Valvular Flashcards
In aortic stenosis is pulse pressure wide or narrow?
Narrow ( pulse pressure is the difference between systolic and diastolic pressure it is wide in AI (regurg) and narrow in AS
A secondary finding in aortic stenosis is?
LVH left ventricular hypertrophy
What are some echo valvular findings in aortic stenosis?
Thickened ao leaflets, decreased valve opening, LVH, post stenotic dilatation of the ao
What are some physical signs/complaints for aortic stenosis?
Angina, dyspnea and syncope/ sudden death, harsh systolic ejection murmur r upper eternal border, decreased or absent a2, decreased and delayed carotid upstroke with bruit thrill transmitted from aov
What are some etiology associated w ao stenosis?
Calcific/degenerative (50 percent start as bicuspid)
Rheumatic(associated w mitral stenosis)
Congenital (bicuspid memnbrane(1-2 percent of population)
Supra and sub valvular obstructions
Prosthetic valve dysfunction
Aortic jet velocities?
Mild 2.6-2.9
Mod3.0-4.0
Severe >4.0
Ava?
Mild >1.5
Mod 1.0-1.5
Severe <1.0
Echo findings for bicuspid AoV?
Possible eccentric closure of mmode (one flap more anterior not in midline - 25 percent will have normal midline closure) Thickened ao leaflets (may be mild) Systolic doming in lax view Bicuspid orifice in sax view (football) Check for coexist coarctation of ao
The best view to diagnose a bicuspid AoV is the parasternal?
Short axis systole (sax) football money shot
Normal desc ao velocity?
1m/sec
Echo findings for ao coarctation?
Congenital membrane or ridge in lvot beneath AoV
Early systolic closure of ao leaflets
Lvh
What view is best for detecting su valvular membranes?
Apical 5ch (approx 15 percent will grow back post surgical removal)
What is takayasu arteritis?
Also called aortic arch syndrome this disease occurs more in young women from Asia. There is fibrosis of the arch and descending ao of unknown etiology. In advanced states multiple coarctations may occur (look for supra valvular as)
Patients bp is 110/84. Aortic velocity is 5m/sec. Peak LV pressure in this patient is?
210 mmhg (add the ao gradient) 100mmhg if the velocity is 5m/sec(to the systolic BP)
The normal Ava is?
3-4cm2
What is a severe Ava?
<1.0cm2
Using the continuity equation when would the severity of as be underestimated?
Lvot measured too large
Which pressure is obtained during Doppler?
Peak or peak instantaneous (for as it’s the highest gradient anytime during systole)
Know that echo gradients are usually higher than cath gradients
Peak instantaneous versus peak to peak
How to determine severe aortic stenosis?
First look at the valve area (must be below 1.0)
Second look at the max gradient (if valve areas are equal)
Third look at the wall thickness (evidence of lvh)
A pt Marfan syndrome might have which of the following cardiac abnormalities?
MVP & aortic dissection
Rheumatic mitral stenosis creates a volume and pressure overload pattern which may result in all the following except?
LV enlargement
Long-standing mitral stenosis leads to all of the following except?
Left ventricular dilatation
Which of the following syndromes fits with aortic regurgitation, aortic dilitation, aortic dissection and aortic aneurysm?
Marfan syndrome. Marfan’s syndrome is a connective tissue disease that can lead to all of these problems with aortic valve and aorta
Using saline contrast, systolic appearance of bubbles in the inferior vena cava would indicate?
Tricuspid regurgitation
One advantage of using the parasternal long asked you to diagnose mitral valve prolapse is?
Falls prolapse caused by the anulus shape is avoided. Due to the curvature of the mitral annulus even normal valves appear like the leaflets prolapse in Apical four chamber view
Afib is most commonly associated with which valvular disease?
Rheumatic mitral stenosis. In rheumatic mitral stenosis the la often dilates enough to cause a fib
What pressure half time by continuous wave Doppler would you expect on the patient with severe aortic insufficiency?
<200 msec. This would indicate that the aortic insufficiency is severe as the pressure halftime slope of the spectral trace is very steep. This means that the pressure between the aorta and left ventricle is almost equal by the end of diastole
When the heart has compensate for increased afterload the ventricle responds by?
Hypertrophy. Yes increasing the afterload will increase the force that the ventricle had to overcome with each contraction. Over time this will lead to LVH
What best describes a sinus of valsalva aneurysm?
Saccular type of dilatation. A sinus of valsalva aneurysm appears as a thin sack pushing away from the proximal aortic root of one of the sinuses.
With a fib and mitral stenosis the Doppler velocity is best performed?
Averaged over 3-5 beats
Complications of rheumatic mitral stenosis include all of the following except?
Dilated LV. Yes the LV does not dilate due to mitral stenosis in pts w Rheunatic valvular disease
Longstanding ms may lead to which of the following?
Pulmonary HTN. As la pressure increases in longstanding ms pilmoanry HTN may result
Which of the following occurs first in the setting of severe mitral regurgitation due to a flailed leaflet
Dilated right ventricle
Systolic flow reversal in the pulmonary veins indicates:?
Severe mural regurg.
Which valve lesion typically has the lowest Doppler peak velocity?
Pulmonic regurgitation
Some etiology for pulmonic stenosis?
Congenital (most common)
Rheumatic (rare)
Carcinoid
Infundibular
Some Pathophysiology for ps?
Systolic pressure overload leads to RVH.
Regional hypertrophy may lead to infundinular stenosis.
Commonly associated w other congenital malformations (vsd, asd, tetralogy of fallot)
Some physical signs of ps?
Dyspnea on exertion.
Systolic ejection murmur left upper sternal border.
Some echo findings for ps?
M-mode may show may show an increase in the pulmonic a-dip of more than 7mm (useful for severe ps only).
Valvular thickening and systolic doming (2-d).
RVH
Ps protects the lungs.
Ps does not cause?
Pulmonary HTN
Doppler findings in ps?
Increased velocity and turbulence at level of obstruction (valvular, sub valvular, or supravalvular.
Measure peak and mean gradients (psax and rvot long)
Normal pulmonary velocity?
1m/sec.
Ex: 4m/sec (64 mmhg)
If unable to obtain ps gradient from the parasternal window were else can you go?
Subcostal short axis
Ps severity?
Mild:Below 3.0m/s or 36mmhg
Mod:3.0-4.0 or 36-64 mmhg
Severe: above 4.0m/s or 64mmhg.
Ps gradients vary w what?
Respiration
Etiology for ms?
Rheumatic (commissarial fusion) most common.
Congenital (rare).
Acquired Mac
Prosthetic valve dysfunction
The insertion of mitral chordae tendineae into a single pap muscle is?
Parachute mitral valve (tunnel stenosis)
Some Pathophysiology for ms?
Diffuse leaflet thickening scarring contraction commisural fusion and chordae shortening and fusion.
Associated mr may be present.
Increased la pressure causes la dilation
Long standing obstruction leads to pul HTN (RV and RA enlargement)
Physical signs of ms?
Diastolic murmur (rumble) with opening snap. A fib is common.
Me murmur =
low frequency “diastolic rumble” with an opening snap.
What is the hockey stick appearance associated w?
Rheumatic ms
Which cardiac valve is the second most common to be affected by rheumatic heart disease?
Aortic (most common mitral 97%)
Pts w ms often develop?
A fib (most common)
Echo findings for ms?
Thickened MV leaflets with decreased mobility.
Tethered MV leaflet tips (hockey stick appearance).
LA enlargement.
Signs of pul HTN in advanced disease.
Ms pts become very symptomatic with ?
A fib. Might lose 50% of diastolic filling since they are very dependent on atrial contraction.
Doppler findings for ms?
Increased Doppler and turbulence across the MV.
Use PHT for valve area.
Mitral regurg might b present.
Measure mean trans valvular gradient.
Normal MVA?
4-5cm2
With a fib ms velocity calculations are best performed?
Averaged over 5-10 beats
Given a mitral PHT of 400m/sec what would the area be?
.5cm2
Equation for MVA?
220➗PHT
Given a mitral deceleration time of 400msec calculate the MV PHT?
116 (equation is deceleration time x .29)
400x.29=116
Given decel time how do you calculate MVA?
759➗decel time
What is decel time in ms?
Is from peak flow to where the slope hits the baseline.
Etiology of TS?
Rheumatic (most common)
Congenital (rare)
Carcinoid (rare)
Prosthetic valve dysfunction
Carcinoid vs Rheumatic?
Carcinoid=fixed body of the leaflets. Rheumatic =tethered leaflet tips
Pathophysiology of TS?
Increased RA pressure causes RA dilation.
Rheumatic TS almost always associated w ms.
Carcinoid heart disease results from increased serotonin production.
Physical signs of TS?
Signs and symptoms may be masked by ms.
Diastolic murmur (varies w respiration) and an opening snap.
Symptoms of R heart failure (ascities peripheral edema
Echo findings in TS?
Mmode shows decreased e-f slope, reduced E wave
Thickened tv leaflets w decreased mobility.
RA and IVC enlargement.
Tethered tv leaflets (doming).
TS severity?
Mean gradient more or equal to 5
Inflow tvi more than 60cm
TVA by continuity less than 1
Etiology of AI?
Primary cusp disease (stenosis, endocarditis, ankylosing (contractility) spondylitis.)
Dilated aortic annulus and root (Marfan, HTN, aneurym).
Loss of commisural support.
Which anomaly goes w aortic dissection?
Marfan syndrome
If you have a uniformly dilated aortic root which term best describes this?
Fusiform
What kind of murmur would you hear in a pt w a rupture of a sinus of valsalva aneurysm?
Continuous
Which is the most common chamber for a sinus of valsalva aneurysm to rupture into?
RA
What is the classic aortic regurg murmur?
Diastolic “blow”
Echo findings of AI?
Mmode may show diastolic fluttering of the mitral valve leaflets (mostly anterior) or ivs.
Mitral valve pre closure w severe acute AI
Pre systolic opening of the aortic leaflets
What can cause MV fluttering on mmode?
AI
What causes MV preclosure?
An elevated LVEDP
Where is normal MV closure on ECG?
In the middle to the end of the QRS complex.
Doppler findings of AI?
Diastolic turbulence in the LVOT.
Diastolic flow reversal in the descending aorta (mod to sev AI)
Obtain the end diastolic gradient from cw Doppler to estimate the LVEDP (diastolic BP - end diastolic gradient)
Ao PHT?
Mild. More than 500msec
Mod. 500-200 msec
Sev. Less than 200 msec (fast)
Another term for descending aorta diastolic flow reversal?
Retrograde
Mild aortic regurg is seen as what in Doppler?
As an incomplete spectral trace.
Etiology for PI?
Primary valve disease
Pul HTN
Carcinoid
Some physical signs of PI?
Low pitched diastolic murmur may increase w inspiration.
W pul HTN a high pitched blowing diastolic murmur (graham Steele) may be heard.
A pt comes to the echo lab w decreased co, cp, syncope, and a possible cerebral infarct. What is the most likely diagnosis?
AS
MV prolapse is seen best in which view?
PlAX
What would you typically expect to see on mmode of an 14 y/o w a bicuspid ao valve?
Eccentric closure. On mmode you can usually see eccentric closure of the aortic leaflets where they are not on the middle of the aorta.
Pts w Marfan syndrome typically die from what?
AO dissection. These pts develop dilated aortic roots and commonly for from AO dissection
MR in pts w rheumatic MS is most likely due to?
LA enlargement. In pts w rheumatic ms as the LA dilates they can get increasing amounts of mr as the annulus stretches.
Inhalation of amyl nitrate might be used to demonstrate which of the following?
Mitral valve prolapse. Since amyl is a vasodilator there is less blood returning to the heart and this might accentuate mitral valve prolapse.
Doppler findings in PI?
Severe PI spectral trace is not holodiastolic. (Early diastolic and nothing else)
How would you calculate pulmonary artery and end diastolic pressure?
Pulmonic insufficiency velocity.
How to calculate PAEDP?
PAEDP=RAP+EDP (4v2)
PAEDP=10+4(1.5)squared
Mitral regurgitation in PT’s with rheumatic mitral stenosis is most likely due to:?
Left atrial enlargement
Which term below describes the type of aortic stenosis that originates at the sinus of valsalva and extends medially to aortic valve cusps?
Degenerative, AS starts outer edges moving inward.
Which of the following is the most common etiology for pulmonic stenosis?
Congenital malformations
All of the following physical findings on PT’s with aortic regurgitation Except:?
Systolic blowing murmur
Which of the following is an etiology of valvular aortic stenosis?
Rheumatic fever
All of the following are m-mode findings in rheumatic mitral stenosis Except:?
Increased E-F slope
Which of the following syndromes fit with aortic regurg, Ao dilatation, Ao dissection & AO aneurysms?
Marfans, a connective tissue disorder
Severe TR can often result in all Except:?
Pulmonary hypertension, TR does not cause pulmonary hypertension
All of the following are etiologies of valvular aortic stenosis Except:?
IHSS, this is hypertrophic involment
A common cause for right ventricular volume overload is?
Tricuspid regurgitation
Severe MR can often result in all of the following Except:?
Systematic hypertension
The development of angina, dyspnea & syncope may be advanced stages of:?
Aortic stenosis
Which of the following is the most common etiology for mitral stenosis?
Thematic fever
Which of the following are common secondary findings for mitral stenosis?
Left atrial enlargement and signs of PHTN.
All of the following are etiologies for aortic regurg Except:?
Pulmonary hypertension
When the heart has to compensate for increased afterload the ventricle responds by:?
Hypertrophy
Marfan syndrome is best described as:?
Connective tissue disorder
All of the following syndromes significantly raise the PT’s risk for aortic dissection Except:?
Down syndrome
What is the best way to determine if severe mitral regurg is present?
Pulmonary venous flow
PT’s with Marfan syndrome are follies by echo to check?
Changes in aortic root dimensions
In echo the use of the continuity equation in PT’s with aortic stenosis is based on the premise that:?
Flow below the valve is equal to flow above the valve
With a mitral pressure 1/2 time of 230m/sec, what will present?
Severe MS
Etiology of valvular aortic stenosis?
Rheumatic fever
In PT’s with moderate aortic stenosis the:?
Left ventricle systolic pressure exceeds that of the aorta
All of the following are physical findings in PT with aortic regurg Except:?
Systolic blowing murmur
Longstanding mitral stenosis may lead to which of the following?
Pulmonary hypertension
Myxoma’s commonly are attached to which of the following?
Interatrial septum
Prolapse is defined as what ?
A systolic movement of one or both mitral leaflets in the LA
What is Marfan disease?
Congenital connective tissue disease causing aortic dilatation and MVP
In Marfan syndrome why does aortic dissection and mvp occur?
Decreased fibrillin
What is ehlers danlos disease?
Another connective tissue disease, like Marfan pts you look for mvp and dilated ao dissection
Severe aortic aneurysms are greater than?
5.0 cm
Physical sign for MVP?
Mid systolic click with or without a systolic murmur, usually a symptomatic may have fatigue dyspnea or anxiety
Do not diagnose prolapse from the AP4CH view!!!
Do not diagnose prolapse in the presence of large pericardial effusion!!! Pe can cause pseudo
With MVP what are the jet directions of the MR?
Posterior leaflet prolapse results in an anteriorly directed jet and anterior leaflet prolapse in a posteriorly directed jet
Etiology of PI?
Due to a primary valve disease such as stenosis and endocarditis, PHTN, carcinoid heart disease
What is the most common valvular abnormality associated w carcinoid syndrome?
TR
What is CVP?
Central venous pressure - refers to the IVC pressure close to the RA
What type of valve is a st. Jude?
Bi-disk
Thickened tricuspid leaflets which are fixed in the open position might mean that the patient has which of the following problems?
Carcinoid heart disease
A patient with marfans syndrome might have which of the following common cardiac abnormalities?
Mitral valve prolapse and aortic dissection, these are common findings
A patient has a blood pressure of 130/80 and a VSD jet of 5 m/s. What is their right ventricular systolic pressure?
30 mmhg
