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Medical > Tissue Doppler and Strain > Flashcards

Tissue Doppler and Strain Flashcards

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USMLE® Step 1 flashcards
1
Q

Define tissue doppler

A
  • an extension of pulsed Doppler
  • focus on measuring regional tissue velocities rather than blood flow velocities
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2
Q

What is the main principal in acquisition of tissue Doppler velocities?

A
  • Elimination of a high-pass filter
    • used for PW Doppler assessment of blood flow
  • focus on the lower velocity signals of tissue
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3
Q

What are disadvantages/limitations of TDI?

A
  • high frame rates are required to accurately collect tissue Doppler imaging (TDI)
  • Angle-dependent technique
    • influenced by cardiac translational motion and tethering
  • Load depdendent
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4
Q

What is the relationship with age and TDI mitral annular velocity?

A

decreases with age

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5
Q

E/e’ has been established as a correlate for these findings:

A

LVEDP

or

PCWP

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6
Q

This TDI finding in patients with heart failure carries an unfavorable five-year survival rate?

A

e’ < 3 cm/s

Elevated E/e’ > 15 - also carries poor prognosis

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7
Q

What is a sensitive and specific marker for cardiac amyloidosis on strain imaging?

A

apical sparing pattern

  • on longitudinal strain imaging
  • “cherry on top”
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8
Q

What additional findings on TDI are consistent with cardiac amyloidosis?

A

Lower e’ and mean LV strain peak

  • both were lower than age matched controls
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9
Q

What is a useful parameter (on TDI) to differntiate pathological LVH (HOCM/hypertensive LVH) from physiologic LVH?

A

s’ < 9 cm/s

s’ = systolic ejection velocity

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10
Q

What is one measure that may differentiate athletic heart from HOCM?

A
  • E/e’
    • E/e’ > 12 = elevated LAP in HOCM patients
    • E/e’ < 8 = trained athletes with normal function
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11
Q

What are disadvantages of speckle tracking?

A

Requires good image quality

  • Cannot be sucessfully applied to approximately 10% of US images
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12
Q

What frame rate is speck tracking performed at?

A

lower frame rates 40-90 frames/s

as compared to TDI > 100 frames/s

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13
Q

What parameter can show a relatively normal value when the myocardium is akinetic?

A

TDI

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14
Q

You perform an Echo on a college hockey player for palpitations. LV wall thickenss is increased. What parameter is consistent with Athlete’s Heart?

A

Septal e’ 15 cm/s

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15
Q

What is one advantage of strain imaging over TDI?

A

Not affected by tethering of segments

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16
Q

What movement indicates a negative number in strain imaging?

A

shortening = negative value

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17
Q

What is the scale for Global Longitudinal Peak systolic strain (16 LV segments)?

A
  • Normal = greater than (more negative than) - 18%
  • Borderline = -16% to -18%
  • Abnormal = less than (less negative than) - 16%
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18
Q

What are strengths of GLS?

A
  • Superiority in predication of all-cause mortality in the general population compared with LVEF
  • Improved risk stratification in patients with HF
  • Ability to recognize early LV dysfunction in patients undergoing cardiotoxic therapy and prognosticate subsequent CTRCD
  • Reproducible when performed by trained operators
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19
Q

What are the limitations of GLS?

A
  • Heavy depdendence on 2D Echo quality
  • Influenced by Loading conditions
  • Lack of long term clinical trials
  • Lack of data on reproducibility
  • Vendor and software specific
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20
Q

Describe the findings

A
  • Bull’s eye plot showing GLS
    • A - baseline GLS
    • B - GLS at 3 months durting trastuszumab-based therapy after anthracyclines
  • GLS has decreased from -20.6% –> - 14.4% (30% decrease)
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21
Q

What is considered a significant change in GLS?

A

> 15% from baseline

22
Q

What is the first step after a significant change in GLS is noted?

A

repeat Echo with GLS to ensure findings are accurate

23
Q

What is the stepwise progression / algorithm for evaluation of suspected CTRCD?

A
24
Q

What are typical Echo features of Athletic heart?

A
  • Normal tissue Doppler E’
  • Normal, pseudorestrictive mitral inflow pattern
  • Normal / mildly increased LA size
  • Strain normal (higher than HCM)
25
Q

What is the normal GLS of the RV?

A

> -25%

26
Q

Strain rate for tissue Doppler is defined as:

A

Change in velocity between two points divided by their distance

  • SR = (V1-V2) / L
    • V1 = velocity at point 1
    • V2 = velocity at point 2
    • L = length
27
Q

When compared with two-dimensional based strain, the biggest disadvantage of TDI-based strain is?

A

Angle depdendency

  • Like all doppler techniques, is sensitive to alignment
    *
28
Q

What is the relationship of TDI-based strain to tethering?

A
  • Not susceptible to tethering to adjacent tissue
    • as myocardial motion is measured relative to the adjacent myocardium and not relative to the transducer
29
Q

If two-dimensional based strain imaging is used to evaluate pathologic processes involving the subendocardium, the preferred modality should be:

A

Longitudinal strain

  • In the subendocardium, the fibers are roughly longitudinally oriented
  • With an angle of 80 degrees with resepect to the circumferential direction of the fibers located in the mid-aspect of the thickness of the myocardium
30
Q

What hemodynamic parameter betst correlates with a combination of mitral E-wave velocity and early diastolic longitudinal velocities of the myocardium (e’)?

A

Mean left atrial pressure

31
Q

When reporting GLS, it is imporant to bear in mind the impact of these parameters?

A
  • Vendor
  • Age
  • Gender
32
Q

What radial strain rate obtained at the mid inferior wall during systole of a patient with ischemic cardiomyopathy is consistent with dyskinesis?

A

Negative rate

  • negative values for radial strain =
    • relaxation (if measured during diastole)
    • dyskinesis (if measured during systole)
  • Positive values for radial strain = active contraction
33
Q

Describe LV torsion

A
  • During isovolumic contraction (phase 1), the apex shows a brief clockwise rotation and the base a short couterclockwise rotation
  • During ejection (phase 2), the direction of the rotation changes to counterclockwise at the LV apex and clockwise at the LV base
34
Q

What is one disadvantage of TDI in regards to motion?

A

It is unable to differentiate between active motion (like myocardial contraction) and passive motion (like tethering)

35
Q

Based on the Expert consensus for the multimodality imaging of the adult patient during and after cancer therapy, subclinical LV dysfunction is defined as:

A

15% reduction in GLS when compared to baseline value

36
Q

In asymmetric septal hypertrophic cardiomyopathy, tissue Doppler e’:

A

Has an inverse relationship with septal thickness

37
Q

In diabetic patients, what does HbA1c correlate with?

A

HbA1c correlates wtih E/e’

  • glycemic control –> microvascular complications –> ischemia and subsequent impaired LV relaxation and increased myocardial stiffness
38
Q

In what condition has e’ been shown to improve after treatment?

A

Aortic stenosis

  • Global LV dysfunction is common secondary to increased afterload
39
Q

What tissue doppler value has been shown to carry the most prognostic value after myocardial infarction (MI)?

A

E/e’ ratio

  • E/e’ > 17 –> mortality rate 40% at 36 months
  • E/e’ < 17 –> mortality rate 5% at 36 months
  • E/e’ > 15 in Echo 1.6 days after MI, followed for 13 months –> most powerful predictor of survival
40
Q

In patients with acute heart failure, this is a powerful predictor of cardiac events and appears to be a better parameter than ejection fraction

A

Global circumferential strain (GCS)

41
Q

This cardiac condition is associated with a normal or high e’?

A

Athletes heart

42
Q

In a patient with a localized basal lateral infarct with evidence of akinesis by two-dimensional Doppler imaging, the expected longitudinal tissue Doppler velocities (m/s) and strain rate (1/s) would be:

A

Tissue Doppler Velocity = 0.2, Strain Rate = 0

  • Strain rate of zero –> akinesis
  • Velocities may be recorded in akinetic segments that are tethered by adjacent moving segments
43
Q

What is the best prediction of mortality for paradoximal severe AS and preserved EF patients?

A

Symptoms + Euroscore + GLS

44
Q

Describe the findings

A

Radial strain map demosntrating Anteroseptal akinesis

45
Q

Describe the findings

A
  • Strain rate imaging with regions of interest selected in the septum (yellow circle) and lateral wall (blue circle) in A4C view
  • Anteroseptal infarct - selected area of the septum (yellow) maintains a strain rate of approximately zero throughout systole and diastole –> finding consistent with akinesis and scar formation
  • Selected area (blue) demonstrates a negative strain rate in systole, signifying appropriate myocardial compressiona dna positive strain rate in diastole, signifying myocardial expansion
46
Q

Describe strain rate values

A
  • Strain rate > 0 = expansion
  • Strain rate < 0 = compression
47
Q

46 year old woman with previous history of breast cancer treated with mastectomy, chemotherapy, and radiation therapy presents for evaluation of symptoms of fatigue. On examination, she has a heart rate (HR) of 100 bpm, BP 85/60 mmHg, elevated JVP, decreased breath sounds at the lung bases, ascites, and 3+ peripheral edema. TEE and TTE Doppler images are shown. What is the most likely diagnosis?

A

Constrictive Pericarditis

48
Q

68 year old woman presents for evaluation of dyspnea on exertion. Tissue Doppler images are shown, what is the most likely diagnosis?

A

Asymmetric septal hypertrophic cardiomyopathy

  • Key finding is reduction in e’ velocity that is much more pronounced in the septum –> consistent with hypertrophic cardiomyopathy
49
Q

41 year old woman with a diagnosis of recurrent triple negative breast cancer who has received a cumulative dose of anthracyclines of 450 mg/m2 undergoes an Echocardiogram with strain.

Describe the image and recommendations

A
  • Radial strain, usuing a short-axis image at the level of the papillary muscles
  • Discontinue anthracycline, finish treatment with a nonanthracycline containing regimen, and initiate beta-blockers
    • ​radial strain is abnormal at 11% (normal is 40%-60%) –> suggestive of subclinical LV dysfunction
50
Q

64 year old diabetic woman is referred fro evaluation of heart failure symptoms. 2D Echo, Color Tissue Doppler images and strain from A4C view are shown. What is the diagnosis?

A

Ischemic heart disease

  • 2D Echo: dilated LV cavity consitent with dilated or ischemic cardiomyopathy
  • TDI Color: shows different color velocity pattern in the septum and lateral wall
  • Strain: reduced deformation in the apical septum (yellow curve) compared with the apical lateral wall (red curve) –> findings consistent with septal MI
51
Q

What findings are indicative of subsequent cardiotoxity in chemotherapy patients?

A

GLS < 19%

or

Troponin I > 30 pg/mL

52
Q

62 year old man with history of rheumatic disease and previous mitral valve repair undergoes Echo for a heart murmur. 2D Echo and color M-mode tissue Doppler are consistent with this:

A

Normal postoperative findings

Paradoxical anterior systolic motion of the interventricular septum

*****Normal finding post pericardiotomy

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