length >2 cm (valve open)
- PL length >1.5 cm (valve open)
53
Mitral Stenosis
| MVA by PHT
MVA = 220 / PHT
54
Mitral Stenosis
| MVA by Deceleration Time
MVA = 759 / DT
55
Mitral Stenosis
| Mean Gradient
Mild: <5 mmHg
Moderate: 5-10 mmHg
Severe: >10 mmHg
56
Mitral Stenosis
| PHT
Normal: 40-70 ms
Mild: 70-150 ms
Moderate: 151-219 ms
Severe: >220 ms
57
Mitral Stenosis
| MVA
Normal: >2.5 cm^2
Mild: 1.6-2.5 cm^2
Moderate: 1-1.5 cm^2
Severe: <1 cm^2
58
Mitral Stenosis
| Peak PA Pressure
Normal: 20-30 mmHg
Mild: <30 mmHg
Moderate: 30-50 mmHg
Severe: >50 mmHg
59
Mitral Stenosis
| PISA
MVA = {[2*3.14*r^2 x (alpha/180)] * Valias} / Vpeak
60
Aortic Stenosis
| Peak Gradient
Mild: 20-39 mmHg
Moderate: 40-69 mmHg
Severe: >70 mmHg
61
RV FAC
Normal >42-56%
| Abnormal <35%
62
RV EF
Normal >51.5-64.5%
| Abnormal <45%
63
TAPSE
Normal 21-27 mm
| Abnormal <17 mm
64
RV Isovolumic Acceleration (IVA)
Normal 1.4 +/- 0.5 m/s^2
65
TV S'
Normal >9.8-16.4 cm/s
| Abnormal <9.5 cm/s
66
RV dP/dT
15 mmHg/dT
Normal >400 mmHg/s
Very sensitive to loading conditions
67
Tricuspid Annulus
ESD 28 +/- 5 mm
| EDD 31 +/- 5 mm
68
Tricuspid Regurgitation
| Jet Area
Mild: <5 cm^2
Moderate: 5-10 cm^2
Severe: >10 cm^2
69
Tricuspid Regurgitation
| VC Width
Mild: <0.3 cm
Moderate: 0.3-0.69 cm
Severe: >0.7 cm
70
Tricuspid Regurgitation
| Hepatic Vein Flow
Mild: S dominant
Moderate: S blunting
Severe: S reversal
71
Tricuspid Regurgitation
| EROA
Mild: <0.2 cm^2
Moderate: 0.2-0.39 cm^2
Severe: >0.4 cm^2
72
Tricuspid Regurgitation
| Regurgitant Volume
Mild: <30 cc
Moderate: 30-44 cc
Severe: >45 cc
73
Tricuspid Stenosis
| Tricuspid Valve Area
TVA = 190/PHT
| Severe: < 1 cm^2
74
Tricuspid Stenosis
| Mean Gradient
Mild: <2 mmHg
Moderate: 2-5 mmHg
Severe: >5 mmHg
75
Pulmonic Regurgitation
| Severe PR
PI Jet Width/PA annulus 0.7
Deceleration time PI trace <260 ms
PHT PI jet <100 ms
Prominent flow reversal in main PA
76
Pulmonic Stenosis
| Velocity
Mild: <3 m/s
Moderate: 3-4 m/s
Severe: >4 m/s
77
Pulmonic Stenosis
| Peak Pressure Gradient
Mild: <36 mmHg
Moderate: 36-64 mmHg
Severe: >64 mmHg
78
RV MPI
MPI = (IVRT + IVCT) / ET
PW Normal: 0.26 +/- 0.085
PW Abnormal: >0.43
TDI Normal: 0.38 +/- 0.08
TDI Abnormal: >0.54
79
ASD
| Ostium Secundum
- Most common ASD
- Defect in septum primum
- A/w MVP
80
ASD
| Ostium Primum
- Endocardidal cushion defect
- A/w cleft AV, cleft septal TV leaflet, and cleft anterior MV leaflet
- A/w Trisomy 21
- Can be a/w restrictive or non-restrictive VSD
81
ASD
| Sinus Venosus
- Located near SVC>IVC
- SVC sinus venosus a/w anomalous drainage of RUPV
- IVC sinus venosus a/w Scimitar Syndrome
82
ASD
| Coronary Sinus
- Least common ASD
| - A/w persistent L SVC
83
```
VSD
Type 1 (Outlet, Supracristal)
```
- Defect just below PV
- Most likely to be a/w prolapse of RCC and resultant AR
- Least common VSD
84
```
VSD
Type 2 (Membranous, subaortic, conoventricular, malalignment)
```
- Most common VSD (70%)
- Located near TV
- A/w LV septal aneurysms
- Can be a/w prolapse of RCC
- A/w TOF
85
```
VSD
Type 3 (Inlet, endocardial cushion defect)
```
- A/w primum ASD
- A/w Trisomy 21
- A/w cleft AV leaflets, cleft septal TV leaflet, and cleft anterior MV leaflet
86
```
VSD
Type 4 (muscular, trabecular)
```
-Located more inferior and posteriorly
87
Tetralogy of Fallot
- VSD (membranous)
- Overriding aorta
- Pulmonary obstruction
- RVH
- A/w R aortic arch (25%) and coronary artery abnormality
88
Ebstein's Anomaly
- Large, sail-like anterior TV leaflet
- Apically displaced septal TV leaflet
- Atrialization of RV
- Dilated RV with severe volume overload 2/2 TR
- A/w ostium secundum ASD
- A/w WPW syndrome, atrial and ventricular arrhythmias
89
Diastology
| Vp
Normal >45-50 cm/s
- Measure 4 cm into LV
- Dependent on preload
- E/Vp >2.5 predicts PCWP >15 in pts with EF <55%
90
Diastology
Grade 0
Normal
e' >10 cm/s
91
Diastology
Grade 1
Impaired Relaxation
e' <10 cm/s
E/e' <8
E/A <0.8
DT >200 ms
ARdur-Adur <30 ms
92
Diastology
Grade 2
Pseudonormal
e' <10 cm/s
E/e' 9-12
E/A 0.8-1.5
DT 160-200 ms
ARdur-Adur >30 ms
93
Diastology
Grade 3
Restrictive
e' <10 cm/s
E/e' >13
E/A >2
DT <160 ms
ARdur-Adur >30 ms
94
Diastology
| Predictors of Increased Filling pressures
E/E' >15
IVRT/Te-e' <2
E/Vp >2.5 predicts PCWP >15 (if EF <55%)
ARdur - Adur >30 ms
95
Diastology (Updated)
| Normal
Mitral E/A ratio >0.8
Average E/e' <10
Peak TR velocity <2.8
LA volume index <34
96
Diastology (Updated)
| Grade 1
Mitral E/A ratio <0.8
Average E/e' <10
Peak TR velocity <2.8
LA volume index normal or increased
97
Diastology (Updated)
| Grade 2
Mitral E/A ratio >0.8 to <2
Average E/e' 10-14
Peak TR velocity >2.8
LA volume index >34
98
Diastology (Updated)
| Grade 3
Mitral E/A ratio >2
Average E/e' >14
Peak TR velocity >2.8
LA volume index >34
99
Wavelength
Length of single cycle
(trough to trough, or peak to peak)
wavelength=velocity/F
100
Spatial Pulse Length
Length of entire pulse
| SPL = Wavelength x # cycles in pulse
101
Axial (LARD) Resolution
Ability to discern 2 separate objects front to back
1/2 SPL
Smaller SPL = better axial resolution
Longitudinal, axial, radial, range, depth
102
Period
Amount of time needed to complete single cycle
| time for trough to trough or peak to peak
103
Pulse Duration
Amount of time needed to complete entire pulse
| PD = Period x # cycles in pulse
104
Pulse Repetition Period
Amount of time needed to go from beginning of 1 one pulse to beginning of next pulse
Pulse Duration + Listening Time
105
Pulse Repetition Frequency
1/Pulse Repetition Period
# pulses/second
Helps determine Nyquist limit
Proportional to frame rate
106
Temporal Resolution
Ability to accurately image moving structures at a particular instance in time
Increased PRF = better temporal resolution
107
Nyquist Limit
Maximum Doppler shift that can be measured without aliasing occurring
= 1/2 PRF
108
Frequency
```
# cycles/second
1/period
F=v/wavelength
```
109
Power
Amount of work US beam can do (transducer output)
110
Intensity
Power/unit area
| Determines bioeffects of US
111
Amplitude
Difference between average and max values of an acoustic variable
Higher amplitude = stronger sound pulse
Power & Intensity proportional to Amplitude^2
112
Lateral (LATA) Resolution
Ability to determine 2 separate objects side by side
Determined by beam width (narrower is better)
Lateral, angular, transverse, azimuthal
113
Elevational Resolution
Ability to determine 2 separate objects along y-axis
| Determined by beam height
114
Gain/Amplification
Amplification of returning US signal
| Post-processing function
115
Time (Depth) Gain Compensation
Compensates for attenuation that occurs with increasing depth
Changes gain in horizontal position
116
Lateral Gain Compensation
Changes gain in vertical position
Compensates for attenuation
Corrects enhancement artifact
117
Compression
Reduces the dynamic range of signals
| High compression produces more highly contrasted image, less "shades of grey"
118
Dynamic Range
Range of signals that can be processed by the machine
Inverse of compression
# of "shades of grey"
119
Focus
Point where US beam is narrowest
| Best lateral resolution
120
Doppler Equation
```
FR-FT = V cos(theta) 2 FT/C
V = velocity of blood flow
Theta = angle between flow and probe
FR = reflected frequency
FT = transmitted frequency
C = speed of US in soft tissue (1540 m/s)
```
121
Range Ambiguity
Inability to discern specific location of Doppler shift
| Seen with CWD
122
Mechanical Index
Ability of the US beam to produce cavitation (bursting of bubbles) of contrast material
MI = peak negative pressure / (frequency)^(1/2)
Depends on transmitted frequency and pressure of sound wave
123
Tissue Harmonics
Small amount of US converted into a harmonic frequency as sound propagates
Occurs at deeper depths
Occurs along main axis
124
Contrast Harmonics
Echo contrast material (microbubbles) expand and compress as it interacts with US, creating harmonic frequencies and lighting up cardiac chambers
125
Cavitation
Rupture of microbubbles causing a great deal of harmonic frequencies
Occurs with MI >1
126
Resonance
Uneven shrinking and compression of microbubbles (expansion>compression) creates new harmonic frequencies
Occurs with MI 0.1-1
127
Acoustic Impedance (Z)
Acoustic resistance to sound traveling through a medium
Z = P x V
P = density
V = velocity
128
Resonant Frequency (RF)
Most common frequency in a pulse
CWD: RF determined by electrical frequency of voltage
PWD: RF = V/2Thickness
129
Bandwidth (BW)
Difference between lowest and highest frequencies in a pulse
| Shorter SPL = higher BW
130
5 Functions of US Receiver
1. Amplification
2. Compensation
3. Compression
4. Demodulation
5. Rejection
131
Demodulation
Changes shape of electrical signal to make it recognizable by image screen
Rectification - turns all negative voltages positive
Smoothing - smoothes out signal
132
Rejection (Threshold, suppresion)
Very low amplitude signals are ignored as noise
133
Reverberation artifact
US ricochets between 2 reflectors creating multiple equally spaced reflections
Ringdown artifact, comet-tail effect
134
Refraction artifact
US beam is refracted by reflector, placing object to the side and deeper than true position
135
Side lobes (grating lobes)
US beams traveling along side axes reflect off of a reflector, but machine assumes it is traveling along main axis
136
Acoustic Shadowing
Very strong reflector doesn't allow penetration of US
137
Mirror Image artifact
US beam reflects off mirror, before hitting true object. Mirror image will be deeper and to the side, and equidistant to mirror as true object
138
Focal Zone
Length of near field (Ln)
| Ln = r^2/wavelength
139
Q Factor
Q Factor = RF/BW
140
Scattering
Random redirection of sound in many directions
Occurs when reflector is smaller than or equal to wavelength of US beam
Directed related to frequency
141
Snell's Law
sin(theta[t])/sin(theta[i]) = v2/v1
| Used for refraction
142
Duty Factor
Amount of time that US machine is producing sound
| =PD/PRP x 100%
143
Propagation Speed Artifact
Structure placed at incorrect depth because TEE assumes sounds travels at exactly 1540 m/s
144
Enhancement Artifact
Occurs when US travels through medium with lower rate of attenuation than surrounding soft tissue
Objects brighter distal to weakly attenuating medium
145
Attenuation Coefficient
Frequency/2
146
Aortic Stenosis
| Prosthetic valve severe stenosis cutoffs
```
EOA <0.8 cm^2
AT > 100 ms
AT/ET >0.4
DVI <0.25
MG > 35 mmHg
Peak Vel >4 m/s
```
147
Mitral Regurgitation
| Predictors for failed MVr for ischemic MR
```
Type IIIb Carpentier motion
Annulus diameter >4 cm
LV diastolic diameter >6 cm
Tethering (tenting) height >10 mm
Tenting Area >1.6 cm^2
Posterior leaflet angle >45 degrees
```
