Cv 2: Final

Front 1

Doppler Effect

Back 1

- Sound wave reflected from a moving object changes it's frequency proportional to the velocity of the object.

- The change in frequency of ultrasound scattered from a moving target.

Front 2

Purpose of the Doppler Effect

Back 2

Used to calculate velocity of red blood cells in relation to the observer.

Front 3

Doppler Equation

Back 3

v= c× ∆ F/ [ 2Ft (cos )]

C =speed of sound in blood (1540 m/sec)

Cos = angle between the ultrasound beam and direction of blood flow

Ft = transmitted frequency

Fs =scattered signal receivedback at the transducer

V =velocity of flow (m/sec)

∆ F: change in frequency

Front 4

Doppler Shift

Back 4

- Change of frequency in backscattered signals from small moving objects.

- Equation:∆F= (Fs –Ft )

- Either positive, negative, or zero

Front 5

Positive Doppler Shift

Back 5

- Displayed above baseline

- Received freq. > transmitted freq.

- Red

- Towards transducer

Front 6

Negative Doppler Shift

Back 6

- Displayed below baseline

- Received freq. < transmitted freq.

- Blue

- Away from transducer

Front 7

Zero Doppler Shift

Back 7

RBC's stationary compared to transducer.

Front 8

Doppler Tells Us:

Back 8

- Absence or presence of blood flow

- Flow direction

- Flow velocity

- Flow characteristics

Front 9

Doppler Equation Definition

Back 9

- The relationship between doppler shift and the velocity of blood flow

- The machine calculates velocity of blood flow by using the doppler equation

Front 10

The Doppler equation is dependent on what 3 factors?

Back 10

- Frequency of transducer

- Velocity of blood

- Intercept angle between direction of blood flow and US beam

Front 11

Doppler Shift in relation to Velocity

Back 11

Directly related

Front 12

Doppler Shift in relation to Transducer Frequency

Back 12

Directly related

Front 13

Doppler Shift in relation to Cosine Angle

Back 13

Directly related

Front 14

Doppler Shift in relation to Speed of Sound (in medium)

Back 14

Indirectly related

Front 15

Velocity

Back 15

- Magnitude AND direction

- Doppler frequency depends on direction

Front 16

Cosine of 0 or 180 Degrees

Back 16

- Equals 1

- Positive or negative doppler shift

- Parallel to flow

Front 17

Cosine of 0 or 90 Degrees

Back 17

- Equals 0

- No doppler shift

- Perpendicular to flow

Front 18

Spectral Analysis: Autocorrelation

Back 18

- Digital technique used to analyze color flow doppler

Front 19

Spectral Analysis: Fast Fourier Transform

Back 19

- Digital technique used to process both PW and CW Doppler

- Spectral display of FFT distinguishes laminar flow from turbulent flow

Front 20

Pulsed Wave Doppler

Back 20

- Allows sampling of blood flow velocities with use of sample volume from specific intracardiac depth

- Uses one crystal

- Has range resolution (can localize and analyze flow at a certain location)

Front 21

Pulse Repetition Frequency (PRF)

Back 21

- # of pulses created by the system in one second

- Can change it by changing the depth

- Depth and PRF are inversely related

Front 22

What does the frequency shift of PW doppler indicate?

Back 22

The direction and velocity of the object.

Front 23

What is the maximum velocity that PW doppler can measure?

Back 23

It cannot resolve velocities >1 m/sec, and cannot measure maximum velocities

Front 24

Sample Volume

Back 24

- Small region where PW doppler velocity is measured.

- Sampling or listening occurs within sample volume (gate size)

- Normal SV range: 5-7 mm, 1-2 is recommended

Front 25

Modal

Back 25

Black in the middle (on PW doppler)

Front 26

Spectral Doppler Display Provides

Back 26

- Velocity at SINGLE SPOT by placing SV at certain location

- Superior temporal resolution (determined by frame rate--high frame rate=better temp. res.)

- Timing and velocity of sample volume are accurately detected

Front 27

Nyquist Limit

Back 27

- Defined as the highest Doppler frequency of velocity that can be measured without the appearance of aliasing (signal wrap around)

- NL (Hz) = 1/2 PRF or PRF/2

- PW Doppler cannot resolve velocities above the Nyquist Limit

Front 28

Signal Aliasing

Back 28

- Doppler frequency or velocity that is above

- Occurs when velocity > Nyquist Limit

Front 29

How to Eliminate Aliasing

Back 29

1. Move baseline

2. Move scale (increase)

3. Increase PRF

4. Use lower frequency transducer

5. Use CW instead

Front 30

High PRF

Back 30

- Use of more than one sample volume at different depths along US beam

- Can sample higher velocities than PW

- Different than CW (uses sample volume)

- Cannot determine exact location due to 1+ SV's

Front 31

Color Flow Doppler

Back 31

- Color Flow superimposed on 2D image

- Decreases frame rate and temporal resolution

- Has range resolution

- Has aliasing

Front 32

Color Flow Doppler provides information on what? Disadvantages?

Back 32

- Direction of jet

- Extent of jet

- Mean velocities

- Detects additional jets (multiple regurgitant jets)

Disadvantages: slow frame rate, limited temporal resolution

Front 33

How to optimize frame rate with color doppler?

Back 33

- Small color box

- Decrease depth

- Decrease sector size

- Decrease the number of bursts from 8 to 4

Front 34

What color is turbulent flow?

Back 34

Green or mosaic

Front 35

Continuous Wave Doppler

Back 35

- Can use guided or non-guided probe (2D probe or pedoff probe)

- Uses 2 crystals

Front 36

Advantages/Disadvantages of CW

Back 36

Advantages:

- Evaluate high velocities accurately

Disadvantages:

- Unable to know the exact location (no range resolution)

Front 37

Pedoff vs. 2D Probe

Back 37

Pedoff: non-imaging, only used for CW, small footprint, steerable

2D: large footprint, can follow image rather than blood flow, steerable

Front 38

PW vs. CW

Back 38

PW: uses SV to determine velocity at specific point, limited ability to resolve high velocity, can be displayed as color flow or spectral envelope

CW: cannot resolve location of velocity, can resolve any physiologic velocity, can only be displayed as spectral envelope

Front 39

Side Lobes

Back 39

Extra acoustic energy created by single crystal transducers

Front 40

Grating Lobes

Back 40

Extra acoustic energy created by array transducers

Front 41

How to adjust if you are seeing a mirror image?

Back 41

- Adjust focal zone or TGC at level of diaphragm

- Scan from multiple windows

Front 42

Hemodynamics/Pressure-Flow Relationship

Back 42

- Hemodynamics: principles of blood flow circulation

- Driving force behind fluid flow

- Pressure difference necessary for fluid flow

- Flow occurs from HIGH to LOW pressure

Front 43

Pulsatile Flow

Back 43

- Arterial

- Cardiac contraction

- High rate

- Higher pressure

Front 44

Phasic Flow

Back 44

- Venous

- Respiration

- Low rate

- Lower pressure

Front 45

Properties of Blood

Back 45

- Density: mass of blood per unit volume, measure resistance to acceleration, the greater the mass-the more resistance to flow

- Viscosity: (gooeyness) resistance of flow by fluid in motion, physical parameter that characterizes fluid's ability to resist change in it's shape, may vary with temperature

Front 46

What are the factors that control flow of fluids within a tube?

Back 46

- Pressure gradient

- Radius of tube

- Length of tube

- Viscosity of fluid (higher RBC concentration=higher viscosity)

Front 47

Poiseuille's Law

Back 47

- Flow = Pressure/Resistance

- Flow increases when pressure increases

- Flow increases when resistance decreases

Front 48

Reynold's Number

Back 48

- Distinguishes between laminar and turbulent flow

- No unit

- Re > 2100 = turbulent flow

- Re < 2100 = laminar flow

Front 49

The point where turbulence occurs depends on:

Back 49

- Velocity

- Viscosity

- Density

- Radius of vessel

Front 50

What factor most determines whether turbulence will occur or not? Why?

Back 50

If vessel size or velocity of blood increases, because viscosity and density of blood is fairly consistent.

Front 51

Determinants of Flow Velocity Profiles

Back 51

- Accelerated flow

- Curvature of vessel

- Branching to smaller vessels

- Obstructed vessel

- Diverging cross section

Front 52

Types of Flow Velocity Profiles

Back 52

- Laminar flow: normal, speed highest at center

- Turbulent flow: unpredictable, coherence of velocities across lumen is lost

- Asymmetric flow: occurs when blood flows around a bend in vessel

Front 53

Asymmetric flow details

Back 53

- Faster on inside of curve when ascending

- Faster on outside of curve when descending

Front 54

Flow through a small orifice can be characterized by what three things?

Back 54

- Proximal flow convergence

- Vena contracta

- Flow disturbance/turbulence

Front 55

Small orifice blood flow picture

Back 55

Front 56

Bernoulli's Equation (simplified)

Back 56

PressureGradient =4V^2

- Measured in mmHg

- P = change in pressure(instantaneous pressure gradient)

- V = instantaneous velocity (m/s)

- Converts velocity to pressure and calculates pressure difference

Front 57

How is Bernoulli's equation applied in echo?

Back 57

- Enables estimation of pressures within cavities and across the valves

- Important in grading degree of valvular stenosis, left atrial pressure, left ventricular filling pressure, right ventricular systolic pressure, etc.

Front 58

Stroke Volume Formula

Back 58

- SV = CSA * VTI

•SV = stroke volume

•CSA = cross sectional area--0.785 x (LVOT diam)²

•VTI: Velocity Time Integral

Stroke volume is the volume of blood ejected per beat.

Front 59

Bernoulli's Principle

Back 59

At the most narrowed location:

- Velocity is the highest

- Kinetic energy is the highest

- Pressure energy is the highest

- Due to the law of conservation of energy pressure energy decreases as kinetic energy increases

Front 60

Gorlin Equation

Back 60

- Also called continuity equation

- Flow before = flow after

- "What goes in must come out"

- Flow across a fixed orifice is:

flow rate = CSA * flow velocity

- Flow across AV is:

SV = CSA * TVI

Front 61

Why is cath lab gradient (using bernoulli equation) lower than echo? How did echo fix that?

Back 61

Because cath lab measures peak to peak gradient, where echo measure instantaneous gradient.

Echo now measures the mean gradient.

Front 62

High velocities relate to a _________ in pressure.

Back 62

Drop

Front 63

At any area of significant narrowing in flow stream, flow velocity ___________ in relation to degree of narrowing.

Back 63

Increases

Front 64

Antegrade and Retrograde Flow

Back 64

Antegrade: forward flow, normal

Retrograde: regurgitant flow, backward flow

Front 65

Normal Flow of Aortic Valve

Back 65

PLAX: Antegrade flow is red during systole, and displayed above the baseline.

Apical 5: Antegrade flow is blue during systole, and displayed below the baseline.

Front 66

Normal Flow of Mitral Valve

Back 66

Apical 4: Antegrade flow is red during diastole, and displayed above the baseline.

Apical 4: Regurgitant flow will be blue during systole and displayed above the below the baseline.

Front 67

Normal Flow of Tricuspid Valve

Back 67

Apical 4: Antegrade flow is red during diastole, and displayed above the baseline.

Apical 4: Regurgitant flow will be blue during systole and displayed above the below the baseline.

Front 68

Normal Flow of Pulmonary Valve

Back 68

ASAX: Antegrade flow is blue during systole, and displayed below the baseline.

ASAX: Regurgitant flow is red during diastole, and displayed above the baseline.

Front 69

Normal Flow of the Pulmonary Vein/LA Filling

Back 69

Apical 2/4: Antegrade flow is red and retrograde flow is blue.

3 peaks on spectral display: 2 above (1-systole and 1-diastole) and 1 below (late diastole)

Front 70

Normal Flow of Hepatic/SVC/RA Filling

Back 70

SC/SSN: Antegrade flow will be blue throughout and below the baseline.

Front 71

Normal Flow of Descending Aorta:

Back 71

SSN: Antegrade flow will be blue during systole and red during diastole.

Front 72

Normal Flow of Abdominal Aorta:

Back 72

SC: Antegrade flow will be red during systole.

Retrograde flow will be blue during diastole.

Front 73

Normal PV (RVOT) peak velocity

Back 73

0.6-0.9 m/sec

Front 74

Normal peak LVOT velocity:

Back 74

0.7-1.1 m/s

Front 75

Normal peak AV velocity:

Back 75

1.0-1.7 m/s

Front 76

LVIF (MV inflow) Normal E and A point velocities

Back 76

E: 0.6-1.3 m/sec

A: 0.2-0.4 m/sec

Front 77

Normal peak velocity for MR

Back 77

4.0-6.0 m/sec

Front 78

RVIF (TV inflow) Normal E and A point velocities

Back 78

E: 0.3-0.7 m/sec

A: 0.2-0.4 m/sec

Front 79

Normal RVSP (right ventricular systolic pressure)

Back 79

15-30 mmHg

Front 80

Normal PAEDP (pulmonary artery end diastolic pressure)

Back 80

4-12 mmHg

Front 81

Normal velocities RVOT and PV/MPA

Back 81

0.6-0.9 m/sec

Front 82

IVS Thickness (diastole)

Back 82

0.6 – 1.1 cm

Front 83

LV Size (diastole)

Back 83

3.7 – 5.6 cm

Front 84

LV Posterior Wall (diastole)

Back 84

0.6 – 1.1 cm

Front 85

LV Size (systole)

Back 85

2.0 – 3.8 cm

Front 86

LVOT Diameter

Back 86

1.8 – 2.4 cm

Front 87

Sinus of Valsalva

Back 87

2.1 – 3.5 cm

Front 88

Sinotubular Junction

Back 88

1.7 – 3.4 cm

Front 89

Mid–ascending Aorta

Back 89

2.1 – 3.4 cm

Front 90

Ejection Fraction

Back 90

55–75%


normal: 50–70
mildly reduced: 40–50
moderately reduced: 30–40
severely reduced: <30

Front 91

All M–mode measurements are leading edge to leading edge except for _________?

Back 91

Left atrial size

Front 92

LVOT TVI

Back 92

18-22 cm

Front 93

LA size (Women and Men)

Back 93

Women: 2.7-3.8 cm

Men: 3.0-4.0 cm

Front 94

SV (Mayo and Reynolds)

Back 94

Mayo: 50-90 cc

Reynolds: 70-100 cc

Front 95

CO (Mayo and Reynolds)

Back 95

Mayo: 4-7 L/min

Reynolds: 4-8 L/min

Front 96

CI

Back 96

2.5-4.5 L/min/m^2

Front 97

LA Volume Index

Back 97

Normal: 22 (+/- 6 cc/m^2) cc/m^2

Mild: 28-33 (+1 SD) cc/m^2

Moderate: 34-39 (+2 SD) cc/m^2

Severe: 40+ (+3 SD) cc/m^2

Front 98

Stroke Volume (cc)

Back 98

SV = LVOT diameter ^2 *0.785 * LVOT TVI

SV = EDV-ESV

Front 99

Cardiac Output (L/min)

Back 99

CO = SV * HR

Front 100

Cardiac Index (L/min/m^2)

Back 100

CI = CO/BSA

Front 101

LA Volume (cc)

Back 101

LA Vol = [0.85 * LAA4C * LAA2C]/LADs

Front 102

Systolic Function Definiton

Back 102

Tells us how well the ventricle is contracting.

Front 103

What can systolic function evaluation tell us?

Back 103

Predictor of the outcome of:
– Ischemic heart disease
– Cardiomyopathies
– Valvular heart disease
– Congenital heart disease

Front 104

Mechanical Systole

Back 104

Segment of cardiac cycle from Mitral Valve closure to Aortic Valve closure.


MV closure to AV closure

Front 105

Electrical Systole

Back 105

Segment of EKG from the onset of QRS to the end of the T wave


Beginning Q to the end of T


Ventricular depolarization through repolarization

Front 106

When does systole begin?

Back 106

When the LV pressure exceeds LA pressure, resulting in closure of the MV.

Front 107

When does systole end?

Back 107

At the dicrotic notch when the aortic pressure exceeds LV pressure, resulting in closure of the AV.

Front 108

Systole (Mechanical/Electrical)

Back 108

MV closure to AV closure


Start of QRS to end of T


Includes isovolumic contraction and ventricular ejection.

Front 109

Volume changes during systole:

Back 109

– LV is at it's maximum volume at the onset of systole (end diastole)


– LV is at it's minimum volume at the end of systole (end systole).

Front 110

Early Systole:

Back 110

LV pressure > LA pressure
– causes MV to close
– MVC followed by IVCT


IVCT
– LV pressure rapidly rising, but volume is constant

Front 111

Mid Systole:

Back 111

Pressure crossover in mid–systole
– When MV pressure > Aortic pressure
– Causes AV to open

Front 112

Late Systole:

Back 112

Aortic pressure > LV pressure
– LV is still emptying but at a slower rate


Aortic Valve closure
– Represented by dicrotic notch on aortic pressure tracing
– Immediately after LVET

Front 113

Stroke Volume Definition

Back 113

Pump performance of the heart.


(a way to measure systolic function)

Front 114

Ejection Fraction Definition

Back 114

Decrease in chamber volume relative to end–diastolic volume.


(a way to measure systolic function)

Front 115

Stroke Volume and Ejection Fraction depend on:

Back 115

1. Contractility
2. Preload
3. Afterload
4. Ventricular geometry

Front 116

Contractility

Back 116

Intrinsic ability of the myocardium to contract independent of loading conditions or geometry.
Affected by:
1. Heart rate
2. Coupling interval
3. Metabolic factors
4. Disease processes
5. Pharmacologic agents

Front 117

Preload

Back 117

– Initial ventricular volume or pressure
– Initial stretching of cardiac myocytes prior to contraction
– Affected by venous BP and rate of venous return
– Increase in end–diastolic volume = increase preload

Front 118

Frank Starling's Law

Back 118

Stroke volume increases in response to increase in volume of blood filling heart when all other factors remain constant.


Greater initial stretch = Greater force of contraction


*too much of an increase affects the heart adversely as well (too much stretching and it loses ability to go back to original size).

Front 119

Afterload

Back 119

Aortic resistance or end systolic wall stress


Increase afterload = Increase BP and AV disease


Increase afterload = Decrease Stroke Volume


*LV needs to try and eject blood against higher pressure (amount of blood ejected is reduced)

Front 120

What do we use to evaluate systolic function?

Back 120

– Stroke volume
– Cardiac output
– Ejection fraction
– Cardiac index

Front 121

Stroke Volume Formula

Back 121

SV = EDV – ESV


SV = CSA * LVOT TVI


CSA = .785 * LVOTd^2

Front 122

Normal Stroke Volume Values

Back 122

70–100 cc (Reynolds)
50–90 cc (Mayo)

Front 123

Cardiac Output Definition

Back 123

Amount of blood ejected from the heart per minute.

Front 124

Cardiac Output Formula

Back 124

CO = SV * HR

Front 125

Cardiac Output Normal Values

Back 125

4–8 L/min (Reynolds)
4–7 L/min (Mayo)

Front 126

Cardiac Index Definition

Back 126

Refers to cardiac output in relation to BSA (body surface area.

Front 127

Cardiac Index Formula

Back 127

CI = CO/BSA

Front 128

Cardiac Index Normal Values

Back 128

2.5–4.5 L/min/m^2

Front 129

Ejection Fraction Definition

Back 129

Percent of blood ejected per beat.

Front 130

Ejection Fraction Formulas

Back 130

EF = SV/EDV *100


EF = LV EDV – LV ESV/LV EDV *100


EF = LVEDD^2 – LVESD^2/LVEDD^2 *100

Front 131

Ejection Fraction Normal Values

Back 131

55–75% (usually 50–70%)


Mildly reduced: 40–50
Moderately reduced: 30–40
Severely reduced: < 30

Front 132

What is the #1 pitfall for assessing cardiac function by echo?

Back 132

Ventricular geometry: Assume that the ventricle is symmetrical, the apical area is hemi–eliptical, and the basal area is cylindrical.


*not all hearts are like this

Front 133

Ventricular volumes can be calculated from:

Back 133

M–mode: using linear measurements


2D and Biplanes: using cross sectional areas


3D: using volume measurements

Front 134

Systolic function during exercise:

Back 134

– Cardiac output increases
– Stroke volume increases
– Ejection fraction increases
– Volumes decrease (EDV and ESV)

Front 135

Abnormal Systolic Function in M–Mode

Back 135

– EPSS >10 is abnormal
– If the LA wall is straight across with no motion that is abnormal
– B–notch, premature MV closure, premature AV opening all indicate increased LVEDP

Front 136

Advantages of M–Mode Assessment of Systolic function:

Back 136

– Good endocardial definition
– Timing with EKG

Front 137

Disadvantages of M–Mode Assessment of Systolic function:

Back 137

– Overestimation of chamber size (if oblique view)
– Overestimation of ejection fraction (if wall motion abnormalities present)

Front 138

Qualitative Evaluation of LV Function:

Back 138

– 2D
– M–Mode
– Volumes
– Global Strain
– %FS (fractional shortening)
– EPSS
– Wall Stress
– LV Mass

Front 139

Requirements/Limitations for 2D Volumes

Back 139

– Must see apex
– Use multiple planes (A2C, A4C)
– Good wall definition


Limitations: geometric assumptions

Front 140

What is the ASE recommended 2D method for volume measurements?

Back 140

Bi–Plane Apical Simpson's (Bi–plane ellipsoid)


– A4C and A2C
– Measure at end diastole for biggest
– Measure at end systole for smallest
– If walls aren't very defined––consider contrast agent

Front 141

Bi–Plane Simpson's EF Formula

Back 141

EF = LV EDV – LV ESV/LV EDV *100



**USE AVERAGE OF A4C and A2C VOLUME MEASUREMENTS!!!**

Front 142

Fractional Shortening Formula and Normal Values

Back 142

LVIDd – LVIDs/ LVIDd * 100


Normal: 25–45%

Front 143

EPSS

Back 143

– E Point Septal Separation
– Due to LV enlargement and decreased flow across MV


– Normal Range: 2–7 mm (>10 is abnormal)

Front 144

LV Mass

Back 144

– Total weight of myocardium
– Calculated by M–mode OR 2D


Normal Values:
Men– Mass: 88–224 g, Mass/BSA: 49–115 g/m^2
Women– Mass: 67–162 g, Mass/BSA: 43–95 g/m^2

Front 145

Which M–Mode measurements are needed to calculate LV mass?

Back 145

– LVPWd
– IVSd
– LVDd

Front 146

Strain

Back 146

– "Deformation Imaging"
– Assessment of myocardial function
– Based on tissue doppler imaging and speckle tracking
– Goal is for a negative number––the more positive it is the more dysfunctional
***based off idea that heart pumps more like you would ring out a towel (base one way, apex the other)***

Front 147

What assumptions are made when calculating stroke volume?

Back 147

– CSA was measured accurately
– Circular geometry
– Laminar flow with flat profile
– Measuring parallel to flow for most accurate velocity
– Diameter and velocity measurements are from same anatomical site

Front 148

What happens to SV when after load increases? When preload increases?

Back 148

Increased afterload = decreased SV


Increased preload = increased SV

Front 149

What does exercise do to SV?

Back 149

Increases the SV

Front 150

Acceleration Time

Back 150

– Length of time it takes from onset of flow to peak velocity
– Measured by PW Doppler with either aortic or pulmonic flow


– Normal AT for Aortic flow: 83–118 msec

Front 151

Ejection Time

Back 151

– Measures time blood is being ejected from LV
– Measured by Doppler or M–Mode (from AV opening to AV closure


Normal ET Value: 265–325 msec

Front 152

dP/dT

Back 152

– Measures rate of change in pressure over time
– Change in pressure/change in time
– MUST have MR to measure dP/dT


Normal Values: >1200 is normal

Front 153

LIMP

Back 153

– Left Index of Myocardial Performance
– Increase in LIMP indicates LV dysfunction
– LIMP = MV closure to opening/AV ejection time


Normal Values: 0.35 (+/–0.05) (unitless)

Front 154

What other modalities assess systolic function?

Back 154

– 3D Echo
– Acoustic Quantification
– Doppler Tissue Imaging
– Color Kinesis

Front 155

Views to evaluate RV systolic function/what is assessed in each view:

Back 155

- PLAX, RVIF, PSAX, A4C, Para-Apical, SC4C

- Assess shape, size, wall thickness, motion of RV free wall, and patterns of septal motion

Front 156

Assessing RV Shape

Back 156

- Triangular shape: broad base and narrow apex

- RV apex: closer to base than LV apex

- No simple geometric shape, which makes it difficult to assess because it wraps around the LV

Front 157

Assessing RV size by comparing to the LV:

Back 157

- Normal: smaller than LV with RV apex more basilar than LV apex

- Mildly dilated: RV enlargement, but still smaller than LV

- Moderately dilated: RV size = LV size

- Severely dilated: RV size > LV size

Front 158

Measuring RV size:

Back 158

- Basal dimension measured at annulus in 4C (< or = 4.2 cm)

- Wall thickness measured in SC (< or = 0.5 cm)

- Outflow tract distal diameter measured in PSAX (< or = 2.7 cm)

- Outflow tract proximal diameter measures in PLAX (< or = 3.3 cm)

Front 159

What causes RV dilation?

Back 159

- Volume overload: ASD, TR, PR

- Pressure overload: pulmonic valve stenosis, pulmonary embolism

Front 160

Assessing RV Wall Thickness

Back 160

- Measured in SC view

- Normal RV wall thickness: < 0.5 cm

- Thick walls point to pressure overload

Front 161

TAPSE

Back 161

- Tricuspid annular plane systolic excursion

- Assessed with M-mode in A4C

- Measures distance of tricuspid annular movement between end-diastole and end-systole

- Normal: > 1.6 cm

Front 162

TASV

Back 162

- Tricuspid annular systolic velocity

- Measured by tissue doppler and PW doppler

- Normal: > 10 cm/sec

Front 163

RIMP

Back 163

- Right index of myocardial performance

- Not dependent on HR or BP

- Dependent on myocardial contractility and relaxation (related to SV, CO, and EF)

- Predicts survival of PHTN patients

- Normal: 0.28 + or - 0.04

Front 164

Normal Septal Motion

Back 164

Diastole: LV circular in SAX, septal curvature convos toward RV and concave toward LV

Systole: Septum thickens, moves toward center of LV, LV circular in SAX

Front 165

Septal Motion in RV Volume Overload

Back 165

Diastole: Reversed curvature, D-shaped LV

Systole: Normalization of curvature

Front 166

Septal Motion in RV Volume Overload

Back 166

- Paradoxical septal motion

- Curvature of septum is reversed in systole and mid-diastole

- RV pressures exceed the LV pressures and there is a D-shaped LV in both systole and diastole

Front 167

RVSP

Back 167

- Right ventricular systolic pressure

- RVSP = 4(TR velocity)^2 + RA pressure

- Normal: 15-30 mmHg

Front 168

Estimation of RA Pressure

Back 168

Normal~~≤ 2.1 cm~~Decrease > 50%~~0 – 5 mmHg (3 mmHg ASE)

Normal~~≤ 2.1 cm~~Decrease ≤ 50%~~5 – 10 mmHg (8 mmHg ASE)

Dilated~~> 2.1 cm~~Decrease > 50%~~10 – 15 mmHg

Dilated~~>2.1 cm~~Decrease ≤ 50%~~15 – 20 mmHg (15 mmHg ASE)

Front 169

Values for Abnormal RVSP

Back 169

Mild PHTN -- 30-40 mmHg

Moderate PHTN -- 40-70 mmHg

Severe PHTN -- >70 mmHg

Front 170

Pitfalls/Limitations of Assessing RVSP with Doppler

Back 170

- Needs to be parallel to TR jet

- Need good envelope of TR

- Mistaking MR for TR (MR velocity is > TR velocity)

Front 171

PAEDP

Back 171

- Diastolic Pulmonary Artery Pressure

- Reflects PA to RV end diastolic pressure difference

- Normal: 4-12 mmHg

*Must have good PR to measure

Front 172

Swan-Ganz Catheter

Back 172

- Gold standard to measure PA pressures

- Placed in subclavian vein and threaded through right side of heart (SVC-RA-RV-MPA-Pulmonary bed)

Front 173

Venous Return

Back 173

- Flow of blood from venous system to RA

- Decreased venous return: decrease CO and SV, increases HR

- Increased venous return: increase CO and SV, decreases HR

Front 174

Maneuvers that Decrease Venous Return

Back 174

- Valsalva

- Amyl Nitrate

- Standing from squatting

- Expiration

Front 175

Maneuvers that Increase Venous Return

Back 175

- Isometric handgrip

- Straight leg raises

- Squatting

- Inspiration

Front 176

Heart Failure

Back 176

- Heart's inability to meet the metabolic demands of the body.

- Occurs due to systemic or pulmonary congestion due to decreased myocardial contractility

- Can cause: abnormal systolic function, pressure/volume overload, diastolic dysfunction

Front 177

Left Heart Failure

Back 177

- Failure of LV is caused by congestion of pulmonary capillaries

- Caused by congestion in lungs due to back up of blood into pulmonary veins and capillaries causing LV to fail

- Increased pressure in pulmonary bed

Front 178

Right Heart Failure

Back 178

- Cor Pulmonale

- Failure of right heart caused by prolonged high blood pressure in PA and RV

- Caused by congestion in systemic circulation which causes RV to fail

- Can develop from long standing left heart failure or pulmonary disease

Front 179

Normal Intracardiac Pressures

Back 179

RA: 5 mmHg

RV: 25/5 mmHg

PAP: 25/5 mmHg

LA: 10 mmHg

LV: 120/10 mmHg

AO: 120/80 mmHg

Front 180

Test Accuracy

Back 180

- Basedon % of patients who are correctly identified as having the disease or not

- CalculatedBy: Sumof True Positives and TrueNegatives dividedby total number of tests performed

Front 181

Sensitivity / Specificity

Back 181

- Sensitivity identifies all true + patients (goal is to diagnose)

- Specificity identifies all true - patients (confirms diagnosis)

- IncreaseSensitivity = DecreaseSpecificity

- DecreaseSensitivity = IncreaseSpecificity

Front 182

Sensitivity

Back 182

Probability that the test is “+” in a patient with the disease.

Front 183

Specificity

Back 183

Probability that the test is “-” in apatient that does not havethe disease.

Front 184

Indications for TTE

Back 184

- Screening Exams

- Monitoring Exams

- Peri and Post-Intervention

- Baseline echo

Front 185

Indications for TEE

Back 185

**TEEHas Higher Sensitivity thanTTE

- Probe in Esophagus

- Posteriorto heart

- Imaging of Posterior Cardiac Structures

Front 186

Indications for Stress echo:

Back 186

- Higher Sensitivity thanStress EKG

- Used if baseline EKG abnormalities exist, to aid in diagnosis of CAD, assess outcome of intervention

Front 187

Contrast Echo

Back 187

AgitatedSaline:

- Usedfor bubble studies

- To assess for shunts (ASD, VSD,PFO) and to highlight TR jets

- Bubble size > pulm. capillaries

Contrast Agents:

- Usedfor LV optimization (LVO)

- Gas filled microbubbles

- Bubble size < pulm. capillaries

Front 188

Directed Exam

Back 188

- Must rule IN OR OUTreason for exam

- Assess additionalabnormalities as they arise

Front 189

Comprehensive Exam

Back 189

- PerformDEFINITE set of images perset protocol

- Regardlessof symptoms or findings