why m-mode is great m-mode and spectral doppler

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M-Mode and Spectral DopplerVAANI PANSE GARG, MDA S S I S T A N T P R O F E S S O R O F M E D I C I N E

A S S O C I A T E P R O G R A M D I R E C T O R C A R D I O L O G Y F E L L O W S H I P

M O U N T S I N A I M O R N I N G S I D E – N E W Y O R K , N Y

I O W A A C C E C H O B O A R D R E V I E W S E R I E S 2 0 2 1

Why M-Mode Is GreatPrecise representation of timing

Enhanced understanding of pathologies

Enhanced understanding of hemodynamic effects

Visual representation of diagnoses

Today’s plan:A tour of important M-Modes and correlating spectral Doppler—pulse wave (PW) and continuous wave (CW)

Normal Aortic Valve M-Mode

RCC

NCC

IVCT

IVRT

Parallelogram in shape

Midline closure

RCC = right coronary cusp

NCC = non-coronary cusp

IVCT = isovolumetric contraction time

IVRT = isovolumetric relaxation time

Normal Mitral Valve M-Mode

Anterior (top) and posterior leaflets

E = Early diastolic filling

E-F slope = early to mid diastolic filling

A = atrial kick or atrial contraction

C = electrical onset of systole

C-D = closure during systole

D = denotes valve opening

E

F

A

C D

Anatomical M-mode

CERERJ ET AL. ECHOCARDIOGRAPHY 2003;MAY 20(4):357-61.

Question 1

KLEIN, A. CLINICAL ECHOCARDIOGRAPHY REVIEW, 2017

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Question 2


Question 3


Question 4


M-mode and The Septum

Normal left

ventricular function

Severe left ventricular

systolic dysfunction

Septal Movement with Breathing

Inspiration

Septal shift toward left

Accommodate incoming preload

Expiration

Normal septal thickening

Paradoxical septal motion Definition = early systolic anterior

(toward RV) motion of the septum

Offset in activation from inferolateraland septal walls compared to normal

Right Ventricular Pacing

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Severe Tricuspid Regurgitation

Diastolic septal

flattening

“D-shaped”

Severe Tricuspid Regurgitation

Parasternal Short Axis

Hepatic vein systolic reversal

Constrictive PericarditisEarly to mid diastolicseptal dip

Reflects right then left ventricular filling

Septal bounce Septal “shudders” in

diastole

Systolic beak

Diastolic dip

Normal septal thickening

Systolic beak during isovolumetric contraction (systole)

Paradoxical septal motion Can diminish contribution to stroke volume

Early diastolic dip More compliant right ventricle

Right to left ventricular pressure gradient

Left Bundle Branch BlockParadoxical

Post Cardiac Surgery

CLANCEY ET AL. AJUM MAY 2018.

Paradoxical septal motion

M-Mode and Resolution

Temporal

M-Mode superior to 2D

Due to higher sampling rate

1000 frames per second (2D is 30-60)

Lateral

M-Mode inferior to 2-D

Due to single scan line used

Axial

M-Mode similar to 2-D

Due to same transducer frequency

Longitudinal or depth resolution

KIREYEVD., HUNG J. (2016) BASICS OF ULTRASOUND PHYSICS. IN: KIREYEVD., HUNG J. (EDS) CARDIAC IMAGING IN CLINICAL PRACTICE.

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M-Mode and Hemodynamics

ADV PHYSIOL EDUC. 2014 JUN; 38(2): 170–175.

M-Mode and HemodynamicsE point septal separation (EPSS; dotted line) Normal < 7 mm

Mid range 7-12 mm Dilated ventricle with chronic aortic

regurgitation

Abnormal >12 mm Cardiomyopathy

Low output state/low forward stroke volume

End diastolic dimension (EDD) and end systolic dimension (ESD) Convention to use 2D for

measurements

B-bump EDD ESD

EPSS

B-bump and Elevated LV End Diastolic Pressure

B-bump

A-C “shoulder”LVEDP >20 mmHg

FEIGENBAUM H. ECHOCARDIOGRAPHY. 1ST ED. PHILADELPHIA, PA: LEA AND FEBIGER; 1972

Low Cardiac Output

Slow tapered closure of aortic valve Cardiomyopathy with low

flow state

Significant mitral regurgitation


Atrial Fibrillation Severe LV Systolic Dysfunction

Beat to beat variability in aortic valve opening

Beat to beat variability in cardiac output

L-waveRobust pulmonary vein flow

Seen in bradycardia

Can be normal finding

Mid-diastolic flow velocity >20 cm/s can represent markedly delayed relaxation and elevated filling pressures

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M-Mode and Valvular Disease

Bicuspid Aortic ValveEccentric closure line

Most common is RCC-LCC fusion

RCC

NCCLCC

Severe Aortic Regurgitation

Early opening of aortic valve

Diastolic reversal in descending aorta

High frequency fluttering of the mitral valve in diastole

Normal septal motion

Early opening of aortic valve

Premature early closure of mitral valve

Dilated LV (if chronic)

Rapid equilibration of LV and aortic diastolic pressures

Here regurgitation is not holosystolic Equilibrates quickly

Early diastolic flow

C-point occurs well before QRS

Severe Aortic Regurgitation

C

Critical Aortic Stenosis Subaortic MembraneAbrupt, very early posterior motion of right cusp

Early systolic premature closure

Fluttering of the aortic leaflets post “dip” due to aortic regurgitation

Can help to distinguish from valvularaortic stenosis

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Hypertrophic Obstructive CardiomyopathySystolic anterior motion of the mitral valve Increased septal thickness narrows LVOT

Anterior displacement of the mitral valve

Elongated mitral valve

Hyperdynamic systolic function

Mid systolic premature closure of aortic valve Similar in stress induced cardiomyopathy

with dynamic LVOT obstruction

Dagger and Lobster Claw

Mid Systolic Cessation of FlowDuration to mitral leaflet-septal contact related to gradient

Mid Cavitary Obliteration

Mitral StenosisReduced E-F slope

Septal “dip” exaggerated Right ventricular flow unimpeded

Left ventricular flow impeded, dips toward LV

Thickened leaflets

Often absence of A-wave due to atrial fibrillation

Large left atrium

Mitral Valve ProlapseMid to late systolic murmur

Not holosystolic

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Mechanical Valves

MitralAortic

M-Mode and Arrhythmia, Pericardial disease, and Other Important Findings

Complete heart block

Atrial fibrillation

Mitral Annular Calcification

Left Atrial MyxomaEcho-free space at mitral valve opening

Echodense space under anterior leaflet

Functional mitral stenosis with diminished mitral EF slope

Myxoma

Cardiac TamponadeRight ventricular diastolic collapse

More specific

Right atrial collapse > 1/3 cardiac cycle More sensitive

Non-significant RA collapse

Significant RV diastolic collapse

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Pulmonary HypertensionFlying W signReflecting elevated pulmonary

vascular resistance

Mid-systolic notch

Rapid acceleration 61 ms

Mid-systolic notch

Rapid pulmonary acceleration time


Severe Pulmonic Stenosis


Severe Pulmonic Regurgitation

Tricuspid Annular Plane Systolic Excursion (TAPSE):Right Ventricular Function

Abnormal TAPSE < 1.7 cm

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Inferior Vena Cava: Right Atrial Pressure Estimate

<2.1 cm IVC and >50% collapse

>2.1 cm IVC and <50% collapse

Question 1

Question 2 Question 3

Question 4

Thank You and Good Luck!

why m-mode is great m-mode and spectral doppler

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