Test 3 - Echo

Minimal/Trivial TR

normal variant of TR, 80-90% of population has this

Proper leaflet motion

What are you looking for in a 2D eval of the TV

Tricuspid regurgitation

What are you looking for when evaluating the TV with Color Doppler

A4C, sample at tips, measure e’,a’, and deceleration time

Describe evaluating the TV using PW

Regurgitation and stenosis; peak velocity, peak gradient, mean gradient, VTI, PHT

What are you looking for when evaluating the TV using CW + what do you measure

Functional regurgitation

Any regurgitation caused by anything other than the leaflet, occurs in 75% of cases

RV abnormalities, LV HD, pulmonary HTN, annulus abnormalities

What can cause functional regurgitation

Structural TR

Any TR caused by the valves

Rheumatic, prolapse, congenital

What can cause structural TR

Jet area, vena contracta, CW shape&density, PISA, and hepatic vein flow

What do you look at when grading the severity of TR

Flow reversal

If there is severe TR, what happens to the hepatic vein

Weak tracing, parabolic shape

In CW, how will a mild TR appear

Dense tracing, triangular shape, max TR decreases as RAP increases

In CW, how will severe TR look

Tricuspid stenosis

Least common stenosis valulopathy

Rheumatic, congenital (Epstein), carcinoid HD, ra tumor

Causes of TS

Carcinoid heart disease

Thick rigid leaflets which appear frozen

SV/ VTI^tri

Continuity equation for TVA

TVA = 190/PHT

Calculate TVA using PHT

<1 m/s

Normal peak systolic velocity for TV

<2mmHg

Normal mean gradient for TV

7-9cm²

Normal TVA

RVOT in PLAX and PSAX basal

Standard views to image the PV, always color and CW trace VTI

Mild to Moderate

What grade of PR is this

Severe PR

What grade of PR is this

Carcinoid disease and post surgical repair of pulmonic stenosis

What are the two most common causes of Pulmonary Regurgitation

The steeper the slope, the more severe the PR

How does slope seen on CW indicate pulmonic regurgitation

Congenital

95% of PV stenosis is ___

Double outlet RV, Tetrology of Fallot

Congenital causes of PV stenosis

PV <3 and PG <36

PV peak velocity and peak gradient MILD values

PV 3-4 PG 26-64

PV peak velocity and peak gradient MODERATE values

PV >4 PG >64

PV peak velocity and peak gradient SEVERE values

Full opening and closing

What is M-Mode looking for when evaluating the mitral valve

Below

In PSAX MR is seen ____ the anterior leaflet of the MV

Above

In PSAX AI is seen ____ the anterior leaflet of the MV

A4C, sample placed at the tips of open MV leaflets

Describe how to properly evaluate the MV using PW

Peak e’ , peak a’, diastolic deceleration time

What do you measure with PW when evaluating the MV

A4C, sample through a jet

describe how to use CW to evaluate the MV

Trace deceleration time, peak velocity, peak gradient, mean gradient, VTI

What do you measure if stenosis is identified through the MV using CW

If the MV appears abnormal, prosthetic, or has been repaired

When should you measure PHT if there is stenosis in the MV

Trace the backflow on spectral, peak velocity, peak gradient, VTI

What do you measure if regurgitation is seen in the MV using CW

Trace perimeter of leaflet tips at largest opening, measure deceleration, continuity equation, PICA

Ways to evaluate/calculate MVA

4-6 cm²

What is normal MCA size

Mitral stenosis

Obstruction of flow from the LA to LV because of MV narrowing

Rheumatic heart disease, calcification, endocarditis, lupus

List four causes of MS

Rheumatic MS

Most predominant cause of MS

Rheumatic MS

MS described by leaflet thickening and calcification starting at the tips and growing in, causes commissural fusion

Opening snap murmur, malar flush, hemoptysis, chest pain, fatigue, tachy

Signs and symptoms of Rheumatic MS

Malar flush

Plum red cheeks due to CO2 retention

Hemoptysis

Coughing up blood

Pulmonary edema and HTN, LAE, MR, increase risk for LA thrombus

List consequences of MS

Commissurotomy, balloon valvuloplasty, MV replacement, medications

List four treatments for MS

Commissurotomy

Procedure where the valve fusion is snipped

Balloon valvuloplasty

Balloon is inserted with a catheter to expand the valve

Anterior leaflet doming, RMS

What is the hockey stick sign and what pathology is it related to

Leaflet thickening, fish mouth appearance, hockey stick sign, chordal thickening

ECHO findings of RMS

Mitral Annular Calcification (MAC)

MC non rheumatic MS

Mitral Annular Calcification (MAC)

Calcium deposits in the mitral valve annulus

Reduces annular dilation, impaired mobility, calcifications on both leaflets

How does MAC affect the leaflets

MAC does not cause commissural fusion

What is one way to differentiate MAC from RMS

Cor Triatrium

Rare anomaly where a fibrous membrane divides the LA into two chambers

Flail Leaflet

Free movement of the leaflet into the LA, caused by ruptured chordae or papillary

Mitral Regurgitation

Retrograde flow from the LV to the LA through an incompetent MV

MV prolapse, flail MV, ischemic HD, RHD, Marfan’s

List 5 causes of MR

Fatigue, dyspnea, and dyspnea on exertion*

Signs and symptoms of MR

LAE, increase LA pressure, Pulmonary HTN, CHF

Complications of MR

Reduce amount of regurg

What is the goal of MR treatment

Mitraclip, surgical repair, MV replacement

Three treatments of MR

MV prolapse

Bulging of MV leaflets into LA during systole

leaflets bulge into LA in systole

What creates the systolic click sound associated with MV prolapse

Flail MV, Marfan’s, flail chordae or paps

Causes of MV prolapse

LAE, increased endocarditis, thrombus caused by afib

Complications of MV prolapse

S wave flip, D wave > S wave

PW sign of severe MR

EROA, Doppler-volumetric method, SV method

Quantitative ways to evaluate for MR

220/PHT

Formula for calculating the MVA using PHT

Hockey stick sign, RMS

What is this image showing

AI is above and MR is below

Which is MR and which is AI

3, Mercedes Bens

The AV has __ cusps and appears as the “____” sign when closed

2

How many coronary arteries arise off the AV cusps

Normal, Rhematic, Calcification, Bicuspid

Label the different AV appearances

Bicuspid AV

Mc congenital abnormality of the AV

Bicuspid AV

Mc cause of isolated AO stenosis in patients under 50

85

AO stenosis occurs in __% of all BAV cases

Non centered valves, systolic doming, oval valves

ECHO features of Bicuspid AV

AO dilation, aneurysm, disection, coartation

Abnormalities associated with bicuspid valves

Stenosis, regurgitation, AO dilation

Complications of bicuspid AV

Unicuspid AV

AV that appears stenosis at birth

Unicuspid AV

AV with one attachment point, solitary opening

Quadricuspid AV

AV that appears like an x on PSAX

Aliasing

What are you looking for in color Doppler at the AV

Peak velocity and VTI, spectral signal (rapid upstroke and ED click

PW eval of the AV measure…

Aortic insufficiency (peak velocity and pressure Half time)

CW eval of the AV look for…

Plaimetry of AV Orfice

Tracing AV in systole to look for calcified AO stenosis

Continuity equation

equation which determines AVA

(CSA lvot x VTI lvot) / VTIav

How do you calculate the AVA

AVA x VTIav = CSA lvot x VTI lvot

Continuity equation

Volume flow rate should be constant throughout the body

What does the continuity equation tell us

Inaccurate LVOT measurement, irregular rhythm, sub AO obstruction, inaccurate sampling

Pitfalls that can affect the continuity equation

Pi x (D/2)²

CSA lvot equation

V lvot / V av

Velocity ratio equation

If there is low EF

When is the velocity ratio used instead of the continuity equation