Ch 10 Apical CD

Question 1

From a physics perspective, any area of flow disruption results in what?

Answer 1

Turbulence

Question 2

Are small amounts of aliasing normal in certain scenarios?

Answer 2

Yes, due to the inherent nature of hemodynamics

(valves cause small areas of turbulence + aliasing which is normal)

Question 3

Is off axis imaging allowed when evaluating pathology as the primary goal?

Answer 3

Yes b/c we are trying to visualize the entirety of the anomaly

Question 4

Where should we put our CD box when imaging the AP4 MV?

Answer 4

-Place over entire LA + at least half of the LV
-MV in center of box

Question 5

What color is flow in AP4?

Answer 5

Red - b/c it is going towards the probe during diastole

Question 6

Is RV + LV inflow biphasic?

Answer 6

Yes:
-early diastolic wave (80%)
-late diastolic wave (20%)

Question 7

What would regurgitation + stenosis look like with CD in AP4?

Answer 7

Regurg: blue/mosaic flow into atria during systole

Stenosis: red/mosaic flow into ventricles during diastole

Question 8

What 3 things other than regurg + stenosis should we watch for within the CD box while in AP4?

Answer 8

-IAS (ASD/PFO)
-IVS (VSD)
-Abnormal pulmonary vein flow (from LA)

Question 9

What pathology could cause pulmonary vein reversal?

Answer 9

MV regurgitation

Question 10

If we had seen a VSD in PLAX or PSAX, what additional image should we take in AP4? How would it be affected by angulation?

Answer 10

-Expand our CD box over the IVS in AP4
-Must make IVS parallel to flow by angling out heart over more in order to best assess the VSD

Question 11

How can we achieve the AP4 pulmonary vein view with CD?

Answer 11

-Increase depth + set box over LA + beyond
-Slight angulation of probe to help bring in PV
-Manipulate CD gains + lower scale to visualize PV blood flow
-RUPV m/c assessed

Question 12

How would the CD flow look with AP4 pulmonary vein?

Answer 12

Red antegrade flow

(abnormal if large amount of blue flow or mosaic colors)

Question 13

Which pulmonary vein is m/c assessed in AP4?

Answer 13

Right upper pulmonary vein (RUPV)

Question 14

Where should we put our CD box when imaging the AP4 TV?

Answer 14

-Place over entire RA + at least half of RV
-TV in middle of box

Question 15

Why would we change our CD scale + shift the baseline to have a different value on the top + bottom of scale?

Answer 15

To show aliasing + regurgitation better when evaluating pathology

Question 16

Where do we put our CD box in AP5?

Answer 16

-Over the SoV to encompass the AoV, LVOT + as much LV as possible
-SoV is m/c in bottom left corner of box

Question 17

What color is flow in AP5?

Answer 17

Retrograde blue flow + some aliasing near the AoV

Question 18

List 3 reasons why some aliasing occurs in AP5?

Answer 18

-Caused by higher velocities
-Mostly parallel angle
-Presence of the AoV

(remember small amounts are normal)

Question 19

List pathology that can be seen within the LVOT in AP5?

Answer 19

-AoV regurg is visible in LVOT
-Aliasing above the AoV, into the LVOT + LV itself can indicate obstructive pathophysiology

-2D can show a thick IVS near LVOT, a membrane, or the AMVL obstructing the area of aliasing in CD

Question 20

What would it look like in color if a thrombus was seen in the LV apex?

Answer 20

-May see aliasing + reversal of flow
-Will see filling defect (no color filling around thrombus)

Question 21

How would regurg + stenosis of the AoV appear on CD in AP5?

Answer 21

Regurg: red/mosaic flow into LV during diastole

Stenosis: blue/mosaic flow through AoV during systole

Question 22

What 4 things other than AoV regurg + stenosis should we watch for within the CD box while in AP5?

Answer 22

-Ao dissection
-IAS (ASD/PFO)
-IVS (VSD, m/c perimembranous)
-MV regurg

Question 23

Where should be put our box when in AP2?

Answer 23

-Place over entire LA + at least half of LV
-MV in middle of box

Question 24

What color is flow in AP2?

Answer 24

Red

Question 25

If we already evaluated the MV with color in AP4, why are we checking it again in AP2?

Answer 25

B/c we are very parallel to flow in AP2, stuff can jump out here + ensures we do not miss anything

Question 26

How would regurg + stenosis look in AP2?

Answer 26

Regurg: blue/mosaic flow into LA during systole

Stenosis: red/mosaic flow into LV during diastole

Question 27

Where should we place CD box in AP3 focusing on MV?

Answer 27

-Place box over entire LA + at least half of LV
-MV in middle of box

Question 28

What color is flow in AP3 when box is over MV?

Answer 28

Red

Question 29

How would regurg + stenosis look in AP3 when box is over MV?

Answer 29

Regurg: blue/mosaic flow into LA during systole

Stenosis: red/mosaic flow into LV during diastole

Question 30

Where should we place CD box in AP3 focusing on AoV?

Answer 30

-Place over SoV to encompass the AoV, LVOT + as much LV as possible
-SoV m/c in bottom right corner of box

Question 31

What color is flow in AP3 when box is over AoV?

Answer 31

Blue, some aliasing may occur close to AoV

(small amount of aliasing due to higher velocities, mostly parallel angle + presence of AoV)

Question 32

Why is AP3 potentially an excellent view for assessing AS/AR/MS/MR/LVOTO?

Answer 32

B/c we are parallel to flow in this view

Question 33

What color would AoV regurg + stenosis be in AP3?

Answer 33

Regurg: red/mosaic flow into LV during diastole

Stenosis: blue/mosaic flow through AoV during systole

Question 34

What 4 things other than AoV regurg + stenosis should we watch for within the CD box while in AP3?

Answer 34

-LVOTO (LVOT obstructions)
-Ao dissection
-IVS (VSD)
-MV regurg

Question 35

What is the most important factor when using CD to ensure accuracy of measurements?

Answer 35

Our alignment of the u/s beam to blood flow

Question 36

How can we help align our u/s beam for CD?

Answer 36

-By tilting + rotating
-Trying multiple views, including off axis imaging

Question 37

If we see something, should we alter our protocol to investigate further?

Answer 37

Yes! Bigger CD boxes often allow us to “catch” pathology we weren’t targeting