echocardiography and hemodynamics review echo ii susan a. raaymakers, mpas, pa-c, rdcs (ae,pe)...

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

raaymasu@gvsu.edu

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

ArteryArteryBasal Anteroseptum

ArteryArtery

Mid Anteroseptum

ArteryArtery

Basal Anteroseptum

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.

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.

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

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.

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

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?

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)

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.

Anterior Mitral Leaflet

Posterior Mitral Leaflet

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

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

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

ArteryArtery

Inferior Septum

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

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.

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

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)

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

TrueTrue

Which letter refers to the Which letter refers to the coronary sinus?coronary sinus?

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

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.

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

ArteryArtery

Mid Inferior

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

ArteryArtery

Apical Lateral

ArteryArtery Apical Anterior

ArteryArtery

Anterior Septum

ArteryArtery Apical Lateral

LAD or CX

Anteroapical myocardial infarction and a Anteroapical myocardial infarction and a

pedunculated, slightly mobile apical thrombus.pedunculated, slightly mobile apical thrombus.

ArteryArtery

Apical Inferior

ArteryArtery

Mid Anterior

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

ArteryArtery

Apical septum

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?

ArteryArtery

Basal Inferior

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?

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

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.

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

ArteryArtery

Basal Inferoseptum

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%

ArteryArtery

Mid Inferolateral

RCA or CX

ArteryArtery

Inferolateral

RCA or CX

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.

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

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.

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?

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?

ArteryArtery

Apical Lateral

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.

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

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?

ArteryArtery

Basal Anterior

ArteryArtery

Mid Anterolateral

LAD or CX

ArteryArtery

Apical Anterior

ArteryArtery

Basal Inferolateral

ArteryArtery

Basal Anterolateral

LAD or CX

ArteryArtery

Inferior

Pseudo apical aneurysm with Pseudo apical aneurysm with suggestion of calcification along rimsuggestion of calcification along rim

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

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.

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

echocardiography and hemodynamics review echo ii susan a. raaymakers, mpas, pa-c, rdcs (ae,pe)...

wall segments

depressed stsegments

ischemiaelevated stsegments

inferior myocardial

kussmauls disease

ischemia results

skeletal muscular system

embryonic right atrium

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