REGISTRY

Which valve separates the areas of greatest pressure diffrences?

Mitral

What valve separates the areas of lowest pressure diffrences?

Pulmonnic

Which aortic leaflet is the superior one in the PLAX veiw?

Right leaflet

From the left parasternal window which of the following are you most likely to get accurate velocity measurements?

Pulmonary artery

Name the tricuspid leaflets in RV inflow tract

posterior and anterior

Where is the LAA on TTE?

Sometimes in the parasternal SAX Ao valve level (better seen in the apical 2ch)

The coronary arteries come off the __

Sinuses of Valsalva

During which phase do the coronaries fill?

Early diastole

What is the normal measurement for TAPSE

≥ 1.7cm

The best images of the ascending aorta are often obtained from which transducer window?

Suprasternal

Name the vessels coming off the Ao arch from most proximal to distal

innominate, left carotid and left subclavian

What cardiac pathology is associated with bicuspid aortic valves?

Coarctation of the aorta

Which window do you use to look for the secondary finding in bicuspid valves?

suprasternal arch

Where do most aortic coarctations occur?

The aortic isthmus (after the takeoff of the left subclavian artery)

Where are the pulmonary veins located? Which ones are seen in the Apical 4CH view?

Left atrium

Right and left lower (inferior) pulmonary veins

From the apical 4CH veiw how do you rotate the transducer to obtain the apical LAX? (3ch)

counterclockwise 120

Where is the coronary sinus located?

Posterior AV groove

Which view do you use to evaluate the coronary sinus?

PLAX

To visualize the coronary sinus in the apical 4CH view you should tilt the transducer

Posterior

Which valve sits at the opening of the coronary sinus?

Thebesian

Where is the Chiari Network located?

Right atrium

What portion of the pulmonary venous PW doppler represents atrial systole?

A wave

Conditions suited for TEE

Prosthetic valves, Ao dissection, Endocarditis, ? Intracardiac source of embolus (SOE), difficult to image from chest wall, ect.

What temperature is it unsafe to use a TEE probe?

40-45 ℃

What 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 “reative refractory period” is during phase 3 and the muscle cell might contract if the stimulus is strong

What does the P wave on the QRS complex mean?

Atrial systole

What is the normal duration for the QRS complex?

0.10 sec

What does the P-R interval on the QRS complex mean?

From atrial to ventricular depolarization

What does the T wave on the QRS complex mean?

Ventricular diastole (repolarization)

What does the QRS mean on the QRS complex mean?

Ventricular systole

What is the Frank-Starling law?

(length - tension relationship)

Increased volume (preload) = increased contractility (to a physiologic limit)

Increased myocardial fiber length = increased tension (rubber band theory)

The greater the load the greater the force of contraction

What is preload?

Load (volume) exerted on the ventricle at end diastole

Determines the force of contraction

The greater the load the greater the force of contraction (Frank-Starling Law)

Causes of increased preload

MR, TR, Pulmonic regurgitation, Aortic regurgitation, Ventricular and atrial septal defects, fluid overload

Echo findings for preload vs afterload

preload = dialation

afterload = hypertrophy

What is afterload?

Resistance against which the ventricle must pump.

Determines the tension of the myocardium must generate

Causes of increased afterload

Hypertension, Aortic stenosis, Pulmonic stenosis

Which study does not allow for the calculation of EF

Chest x-ray

How do you eliminate aliasing on PW spectral doppler?

Switch to CW doppler

What does VTI x CSA equal?

Doppler stroke volume

What is VTI

The velocity time intergral; represents how far the blood travels in centimeters with each ejection.

Normally 12cm for the mitral and 20cm for the aortic

Does venous return increase or decrease with insperation

Increase

Does venous return increase or decrease with expiration

decrease

Inhalation of amyl nitrate causes

Decreased afterload

Mitral valve velocity during inspiration

decreases

Does standing increase or decrease venous return?

decrease

Does squatting increase or decrease venous return?

Increases ; also increases SV & CO (Increases AR, decreases IHSS)

Handgrip maneuver

Increases HR, CO, arterial pressure (decreases AS, increases MR)

Valsalva maneuver

2 main phases strain and release

**Strain - decreases venous return, SV, and CO (most murmurs decrease during straining, IHSS increases)

Release- increase venous return, CO, BP

What is the duration of IVRT and IVCT

70 msec

During the cardiac cycle this NEVER happens

Ao valve is open and mitral valve is open

On the wiggers diagram when is the MV open??

4-1

The duration of IVRT will be increased with

bradycardia

When is the LV and LA volumes the highest?

LV= end-diastole

LA= end-systole

What is the normal arterial pressure

120/80 mmHg

What is the normal LA pressure?

10 mmHg

Arteries

Elastic, thick walled blood vessels

Expand during systole then recoil during diastole to keep blood moving forward

Veins

Thin walled blood vessels that collapse easily

Able to expand rapidly to accommodate large volumes of blood

Contain the majority of circulating blood

What are normal pressures in the pulmonary artery?

25/10

Where is the O2 saturation the lowest?

Coronary sinus

What is the O2 saturation for the pulm. veins __ arteries?

Pulmonary veins → 95%

Pulmonary arteries → 75%

Best cath technique for LV function

LV angiogram

What is PCW (Pulmonary Capillary Wedge) measuring?

LA pressure

To determine AS where are 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 sepreate sensors

Does tissue harmonic imaging result in thicker or thinner valve leaflets?

Thicker

Apical swirling of echo contrast for LVO is caused by

High MI

Sonographers should do peer to peer reviews how often for quality/technical review?

2 times per month

Whose responsibility is it to obtain the informed consent prior to a TEE

Physician

A secondary finding in Ao stenosis is

Left ventricular hypertrophy

In Ao 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)

Bicuspid AoV

Possible eccentric closure on M-mode (25% will have normal midline closure)

Thickend AO leaflets (may be mild)

Ststolic doming in LAX veiw

Bicuspid orifice in SAX view (football)

Check for coexisting coarctation of the AO

post-stenotic dialation of the AO

LV hypertrophy

The best view to diagnosis a bicuspid Aov is the parasternal

Short axis systole

What is a common symptom of aortic coarctation

Systemic hypertension

Best veiw for detecting subvalvular membranes?

5CH

What is Takayasu’s arteries

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 supravalvular AS)

Patients BP= 110/84. AO velocity is 5m//sec. Peak LV pressure in this patient is??

210 mmHg

Add the Ao gradient (100 mmHg if the velocity is 5 m/sec) to the ststolic BP.

The normal aortic valve area is

3-4 cm²

Using the continuity equation when would the severity of AS be underestimated?

LVOT measured too large

What is the area for a severly stenotic AO valve

<1.0 cm²

AoV dimensionless index

Ratio of the LVOT and AS velocities or VTI. When the LVOT cannot be accurately measured, or in the setting of LV dysfunction, using this ratio may help calculate the sevirity of AS.

DI= LVOT vel (VTI) / AS vel (VTI)

Mild = >0.50 ; Moderate = 0.25-0.50 ; Severe = <0.25

Which pressure is obtained during Doppler?

Peak or peak instantaneous (for AS its the highest gradient anytime during systole)

Know that echo gradients are usually higher than cath gradients

Peak instantaneous versus peak-to-peak

Noonan Syndrome

Classified as a cardiofacial syndrome with PS, HCM, and ASD (30%)

Pulmonic stenois

Etiology- Congenital (most common), Rheumatic (rare), Carcinoid, Peripheral (PPS-junction of the R & L PAs), Infundibular (subvalvular), Prosthetic valve dysfunction

Does PS cause pulmonary hypertension?

NO

Echo findings of PS

M-mode may show an increase in the pulmonic “a” dip of more than 7mm (Usuful for severe PS only)

Valvular thickening and systolic doming(2-D)

Right ventricular hypertrophy

Post-stenotic dialation of the pulmonary artery (PA)

Narrowing of RVOT in infundibular PS (subvalvular in RVOT)

Physical signs of pulmonic stenosis

Dyspnea on exertion, sysolic ejection murmur left upper sternal border, pulmonary ejection sound, decreased/delayed p2, Increased A wave or jugular venous pulsation, Sustained RV impulse at mid -lower left sternal border

Pathophysiology of Pulmonic Stenois

Systolic pressure overload leads to RVH, regional hypertrophy may lead to infundibular stenois, commonly associated with other congenital malformations (VSDs,ASDs, TET), RV chamber usually normal, RA will enlarge, Increased risk for endocarditis

Asked if unable to obtain PS gradient from the parasternal window where else can you go?

Subcoastal short-axis

AHA/ACC guidelines for pulmonary stenosis sevirity

Peak velocity (m/s) → Mild = <3.0 ; moderate = 3.0-4.0 ; Severe = >4.0

Peak gradient (mmHg) → Mild = <36 ; Moderate = 36-64 ; Severe = >64

Mitral stenosis Etiology

Rheumatic (commissarial fusion) (most common) , Congenital (rare) , Acquired (Mitral annular calcification- MAC) , Prosthetic valve dysfunction

Mitral stenosis Pathophysiology

Diffuse leaflet thickening, scarring, contraction, commissural fusion and chordae shortining and fusion.

Associated MR may be present

Increased LA pressure causing dialation

Long standing obstruction leads to pulmonary hypertenstion (RV & RA enlargment)

Decrease in CO

Acute rheumatic fever: beta-hemolytic strep, polyarthritis, fever, subcutaneous nodules, carditis and rash (45% develope MS)

Increased risk for endocarditis

Which cardiac valve is the second most common to be affected by rheumatic heart disease?

Aoritc

Patients with mitral stenosis often develop

Atrial fibrillation (because the LA enlarges and destroys node tracks)

AHA/ACC guidlines for mitral stenosis severity

MVA (cm²) → Mild = >1.5 ; Moderate = 1.0-1.5 ; severe = <1.0

supportive findings

Mean gradient (mmHg) → Mild = <5 ; Moderate = 5-10 ; Severe = >10

Pulm. Artery pressure (mmHg) → Mild = <30 ; Moderate = 30-50 ; Severe = >50

With atrial fibrillation mitral stenois velocity calculations are best performed

averaged over 5-10 beats

In the PSAX view which method is used to asses the MV area?

Planimetry

Normal Mitral valve area?

4-5 cm² (Severe = <1cm²)

Given a mitral pressure half-time of 400 msec what would the area be?

0.5 cm²