UNIT 3 RCM ECHO FEATURES

List the 7 main 2D echo features of restrictive cardiomyopathy.

• Biatrial enlargement

• Preserved wall thickness, although it may be mildly thickened to <13mm

• Preserved systolic function

• Small to normal LV cavity size

• Diffuse speckled or granular appearance of the myocardium

• Possible pericardial or pleural effusion

• Thickened valves

What myocardial appearance may be seen with amyloidosis?

A ground-glass appearance.

Simple reminder:
RCM usually has large atria, a small or normal LV, preserved EF, and abnormal stiff-looking myocardium.

List the 5 measurement categories that should be evaluated during an RCM echo.

• LV dimensions

• Diastology

• LA volume

• Right heart pressures

• Quantitative assessment of mitral regurgitation

List the 3 main abnormal variables used to assess LV diastolic function and estimate LAP.

• Reduced e′ velocity

• Increased E/e′ ratio

• Increased TR velocity or PASP

What values indicate reduced e′ velocity?

• Septal e′ ≤6 cm/s

• Lateral e′ ≤7 cm/s

• Average e′ ≤6.5 cm/s

What values indicate an increased E/e′ ratio?

• Septal E/e′ ≥15

• Lateral E/e′ ≥13

• Average E/e′ ≥14

What TR velocity or PASP indicates an abnormal value?

• TR velocity ≥2.8 m/s

• PASP ≥35 mmHg

If all 3 variables are normal, what is the estimated LAP?

Normal LAP.

If all 3 variables are abnormal, what is the estimated LAP?

Increased LAP.

How are Grade II and Grade III diastolic dysfunction separated once LAP is elevated?

• E/A <2 = Grade II

• E/A ≥2 = Grade III

List the 5 diastolic findings associated with restrictive cardiomyopathy.

whats the grade?

E/A Ratio

DT, IVRT, e’, E/e’

• Elevated filling pressures with Grade II or greater diastolic dysfunction

• E/A ratio >2, indicating Grade 3 dysfunction ( E wave increased A reduced resistrictive pattern)

• Short deceleration time, <150 ms (reduced compliance, imparied relaxtion) high LA pressure acclerate early filling but ends prematurely, steeper E wave DT)

• Short IVRT, <60 ms

• e′ <7 cm/s (both septal and lateral walls e ‘ reduced) the restriction and the inability for the heart to relax = reduced e ‘ velocity, LV stiffeness causes a rapid raise in the early diastolic pressure which leads to early stopping of th early filling

• E/e′ >14 (elavted filling pressures*)

• (short steep e wave DT, LV stiffeness causes raise in filling pressureleads to early stopping of filling, filling pressure increase - grade 2 or higher)

Simple reminder:
Restrictive filling = large E wave, small A wave, short DT, short IVRT, low e′, and high E/e′.

Short DT <150 ms (Deceleration Time): Indicates very stiff, non-compliant heart muscle. Because the ventricle is so rigid, pressure equalizes extremely fast between the left atrium and left ventricle during early filling, causing blood to decelerate rapidly.

Short IVRT <60 ms (Isovolumic Relaxation Time): Signals that the ventricle's ability to relax is severely impaired and filling pressures inside the left atrium are dangerously high. The pressure gradient is so high that the mitral valve is forced to open much earlier than normal.

Normally, the LV relaxes and stretches open, so blood flows from the LA into the LV at a steady rate, Because the LV is flexible, the pressure inside it rises slowly. That gives a longer, more gradual deceleration time.

RCM =The LA pushes blood into the LV very quickly at the beginning of diastole because the LA pressure is high.

But the LV is stiff, so it fills only briefly and then stops quickly.

High LA pressure → fast early filling into LV → stiff LV reaches its limit fast → short deceleration time

List the 3 pulmonary vein Doppler findings associated with RCM.

1. Progression to a dominant _____pattern

2. S/D ratio = what

3. Has a prominent what velocity & talk about the duration

1. Progression to a dominant diastolic pattern

2. S/D ratio <0.5 S < D

3. Prominent atrial reversal velocity with an atrial A duration > mitral

   inflow A duration

Simple reminder:
High LA pressure causes the pulmonary vein D wave to dominate and increases atrial reversal.

• Prominent Atrial Reversal Velocity: High retrograde flow (often > 35 cm/s) going backward into the pulmonary veins.

• Duration Comparison (Ar - A): The pulmonary venous atrial reversal (Ar) duration is greater than the mitral inflow A-wave duration. When the Ar wave lasts at least 30 ms longer than the mitral A wave, it is a highly sensitive and specific indicator that LVEDP exceeds 15-20 mmHg.

A "Prominent atrial reversal velocity with an atrial A duration > mitral inflow A duration" indicates severely elevated left ventricular end-diastolic pressure (LVEDP). It signifies a stiff, non-compliant heart muscle, pointing toward an advanced, restrictive filling pattern.

When the echo report says the backward flow lasts longer than the forward flow, it means the bottom chamber is very stiff. It is fighting back against the blood trying to enter, causing high pressure to back up into your system.

Differential Diagnosis for Pulmonary veins list 4

Normal at young age ( < 40 years old)

High LA pressure at older age

AFIB

Moderate to severe MR

RCM

(High LVEDP, short pr interval, intra - atrial conduction delay)

List the 2 main right-heart findings in RCM.

• RA enlargement

• TR is usually present because of biatrial enlargement

List the 4 measurements used to quantify MR severity.

• EROA

• Regurgitant volume

• Regurgitant fraction

• Vena contracta

List the 4 values that indicate mild MR.

• EROA <0.20 cm²

• Regurgitant volume <30 mL

• Regurgitant fraction <30%

• Vena contracta <0.3 cm

List the 4 values that indicate moderate MR.

• EROA 0.20–0.29 cm²

• Regurgitant volume 30–44 mL

• Regurgitant fraction 30–39%

• Vena contracta 0.3–0.7 cm

List the 4 values that indicate moderate-to-severe MR.

• EROA 0.30–0.39 cm²

• Regurgitant volume 45–59 mL

• Regurgitant fraction 40–49%

• Vena contracta 0.3–0.7 cm

List the 4 values that indicate severe MR.

• EROA ≥0.40 cm²

• Regurgitant volume ≥60 mL

• Regurgitant fraction ≥50%

• Vena contracta ≥0.7 cm

what is the Continuity Equation for MR

MV stroke volume = MV CSA × MV VTI

LVOT stroke volume = LVOT CSA × LVOT VTI

Regurgitant volume = MV stroke volume − LVOT stroke volume

Regurgitant fraction = MR regurgitant volume ÷ MV stroke volume

EROA = MR regurgitant volume ÷ MR VTI

what is the PISA for MR

PISA flow rate = 2πr² × aliasing velocity

PISA EROA = PISA flow rate ÷ peak MR velocity

Regurgitant volume = EROA × MR VTI

List the 4 M-mode features of RCM. key findings

• Biatrial enlargement

• Normal or small LV cavity size

• Normal or increased LV wall thickness

• Pleural or pericardial effusion

PRACTICE

A calculated MR regurgitant volume is 45 mL. How is the MR graded?

Moderate-to-severe MR, because a regurgitant volume of 45–59 mL is moderate-to-severe.

PRACTICE

Interpret the following diastolic measurements: E/A 1.1, E/e′ 34.8, LAVI 52 mL/m², and TR peak velocity 2.7 m/s.

• E/e′ of 34.8 is severely elevated and indicates increased filling pressure.

• LAVI of 52 mL/m² is severely enlarged.

• TR velocity of 2.7 m/s is below the 2.8 m/s abnormal cutoff.

• The overall findings support elevated LAP and significant diastolic dysfunction, even though the E/A ratio is not above 2.

PRACTICE

Interpret an MR PISA regurgitant volume of 70 mL and EROA of 0.5 cm².

Both values indicate severe mitral regurgitation because:

• Regurgitant volume is ≥60 mL

• EROA is ≥0.40 cm²

PRACTICE

Interpret the following measurements: E/A 2.07, E/e′ 31, LAVI 86 mL/m², and TR peak velocity 3.3 m/s.

• E/A 2.07 indicates Grade III restrictive diastolic dysfunction.

• E/e′ 31 indicates markedly elevated filling pressure.

• LAVI 86 mL/m² indicates severe LA enlargement.

• TR velocity 3.3 m/s indicates elevated pulmonary pressure.

These findings support advanced restrictive physiology with markedly elevated LAP and pulmonary hypertension.

PRACTICE

What does a TR peak velocity of 3.3 m/s indicate?

It is above the 2.8 m/s abnormal cutoff and supports elevated right-heart or pulmonary artery pressure.

List the 10 major echo findings that support restrictive cardiomyopathy.

Biatrial enlargement

Small to normal LV cavity

Normal or mildly increased LV wall thickness

Preserved systolic function early

Speckled or granular myocardium

Grade II or III diastolic dysfunction

E/A ratio >2 in Grade III

Short DT and IVRT

Low e′ and elevated E/e′

Pulmonary hypertension, TR, and possible pleural or pericardial effusion