echocardiography and hemodynamics review echo ii
DESCRIPTION
ECHOCARDIOGRAPHY AND HEMODYNAMICS REVIEW ECHO II. Susan A. Raaymakers , MPAS, PA-C, RDCS (AE,PE) Coordinator of Radiologic and Imaging Sciences - Echocardiography Grand Valley State University, Grand Rapids, Michigan [email protected]. Anatomy. Right Atrium SVC, CS, IVC Smooth walled - PowerPoint PPT PresentationTRANSCRIPT
ECHOCARDIOGRAPHY ECHOCARDIOGRAPHY AND HEMODYNAMICS AND HEMODYNAMICS
REVIEWREVIEW
ECHO IIECHO II
Susan A. Raaymakers, MPAS, PA-C, RDCS (AE,PE)Susan A. Raaymakers, MPAS, PA-C, RDCS (AE,PE)Coordinator of Radiologic and Imaging Sciences - Coordinator of Radiologic and Imaging Sciences -
EchocardiographyEchocardiographyGrand Valley State University, Grand Rapids, MichiganGrand Valley State University, Grand Rapids, Michigan
AnatomyAnatomy
Right AtriumRight Atrium SVC, CS, IVCSVC, CS, IVC Smooth walledSmooth walled Derived from embryonic right atrium Derived from embryonic right atrium
called the sinus venosus called the sinus venosus Right atrial appendageRight atrial appendage Sulcus terminalisSulcus terminalis
Posterior external ridge that extends Posterior external ridge that extends vertically from the SVC to the inferior vena vertically from the SVC to the inferior vena cavacava
Pectinate musclesPectinate muscles
Name this complication of Name this complication of coronary artery diseasecoronary artery disease
acute inferoseptal and inferior myocardial acute inferoseptal and inferior myocardial infarction resulting in ventricular septal infarction resulting in ventricular septal defectdefect
3. ______
1. ______
2. ______
Name the Wall Segments AND Name the Wall Segments AND Typical Perfusing Coronary Typical Perfusing Coronary
ArteryArtery Apical Cap
LAD
Name the Wall Segments AND Name the Wall Segments AND Typical Perfusing Coronary Typical Perfusing Coronary
ArteryArteryBasal Anteroseptum
LAD
Name the Wall Segments AND Name the Wall Segments AND Typical Perfusing Coronary Typical Perfusing Coronary
ArteryArtery Apical Cap
LAD
Name the Wall Segments AND Name the Wall Segments AND Typical Perfusing Coronary Typical Perfusing Coronary
ArteryArtery
Mid Anteroseptum
LAD
Name the Wall Segments AND Name the Wall Segments AND Typical Perfusing Coronary Typical Perfusing Coronary
ArteryArtery
Basal Anteroseptum
LAD
1. _________
2. _________
3. ________
What is this complication of What is this complication of myocardial infarction called? myocardial infarction called?
When does it occur?When does it occur? Dressler’s Dressler’s
Syndrome: Syndrome: delayed form of delayed form of pericarditis: an pericarditis: an immunologic immunologic reactionreaction
Occurs one to 12 Occurs one to 12 weeks post MIweeks post MI
Symptoms: fever, Symptoms: fever, pleuropericaridial pleuropericaridial pain, malaisepain, malaise
Cardiac Cardiac tamponade is raretamponade is rare
What is polyarteritis?What is polyarteritis?
(Also called (Also called Kussmaul's diseaseKussmaul's disease, , periarteritis periarteritis nodosa)nodosa)
Systemic inflammation and necrosis Systemic inflammation and necrosis occurring in medium-sized or small arteries.occurring in medium-sized or small arteries.
Kidneys, heart, liver, GI tract, pancreas, Kidneys, heart, liver, GI tract, pancreas, testes, skeletal muscular system, central testes, skeletal muscular system, central nervous system (CNS), and skin are involved.nervous system (CNS), and skin are involved.
1. _________
2. _________
3. _________
Ischemia results in narrow of Ischemia results in narrow of __________ percentage of luminal __________ percentage of luminal cross sectional area. This causes cross sectional area. This causes blood flow to become inadequate to blood flow to become inadequate to meet demand with exercise, mental meet demand with exercise, mental stress or pharmacologic stress or pharmacologic interventions.interventions.
>70%
T/F This spectral Doppler image of T/F This spectral Doppler image of mitral regurgitation is consistent with mitral regurgitation is consistent with a reduced dP/dt and is consistent with a reduced dP/dt and is consistent with increased left ventricular end-diastolic increased left ventricular end-diastolic
pressure.pressure.
True.
The MR is quickly leaving the LV causing the LA to quickly increase in pressure.
Name four risk factors for Name four risk factors for coronary artery disease.coronary artery disease.
Increased LDLIncreased LDL SmokingSmoking DiabetesDiabetes HypertensionHypertension Genetics (hereditary)Genetics (hereditary) Type “A” personalitiesType “A” personalities AgingAging ObesityObesity Sedentary lifestyleSedentary lifestyle Chronic stressChronic stress
Name this complication of Name this complication of coronary artery diseasecoronary artery disease
Portion of papillary muscle seen in Portion of papillary muscle seen in transesophageal echocardiogramtransesophageal echocardiogram
Put the following in Put the following in order.order.
Ischemic CascadeIschemic Cascade
A.A. Chest PainChest Pain
B.B. EKG changesEKG changes
C.C. Perfusion defectsPerfusion defects
D.D. Wall motion abnormalitiesWall motion abnormalities
E.E. Diastolic dysfunctionDiastolic dysfunction
C, E, D, B, A
What is the term used for a What is the term used for a myocardium that does not contract myocardium that does not contract
normally due to a brief period of normally due to a brief period of ischemia following by a gradual return ischemia following by a gradual return
of contraction due to reperfusion?of contraction due to reperfusion?
StunningStunning HybernationHybernation
An acute myocardial infarction An acute myocardial infarction on an ECG may be indicated on an ECG may be indicated
by:by:A.A. Elevated ST segmentElevated ST segment
B.B. Depressed ST segmentDepressed ST segment
C.C. Tall T wavesTall T waves
D.D. Enlarged P wavesEnlarged P waves
E.E. Tall Q wavesTall Q waves
An acute myocardial infarction An acute myocardial infarction on an ECG may be indicated on an ECG may be indicated
by:by:A.A. Elevated ST segmentElevated ST segment B.B. Depressed ST segmentDepressed ST segmentC.C. Tall T wavesTall T wavesD.D. Enlarged P wavesEnlarged P wavesE.E. Tall Q wavesTall Q waves
ST-T segment changes: ST-T segment changes: Depressed ST-segments suggest ischemiaDepressed ST-segments suggest ischemia Elevated ST-segments suggest acute myocardial Elevated ST-segments suggest acute myocardial
infarctioninfarction
What is the leading cause What is the leading cause of coronary artery disease?of coronary artery disease?
A.A. Old ageOld age
B.B. HeredityHeredity
C.C. ObesityObesity
D.D. Diabetes mellitusDiabetes mellitus
E.E. AtherosclerosisAtherosclerosis
What is the leading cause What is the leading cause of coronary artery disease?of coronary artery disease?
A.A. Old ageOld age
B.B. HeredityHeredity
C.C. ObesityObesity
D.D. Diabetes mellitusDiabetes mellitus
E.E. AtherosclerosisAtherosclerosis
Although aneurysm formation may Although aneurysm formation may occur in any part of the ventricle, occur in any part of the ventricle,
what is the most common site what is the most common site visualized 2D?visualized 2D?
A.A. Anterior left ventricle and apexAnterior left ventricle and apex
B.B. Posterior left ventricular wallPosterior left ventricular wall
C.C. Right ventricular apexRight ventricular apex
D.D. Basal portion of the left ventricleBasal portion of the left ventricle
E.E. Lateral left ventricular wallLateral left ventricular wall
Although aneurysm formation may Although aneurysm formation may occur in any part of the ventricle, occur in any part of the ventricle,
what is the most common site what is the most common site visualized 2D?visualized 2D?
A.A. Anterior left ventricle and apexAnterior left ventricle and apexB.B. Posterior left ventricular wallPosterior left ventricular wallC.C. Right ventricular apexRight ventricular apexD.D. Basal portion of the left ventricleBasal portion of the left ventricleE.E. Lateral left ventricular wallLateral left ventricular wall
After acute MI, 15% to 20% of patients develop After acute MI, 15% to 20% of patients develop LV aneurysm. Look for thrombus within LV aneurysm. Look for thrombus within aneurysm and patients often have persistent aneurysm and patients often have persistent ST wave elevationST wave elevation
What is the term for systolic What is the term for systolic expansion of a segment that is expansion of a segment that is thin and moves paradoxically thin and moves paradoxically compared to the surrounding compared to the surrounding
myocardium?myocardium?A.A. HyopkinesisHyopkinesis
B.B. AkinesisAkinesis
C.C. DyskinesisDyskinesis
D.D. HyperkinesisHyperkinesis
E.E. Paradoxical Paradoxical
What is the term for systolic expansion What is the term for systolic expansion of a segment that is thin and moves of a segment that is thin and moves
paradoxically compared to the paradoxically compared to the surrounding myocardium?surrounding myocardium?
A.A. HyopkinesisHyopkinesisB.B. AkinesisAkinesisC.C. DyskinesisDyskinesisD.D. HyperkinesisHyperkinesisE.E. Paradoxical Paradoxical
You will hear both dyskinesis and You will hear both dyskinesis and paradoxical. You will also hear dyskinetic paradoxical. You will also hear dyskinetic as a term referring to abnormal. For as a term referring to abnormal. For board exam purposes use dyskinetic.board exam purposes use dyskinetic.
Name this complication of Name this complication of coronary artery diseasecoronary artery disease
Basal inferior aneurysmBasal inferior aneurysm
Which of the following mitral Which of the following mitral valve M-mode findings might be valve M-mode findings might be
visualized when LV dysfunction is visualized when LV dysfunction is present?present?
A.A. Increased E point/septal separation with Increased E point/septal separation with abnormal fractional shorteningabnormal fractional shortening
B.B. Decreased amplitude decreased E point Decreased amplitude decreased E point septal separation with normal fractional septal separation with normal fractional shorteningshortening
C.C. A point less than E pointA point less than E pointD.D. Ejection fraction of 65%Ejection fraction of 65%E.E. Fraction thickening of 10%Fraction thickening of 10%
Which of the following mitral Which of the following mitral valve M-mode findings might be valve M-mode findings might be
visualized when LV dysfunction is visualized when LV dysfunction is present?present?
A.A. Increased E point/septal separation with Increased E point/septal separation with abnormal fractional shorteningabnormal fractional shortening
B.B. Decreased amplitude decreased E point Decreased amplitude decreased E point septal separation with normal fractional septal separation with normal fractional shorteningshortening
C.C. A point less than E pointA point less than E pointD.D. Ejection fraction of 65%Ejection fraction of 65%E.E. Fraction thickening of 10%Fraction thickening of 10%
T/F Myocardial rupture with acute T/F Myocardial rupture with acute electromechanical dissociation, electromechanical dissociation,
hypotension and shock is usually hypotension and shock is usually fatal.fatal.
TrueTrue
Name this complication of Name this complication of coronary artery disease.coronary artery disease.
Large apical aneurysmLarge apical aneurysm
Name this complication of Name this complication of coronary artery diseasecoronary artery disease
Basal inferior aneurysm with Basal inferior aneurysm with thrombus formationthrombus formation
Please describe this Please describe this image.image.
Right ventricular infarctionRight ventricular infarction
Please describe this dynamic Please describe this dynamic image.image.
Akinesis of anterior septum due to acute Akinesis of anterior septum due to acute left anterior descending coronary artery left anterior descending coronary artery occlusionocclusion..
Please describe this dynamic Please describe this dynamic image.image.
Normal thickening and motion of the Normal thickening and motion of the myocardiummyocardium
You are asked to perform an You are asked to perform an echocardiogram due to a friction echocardiogram due to a friction
rub. What is a friction rub?rub. What is a friction rub? Patients with pericarditis, an inflammation of the Patients with pericarditis, an inflammation of the sac surrounding the heart may have an audible sac surrounding the heart may have an audible pericardial friction rubpericardial friction rub
Pericardial friction rub: scratching, creaking, high pitched Pericardial friction rub: scratching, creaking, high pitched sound emanating from the rubbing of both layers of sound emanating from the rubbing of both layers of inflamed pericardium.inflamed pericardium.
Loudest in systole, but can often be heard also at the Loudest in systole, but can often be heard also at the beginning and at the end of diastole.beginning and at the end of diastole.
Dependent on body position and breathing, and changes Dependent on body position and breathing, and changes from hour to hour.from hour to hour.
T/F T/F
Lower viscosity equals higher Lower viscosity equals higher velocityvelocity
TrueTrue
Name the Wall Segment AND Name the Wall Segment AND the Typical Perfusing Coronary the Typical Perfusing Coronary
ArteryArtery
Anteroseptal LAD
Name this rhythmName this rhythm
Ventricular Tachycardia
What supplies are missing for What supplies are missing for a TEE procedure?a TEE procedure?
Equipment, suppliesEquipment, supplies Oximeter: continuous measurement of oxygen Oximeter: continuous measurement of oxygen
saturation is strongly recommendedsaturation is strongly recommended Suction equipmentSuction equipment Oxygen delivery systemOxygen delivery system Automated blood pressure monitoring deviceAutomated blood pressure monitoring device ECG monitoring (present on the ultrasound ECG monitoring (present on the ultrasound
machine)machine) Supplies for contrast administration Supplies for contrast administration
(stopcocks, syringes, IV tubing)(stopcocks, syringes, IV tubing)
Bite Block
Does increased preload Does increased preload result in increased IVRT?result in increased IVRT?
NONO
List Indications for Stress List Indications for Stress Echocardiography Testing.Echocardiography Testing.
Indications for stress echocardiography Indications for stress echocardiography testingtesting Detection of coronary artery diseaseDetection of coronary artery disease Assessment of the area of myocardium at riskAssessment of the area of myocardium at risk Risk stratification after myocardial infarctionRisk stratification after myocardial infarction Evaluation after revascularization Evaluation after revascularization Detection of myocardial infarctionDetection of myocardial infarction Women with chest pain symptoms and/or cardiac Women with chest pain symptoms and/or cardiac
risk factorsrisk factors Patients after heart transplantationPatients after heart transplantation Patients being considered for renal transplantPatients being considered for renal transplant Patients undergoing vascular surgeryPatients undergoing vascular surgery
How do you prepare the How do you prepare the right ventricular right ventricular
opacification agent?opacification agent? Rapidly agitate 5 mL of sterile saline, with a Rapidly agitate 5 mL of sterile saline, with a
small amount (approximately 0.2 mL) of air small amount (approximately 0.2 mL) of air between two syringes connected with a three-between two syringes connected with a three-way stopcock. way stopcock.
Results in production of large, highly variable Results in production of large, highly variable sized microbubbles that do not pass through sized microbubbles that do not pass through the pulmonary vascular bed.the pulmonary vascular bed.
When the saline appears opaque, it is injected When the saline appears opaque, it is injected rapidly (to avoid coalescence) into a peripheral rapidly (to avoid coalescence) into a peripheral vein during echocardiographic imaging. vein during echocardiographic imaging. The contrast effect may be enhanced by following The contrast effect may be enhanced by following
the contrast injection with 10 mL of non-agitated the contrast injection with 10 mL of non-agitated saline.saline.
Fill in the blankFill in the blank
_________________ are mechanical _________________ are mechanical vibrations which induce rarefractions vibrations which induce rarefractions and compressions of any physical and compressions of any physical medium due to an increase and medium due to an increase and decrease of densitydecrease of density
Sound WavesSound Waves
Which plane divides Which plane divides into superior and into superior and inferior?inferior?
In this image the In this image the transverse plane. transverse plane.
T/FT/F
Image resolution is no Image resolution is no greater than 1 to 2 greater than 1 to 2 wavelengths wavelengths (typically 1 mm)(typically 1 mm)
True
Name This RhythmName This Rhythm
Atrial FlutterAtrial Flutter
Is this right ventricular volume Is this right ventricular volume or pressure overload?or pressure overload?
Right ventricular volume overloadRight ventricular volume overload Maximum reversal of curvature seen in Maximum reversal of curvature seen in
mid-diastole with normalization in mid-mid-diastole with normalization in mid-systolesystole
List two complications of List two complications of TEEsTEEs
Complications of TEEs are rare:Complications of TEEs are rare: AspirationAspiration ArrhythmiaArrhythmia Perforation of the esophagusPerforation of the esophagus LaryngospasmLaryngospasm HematemesisHematemesis Medication complicationsMedication complications
HypotensionHypotension HypertensionHypertension HypoxiaHypoxia Death (very rare)Death (very rare)
Which view is the following? Apical Four Chamber with Anterior Tilt
What view is this? What view is this? Please label the following.Please label the following.
IVS
RCC
NCC
Anterior Mitral Leaflet
Posterior Mitral Leaflet
1
2
3
4
5
PLAXPLAX
Does increased preload Does increased preload result in increased E wave?result in increased E wave?
YesYes
How long should a patient How long should a patient fast before undergoing a fast before undergoing a
TEE?TEE?
4 to 6 hours4 to 6 hours
Which valve can be Which valve can be evaluated in this M-mode evaluated in this M-mode
image?image?Mitral
Which view is this? Which view is this? RVITRVIT
Please Identify These Please Identify These LeafletsLeaflets
Posterior/Septal
Anterior
The Medial Leaflet of the Tricuspid The Medial Leaflet of the Tricuspid
valve is not seen in this view.valve is not seen in this view.
What is the What is the name of this name of this
view? view?
PSAX-AoPSAX-Ao
Is there diastolic filling Is there diastolic filling dysfunction? If so, qualify it. dysfunction? If so, qualify it.
Restrictive Filling Restrictive Filling DefectDefect
Doppler ValuesDoppler Values E/A >2E/A >2 DT <150 msDT <150 ms S/D <1S/D <1
Please identify the Please identify the cusps.cusps.
Right Coronary Cusp
Left Coronary Cusp
Non Coronary Cusp
Please Label the FollowingPlease Label the Following
Anterior Mitral Leaflet
True/FalseTrue/False
A heart rate of 150 bpm allows A heart rate of 150 bpm allows adequate filling time in diastole and adequate filling time in diastole and does not affect preload in any way.does not affect preload in any way.
False. Tachycardia does not allow False. Tachycardia does not allow enough time for the left ventricle to enough time for the left ventricle to fill in diastole and decreases fill in diastole and decreases preload.preload.
Please Label the Following.Please Label the Following.
Posteriomedial Papillary Muscle
Anterolateral Papillary Muscle
Please identify the Please identify the following structure in this following structure in this
TEE.TEE.
Left Atrial Appendage
Please identify the following. Please identify the following. Which view is this? Which view is this?
Subcostal Four ChamberSubcostal Four Chamber
Please identify the Please identify the following valve leafletsfollowing valve leaflets
1
2
What are two What are two contraindications to contraindications to
TEE?TEE?Esophageal pathologyEsophageal pathology Severe dysphagiaSevere dysphagia Esophageal strictureEsophageal stricture Esophageal diverticulaEsophageal diverticula Bleeding esophageal varicesBleeding esophageal varices Esophageal cancer Esophageal cancer
Cervical spine disordersCervical spine disorders Orthopedic conditions that prevent neck Orthopedic conditions that prevent neck
flexionflexion
T/FT/F
M-mode and 2D images will be best if M-mode and 2D images will be best if the sound wave is positioned the sound wave is positioned perpendicular (90 degrees)perpendicular (90 degrees)
TrueTrue
Name two advantages of left hand Name two advantages of left hand
scanningscanning Sonographer has eye contact with the patientSonographer has eye contact with the patient
Patient is able to watch the video monitor, which can help Patient is able to watch the video monitor, which can help keep the patient occupiedkeep the patient occupied
Sonographer can help explain various aspects of the Sonographer can help explain various aspects of the procedures without providing any diagnostic informationprocedures without providing any diagnostic information
Sonographer can see if the patient is experiencing any Sonographer can see if the patient is experiencing any distress during the examdistress during the exam
Reduces the chance of back injury to the sonographer. Reduces the chance of back injury to the sonographer. When scanning from the right, the sonographer needs to When scanning from the right, the sonographer needs to reach around the patient potentially overextending back reach around the patient potentially overextending back muscles.muscles.
Sonographer is able to see where the transducer is being Sonographer is able to see where the transducer is being placed.placed.
What is an advantage of What is an advantage of scanning right-handed?scanning right-handed?
Many in-patient hospital Many in-patient hospital situations dictate the scanning situations dictate the scanning sideside
Altering right and left hand Altering right and left hand scanning decreases repetitive scanning decreases repetitive motion injuriesmotion injuries
What is the PMI?What is the PMI?
Point of maximum Point of maximum impulseimpulse
Where would you find the Where would you find the moderator band?moderator band?
In the right ventricleIn the right ventricle
If this pulse is one If this pulse is one second, what is the second, what is the
frequency?frequency?.. Frequency is defined as the number of complete variations (cycles) that an acoustic variable goes through in 1 sec.
In this figure of complete variations (cycles), the frequency is 4 complete variations per second, or 4 Hz
T/FT/F
Lower frequencies have decreased Lower frequencies have decreased penetrationpenetration
False. Lower frequencies have:1. Increased penetrations2. Decreased resolution
Name this rhythmName this rhythm
Torsades du Pointe
What is temporal What is temporal resolution.resolution.
Temporal Resolution: The Temporal Resolution: The resolution of the image (quality) resolution of the image (quality) as it pertains to moving objects. as it pertains to moving objects. The higher the frame rate the The higher the frame rate the better the temporal resolution.better the temporal resolution.
What is the frequency of What is the frequency of ultrasound?ultrasound?
Ultrasound:Ultrasound: > 20 KHz> 20 KHz
What is the difference between these What is the difference between these two images? What control on the two images? What control on the
echocardiography machine is being echocardiography machine is being utilized?utilized?
Too much gain is used, distorting the image, Too much gain is used, distorting the image, reducing resolution, and increasing noise.reducing resolution, and increasing noise.
What is this structure?What is this structure?An example of a false tendon (An example of a false tendon (arrowsarrows) in the ) in the
left ventricular (left ventricular (LVLV) apex is demonstrated.) apex is demonstrated.
Which valve is positioned Which valve is positioned most apically?most apically?
TricuspidTricuspid
How do you evaluate for How do you evaluate for pulmonary hypertension pulmonary hypertension
using tricuspid using tricuspid regurgitation?regurgitation?
4 m/sec
4V2 + RAP (derived from IVC reactivity)
The following definition The following definition describes which modality?describes which modality?
Motion can be introduced by plotting the Motion can be introduced by plotting the B-Mode display against time. In other B-Mode display against time. In other words, this allows a single dimension of words, this allows a single dimension of anatomy to be graphed against time. anatomy to be graphed against time. Often described as the “ice-pick” view of Often described as the “ice-pick” view of the heart. This modality is obtained using the heart. This modality is obtained using a single interrogation beam. a single interrogation beam.
M-ModeM-Mode
Name the Wall Segments AND Name the Wall Segments AND Typical Perfusing Coronary Typical Perfusing Coronary
ArteryArtery
Inferior Septum
RCA
The following definition The following definition describes which modality?describes which modality?
Used primarily to examine the flow Used primarily to examine the flow of blood. _________ imaging is of blood. _________ imaging is concerned with direction, velocity concerned with direction, velocity and then pattern of blood flow and then pattern of blood flow through the heart and great vessels. through the heart and great vessels. ________ imaging focuses on ________ imaging focuses on physiology and hemodynamicsphysiology and hemodynamics
Doppler
Doppler
What is the best view for What is the best view for evaluation of proximal evaluation of proximal
coronary arteries?coronary arteries?PSAX-AoPSAX-Ao
Which is the best view for Which is the best view for assessing the length of inferior assessing the length of inferior
left ventricular wall? left ventricular wall? Apical 2 ChamberApical 2 Chamber
Inferior
The tip of the heart is The tip of the heart is called the ___________.called the ___________.ApexApex
The coronary arteries The coronary arteries originate from the sinuses originate from the sinuses
of ______________.of ______________.ValsalvaValsalva
The mitral valve has ______ The mitral valve has ______ leaflets and _______ leaflets and _______
commissures.commissures.
two
two
The interventricular The interventricular septum normally bows septum normally bows towards which cardiac towards which cardiac
chamber?chamber?
Left ventricleLeft ventricle
What is being measured What is being measured between the arrows?between the arrows?
Define the following:Define the following:
TranslationTranslation
RotationRotation
TorsionTorsion
92
Movement in the chest as a Movement in the chest as a wholewhole
Circular motion around the long Circular motion around the long axis of the left ventricleaxis of the left ventricle
Unequal rotation motion at the apex Unequal rotation motion at the apex versus the base of the left ventricleversus the base of the left ventricle
Are these statements true Are these statements true according to the American Society according to the American Society of Echocardiography Guidelines of Echocardiography Guidelines for Image Orientation in Adults?for Image Orientation in Adults?
Recommended orientation: Recommended orientation: Transducer position (narrowest Transducer position (narrowest
portion of sector scan) at the top portion of sector scan) at the top of the screenof the screen
Lateral cardiac structures Lateral cardiac structures displayed on the left side of the displayed on the left side of the screen (similar to other screen (similar to other tomographic imaging techniques)tomographic imaging techniques)
93
TrueTrue
False, False, Right Right SideSide
Are these statements true Are these statements true according to the American Society according to the American Society of Echocardiography Guidelines of Echocardiography Guidelines for Image Orientation in Adults?for Image Orientation in Adults?
Recommended orientation: Recommended orientation: Short-axis can be considered Short-axis can be considered
looking for the apex toward the looking for the apex toward the cardiac basecardiac base
Four chamber and short axis: Four chamber and short axis: lateral structures on the right side lateral structures on the right side and the medial structures on the and the medial structures on the left sideleft side
94
TrueTrue
TrueTrue
Which letter refers to the Which letter refers to the coronary sinus?coronary sinus?
A
B
What is the region just proximal to What is the region just proximal to the pulmonic valve in the right the pulmonic valve in the right ventricular outflow tract called?ventricular outflow tract called?
What valve is transected by What valve is transected by the M-mode line of the M-mode line of
interrogation?interrogation?PulmonicPulmonic
Which M-mode of the Which M-mode of the pulmonic valve depicts pulmonic valve depicts
pulmonary hypertension?pulmonary hypertension?
What is the vessel entering What is the vessel entering at the arrow?at the arrow?
Superior Vena CavaSuperior Vena Cava
Which chordae originate at the Which chordae originate at the tips of the papillary muscle, tips of the papillary muscle,
branch into several thinner stands branch into several thinner stands and attach at the extreme edge of and attach at the extreme edge of
the leaflets?the leaflets? 11stst order order
Which papillary muscle is Which papillary muscle is typically perfused only by the typically perfused only by the
right coronary artery and right coronary artery and therefore is more susceptible therefore is more susceptible
to rupture?to rupture? Posterior medialPosterior medial
What does antegrade What does antegrade flow?flow?
Forward flow in contradiction to Forward flow in contradiction to retrograde flow such as retrograde flow such as regurgitationregurgitation
Which regurgitation is Which regurgitation is present in 80 to 90 percent present in 80 to 90 percent
of healthy individuals?of healthy individuals?TricuspidTricuspid
What opacification agent is What opacification agent is used to evaluate for atrial used to evaluate for atrial
shunts.shunts.Agitated salineAgitated saline
Name the Wall Segments AND Name the Wall Segments AND Typical Perfusing Coronary Typical Perfusing Coronary
ArteryArtery
Basal Inferolateral
RCA or CX
List two advantages of List two advantages of using agitated saline.using agitated saline.
Excellent safety profileExcellent safety profile InexpensiveInexpensive Easily storedEasily stored Widely availableWidely available
A patient was referred to the A patient was referred to the echocardiography lab with echocardiography lab with
suspicion of an pulmonary AVM. suspicion of an pulmonary AVM. What is an pulmonary AVM?What is an pulmonary AVM?
Pulmonary arteriovenous malformation Pulmonary arteriovenous malformation Abnormal passageway (fistula) Abnormal passageway (fistula) between an artery and vein that occurs between an artery and vein that occurs in the blood vessels of the lungs. in the blood vessels of the lungs.
The result is a shunting of blood, and The result is a shunting of blood, and thus the blood is not oxygenated thus the blood is not oxygenated properly.properly.
List three qualities of an List three qualities of an ideal left ventricular ideal left ventricular opacification agent.opacification agent.
Ideal Contrast AgentIdeal Contrast Agent Nontoxic (complete safety)Nontoxic (complete safety) Inert and poorly soluble gasInert and poorly soluble gas Small size(for transcapillary passage)Small size(for transcapillary passage) Excellent opacification (reflectivity)Excellent opacification (reflectivity) Capable of oscillation upon ultrasonic Capable of oscillation upon ultrasonic
stimulation (to allow detection of harmonic stimulation (to allow detection of harmonic images)images)
Long half-lifeLong half-life Intravenous administrationIntravenous administration Similar rheology to RBCsSimilar rheology to RBCs
What are ideal settings for the ultrasound What are ideal settings for the ultrasound machine using a left ventricular opacification machine using a left ventricular opacification
agent? List two settingsagent? List two settings.. Set mechanical index (MI): 0.4 to 0.6Set mechanical index (MI): 0.4 to 0.6
Select harmonic imagingSelect harmonic imaging
Optimize transmit focus location (usually far-Optimize transmit focus location (usually far-field; may be apical)field; may be apical)
Optimize TGCs and gainOptimize TGCs and gain
Optimize compressionOptimize compression
Minimize near-field gainMinimize near-field gain
Use and modify contrast presets supplied by Use and modify contrast presets supplied by specific vendorsspecific vendors
You are asked to assist in an ICE You are asked to assist in an ICE procedure in the cardiac procedure in the cardiac
catheterization lab. What is this?catheterization lab. What is this?
What are complications What are complications of ICE?of ICE?
Intracardiac thrombus Intracardiac thrombus formationformation
Pericardial effusionPericardial effusionPulmonary vein obstructionPulmonary vein obstruction
True/False True/False If the goal a a test is to identify all If the goal a a test is to identify all
patients with disease then prefer patients with disease then prefer high sensitivity.high sensitivity.
True.
Transversely if the goal is to determine those patients who do not have the disease then specificity is preferred.
What is a disadvantage of What is a disadvantage of low yield screening?low yield screening?
Major negative impact use of this Major negative impact use of this technique if only a limited number of technique if only a limited number of echocardiograms can be performed echocardiograms can be performed (depends on number of instruments, (depends on number of instruments, physicians and sonographers)physicians and sonographers)
May the sonographer May the sonographer recommend other testing recommend other testing
modalities on the worksheet?modalities on the worksheet?Worksheets should include:Worksheets should include: All measurementsAll measurements Reference to previous studiesReference to previous studies Degree of severity of findings Degree of severity of findings Left ventricular systolic function is quantifiedLeft ventricular systolic function is quantified Information is interpreted and correlatedInformation is interpreted and correlated Often image quality is reportedOften image quality is reported
Other testing modalities or Other testing modalities or intervention may be intervention may be recommended recommended
Report need for immediate care for patientReport need for immediate care for patient
Name the Wall Segments AND Name the Wall Segments AND Typical Perfusing Coronary Typical Perfusing Coronary
ArteryArtery
Mid Inferior
RCA
How many echocardiographic How many echocardiographic studies should a physician be studies should a physician be
involved in annually to be involved in annually to be considered competent in Level 3?considered competent in Level 3?
Level 3Level 3 Additional qualifications to supervise an Additional qualifications to supervise an
echocardiography laboratoryechocardiography laboratory 12 months12 months 300 studies performed300 studies performed 750 studies interpreted750 studies interpreted 500 annual studies to maintain 500 annual studies to maintain
competencecompetence
How long must patient records How long must patient records be kept?be kept?
Seven yearsSeven years
Name the Wall Segments AND Name the Wall Segments AND Typical Perfusing Coronary Typical Perfusing Coronary
ArteryArtery
Apical Lateral
LAD
Name the Wall Segments AND Name the Wall Segments AND Typical Perfusing Coronary Typical Perfusing Coronary
ArteryArtery Apical Cap
LAD
Name the Wall Segments AND Name the Wall Segments AND Typical Perfusing Coronary Typical Perfusing Coronary
ArteryArtery Apical Anterior
LAD
Name the Wall Segments AND Name the Wall Segments AND Typical Perfusing Coronary Typical Perfusing Coronary
ArteryArtery
Anterior Septum
LAD
Name the Wall Segments AND Name the Wall Segments AND Typical Perfusing Coronary Typical Perfusing Coronary
ArteryArtery Apical Lateral
LAD or CX
Name this complication of Name this complication of coronary artery disease.coronary artery disease.
Anteroapical myocardial infarction and a Anteroapical myocardial infarction and a
pedunculated, slightly mobile apical thrombus.pedunculated, slightly mobile apical thrombus.
Name the Wall Segments AND Name the Wall Segments AND Typical Perfusing Coronary Typical Perfusing Coronary
ArteryArtery
Apical Inferior
LAD
Name the Wall Segments AND Name the Wall Segments AND Typical Perfusing Coronary Typical Perfusing Coronary
ArteryArtery
Mid Anterior
LAD
Which occurs first, mitral Which occurs first, mitral stenosis or aortic stenosis stenosis or aortic stenosis
in the cardiac cycle?in the cardiac cycle?
Aortic Regurgitation, AI occurs Aortic Regurgitation, AI occurs during isovolumic relaxation as well during isovolumic relaxation as well as during diastole.as during diastole.
Mitral stenosis only occurs during Mitral stenosis only occurs during diastole.diastole.
What does this m-mode tell you What does this m-mode tell you about the left ventricular about the left ventricular
function?function?Poor anterior and posterior leaflet separation indicates poor transmitral flow. This most likely is due to elevated end systolic pressure in the left ventricle and therefore poor left ventricular function.
T/FT/FDuring systolic contraction During systolic contraction
the cardiac base moves the cardiac base moves toward the apex.toward the apex.
True.True.Descent of Cardiac BaseDescent of Cardiac Base
During ventricular contraction, the base of the heart moves toward the During ventricular contraction, the base of the heart moves toward the apex apex
The magnitude of this motion is directly proportional to systolic The magnitude of this motion is directly proportional to systolic functionfunction
Typically, M-mode interrogation is undertaken at the lateral mitral valve Typically, M-mode interrogation is undertaken at the lateral mitral valve annulus and the amount of excursion toward the transducer is annulus and the amount of excursion toward the transducer is determineddetermined
This measurement is rarely used today but same principle is used in This measurement is rarely used today but same principle is used in tissue Doppler imaging (DTI) for determination of diastolic and systolic tissue Doppler imaging (DTI) for determination of diastolic and systolic functionfunction
Normal >8 mm (98% specificity); mean 12Normal >8 mm (98% specificity); mean 12±mm in both four and two ±mm in both four and two chamber viewschamber views
List one method of List one method of evaluating LV volumesevaluating LV volumes
Biplane method of discs (modified Biplane method of discs (modified
Simpson’s rule)Simpson’s rule)
Single plane area-lengthSingle plane area-length
Quick method (Hemisphere-cylinder)Quick method (Hemisphere-cylinder)
Which method for evaluation of left Which method for evaluation of left ventricular volumes assumes that the ventricular volumes assumes that the
left ventricle is approximated by a left ventricle is approximated by a cylinder and the apex is an ellipsoid?cylinder and the apex is an ellipsoid?
““Bullet” FormulaBullet” Formula
Short-axis endocardial area at the Short-axis endocardial area at the mid-ventricular level Am and a long-mid-ventricular level Am and a long-axis lengthaxis length Volume = 5/6 x Am x LVolume = 5/6 x Am x L
Which method of evaluating LV volumes most Which method of evaluating LV volumes most closely predicts angiographic volume? closely predicts angiographic volume?
Simpson’s BiplaneSimpson’s Biplane
Represents cavity as stack of discs and Represents cavity as stack of discs and sums individual volumes of each disc sums individual volumes of each disc
Endocardial borders are traced in apical Endocardial borders are traced in apical four-chamber and two-chamber views four-chamber and two-chamber views with are used to define a series of with are used to define a series of orthogonal diametersorthogonal diameters
Using Simpson’s Rule how do you determine Using Simpson’s Rule how do you determine when to trace the diastolic volume?when to trace the diastolic volume?
Image maximizationImage maximization•Both AV valves imagedBoth AV valves imaged•Avoid aorta and coronary sinusAvoid aorta and coronary sinus•End-diastolic frame is largest LV End-diastolic frame is largest LV cavity just after MV closure at cavity just after MV closure at electrocardiographic R waveelectrocardiographic R wave
Which law states that as Which law states that as heart volume increases the heart volume increases the
length of the myocardial length of the myocardial fiber increases resulting in fiber increases resulting in
a stronger recoil?a stronger recoil?Frank-Starling LawFrank-Starling Law
Name the Wall Segments AND Name the Wall Segments AND Typical Perfusing Coronary Typical Perfusing Coronary
ArteryArtery
Apical septum
LAD
List three causations of List three causations of increased wall tension.increased wall tension.
Ventricular volume and Ventricular volume and pressurepressure
Arterial resistanceArterial resistanceAortic impedanceAortic impedanceMass of blood in aortaMass of blood in aortaViscosity of bloodViscosity of blood
What is indicated by What is indicated by these arrow?these arrow?
Left bundle branch block causing septal contraction prior to inferolateral contraction.
T/FT/FIVRT is affected by impaired left IVRT is affected by impaired left
ventricular relaxation.ventricular relaxation.
TrueTrue Time interval between aortic valve closure and mitral Time interval between aortic valve closure and mitral
valve openingvalve opening
Normal isovolumic relaxation time i.e. approximately Normal isovolumic relaxation time i.e. approximately 80 to 100 msec80 to 100 msec Normal range varies with age and heart rateNormal range varies with age and heart rate
Impaired relaxation is associated Impaired relaxation is associated with prolonged IVRTwith prolonged IVRT
Measured from A4 angulated anteriorly to show Measured from A4 angulated anteriorly to show outflow tract and aortic valve midway between aortic outflow tract and aortic valve midway between aortic valve and mitral valvevalve and mitral valve
What is this complication of What is this complication of myocardial infarction myocardial infarction
called? called?
True apical aneurysm
Does the following m-mode Does the following m-mode indicate normal or abnormal indicate normal or abnormal
stroke volume? Why?stroke volume? Why?
Name the Wall Segments AND Name the Wall Segments AND Typical Perfusing Coronary Typical Perfusing Coronary
ArteryArtery
Basal Inferior
RCA
Name this rhythmName this rhythm2nd Degree Block Mobitz I, Wenkebach
Note the gradual lengthening of the P-R with the eventual drop
Is this right ventricular Is this right ventricular pressure overload or volume pressure overload or volume
overload?overload? Right ventricular pressure overloadRight ventricular pressure overload
Increased mass (due to increased wall Increased mass (due to increased wall thickness) with non-dilated chamberthickness) with non-dilated chamber
Leftward shift of septal motion throughout Leftward shift of septal motion throughout cardiac cycle with reversal curvature at end-cardiac cycle with reversal curvature at end-systolesystole
Is the left atrial pressure Is the left atrial pressure increased?increased?
Is the left atrial pressure elevated?Is the left atrial pressure elevated?
Yes. Yes. PseudonormalPseudonormal..
E/A >1E/A >1
Relatively normal decel Relatively normal decel timetime
Pattern distinguished Pattern distinguished from normal by Em<Am from normal by Em<Am and pulmonary venous and pulmonary venous inflowinflow Pd>Pa, duration longer than Pd>Pa, duration longer than
mitral A duration suggestive mitral A duration suggestive of of elevated left ventricular elevated left ventricular filling pressuresfilling pressures
Explain what happens to Explain what happens to right-sided murmurs with right-sided murmurs with
inspiration.inspiration. Right-sided murmurs generally Right-sided murmurs generally
increase in intensity with increase in intensity with inspirationinspiration Inspiration causes a decrease in Inspiration causes a decrease in
intrathroacic pressure allowing air to intrathroacic pressure allowing air to enter the lungs. enter the lungs.
This decrease in intrathoracic pressure This decrease in intrathoracic pressure allso causes an increase in the venous allso causes an increase in the venous blood return to the right side of the blood return to the right side of the heart.heart.
How is pseudonormal diastolic How is pseudonormal diastolic filling patterns altered with a filling patterns altered with a
Valsalva maneuver?Valsalva maneuver?
Reduction in venous return during Valsalva maneuver Reduction in venous return during Valsalva maneuver results in an overall decrease of LV filling velocities without results in an overall decrease of LV filling velocities without significant change in the E/A ratio in normal.significant change in the E/A ratio in normal.
Decrease in venous return does change in pseudonormal Decrease in venous return does change in pseudonormal because atrial empting is abnormal. Due to reduced because atrial empting is abnormal. Due to reduced emptying in early diastole, emptying with atrial contraction emptying in early diastole, emptying with atrial contraction will atrial increasewill atrial increase
Is the left atrial pressure Is the left atrial pressure elevated?elevated?
NoNo
How does increased heart How does increased heart rate affect diastasis?rate affect diastasis?
At high heart rates diastole is At high heart rates diastole is shorter- particularly the period shorter- particularly the period of diastasisof diastasis When overlap of these two velocity When overlap of these two velocity
curve occurs the curve occurs the AA velocity is added velocity is added to to EE velocity curve resulting in a velocity curve resulting in a higher higher AA velocity velocity
Approximately what age Approximately what age signifies equalization of the signifies equalization of the
E and A waves?E and A waves? Aging adultsAging adults
EE velocity diminishes velocity diminishes Atrial contribution becomes more prominentAtrial contribution becomes more prominent
Equalization of Equalization of EE and and AA velocities velocities at approximately age 60 yearsat approximately age 60 years
Reversal of Reversal of EE and and AA velocities post 60 years velocities post 60 years oldold
Early diastolic deceleration time Early diastolic deceleration time progressively prolonged progressively prolonged
Slight increase in isovolumic relaxation time Slight increase in isovolumic relaxation time with agewith age
A patient is considered A patient is considered obese when he/she is obese when he/she is
overweight by overweight by _____percent of the ideal _____percent of the ideal
body weight body weight
3030
After performing an After performing an echocardiogram you echocardiogram you
calculate a wall motion calculate a wall motion score of 2.1. Is this score of 2.1. Is this considered normal?considered normal?Normal contracting has a wall Normal contracting has a wall
motion score index of 1. Patients motion score index of 1. Patients with a wall motion score index of with a wall motion score index of >2.0 are abnormal.>2.0 are abnormal.
Name the Wall Segment AND Name the Wall Segment AND the Typical Perfusing Coronary the Typical Perfusing Coronary
ArteryArtery
Basal Inferolateral
Cx or RCA
What is a NYHA What is a NYHA classification IV mean?classification IV mean?
A functional and therapeutic classification for prescription of A functional and therapeutic classification for prescription of physical activity for cardiac patients.physical activity for cardiac patients.
Class I: patients with no limitation of activities; they suffer no Class I: patients with no limitation of activities; they suffer no symptoms from ordinary activities. symptoms from ordinary activities.
Class II: patients with slight, mild limitation of activity; they are Class II: patients with slight, mild limitation of activity; they are comfortable with rest or with mild exertion. comfortable with rest or with mild exertion.
Class III: patients with marked limitation of activity; they are Class III: patients with marked limitation of activity; they are comfortable only at rest. comfortable only at rest.
Class IV: patients who should be at Class IV: patients who should be at complete rest, confined to bed or complete rest, confined to bed or chair; any physical activity brings on chair; any physical activity brings on discomfort and symptoms occur at discomfort and symptoms occur at rest. rest.
What are the oxygen What are the oxygen saturations?saturations?
Which plane divides into anterior Which plane divides into anterior and posterior?and posterior?
Coronal PlaneCoronal Plane
At rest, what is the At rest, what is the approximate stroke approximate stroke
volume in mL?volume in mL? 70 mL at rest70 mL at rest
Name the Wall Segments AND Name the Wall Segments AND Typical Perfusing Coronary Typical Perfusing Coronary
ArteryArtery
Basal Inferoseptum
RCA
Where are red blood cells Where are red blood cells produced? produced?
What percentage do red blood What percentage do red blood cells make up of the formed cells make up of the formed
elements in the blood?elements in the blood?
Bone marrowBone marrow
45%45%
Name the Wall Segments AND Name the Wall Segments AND Typical Perfusing Coronary Typical Perfusing Coronary
ArteryArtery
Anterior
LAD
Name the Wall Segments AND Name the Wall Segments AND Typical Perfusing Coronary Typical Perfusing Coronary
ArteryArtery
Mid Inferolateral
RCA or CX
Name the Wall Segments AND Name the Wall Segments AND Typical Perfusing Coronary Typical Perfusing Coronary
ArteryArtery
Inferolateral
RCA or CX
Name the Wall Segments AND Name the Wall Segments AND Typical Perfusing Coronary Typical Perfusing Coronary
ArteryArtery
Mid Inferoseptum
RCA or LAD
______________ is the ______________ is the abnormal decrease of abnormal decrease of
red blood cells.red blood cells.
An abnormal increase in An abnormal increase in the number of red blood the number of red blood
cells is called cells is called _____________________._____________________.
AnemiaAnemia
polycythemiapolycythemia
Which requires a higher Which requires a higher myocardial contraction?myocardial contraction?
Polycythemia or anemiaPolycythemia or anemia
Polycythemia (Polycythemia (Abnormal Abnormal increase in the number of red increase in the number of red blood cells)blood cells)
Greater viscocity requires Greater viscocity requires greater force to move greater force to move through vascular system.through vascular system.
Name the Wall Segments AND Name the Wall Segments AND Typical Perfusing Coronary Typical Perfusing Coronary
ArteryArtery
Anterolateral
LAD or CX
You are asked to perform a cardiac You are asked to perform a cardiac ultrasound on a 90 year old female ultrasound on a 90 year old female
with an SaOwith an SaO22 of 79%. of 79%. What does What does an SaOan SaO22 of 79% indicate? of 79% indicate?
SaOSaO2 2 value refers to value refers to arterial oxygen arterial oxygen saturation.saturation.• Below 90% is considered Below 90% is considered
hypoxemichypoxemic
On M-mode what is displayed On M-mode what is displayed on the horizontal axis (x)?on the horizontal axis (x)?
Motion or time displayed on Motion or time displayed on horizontal axis (X)horizontal axis (X)
True/FalseTrue/FalseOn M-mode echo strength is On M-mode echo strength is directly proportional to the directly proportional to the
strength of the reflected echoesstrength of the reflected echoes TRUE. Echo strength is represented TRUE. Echo strength is represented
as the brightness of structures on the as the brightness of structures on the image displayimage display
Blood-filled cavities do not produce Blood-filled cavities do not produce echoesechoesSolid structures such as cardiac valves Solid structures such as cardiac valves and walls produce strong echoesand walls produce strong echoes
True/FalseTrue/FalseTemporal resolution is an Temporal resolution is an
advantage that M-mode has over advantage that M-mode has over
B-mode.B-mode. TrueTrue Superior temporal resolution Superior temporal resolution
and rapid sampling frequencyand rapid sampling frequency
Name the Wall Segment AND Name the Wall Segment AND the Typical Perfusing Coronary the Typical Perfusing Coronary
ArteryArtery
Basal Inferior Wall: RCA
What does this What does this Wiggers’ Diagram Wiggers’ Diagram
Indicate?Indicate?
What modality(ies) is(are) used to What modality(ies) is(are) used to create this image?create this image?
Color M-modeColor M-mode
Label this m-mode image Label this m-mode image of the pulmonic valve of the pulmonic valve
leaflet.leaflet.
1
1
2
3
4
5
6
What does each letter What does each letter indicate?indicate?A:A: reflects small posterior deflection occurring at atrial reflects small posterior deflection occurring at atrial
systolesystole
B: notes small anterior deflection occurring at and of B: notes small anterior deflection occurring at and of atrial systole and onset of ventricular systoleatrial systole and onset of ventricular systole
C: large posterior deflection immediately following C: large posterior deflection immediately following ventricular ejectionventricular ejection
D: gradual anterior motion of the leaflet during the D: gradual anterior motion of the leaflet during the ventricular ejection periodventricular ejection period
E: closed position of the leaflet upon completion of E: closed position of the leaflet upon completion of ventricular ejectionventricular ejection
F: represents the slight posterior movement of the F: represents the slight posterior movement of the leaflet during diastole and is the point immediately leaflet during diastole and is the point immediately prior to atrial contraction and the next A point.prior to atrial contraction and the next A point.
What is this complication of What is this complication of myocardial infarction myocardial infarction
called? called?
Ruptured Papillary Muscle
List two methods for List two methods for evaluation of LV mass.evaluation of LV mass.
Penn Cube Penn Cube ASEASE
Biplane method of discs (modified Simpson’s Biplane method of discs (modified Simpson’s Rule)Rule)
Which method for ejection fraction Which method for ejection fraction utilizes the following traces?utilizes the following traces?
What is the specific gravity What is the specific gravity of the myocardial muscle?of the myocardial muscle? 1.04 g/ml1.04 g/ml
The word “Hemo” means:The word “Hemo” means:
a)a) BloodBlood
b)b) Force or powerForce or power
c)c) Kinetic energyKinetic energy
d)d) Decreased pressureDecreased pressure
What is the normal What is the normal fractional shortening fractional shortening
percentage?percentage? 21 to 40%21 to 40%
What is the first heart tone?What is the first heart tone?
First heart tone,First heart tone, SS11, caused by the , caused by the closure of AV valves at the at the closure of AV valves at the at the beginning of ventricular contraction, beginning of ventricular contraction, or systole. or systole.
What is the first heart tone?What is the first heart tone?
Name this complication of Name this complication of coronary artery disease.coronary artery disease.
True apical aneurysmTrue apical aneurysm
Where would you Where would you measure the measure the
sinotubular junction?sinotubular junction?
Answer: 3Answer: 31. Aortic annulus, 2 Trans-sinus or 1. Aortic annulus, 2 Trans-sinus or
sinus of Valsalva, 4. Ascending aortasinus of Valsalva, 4. Ascending aorta
Which set of images would you Which set of images would you use to measure for stroke volume?use to measure for stroke volume?
During which phase does the left During which phase does the left ventricular pressure exceed the ventricular pressure exceed the
aortic pressure?aortic pressure?
Name the Wall Segments AND Name the Wall Segments AND Typical Perfusing Coronary Typical Perfusing Coronary
ArteryArtery
Apical Lateral
LAD
During which phases are the During which phases are the semilunar valves open?semilunar valves open?
Pulmonic stenosisPulmonic stenosis
Assuming that this Wigger’s Assuming that this Wigger’s diagram was obtained from the diagram was obtained from the
right-sided pressures, what does right-sided pressures, what does this diagram indicate?this diagram indicate?
Name the points on Name the points on this M-mode.this M-mode.
1
2
3
4
5
T/FT/F
In the autonomic nervous system, the In the autonomic nervous system, the FLIGHT OR FIGHT RESPONSE, refers to FLIGHT OR FIGHT RESPONSE, refers to the parasympathetic division of the the parasympathetic division of the autonomic nervous system.autonomic nervous system.
False, The FLIGHT OR FIGHT RESPONSE False, The FLIGHT OR FIGHT RESPONSE refers to the refers to the sympathetic nervous sympathetic nervous systemsystem, in which the heart rate is , in which the heart rate is increased, AV node conduction and increased, AV node conduction and increases irritability. increases irritability.
LabelLabel
1 2 3
4
5
6
7 8
Mitral stenosisMitral stenosis
Assuming that this Wigger’s Assuming that this Wigger’s diagram was obtained from diagram was obtained from
pressures left atrium and left pressures left atrium and left ventricle, what does this diagram ventricle, what does this diagram
indicate?indicate?
What is this complication of What is this complication of
myocardial infarction called?myocardial infarction called?
Acute anterior apical infarct with early thrombus formation. Regional dilation of the LV at apex and pedunculated, multilobulated mas protruding into the cavity of the LV
What is Pressure What is Pressure Recovery?Recovery?Hydrodynamic principle based on
conservation of energy
•Highest velocity and lowest pressure: narrowest point of the orifice (vena contracta)
•Pressure of fluid decreases as the velocity increases
•After flow passes through orifice pressure recovers and increases toward its original valve
Gradual pressure recovery: cath and echo gradients correlate
Rapid pressure recovery: cath and echo gradients do not correlate. Echo will have a higher gradient than cardiac catheterization
The longer the interval between The longer the interval between contractions, the ____________ the contractions, the ____________ the contraction.contraction.
A.A. shortershorter B.B. strongerstronger C.C. weakerweaker D.D. longerlonger
In M-mode does the root of the In M-mode does the root of the aorta move anterior or aorta move anterior or posterior?posterior?
AnteriorAnterior
What is this diagram called? What is this diagram called? Is this a normal tracing?Is this a normal tracing?Yes
Wiggers
How does the cardiac How does the cardiac catheterization laboratory catheterization laboratory calculate valvular area?calculate valvular area?
Gorlin formulaGorlin formula
What velocity would you use What velocity would you use in the calculation of the in the calculation of the
Effective Orifice of mitral Effective Orifice of mitral regurgitation using PISA?regurgitation using PISA?
Name the Wall Segments AND Name the Wall Segments AND Typical Perfusing Coronary Typical Perfusing Coronary
ArteryArtery
Basal Anterior
LAD
Name the Wall Segments AND Name the Wall Segments AND Typical Perfusing Coronary Typical Perfusing Coronary
ArteryArtery
Mid Anterolateral
LAD or CX
Name the Wall Segments AND Name the Wall Segments AND Typical Perfusing Coronary Typical Perfusing Coronary
ArteryArtery
Apical Anterior
LAD
Name the Wall Segments AND Name the Wall Segments AND Typical Perfusing Coronary Typical Perfusing Coronary
ArteryArtery
Basal Inferolateral
LAD
Name the Wall Segments AND Name the Wall Segments AND Typical Perfusing Coronary Typical Perfusing Coronary
ArteryArtery
Basal Anterolateral
LAD or CX
Name the Wall Segments AND Name the Wall Segments AND Typical Perfusing Coronary Typical Perfusing Coronary
ArteryArtery
Inferior
RCA
Name this complication of Name this complication of coronary artery disease.coronary artery disease.
Pseudo apical aneurysm with Pseudo apical aneurysm with suggestion of calcification along rimsuggestion of calcification along rim
Name the Wall Segments AND Name the Wall Segments AND Typical Perfusing Coronary Typical Perfusing Coronary
ArteryArtery
Mid Inferolateral
RCA or CX
What information What information must you obtain to must you obtain to calculate the Tei calculate the Tei
Index?Index?Left ventricular ejection time
Systolic time including isovolumic contraction
What is the second heart sound?What is the second heart sound? SS22, second heart sound, second heart sound, caused by , caused by
the closure of the aortic and the closure of the aortic and pulmonic valves at the end of pulmonic valves at the end of ventricular systole.ventricular systole.
In a patient with a In a patient with a ventricular septal defect ventricular septal defect how might you determine how might you determine
the right ventricular the right ventricular pressure?pressure?
What is Pulmonary What is Pulmonary Artery Capillary Wedge Artery Capillary Wedge
Pressure?Pressure? Indirect assessment of left atrial Indirect assessment of left atrial pressure pressure Useful in diagnosis of left Useful in diagnosis of left
ventricular heart failureventricular heart failure Swan-Ganz catheterSwan-Ganz catheter
What is this complication of What is this complication of myocardial infarction called?myocardial infarction called?
Pseudoaneurysm
The following formula may be The following formula may be used to calculate valvular area. used to calculate valvular area.
What is this formula?What is this formula?
CSACSA11 x VTI x VTI11 = CSA = CSA22 x VTI x VTI22
CSACSA2 2 == CSACSA11 x VTI x VTI11
VTIVTI22Continuity EquationContinuity Equation
Name the Wall Segment AND Name the Wall Segment AND the Typical Perfusing Coronary the Typical Perfusing Coronary
ArteryArtery
Mid Inferoseptum: RCA
What does this What does this Wiggers’ Diagram Wiggers’ Diagram
represent?represent?
Name this RhythmName this Rhythm
Atrial Flutter 4:1
Explain what happens to Explain what happens to left-sided murmurs with left-sided murmurs with
inspiration.inspiration. Left-sided murmurs generally Left-sided murmurs generally
decrease in intensity with decrease in intensity with inspirationinspiration Increased volume of blood entering the Increased volume of blood entering the
right sided chambers of the heart right sided chambers of the heart restricts the amount of blood entering restricts the amount of blood entering the left sided chambers.the left sided chambers.
Increased preload leads to _________.Increased preload leads to _________. A.A. increased contractilityincreased contractility B.B. decreased contractilitydecreased contractility C.C. shorter contractility timeshorter contractility time D.D. none of the above.none of the above.
T/FT/F
An example of afterload is An example of afterload is hypertensionhypertension
TrueTrue
T/FT/F
Standing decreases venous return, Standing decreases venous return, stroke volumestroke volume
TrueTrue
T/FT/F Amyl nitrate increases the heart rateAmyl nitrate increases the heart rate
TrueTrue
What is the third heart What is the third heart sound?sound?
Third Heart Tones, SThird Heart Tones, S33
Caused by vibration of the ventricular Caused by vibration of the ventricular wallswalls Resulting from the first rapid filling so it is Resulting from the first rapid filling so it is
heard just after Sheard just after S22
Low in frequency and intensityLow in frequency and intensity Commonly heard in child and young adultsCommonly heard in child and young adults In older adults SIn older adults S33 often indicates heart often indicates heart
failurefailure
How do wall filters affect How do wall filters affect spectral Doppler?spectral Doppler?
On the left notice that the low velocity blood On the left notice that the low velocity blood flow has been filtered out.flow has been filtered out.
Name the Wall Segment AND Name the Wall Segment AND the Typical Perfusing Coronary the Typical Perfusing Coronary
ArteryArtery
Apical Septum, Apical Cap and Apical Lateral: LAD
When a patient has aortic stenosis, the When a patient has aortic stenosis, the pressure in the left ventricle will:pressure in the left ventricle will:
a)a) DecreaseDecrease
b)b) IncreaseIncrease
c)c) Remain the sameRemain the same
What does this formula What does this formula calculate?calculate?
(7*LVIDD(7*LVIDD33))
(2.4+LVIDD)(2.4+LVIDD)
End diastole volume (EDV) mlEnd diastole volume (EDV) ml
Teichholz methodTeichholz method