Exam 9

Question 1

POCUS: uses

Answer 1

*may identify presence of disease
*screening populations at risk of heart disease
*useful tool in medical education
*useful for periodic checks to known abnormality and how it responds to treatment

Question 2

POCUS is helpful in Rapid Diagnosis of:

Answer 2

• pleural/pericardial effusion/tamponade
  -ventricular size, wall thickness, global function
  -segmental wall motion abnormalities
  -LA and IVC size
  -signs of pulmonary embolus
  -heart failure symptoms with or without preserved EF
  -intravascular volume assessment
  -guidance of pericardiocentesis and transverse pacing wire placement

Question 3

POCUS: highest diagnostic accuracy

Answer 3

-presence or absence of a pericardial effusion
-presence or absence of LV systolic dysfunction

Question 4

POCUS: Limitations

Answer 4

-lower accuracy for regional wall motion and vascular heart disease
-missed diagnosis due to an inexperienced operator or suboptimal image quality
-limited recording capacity so accurate reporting is essential

Question 5

3D Acquisition Modalities

Question 6

3D usefulness

Answer 6

-Quantification of LV volume and EF
-Evaluation of MV pathology
-Guidance of transcatheter procedures
-Promising in RV volumes/EF

Question 7

3D display/graphs

Question 8

Measures of Myocardial Mechanics

Answer 8

-Displacement: the distance a cardiac structure or myocardial element moves between 2 consecutive image frames (distance cm)
-Velocity: the speed of movement of a cardiac structure or myocardial element (velocity cm/s)
-Strain: the fractional change in length of a myocardial segment; a unitless measure of myocardial deformation (positive/negative percentage %)
-Strain Rate: the rate of change in strain with units of 1 per second
-Rotation: the circular motion of the LV myocardium around its long axis (degrees)
-Twist: the absolute difference in rotation between the LV base and apex (degrees)
-Torsion: the gradient in rotation angle from base to apex (degrees per cm)

Question 9

Advantages of STE over Advanced TDI

Answer 9

-measures all mechanics (limited rotation, twist, torsion)
-simpler data acquisition with multiple simultaneous measurements presented
-lack of angle dependence
-direct measurement of strain
-circumferential and radial in addition to longitudinal strain
-ability to do analysis after image acquisition

Question 10

Interpreting STE display

Answer 10

tracking the motion of small bright spots on the gray scale image as they move during the cardiac cycle

Question 11

Function of Agitated Saline

Answer 11

allows for the detection of shunts by the appearance of contrast in the left heart within one to two beats of contrast appearance in the right heart

Question 12

Advantages of ICE

Answer 12

-primarily for monitoring invasive procedures
-allows physician to evaluate pre-procedure, position during procedure, check effectiveness after procedure
-well tolerated, accurate, provides continuous monitoring

Question 13

ICE probe positions and uses

Answer 13

• positioned in IVE, RA, and RV

Question 14

IVUS modality (Intravascular Ultrasound)

Answer 14

-uses 30-50 MHz transducer element on a steerable catheter that is positioned in the coronary arteries during interventional coronary procedures
-assess effectiveness of PCI
-used when standard angiographic data are inadequate to evaluate the length and severity of narrowing and the composition of plaque which guides the therapeutic approach

Question 15

How pharmacological agents simulate stress

Answer 15

-increases the strength of contraction and HR
-ischemia is induced by increasing the myocardial oxygen demand by exercise or pharmacologic interventions

Question 16

Stress Echo Acquisition

Answer 16

-use Plax or A3, PSAX PM, A4, or A2: all myocardial segments visualized in at least one but preferably two views
-compare rest with exercise images
-record images in digital cine loop format

Question 17

Dobutamine Protocol

Answer 17

-administered via IV in increments to increase HR and contractility
-administered at low dose (5ug/kg/min) and increase quantity every 3 mins until target HR is achieved or 40 ug/kg/min
-have emergency meds/equipment in case of adverse effects
-monitor 12 lead EKG, symptoms, BP, wall motion views at each stage
-quad display: rest, low dose, high dose, and recovery
-helpful in identifying shunned or hibernating myocardium

Question 18

Shunned Myocardium

Answer 18

patient received thrombolytic in the field

Question 19

Hibernating Myocardium

Answer 19

patient discovered to have undiagnosed resting wall motion abnormality

Question 20

Viable myocardium

Answer 20

benefits from revascularization
-increased contractility with low dose but loses contractility with higher dose (biphasic response)

Question 21

Alternate approaches to Stress Echo

Answer 21

-Stress Test
-Nuclear Test
-Coronary Angiography
-PET: Pharmacologic Position Emission Tomography
-Computed Tomography Coronary Angiography
-Cardiac Magnetic Resonance Imaging

Question 22

Diastolic Dysfunction Benchmark

Question 23

HCM Indication

Question 24

LV function and Lung Images

Question 25

MR parameters

Question 26

MS benchmark

Question 27

Assessing LF-LG AS

Answer 27

Flow Reserve:
Without Flow Reserve:

Question 28

Classical LF-LG AS

Answer 28

PW doppler LVOT, CW doppler AV, LV views
EF < 50%, MPG < 40mmHg, AVA < 1cm2

Question 29

Paradoxical LF-LG AS

Answer 29

EF ≥ 50%, SVI < 35 ml/m2 , AVA < 1 cm2, AVAI < .6 cm2/m2, MPG < 40mmHg at rest