Lecture 21
Adult Echocardiography
Final Exam Prep 2
• Harry H. Holdorf PhD, MPA, RDMS (Ab, OB, BR), RVT, LRT(AS)
Which valve separates the areas of greatest
pressure differences?
• Mitral valve
Know the anatomical locations of the
following:
• Superior Vena Cava
• Aorta
• Pulmonary Artery
• Left Anterior Descending Coronary artery and vein
• Great cardiac Vein
• LAD lies in the anterior interventricular groove or SULCUS
Which aortic leaflet is the superior one in the
parasternal long axis view?
• Right leaflet is superior
• Non-coronary is the posterior leaflet
From the left parasternal window, which of the
following are you most likely to get accurate
velocity measurements?
• Pulmonary artery
Know the basic anatomy by other imaging
techniques
• MRI study showing the descending aorta (view mimics the LAX)
Name the tricuspid leaflets
• Posterior and anterior
Know that the RV inflow tract view is the only
standard view in which you see the posterior
tricuspid leaflet
• How to visualize the posterior leaflet of the tricuspid valve?
• Also, in this view, red inflow at the image bottom would be…the IVC.
The inter-atrial septum connects to which
aortic valve?
• The non-coronary
The coronary arteries come off the?
• Sinuses of Valsalva
It is important to visualize the origin of the
coronary arteries because…
• Patients, when exerting and dilating the great vessels, can suffer ischemia,
angina, or sudden death
•
Anomalous coronaries
During which phase do the coronaries fill?
• Early diastole
In the super-sternal arch view, what is the
structure seen under the arch?
• Right pulmonary artery
What cardiac pathology is associated with
bicuspid aortic valves?
• Coarctation of the aorta
Where do most aortic coarctations occur?
• After the take-off of the left subclavian artery, or within the aortic isthmus.
• (The beginning of the descending aorta)
On a apical four chamber view:
Where are the pulmonary veins located?
Which ones are seen on this view?
• Right and left upper (superior) pulmonary veins
Which other view would give you the same
information as the parasternal LAX?
• Apical LAX
Which standard 2D TTE view typically allows
viewing of the Left atrial appendage?
• Apical 2 chamber
Where is the coronary sinus located?
• Posterior Atrial ventricular groove
• Also, know that the “dot” on the coronary sinus LAX view that is to the right
and posterior to the coronary sinus is the descending aorta
To visualize the coronary sinus in the apical 4
chamber view, you should tilt the transducer
• Posterior
Which valve sits at the opening of the coronary
sinus?
• Thebesian
What portion of the pulmonary venous PW
Doppler represents atrial systole?
• A wave
At what temperature is it unsafe to use the TEE
probe?
• 40-45C
Know where the LA appendage is by TEE.
• To the left of the image, coming of the LA at 3 o’clock and turning down
Know the TEE views by esophageal level
Regarding cardiac physiology, which has the
fastest intrinsic rate?
• SA node
What is the absolute refractory state?
• That period when a muscle cell is not excitable- from phase 1 until into
phase 3
• The relative refractory period is during phase 3 and the muscle cell might
contract if the stimulus is strong
Know what P wave, P-R interval, and T wave
represents
• P wave = atrial systole
• P-R interval = includes P-R segment from atrial ventricular depolarization
• T wave = ventricular diastole (repolarization)
What is the normal duration for the QRS
complex
• 0.10 sec to .12 sec
Electrocardiogram
• 1 small box = 0.04 seconds
• 1 big box = 0.2 seconds
• 5 big boxes = 1 second
Know Frank-Starling Law
• Increased volume (preload) = increased contractility (to a physiologic limit)
• Increased myocardial fiber length = increased tension (rubber band theory)
Chronic vs. Acute shift in the Frank – Starling
graph
• Acute AI is hyper contractile because we shift up the Starling curve
• Chronic AI is failure when we drop off the end
Echo findings for preload vs. afterload
• Preload = dilatation
• Afterload = hypertrophy
Which study does not allow for the calculation
of ejection fraction?
• Chest x-ray
Calculate cardiac output (CO)
• Co = SV (stroke volume) x HR (heart rate)
• Normal is 4-8 L/min (5 Average)
How does switching to a lower frequency
transducer affect aliasing?
• Aliasing will occur at higher frequencies
What does VTI (Velocity time integral) x CSA
(Cross sectional area) equal?
• Doppler stroke volume
Does venous return increase or decrease with
inspiration?
• increase
Inhalation of amyl nitrate causes:
• Decreased afterload
•
•
Vaso dilator- drops BP
Tachycardia response- increased stroke volume- increase heart rate
Mitral valve velocity during inspiration:
• Decreases
Know Wiggers Diagram
• Mitral closure
• Aortic opens
• Aortic closure
• Mitral opens
•
•
•
•
•
•
Wiggers:
Know isovolumetric timing with ECG:
•
•
After R wave – isovolumic contraction
After T wave – isovolumic relaxation
Know the duration of IVRT and IVCT
•
70 msec
On Wiggers, when is the mitral valve open?
•
4-1
The duration of isovolumetric relaxation time will be increased with
•
Bradycardia
Between which heart sounds will the murmur of aortic stenosis be heard?
•
S1-S2
During the cardiac cycle, this event NEVER happens:
•
Ao valve is open and mitral valve is open
Stuff you gotta know regarding the cardiac
cycle
• Normal arterial pressure is approx. 120/80. Thus, the aortic pressure lives
high
• Normal left atrial pressure is approx. 10 mmHg. Thus, the atrial pressure
lives low
• The left ventricular pressure bounces between aortic and atrial. High and
Low
• The valve that lives between the atrium and the left ventricle is the mitral
valve. The mitral valve lives low.
• When a normal valve is open, there is very little pressure difference between
the chambers on either side of the valve.
What is the normal pressures in the pulmonary
artery?
• 25/10
Where is the O2 saturation the lowest in the
heart
• Coronary sinus
O2 saturation…
• Pulmonary veins = 95%
• Pulmonary arteries = 75%
Best cath. Technique for LV function
• LV angiogram
Know pressure waveforms for
Aortic Stenosis
Mitral Stenosis
Mitral Regurgitation
• See next three slides
What is PCW (Pulmonary Capillary Wedge)
measuring?
• Left atrial pressure
To determine AS, where are the catheters
placed?
• One in the LV and one in the Ao or one in the LV and pulled back across the
AoV or one catheter with two separate sensors.
Technique
• Tissue harmonic imaging results in thicker valve leaflets
A secondary finding in aortic stenosis is?
• Left ventricular hypertrophy
In aortic stenosis, is pulse pressure wide or
narrow?
• Narrow
•
Pulse pressure is the difference between systolic and diastolic pressures – it is wide in
AI and narrow in AS
The best view to diagnosis a bicuspid aortic
valve is the parasternal…
• Short-axis systole
Systemic hypertension…
• Is a common symptom of aortic Coarctation
What is Takayasu’s arteritis?
• Also called aortic arch syndrome: 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 supravalvular
aortic stenosis)
The normal aortic valve areas is?
• 3-4 cm sq.
Patients BP = 110/84
Aortic velocity is 5 m/sec
Peak LV pressure in this patient is?
• 210 mm Hg
• Add the Ao gradient (100 mm Hg if the velocity is 5 m/sec) to the systolic BP.
Using the continuity equation, when would be
severity of Aortic Stenosis be underestimated?
• LVOT measured too large
Which pressure is obtained during Doppler?
• Peak or peak instantaneous
• For AS it is the highest gradient anytime during systole
Know that echo gradients are usually higher
than catheter gradients
• Peak instantaneous vs. peak-to-peak
Noonan Syndrome
• Classified as a cardio-facial syndrome with Pulmonary Stenosis,
Hypertrophy Cardiomyopathy, and Atrial Septal Defect (30%)
Pulmonary Stenosis…
• Does NOT cause pulmonary hypertension
Asked if unable to obtain pulmonary stenosis
gradient from the parasternal window, where else
would you go?
• Subcostal short-axis
The insertion of mitral chordae tendineae into
a single papillary muscle is
• Parachute mitral valve
Which cardiac valve is the second most common to
be affected by rheumatic health disease?
• Aortic
Longstanding Mitral Stenosis leads to all of the
following :
Congestive heart failure
Pulmonary hypertension
Left atrial dilatation
Mitral stenosis = low frequency…
• Diastolic Rumble
• Opening SNAP
Rheumatic Mitral Stenosis…
• “Hockey-Stick” presentation
With atrial fibrillation, mitral stenosis velocity
calculations are best performed…
• Averaged over 5-10 beats
Regarding Tricuspid Stenosis:
Carcinoid vs. Rheumatic…
• Carcinoid – fixed body of the leaflets
• Rheumatic – tethered leaflet tips
Which anomaly goes with aortic dissection?
• Marfan syndrome
If you have a uniformly dilated aortic root,
which best describes this?
• fusiform
Which is the most common chamber for a
sinus of Valsalva aneurysm to rupture into?
• Right atrium
What kind of murmur would you hear in a patient
with a rupture of a sinus of Valsalva aneurysm?
• Continuous
The classic aortic regurgitation murmur is …
• Diastolic “blow”
Diastolic Mitral valve from aortic regurgitation
is demonstrated by…
• M-mode fluttering
What causes Mitral valve preclosure?
• An elevated LVEDP
• Left Ventricular End diastolic pressure
Know color Doppler M-mode of aortic insufficiency
AKS Aortic Insufficiency
Know descending aorta diastolic flow reversal
(AKA retrograde)
Mild aortic regurgitation
• Has an incomplete spectral trace
How would you calculate pulmonary artery
end diastolic pressure?
• Pulmonic insufficiency velocity
Systolic flow reversal of bubbles in the IVC
Tricuspid Regurgitation or
Tamponade?
• Tricuspid regurgitation
What is the most common valvular abnormality
associated with carcinoid syndrome?
• Tricuspid regurgitation
CVP (central Venous Pressure)
• Refers to the IVC pressure close to the Right atrium
Hepatic venous flow reversal indicates
• Severe tricuspid regurgitation
A patient has a right ventricular systolic pressure
(RVSP) of 60 mm Hg. One year later RVSP is 30 mm
Hg. What happened to this patient?
• Dilated cardiomyopathy
A vena contracta (narrowest part of a color jet)
might be seen in which type of cardiomyopathy?
• Dilated
Coanda Effect
• Happens with wall hugging jets.
• May underestimate jet size.
If you suspect severe Mitral regurgitation,
where else should you look?
• Pulmonary veins
The greatest source of error in measuring Proximal
iso-velocity surface area (PISA) is with
• Radius of the flow convergence
Which of the following is used in echo to measure
dP/dt? (the rate of rise of Left ventricular pressure)
• Mitral regurgitation
dP/dt measurement of mitral regurgitation
assesses what?
• LV systolic function
Know pressure waveforms for Mitral
regurgitation (late systolic jump in LA pressure
Mitral valve prolapse:
Know about Marfan disease
• Congenital connective tissue disease causing aortic dilatation and mitral
valve prolapse (MVP)
In Marfan syndrome, why does aortic
dissection and MVP occur?
• Decreased fibrillin
Know Ehlers-Danlos
• Another connective tissue disease:
• Like Marfan patients, you would look for MP, Dilated Ao, and dissection
Severe aortic aneurysms are greater than:
• 5.0 cm
MVP
• Usually will be shown a 4-chamber image with obvious MVP
Regarding Endocarditis
Libman-Sachs
Marantic endocarditis
• Libman-Sachs = endocarditis caused by lupus
• Marantic = non-bacterial NBTE
Patients with a history of IV drug abuse may
present with:
• Tricuspid endocarditis
Can one tell old vs. new vegitations?
• no
In order to be seen by 2-D, vegetations need to
be at least
• 3 mm
Know what a ball and cage Mitral Valve looks
like
Know that St. Jude is a bi-leaflet valve
Autographs…
• Use patient’s own tissue
• Regarding prostatic valves:
•
•
•
Acoustic shadowing with mitral valve prosthesis
Know echo appearance of common valves
Know the term Pannus = host tissue overgrowth
The normal pressure half-time for a mitral
prosthetic valve is
• < 170 msec
Cardiomyopathies:
Which cardiomyopathy is autosomal dominant?
• hypertrophic
HOCM
• Hypertrophic obstructive cardiomyopathy
The ratio of assessing asymmetric
hypertrophy:
• 1.3:1
The Venturi Effect
• Law of conservation of energy means that when the velocity of fluid
increased, the pressure decreases.
The Venturi Effect can be associated with
which cardiomyopathy?
• hypertrophic
LVOT obstruction causes the aortic valve to
• Close in mid systole
Mitral inflow shows A wave greater than E
• Some degree of diastolic dysfunction, abnormal relaxation
Does Inderal (beta Blocker) increase SAM?
Systolic Anterior Motion
• No
• Decreases heart rate
• Reduces SAM with exercise
A late peaking Doppler jet…
• Goes along with:
•
•
HOCM: Hypertrophic Obstructive Cardiomyopathy
IHSS: Idiopathic hypertrophic Subaortic Stenosis
• 61 year old male with IHSS and a resting gradient of 144 mm Hg.
• Admitted to the hospital with chest pain.
• Next day the resting gradient was 15 mm Hg.
• What happened?
•
Left ventricular infarct
Strain: measures the deformation within the
myocardium
Global Longitudinal Strain in patients with HOCM is
typically:
• -10
Chagas’ disease
• Posterior and apical thinning of the myocardium
• Septum is usually normal
Know the Echo signs of congestive
cardiomyopathies
What is the cause of a B-notch
• Increased LVEDP
• Left Ventricular End Diastolic Pressure
Know post-transplant 2-D appearance
Will have double atria
Amyloid and sarcoid are what type of cardiac
abnormalities?
• Infiltrative is via pathology and is the correct answer
• Restrictive would be via physiology
Hemochromatosis
• Excessive iron
Amyloidosis involves abnormal proteins.
• Some may describe it as a translucent waxy protein build-up on the
myofibrils
Ground glass appearance:
Related to infiltrative myocarditis
A restrictive cardiomyopathy has:
• Decreased Left Ventricular Compliance
A typical ejection fraction in a dilated
cardiomyopathy patient might be? (for a HCM
patient)
• 15-25% (pick the lowest range given)
The majority of ventricular filling occurs
during:
• First third of diastole
Know the following filling patterns:
If a patient has a normal Mitral valve inflow but the
pulmonary veins showed a decreased S-Wave and
D-Wave…
• Consider that they might have a pseudonormal pattern
Diastolic Function values
• In elderly patients (>60), the A wave is normally equal to or higher than the
E-wave
Know how the normal Doppler waveform at the
mitral annulus differs from flow at the mitral leaflet
tips:
• E and A are reversed at these two sample sites
How would you determine if a patient has
constrictive versus restrictive disease?
• Mitral valve inflow with respiratory variation with constrictive disease
In constrictive pericarditis, does the E wave
increase or decrease with inspiration
• decrease
Name the three layers of the pericardium
• 1. fibrous pericardium –thick outer sack
• 2. serous parietal-bound to fibrous pericardium smooth, wall of the cavity
• 3. serous visceral – bound to epicardium smooth, toward the organ
• Pericardial fluid is found in between the two serous layers
A pericardial effusion can often be seen in
patients with:
• Renal failure
Know the classic M-mode pattern of a pericardial effusion
M-mode echocardiogram showing moderate pericardial effusion present anteriorly(PE) and
posteriorly(PPE). RVW=right ventricular wall
Know the anterior echo free space
shown on a 2-D Parasternal LAX
• Anterior echo-free space is probably an epi-cardial fat pad
Know what a large pericardial effusion looks
like (>500 cc)
Pericardial Effusion Grading Criteria
• Small = posterior fluid < 1 cm
• Medium = Anterior & posterior < 1 cm
• Large = Surrounding the heart > 1 cm
• ALSO: measure spaces in Diastole
Identify the coronary sinus vs. the descending Ao
and it’s importance
Pleural Effusion
Know where the oblique sinus of the
pericardium lies:
• Posterior to the LA in the PLAX view – area between the two sets of
pulmonary veins
What to do if tamponade is suspected?
• Immediate interpretation
Know Beck’s triad
• A. Elevated venous pressure
• B. Hypotension
• C. Quiet heart
• Elevation of venous veins (look at the Internal Jugular Vein in the neck)
The most sensitive way to diagnosis cardiac
tamponade is:
• RV diastolic collapse
• RV systolic collapse
• M-Mode of the LA wall motion
• Respiratory variation
What cardiac condition would prevent diastolic
right ventricular collapse?
• Concentric LVH
• High systemic hypertension
• Pulmonary hypertension
• Tricuspid regurgitation
Flow Variation in Tamponade
Know how respiration affects the mitral and
tricuspid flows in tamponade
• Reversal of normal
• In Tamponade what happens to hepatic diastolic and systolic flows during
expiration?
• What happens in a normal patient?
What other pericardial abnormality also causes
impaired ventricular filling?
• Constrictive pericarditis
A huge, dilated Pulmonary Artery, severe Tricuspid
regurgitation, and Right Ventricular enlargement
best describes…
• Pulmonary hypertension
Know Eisenmenger Syndrome
• Eisenmenger's syndrome is defined as obstructive pulmonary vascular
disease that develops as a consequence of a large pre-existing left-to-right
shunt causing pulmonary artery pressures to increase and approach
systemic levels, such that the direction of blood flow then becomes bidirectional or right-to-left.
What is represented with a decreased “a” wave and
a flying W?
Pulmonary hypertension by M-mode
With small pulmonary emboli, the heart may
be normal.
• With large pulmonary emboli, the Right ventricle/right atria will dilate.
• Pulmonary hypertension or Right ventricular systolic dysfunction may be
present
• SAX LV in PHTN stays flattened, while RV volume overload rounds some in
systole.
Given tricuspid regurgitation with 60 mm Hg
gradient, grade the severity of pulmonary
hypertension
• Severe
Pulmonary artery pressure
• Normal = 18 – 30 mm Hg
• Mild = 30-40 mm Hg
• Moderate = 40-70 mm Hg
• Severe = >70 mm Hg
Your patient has PHTN with a dilated IVC (3cm)
which collapsed 50% with sniff. Estimate the RA
pressure.
• 15 mm Hg
• Hint: IVC= anything over 2 is dilated
The size of aneurysms during systole…
• Increases
The most common (mechanical) complication
of an MI…
• Aneurysm formation
Dressler syndrome
• Post MI Peri-Carditis
What type of MI causes papillary muscle
rupture?
• Inferior MI
Which of the following occurs first in the setting of
severe mitral regurgitation due to a flail leaflet?
• Dilated right ventricle
Know true vs. pseudo aneurysm
• True
•
•
•
Wide base
Walls composed of myocardium
Low risk of free rupture
• Pseudo
•
•
•
Narrow base
Walls composed of thrombus and pericardium
HIGH RISK OF FREE RUPTURE
The most common location for
Pseudoaneurysm:
• Inferior basal, NOT apical
Does the wall of a Pseudoaneurysm contain
endocardium?
• No
• It’s a rupture across both endo and myocardium
What information do you need pre-op in a
patient with a LV aneurysm?
• Movement of other walls
Color Doppler in ischemic disease can be good
for?
• Ventricular septal defect, because you can use PW & CW Doppler for
detecting MR
What do you look for in a patient with
Kawasaki disease?
• Coronary artery aneurysms
What term refers to a decrease in wall motion?
• hypokinesis
Akinesis
Dyskinesis
• Akinesis = no motion and no thickening of walls
• Dyskinesis = Left bundle block branch
What is the IVS motion in a patient with LBBB?
• Dyskinetic or paradoxical
From where do the coronaries originate?
• In the left and right aortic sinus of Valsalva
What is meant by “right Dominance”?
• When the right coronary gives rise to the posterior descending artery (85%
of the time).
Which coronary supplies the inter-atrial
septum?
• Right (also usually supplies the SA and AV nodes)
Which coronary artery feeds the infero-septal
wall?
• Right coronary artery
Know the indications for stress echo…
• To aid in the diagnosis of chest pain
• To determine the severity and prognosis of coronary artery disease
• To guide post MI rehab
• To evaluate cardiac arrhythmias
• To screen high risk or asymptomatic patients with multiple risk factors
Know that in multi-vessel disease, stress echo
is better than…
• Nuclear stress scans
• Single vessel disease: Nuclear medicine is better
• Multiple vessel disease: Echo stress is better
Normal response to stress includes all of the
following:
• Hyper-dynamic walls
• Systolic thickening
• Decreased systolic cavity
• Normal diastolic dimensions
What would be a contraindication to perform a
stress test on an athlete with chest pain?
• Unstable angina
Pharmacological Stress Echo:
• Know that Atropine may be given at peak does if the target hart rate is not
reached.
When the 2-D image appears to have three atria, it
might mean that the patient has a Cor Triatium
• This is a congenital malformation where there is a membrane above the
level of the mitral valve. In severe cases, there is supravalvular stenosis.
What is the most common type of Atrial Septal
Defect?
• Secundum (70%)
•
mid-septal area
Partial anomalous pulmonary venous return is
seen with what type of ASD?
• Sinus venosus
•
Superior septal area- associated with anomalous pulmonary venous return (80%)
Which is the best view to diagnosis a sinus
venosus ASD?
• Modified subcostal four chamber view
Best view to demonstrate an ASD?
• Subcostal 4-chamber
If you see anechoic dropout of the interatrial
septum in the apical 4 chamber view, what should
you do?
• Look in the subcostal 4-chamber view
What is the standard echo view for contrast
studies of an ASD?
• Apical 4-chamber
How many beats to see contrast on the left side in a
patient with an ASD?
With a pulmonary shunt?
• 1-2 beats for an ASD
• 3-5 beats for pulmonary shunt
Persistent Left Vena Cava has a dilated
coronary sinus
• Most common venous malformation
Where should contrast be injected in order to
diagnosis a persistent left superior vena cava?
• Left arm
Know endo-cardiac cushion defect (AV
septal)…
• Are associated with Down Syndrome or trisomy 21
Which is the most common type of VSD?
• Peri-membranous
Know Supra-cristal location
• High near the aortic and pulmonary valves
Know inlet location
• Subvalvular low near the mitral and tricuspid valves
The typical murmur of a ventricular septal defect.
It is usually best heard over the “tricuspid area”, or the lower left sternal border, with radiation to
the right lower sternal border because this is the area which overlies the defect. It is
characteristically a holosystolic murmur because the pressure difference between the ventricles
is generated almost instantly at the onset of systole, with a left to right shunt continuing
throughout ventricular contraction. If the defect persists without treatment, irreversible pulmonary
hypertension may develop with reversal of the shunt into a right to left flow pattern (Eisenmenger
syndrome). There is usually no diastolic component to the murmur, as the pressure between the
ventricles during diastole is not sufficiently different to generate an audible flow.
Because the flow pattern is usually left to right, the right ventricle suffers from volume
overload and takes longer to eject the stroke volume. This causes a slight delay in the closing of
the pulmonary valve, and a widely split S2 may result.
What congenital abnormality has a displaced
Tricuspid Valve?
• Ebstein’s
What is Wolff-Parkinson-White Syndrome?
• Wolff–Parkinson–White syndrome (WPW) is one of several disorders of
the conduction system of the heart that are commonly referred to as preexcitation syndromes. WPW is caused by the presence of an
abnormal accessory electrical conduction pathway between the atria and
the ventricles. Electrical signals traveling down this abnormal pathway
(known as the bundle of Kent) may stimulate the ventricles to contract
prematurely, resulting in a unique type of supra-ventricular
tachycardia referred to as an atrioventricular reciprocating tachycardia.
If a large PDA (patent ductus arteriosus) is not
corrected, what might develop?
• Eisenmenger Syndrome
All are Tetralogy of Fallot defects
• Large VSD
• Pulmonary stenosis
• Right ventricular hypertrophy
Regarding missiles:
• For foreign bodies: use x-rays for reference.
• Use off-axis views
What part of the heart is most likely to be
affected by cardiac contusion
• Right ventricle
Regarding Masses:
What might be the 1st indication of metastatic
cardiac disease?
• Pericardial effusion
Which cardiac chamber is most likely involved
with metastatic tumors?
• Right atrium
The most common benign tumor on the aortic
valve is:
• Papillary fibroelastoma
Left atrial myxomas are usually located…
• Interatrial septum