Evaluation of size, function, and hemodynamics

Question 1

Subjective assessment: Right parasternal long-axis LV outflow view:
When a clear right ventricular wall is seen; its thickness is usually about ………… the thickness of the LV free wall

Answer 1

When a clear right ventricular wall is seen; its thickness is usually about 1/3 to 1/2 the thickness of the LV free wall.
An increase in right ventricular wall thickness suggests the presence of right ventricular hypertrophy. Fig 4.1

Question 2

The interventricular septum is typically slightly …………… than the LV free wall in dogs and cats.

Answer 2

The interventricular septum is typically slightly thicker than the LV free wall in dogs and cats.

Question 3

In the presence of right ventricular hypertrophy, the interventricular septum may also be hypertrophied so compare the right ventricular wall to the …………

Answer 3

In the presence of right ventricular hypertrophy, the interventricular septum may also be hypertrophied so compare the right ventricular wall to the LV free wall.

When quantitative measurements reveal a thin LV wall, then the relationship of right ventricular wall thickness to the left ventricular wall thickness should be reevaluated.

Question 4

Left ventricular outflow view: subjective assessment in dogs:

Answer 4

There is no curving of the IVS (should be straight)
IVS and LVW are similar in size.
IVS does not extend into LVOT
RW wall is about 1/2 thickness of LVW
RV chamber size is about 1/3 of LV chamber size
LA and AO are similar in size
MV excursion almost to IVS
There are no valvular lesion

Question 5

Displacement of the IVS toward the left side of the heart tends to indicate ….

Answer 5

Right ventricular volume or pressure overload, or in some cases may be a manifestation of left ventricular hypertrophy. Fig 4.4

Question 6

Many normal cats have a slight upward ………. of the interventricular septum (Fig 4.5).

Answer 6

Many normal cats have a slight upward curve of the interventricular septum (Fig 4.5).
The base of the inter ventricular septum in normal cats tends to protrude into the left ventricular outflow tract slightly.

Question 7

Biventricular dilation often keeps the pressure relationship between both ventricles the same, and bowing of the septum will not be present.

Answer 7

Biventricular dilation often keeps the pressure relationship between both ventricles the same, and bowing of the septum will not be present.

Question 8

The relationship of right ventricular size to left ventricular size in a normal heart should be approximately …..to ………

Answer 8

The relationship of right ventricular size to left ventricular size in a normal heart should be approximately 1 to 3.
Fig 4.1, 4.6

Question 9

The interventricular septum in all animals but cats should also not extend into the left ventricular outflow tract.

The width of the outflow tract should be about the same as the wist of the ………….

Answer 9

The interventricular septum in all animals but cats should also not extend into the left ventricular outflow tract.

The width of the outflow tract should be about the same as the wist of the aortic root. Fig 4.7.

Question 10

The relationship of wall thicknesses and chamber sizes are different in neonates.

Answer 10

The relationship of wall thicknesses and chamber sizes are different in neonates.
Right ventricular wall thickness is as great or greater than LV wall thickness in all neonates, and the volume may remain large for several weeks.

Question 11

Assessment of cardiac size in neonates is often a challenge, and unless there is clear pathology, re-evaluation of the heart may be necessary after the animal is 3-6 months old.

Answer 11

Assessment of cardiac size in neonates is often a challenge, and unless there is clear pathology, re-evaluation of the heart may be necessary after the animal is 3-6 months old.

Question 12

Left ventricular outflow view: Assessment cats:

Answer 12

Slight bowing of the IVS is possible
IVS and LVW are similar in size
IVS extends slightly into LVOT
RV wall is about 1/2 thickness of LVW
RV chamber size is about 1/3 of LV chamber size
LA is up to 1,7 times size of the Ao
MV excursion is almost to IVS
There are no valvular lesions.

Question 13

Cats tend to have a larger atrium with respect to the aorta than dogs, and the visual ratio of left atrium to aorta may be 1,6 to 1,0 in healthy cats.

Answer 13

Cats tend to have a larger atrium with respect to the aorta than dogs, and the visual ratio of left atrium to aorta may be 1,6 to 1,0 in healthy cats.
Fig 4,5 and 4,7

Question 14

The ratio of left atrium to aorta in all animals can be deceiving if the aortic root itself is small or large, and so this ratio is only a rough assessment of atrial size.

Answer 14

The ratio of left atrium to aorta in all animals can be deceiving if the aortic root itself is small or large, and so this ratio is only a rough assessment of atrial size.

Question 15

Left atrial size …………… within hours after birth as the ductus and foramen close resulting in …………….. atrial volume so echo exams even at several weeks of age should show the same left atrial to aortic root ration as that seen in mature animals.

Answer 15

Left atrial size decreases within hours after birth as the ductus and foramen close resulting in decreased atrial volume so echo exams even at several weeks gf age should show the same left atrial to aortic root ration as that seen in mature animals.

Question 16

The tip of the septal mitral valve leaflet should almost touch the ventricular septum during diastole. There should be no ……………or ……………… shape to the leaflet at end diastole.

Answer 16

The tip of the septal mitral valve leaflet should almost touch the ventricular septum during diastole. There should be no convex or concave shape to the leaflet at end diastole.
Fig 4.8

Question 17

An abnormal shape at end diastole cold indicate ….(3)?

Answer 17

….decreased LV ejection fraction, severe aortic insufficiency, or mitral stenosis.

Question 18

The valve itself should appear to be the same thickness throughout its length from the base of the leaflet, where it attaches near the aortic root, to its tip. When is this best assessed?

Answer 18

During diastole when the valve is wide open and not during systole when the leaflet edges are touching each other and may appear thick.

Do not mistake chordae teninae for lesions as they extend from the leaflets especially when the valve is closed. (Fig 4.9).

Question 19

Smoke-like echoes of circulating blood have been reported in experimental healthy seated dogs. It is seen more readily with high frequency transducers than low frequency transducers in the same animal because of increased lateral and longitudinal resolution. It has not been reported in clinically healthy unseated or unanesthetized dogs…..(är väl inte så?).

Answer 19

Smoke-like echoes of circulating blood have been reported in experimental healthy seated dogs. It is seen more readily with high frequency transducers than low frequency transducers in the same animal because of increased lateral and longitudinal resolution. It has not been reported in clinically healthy unseated or unanesthetized dogs…..(är väl inte så?).

Question 20

Right parasternal long-axis four chamber view:
Right ventricular chamber size appears slightly larger in right parasternal long-axis four chamber views than in the right parasternal inflow outflow long-axis plane, but the ………..relationship with the left ventricle should still predominate.

Answer 20

Right parasternal long-axis four chamber view.
Right ventricular chamber size appears slightly larger in right parasternal long-axis four chamber views than in the right parasternal inflow outflow long-axis plane, but the 1-to-3 relationship with the left ventricle should still predominate.

Question 21

Right parasternal long-axis four chamber view: The interventricular septum should extend straight to the apex of the heart, parallel to the LV wall with only a slight deviation to the right at the ……. of the septum near the …………………

Answer 21

The inter ventricular septum should extend straight to the apex of the heart, parallel to the LV wall with only a slight deviation to the right at the base of the septum near the mitral valve annulus. Fig 4.10.

Question 22

Right parasternal long-axis four chamber view assessment:

Answer 22

• There is not curving of the IAS or IVS

- There are no valvular lesions.

Question 23

Right parasternal long-axis four chamber view assessment:

-The atrial septum should also be straight with no curvature to the right or left side of the heart.
-There is often a thinner area midway along the atrial septum that at times looks like an opening.
This thin area of tissue is the …………… , the membrane that closed the foramen ovale.

Answer 23

-The atrial septum should also be straight with no curvature to the right or left side of the heart.
-There is often a thinner area midway along the atrial septum that at times looks like an opening. Fig 4.11
This thin area of tissue is the fossa ovals, the membrane that closed the foramen ovale.

The right atrium may appear somewhat smaller than the left atrium in this view.

Question 24

Right parasternal long-axis four chamber view assessment:
The tricuspid annulus is slightly closer to the ……… of the heart than the mitral annulus but not by more than a millimeter or two.

Answer 24

The tricuspid annulus is slightly closer to the apex of the heart than the mitral annulus but not by more than a millimeter or two.

Question 25

Right parasternal long-axis four chamber view assessment: Right ventricular to left ventricular free wall thickness ratios are often easier to visualize in this image plane and should be about .......to..........

Answer 25

Right ventricular to left ventricular free wall thickness ratios are often easier to visualize in this image plane and should be about 0.5 to 1.0

Question 26

The 4 ch view of the heart is excellent for examination of the arterioventricular valves. Valve thickness should remain the same from the base of the leaflet to its tip. The closed AV valve should have a ............. cure toward the ventricular chamber as they extend from the annulus.

Answer 26

The 4 ch view of the heart is excellent for examination of the arterioventricular valves. Valve thickness should remain the same from the base of the leaflet to its tip. The closed AV valve should have a concave cure toward the ventricular chamber as they extend from the annulus. Fig 4.10

Question 27

Right parasternal transverse left ventricle: How should a good transverse view of the LV chamber at the level of the papillary muscles be?

Answer 27

Uniform shortening Circular outer shape Round and symmetrical Mushroom LV internal shape The papillary muscles should be symmetrical and similar in size, The septum should not be flattened. The septum and free wall, excluding the papillary muscles, should be similar in size in small animals.

Question 28

Right ventricular pressure or volume overload often flatten the septum creating a triangular-shaped LV chamber.

Answer 28

Right ventricular pressure or volume overload often flatten the septum creating a triangular-shaped LV chamber.

Question 29

The right ventricular chamber should be .............. in all animals.

Answer 29

The right ventricular chamber should be crescent-shaped in all animals. Transverse sections of papillary muscles and trabecular irregularities on the right ventricular side of the septum are common and normal in this view. Fig 4.13, 4.14

Question 30

Right parasternal transverse heart base: Diameters of the ......... and pulmonary artery at the level of their valves should be similar on right parasternal transverse images of the heart base.

Answer 30

Diameters of the aorta and pulmonary artery at the level of their valves should be similar on right parasternal transverse images of the heart base. Fig 4.15

Question 31

Enlargement of the pulmonary artery may be seen with ........... or ....................

Answer 31

Enlargement of the pulmonary artery may be seen with poststenotic dilation or volume overload.

Question 32

Pulmonary valve cusps often have a slight ................. curvature to them.

Answer 32

Pulmonary valve cusps often have a slight upward curvature to them.

Question 33

Should there be any change in diameter of the pulmonary artery from the level of the pulmonary valve to the bifurcation?

Answer 33

There should be no change in diameter of the pulmonary artery from the level of the pulmonary valve to the bifurcation.

Question 34

Diameters of the aorta and left atrium in the dog should also be fairly close to the same size at the right parasternal transverse heart base:

Answer 34

Diameters of the aorta and left atrium in the dog should also be fairly close to the same size at the right parasternal transverse heart base. The cat has a larger left atrium compared to the aorta.

Question 35

Quantitative measurement of size: The use of tissue harmonic imaging, although it enhances images, does lead to small increase in ......?

Answer 35

The use of tissue harmonic imaging, although it enhances images, does lead to small increase in measurements of wall and septal thicknesses and small decreases in chamber sizes. These differences are probably minimal but should be kept in mind. Reference ranges in this book are derived from fundamental imaging.

Question 36

Measurements of cardiac size obtained from 2D images involve freezing the image at?

Answer 36

End diastole and at end systole.

Question 37

End diastole is identified as the largest LV dimension just before or as the mitral valve?

Answer 37

The mitral valve closes?

Question 38

End systolic frames are identified as the smallest ventricular chamber size just before the mitral valve .....

Answer 38

The mitral valve opens?

Question 39

Measurements of chamber size are obtained from the endocardial surface of the ventricular septum to the endocardial surface of the LV wall.

Answer 39

Measurements of chamber size are obtained from the endocardial surface of the ventricular septum to the endocardial surface of the LV wall. This is called the trailing edge to leading edge method.

Question 40

Left ventricular wall measurements are taken from .....?

Answer 40

Left ventricular wall measurements are taken from the top of the wall, including the endocardial surface to the top of the pericardial sac.

Question 41

Septal measurement however are made from ............?

Answer 41

Septal measurement however are made from the trailing edge of the right side of the septum to the trailing edge of the LV side of the septum. Therefore, the line defining the top of the inter ventricular septum is not included in the septal thickness measurement.

Question 42

Are measuring planes similar for dogs and cats?

Answer 42

Yes. The only exception involves measurement of the LV wall, septum, and chamber from the right parasternal long-axis view in the dog. The measurements in dogs were derived from images that do not have a well-defined aorta, while the measurements in cats were obtained from standard LV inflow imaging planes.

Question 43

Left ventricular chamber, wall, and septum: Measurements of the minor dimension through the LV chamber are made from a right parasternal long-axis view that includes part of the LV outflow tract and aortic valve, the left atrium, and mitral valve.

Answer 43

Measurements of the minor dimension through the LV chamber are made from a right parasternal long-axis view that includes part of the LV outflow tract and aortic valve, the left atrium, and mitral valve. Fig 4.17. A line perpendicular to the septum and the wall just beyond the tips of the mitral valves at the largest LV dimension when they are wide open is used to identify the measurement location for this LV diameter. Advance the image until the largest and smallest chamber sizes corresponding to diastolic and systolic dimensions respectively are identified.

Question 44

The minor chamber size may also be measured from the right parasternal short-axis view of the heart at the level of the chordae tendinae. Fig 4.18.

Answer 44

The minor chamber size may also be measured from the right parasternal short-axis view of the heart at the level of the chordae tendinae. Fig 4.18. A line connecting the septum and wall, dividing the ventricle into equal and symmetrical image halves is used to identify measuring points. The line should be perpendicular to a line connecting the chordae on each side of the image.

Question 45

Wall and septal thicknesses are measured from either long-or short-axis imaging planes along the same lines used to measure ventricular chamber dimensions. The trailing edge method is used for the septum, and the leading edge method is used for the wall.

Answer 45

Wall and septal thicknesses are measured from either long-or short-axis imaging planes along the same lines used to measure ventricular chamber dimensions. The trailing edge method is used for the septum, and the leading edge method is used for the wall.

Question 46

Can LV length be measured using M-mode

Answer 46

LV lenght is a measurement that does not have a corresponding M-mode parameter.

Question 47

LV length measurement is obtained from ..?

Answer 47

The right parasternal long--axis four chamber view or a modified right parasternal long-axis LV outflow view where the LA is no longer visible and only a portion of the ascending aorta is seen. A clear definition of the LV apex should be seen.

Question 48

On the 4 chamber plane, a line defining the mitral annulus is drawn. The measurement of LV length is then made along a line connecting the apex to the point that bisects the annulus equally Fig 4.19

Answer 48

On the 4 chamber plane, a line defining the mitral annulus is drawn. The measurement of LV length is then made along a line connecting the apex to the point that bisects the annulus equally Fig 4.19

Question 49

The measurement of LV length is then made along a line connecting the apex to the point that bisects the annulus equally. On the modified view, 2 slightly different locations may be used to measure LV length. How?

Answer 49

A reference line defining the aortic annulus is drawn. Fig 4.20. One measurement extends from the apex of the LV to a point midway across the aortic valve. Another measurement can be taken along a line that extends from the apex to the point where the aortic valve and mitral valve meet.

Question 50

Can left parasternal apical 4 ch views also be used to measure LV length on?

Answer 50

Left parasternal apical 4 ch views can also be used to measure LV length. Fig 4.21. A reference line is drawn along the ventricular side of the mitral annulus. The length is measured along a line extending from the apex to a point that bisects the reference line in half.

Question 51

LV mass. | Cardiac hypertrophy usually involves an increase in .....

Answer 51

LV wall thickness. It is not always visibly apparanct since there may be wall thinning as the heart dilated. This increase in mass can be quantified by several methods, including angiography, M-mode echo, and 2 D echo.

Question 52

M-mode echo assumes a hypertrophy pattern that remains consistent ....................

Answer 52

M-mode echo assumes a hypertrophy pattern that remains consistent throughout the heart.

Question 53

2 D assessment of the LV mass has proven to be superior to M-mode measurement of mass because the entire geometry of the heart is taken into consideration. 2D methods of determining mass have been tested in the dog and proven to be quite accurate with a correlation coefficient of 0.98 between echo determined ventricular mass and necropsy determined mass in dogs.

Answer 53

2 D assessment of the LV mass has proven to be superior to M-mode measurement of mass because the entire geometry of the heart is taken into consideration. 2D methods of determining mass have been tested in the dog and proven to be quite accurate with a correlation coefficient of 0.98 between echo determined ventricular mass and necropsy determined mass in dogs.

Question 54

Is there an effect of sex on ventricular mass?

Answer 54

No, but there is significant curvilinear or second order correlation between BW and ventricular mass in dogs.

Question 55

Mass determination is an involved process, and it is not routinely performed during a clinical exam. How can this be measured?

Answer 55

External and internal volumes of the heart are measured, and the difference between the 2 should equal myocardial volume. The myocardial volume is the multiplied by density in order to calculate ventricular mass.

Question 56

Mass should remain constant throughout the cardiac cycles, and does so with a high correlation (0.92) between measurements taken in diastole and systole in the dog.

Answer 56

Mass should remain constant throughout the cardiac cycles, and does so with a high correlation (0.92) between measurements taken in diastole and systole in the dog. Papillary muscles and trabecula are easier to differentiate and eliminate in endocardial traces when they are made during diastole however. Measurements are taken in diastole just before atrial contraction. This created the least amount of cardiac motion and the best visualization of muscle boundaries.

Question 57

Only one method of mass determination using the long-axis and transverse views will be described here, but 2 methods of measurement for mass determination have been studied in the dog. One is based on an assumption that the heart is shaped like a truncated ellipse. The other uses basically the same approach to mass determination but follows a simpler area length methodology. Is one more accurate than the other?

Answer 57

Neither is more accurate than the other.

Question 58

The truncated ellipse has proven to eb accurate in both normal and hypertrophied canine hearts and during both diastole and systole. Fig 4.22. How is volume determined?

Answer 58

Volume is determined from the longest possible apical 4-ch view of the heart. This method of analysis requires measurements of chamber size to be taken along 3 directions on the apical 4 ch view.

Question 59

Fig 4.22: The minor axis is located at the tip of the papillary muscles at the point of chordal attachment (b). The long axis of the heart is divide into both a semi major (a) and a truncated semi major axis (d).

Answer 59

Fig 4.22: The minor axis is located at the tip of the papillary muscles at the point of chordal attachment (b). The long axis of the heart is divide into both a semi major (a) and a truncated semi major axis (d).

Question 60

Fig 4.22: The minor axis is the dividing line between the semi major axis and the truncated semi major axis. The minor axis is also represented by the diameter of the LV on both long-and short-axis views of the heart at the level of the chordae.

Answer 60

Fig 4.22: The minor axis is the dividing line between the semi major axis and the truncated semi major axis. The minor axis is also represented by the diameter of the LV on both long-and short-axis views of the heart at the level of the chordae.

Question 61

Fig 4.22: In addition to the measurements of LV length and width, wall thickness (t) is measured. On the transverse plane at the tips of papillary muscles, both the epicardial and endocardial surfaces are traced. The papillary muscles and any trabeculae are not included in the trace. Subtracting the systolic area from the diastolic area gives a mean wall thickness measurement. All the measurements are inserted into the equation shown in fig 4.22 to calculate volume.

Answer 61

In addition to the measurements of LV length and width, wall thickness (t) is measured. On the transverse plane at the tips of papillary muscles, both the epicardial and endocardial surfaces are traced. The papillary muscles and any trabeculae are not included in the trace. Subtracting the systolic area from the diastolic area gives a mean wall thickness measurement. All the measurements are inserted into the equation shown in fig 4.22 to calculate volume.

Question 62

The equation calculated volume of the LV when the epicardium is traced and volume of the ventricle when the endocardium is traced. Subtracting the 2 volumes results in volume of the ventricular myocardium. Mass is then calculated by multiplying the volume by myocardial specific gravity, which is?

Answer 62

Mass = 1.05 V The echo derived mass has an excellent correlation with post mortem mass (r = 0.98) in dogs.

Question 63

Once echo mass is determined, the value is inserted into a regression equation that correlates echo-derived mass to actual post mortem mass as follows?

Answer 63

Echo mass = 0.9 (actual weight) + 4.2 Where actual weight is in kg.

Question 64

Aorta and left atrium: | Left atrial size can be measured from the ?

Answer 64

Right parastenral long-axis 4 ch view in the dog. Fig 4.19

Question 65

A reference line connecting the mitral annulus is drawn on the atrial side of the valve. The anterior posterior dimension of the LA is measured by drawing a line that as closely as possible bisects the atrium into equal halves and is parallel to the line defining the annulus.

Answer 65

A reference line connecting the mitral annulus is drawn on the atrial side of the valve. The anterior posterior dimension of the LA is measured by drawing a line that as closely as possible bisects the atrium into equal halves and is parallel to the line defining the annulus.

Question 66

An apical basilar dimension may also be measured on 2D images. How is this done?

Answer 66

By drawing a line perpendicular to the line defining the annulus and again dividing the atria as closely as possible into equal halves. Fig. 4.19. The apical basilar measurement extends from the base of the atrium to the reference line, and not the valve leaflet themselves.

Question 67

The LA in dogs may also be measured on...?

Answer 67

Left parasternal apical 4 ch views, which maximize LA size. Fig 4.21 This plane may be slightly different than the one used to measure LV length since each chamber should be maximized for the parameter to be measured.

Question 68

Left parasternal apical 4 ch views: A line defining the mitral annulus on the atrial side is used as a reference for the other measuring points. The basal apical measurement is made from a line that as closely as possible divides the atrium into equal halves and is perpendicular to the reference line. The basal apical measurement starts at the base of the atrial septum and stops at the reference line. A lateral medial measurement can also be made. This is done from aline that divides the atrium into equal halves and is parallel to the reference line at the annulus.

Answer 68

A line defining the mitral annulus on the atrial side is used as a reference for the other measuring points. The basal apical measurement is made from a line that as closely as possible divides the atrium into equal halves and is perpendicular to the reference line. The basal apical measurement starts at the base of the atrial septum and stops at the reference line. A lateral medial measurement can also be made. This is done from aline that divides the atrium into equal halves and is parallel to the reference line at the annulus.

Question 69

Which view is used instead of the long-axis 4 ch view to measure LA size in cats?

Answer 69

The long-axis LV inflow outflow view. The frame just before mitral valve opening is used. The largest LA dimension is measured along a line that is parallel to the mitral annulus. Aortic root size from right parasternal long-axis are made at both the level of the valve and at the maximum distance across the sinus of Valsalva. Fig 4.23

Question 70

Which imaging plane is use to measure LA size in dog and cat?

Answer 70

The transverse image at the level of the aorta and LA. All 3 aortic valve cusps must be seen with symmetry. In other words, all cusps should be relaivel equal in size. This assures that the image is a s close to a true transverse imaging plane as possible. The left auricular appendage and atrial septum should also be clearly seen.

Question 71

The frame just after aortic valve closure is selected, and the LA is measured along a line that is an extension of the line that defines the junction between the non coronary and left coronary cusps.

Answer 71

The frame just after aortic valve closure is selected, and the LA is measured along a line that is an extension of the line that defines the junction between the non coronary and left coronary cusps. Fig 4.24

Question 72

The area of the LA may be obtained from any of these planes. Fig 4.24, 4.25. Trace the endocardial surface of the LA along the inside of the mitral valve and exclude the pulmonary veins.

Answer 72

The area of the LA may be obtained from any of these planes. Fig 4.24, 4.25. Trace the endocardial surface of the LA along the inside of the mitral valve and exclude the pulmonary veins. Area calculation of the aortic root is made at the level of the valves on transverse images.

Question 73

2D transverse heart base: LA/AO: Image

Answer 73

- All 3 aortic valve cusps seen - Good atrial septum seen - Good left auricle seen - First frame just after AO valve closes

Question 74

2D transverse heart base: | Measurement location:

Answer 74

- Measure AO along line defined by the non coronary and right coronary cusps - Measure LA along line defined by non coronary and left coronary cusps. - Internal dimensions.

Question 75

Aortic root measurements are made from a right parasternal long-axis view that maximizes the aorta at the expense of the left atrium. Fig 4.23

Answer 75

Aortic root measurements are made from a right parasternal long-axis view that maximizes the aorta at the expense of the left atrium. Fig 4.23 A well-defined aorta and 2 valve cusps should be seen. A line defining the annulus is used to measure the aortic diameter. Additionally, the distance across the sinus of Valsalva can also be measured. The largest dimension is selected and is measured along a line parallel to the one defining the aortic valve annulus.

Question 76

The left parasternal long-axis LV outflow view is also used to measure aortic root size. The annulus is measured on the aortic side of the valve, and this is also used as a reference line. Fig 4.26.

Answer 76

The left parasternal long-axis LV outflow view is also used to measure aortic root size. The annulus is measured on the aortic side of the valve, and this is also used as a reference line. Fig 4.26. The ascending aorta distal to the sinus may also be measured. Divide the measurement of the sinus of Valsalva in half and measure the ascending aorta that far away from the line that defined the measurement for the sinus.

Question 77

Planimetry of the aorta is done on either the right or left parasternal transverse views of the aorta. Fig 4.24. Trace along the internal surface of the aorta at the level of the aortic valve cusps.

Answer 77

Planimetry of the aorta is done on either the right or left parasternal transverse views of the aorta. Fig 4.24. Trace along the internal surface of the aorta at the level of the aortic valve cusps.

Question 78

Right ventricular chamber measurement is typically obtained from the ....

Answer 78

Apical 4 ch view.

Question 79

Measurement of the right ventricular chamber is made across the width of the tricuspid valve annulus and the ..... ventricular chamber, and length is measured from the annulus to the apex.

Answer 79

Measurement of the right ventricular chamber is made across the width of the tricuspid valve annulus and the mid ventricular chamber, and length is measured from the annulus to the apex.

Question 80

Normal reference ranges of the right ventricular chamber are limited in animals, but linear changes in size can be used in the individual animal.

Answer 80

Normal reference ranges of the right ventricular chamber are limited in animals, but linear changes in size can be used in the individual animal.

Question 81

Wall thickness of the right ventricular chamber is measured from parasternal 2 D 4 ch images at the level of the tricuspid valve chordae tendinae. Be careful not to include trabeculae.

Answer 81

Wall thickness of the right ventricular chamber is measured from parasternal 2 D 4 ch images at the level of the tricuspid valve chordae tendinae. Be careful not to include trabeculae.

Question 82

Evaluation of quantitative measurements: | Parameters of ventricular size correlate to ................

Answer 82

Evaluation of quantitative measurements: | Parameters of ventricular size correlate to body surface area (BSA).

Question 83

Ratios of LA to aorta and wall thickness to chamber size do not correlate with body size, nor does any parameter of function.

Answer 83

Ratios of LA to aorta and wall thickness to chamber size do not correlate with body size, nor does any parameter of function.

Question 84

Evaluation of quantitative measurements: DOGS: Systolic and diastolic dimensions derived from short-axis views tend to be slightly......than those obtained from long-axis views, but the difference is not significant and the correlation between chamber sizes and wall thicknesses obtained from long-versus short-axis images are high with correlation coefficients of 0.93 for diastolic dimensions, 0.88 for systolic dimensions, 0,95 for diastolic wall thickness, and 0.86 for systolic wall thickness.

Answer 84

greater

Question 85

Evaluation of quantitative measurements: DOGS: Septal thickness measurements also show no significant difference between imaging planes, but the correlation coefficients were slightly lower.

Answer 85

Septal thickness measurements also show no significant difference between imaging planes, but the correlation coefficients were slightly lower.

Question 86

Evaluation of quantitative measurements: DOGS: There are also no sign differences between measurements taken from right or left parasternal imaging planes for the LA and aorta.

Answer 86

There are also no sign differences between measurements taken from right or left parasternal imaging planes for the LA and aorta.

Question 87

Evaluation of quantitative measurements: DOGS: Ventricular lengths during diastole and systole show no sign differences between any of the three measuring techniques on right parasternal images.

Answer 87

Ventricular lengths during diastole and systole show no sign differences between any of the three measuring techniques on right parasternal images. However, the right parasternal images were much better than left parasternal images for measuring length since the left parasternal images tended to foreshorten the ventricular chamber.

Question 88

Evaluation of quantitative measurements: Cats: Mean values from long-and short-axis planes are not sign different. There is no sign correlation between BSA or weight and parameters of cardiac size in the cat. This is probably due to the small weight range within the adult cat population.

Answer 88

Mean values from long-and short-axis planes are not sign different. There is no sign correlation between BSA or weight and parameters of cardiac size in the cat. This is probably due to the small weight range within the adult cat population.

Question 89

2D and M-mode measurements in cats are very similar, bot the closet relationshop appears between measurements taken from 2D short axis measurements and M-mode values.

Answer 89

2D and M-mode measurements in cats are very similar, bot the closet relationshop appears between measurements taken from 2D short axis measurements and M-mode values. (M-modes in the reported sutyd were however, not obtained with 2D guidance.

Question 90

Measurement and assessment of M-mode images. | Recommendations in man set by?

Answer 90

The american society of echocardiography (ASE). The same guidelines are followed for veterinary species. The guidelines are made because they generated the least variability among human echocardiographers.

Question 91

The ASE recommends that all diastolic measurements should be made at the .......of the QRS complex.

Answer 91

onset

Question 92

Value of using the ECG for timing and measurements purposes?

Answer 92

Using the ECG for timing and measurements purposes assures consistency in measuring methods among examiners as well as providing greater accuracy in comparing measurements from serial examinations in the same patient.

Question 93

When an ECG is not recorded on the M-mode image, use the largest ventricular dimension for diastolic measurements.

Answer 93

When an ECG is not recorded on the M-mode image, use the largest ventricular dimension for diastolic measurements. In man, very little difference is found between measurements made by the beginning of the QRS complex and those made at the largest ventricular dimension except in children where there is a greater increase in dimension at the very end of diastole.

Question 94

The ASE also adheres to a measuring method referred to as the leading edge theory. This means?

Answer 94

This means that measurements are mad from leading or top edge of one structure to the leading edge of the next structure.

Question 95

Value of the leading edge theory?

Answer 95

This helps eliminate any variability in boundary thickness created by different ultrasound equipment as well as differences in gain settings, both of which may increase the perceived thickness of structures.

Question 96

The ASE recommends making measurements at end-respiration. At least 3-5 cardiac cycles should be used, and averaged for each measurement. Value of this strategy?

Answer 96

This should negate any effects of respiration and changes in filling secondary to sinus arrhythmias.

Question 97

M-modes may be obtained and measured from long-or short-axis views. Studies comparing M-mode values to 2D measurements found better correlation between short-axis M-mode and 2D measurements but the M-modes were not obtained with RT guidance.

Answer 97

M-modes may be obtained and measured from long-or short-axis views. Studies comparing M-mode values to 2D measurements found better correlation between short-axis M-mode and 2D measurements but the M-modes were not obtained with RT guidance.

Question 98

Care to obtain very specific sites and planes when placing the M-mode cursor over cardiac structures on either the long or short-axis views should yield similar values. Normal values have been generated using both methods.

Answer 98

Care to obtain very specific sites and planes when placing the M-mode cursor over cardiac structures on either the long or short-axis views should yield similar values. Normal values have been generated using both methods.

Question 99

The goals when obtaining 2D images for generation of M-mode images are to maximize LV size on long-axis LV outflow and to minimize it on transverse LV views.

Answer 99

The goals when obtaining 2D images for generation of M-mode images are to maximize LV size on long-axis LV outflow and to minimize it on transverse LV views.

Question 100

What is anatomic M-mode?

Answer 100

Anatomic M-mode is the ability of ultrasound technology to create M-modes from saved echo 2D video lopps. The cursor can be manipulated to align across the 2D structures in directions different from the axis of the ultrasound beam. Anatomical M-mode can be superior to conventional M-mode if the 2D image is of high enough quality and if the angle of correction is less than 30 grader.

Question 101

All parameters of chamber size and wall thickness in the dog have a linear or logarithmic relationship with weight and BSA. Is the correlation coefficients for these cardiac dimensions with weight or body surface area similar?

Answer 101

The correlation coefficients for these cardiac dimensions with weight or body surface area are very similar. The difference in actual measurements is minimal with most predictions for normal ranges falling within 2 mm of each other when using either method. In order to make application of the data easier in the adult dog, the appendix includes charts with normal ranges for each parameter at each BSA. weights corresponding to each BSA are included in the charts. See appendix.

Question 102

Is there a correlation between feline heart dimensions and body size?

Answer 102

There is a correlation between feline heart dimensions and body size, but the correlation is weak, probably due to the small degree of variation in weight.

Question 103

Values corresponding to cardiac parameter ro BSA or weight are generally not used, and a single reference range for each variable is used for all cats.

Answer 103

Values corresponding to cardiac parameter ro BSA or weight are generally not used, and a single reference range for each variable is used for all cats.

Question 104

Cardiac dimensions obviously must increase as an animal grows, and several studies have been performed in puppies with established growth-related changes in cardiac dimensions and function. Which dimension is the only one increasing with advancing age after the animal reaches maturity?

Answer 104

Only the left ventricular wall thickness. All other parameters appear to remain static during the aging process. Some puppies have there owns reference values. Such as Bull Mastiffs Spanish masitff English pointer Portugese water dog.

Question 105

Inverse relationships exist for HR and weight, LV systolic and diastolic dimensions, and LA size. The effect of HR on ventricular dimension is ......however.

Answer 105

Nominal

Question 106

Each individual M-mode measurement of size and function is just one piece of the puzzle and should not be used alone when making an echo interpretation. All the onto should be put tighter and analyzed as a whole. The entire set of data should fit tighter logically. If some info does not fit the puzzle, technical error maybe a factor, but just as likely another problem is present that has not been identified.

Answer 106

Each individual M-mode measurement of size and function is just one piece of the puzzle and should not be used alone when making an echo interpretation. All the onto should be put tighter and analyzed as a whole. The entire set of data should fit tighter logically. If some info does not fit the puzzle, technical error maybe a factor, but just as likely another problem is present that has not been identified.

Question 107

Left ventricular M-modes are obtained from 2D images with the cursor placed .............?

Answer 107

Left ventricular M-modes are obtained from 2D images with the cursor placed between the papillary muscles and the tip of the mitral valve leaflets. Fig 4.27 This location is easier to identify on long-axis LV inflow outflow images. Maximize the length and width of the LV chamber when using the long-axis view.

Question 108

How should you know that the longest, widest left ventricular chamber has been obtained?

Answer 108

When the septum and left ventricular wall are parallel to each other on the long-axis image, the longest, widest left ventricular chamber has been obtained, even if the apex of the heart is not in the sector image. Make sure that the aortic valve is seen and that mitral valve is moving well when using this imaging plane to generate M-modes. The cursor should be perpendicular to the LV wall.

Question 109

M-mode measurement of the LV: From the long axis:

Answer 109

``` LV inflow outflow vies Maximize length and width of LV No curve to LV wall Good MV motion Aortic valve in middle of aorta ```

Question 110

M-mode measurement of the LV: From the short axis:

Answer 110

Level of chordae tendinae Smallest symmetrical chamber See a good RV

Question 111

When a transverse image is used to create LV M-mode, fan the transducer between the level of the papillary muscles and the mitral valve until a good image of the ...... are obtained within a symmetrical circular LV chamber. Obtain the .......... LV chamber at the level of the chordae.

Answer 111

When a transverse image is used to create LV M-mode, fan the transducer between the level of the papillary muscles and the mitral valve until a good image of the chordae are obtained within a symmetrical circular LV chamber. Obtain the smallest LV chamber at the level of the chordae. This assures that the image is obtained along the true transverse image.

Question 112

M-mode measurement of the LV: From the short axis: | If the imaging plane is oblique to the true transverse plane of the LV chamber, the diameter will be .........

Answer 112

If the imaging plane is oblique to the true transverse plane of the LV chamber, the diameter will be larger.

Question 113

M-mode measurement of the LV: From the short axis: The right ventricular chamber should be seen at the top of the sector image with enough space to show a clearly defined top to the interventricualr septum.

Answer 113

The right ventricular chamber should be seen at the top of the sector image with enough space to show a clearly defined top to the interventricualr septum.

Question 114

If the right ventricle is not appreciated well, the transducer is probably too .....

Answer 114

close to the apex of the heart. Twist the transducer to the long axis; if the apex is higher on the sector image than the base of the heart, the transducer is too close to the apex and not under the middle of the heart.

Question 115

The M-mode cursor should bisect the left ventricular chamber into equal and symmetrical halves, and be perpendicular to a line that connects the chordae tendinae.

Answer 115

The M-mode cursor should bisect the left ventricular chamber into equal and symmetrical halves, and be perpendicular to a line that connects the chordae tendinae.

Question 116

The M-mode image can show some chordae teninae within the left ventricular chamber. Fig 4.28-4.29.

Answer 116

The M-mode image can show some chordae teninae within the left ventricular chamber. Fig 4.28-4.29.

Question 117

In small animals like kittens and very young puppies, the distance between the mitral valve and papillary muscles is often much closer and more mitral valve is recorded in M-modes of the LV. The recommendation by the ASE is to ..............?

Answer 117

The recommendation by the ASE is to record and measure the LV at the level of the mitral valve tips/chordae in young children and infants. This may be necessary in many puppies and kittens although no standard have been set.

Question 118

When LV images are not oriented on the sector to allow perpendicular placement of the M-mode cursor to the septum and LV free wall, more accurate measurements of size and function will be obtained from the 2D image itself.

Answer 118

When LV images are not oriented on the sector to allow perpendicular placement of the M-mode cursor to the septum and LV free wall, more accurate measurements of size and function will be obtained from the 2D image itself. Use a cine loop if available and advance the loop frame by frame until the largest and smallest LV dimensions are identified for measurements.

Question 119

While the ASE recommend measuring diastolic chamber dimensions at the ................, the recommendation for measurement of systolic chamber size is at the ................... Fig 4.30

Answer 119

While the ASE recommend measuring diastolic chamber dimensions at the beginning of the QRS complex, the recommendation for measurement of systolic chamber size is at the peak downward point of septal motion. Fig 4.30 The free wall should be used when septal motion is abnormal.

Question 120

Measurements should be made straight up or down from whatever point is selected, do not move diagonally across the ventricular chamber from septum to wall.

Answer 120

Measurements should be made straight up or down from whatever point is selected, do not move diagonally across the ventricular chamber from septum to wall.

Question 121

Diastolic and systolic LV chamber measurements are made from the top of the ............. surface of the LV side of the septum to the top of the .................

Answer 121

Diastolic and systolic LV chamber measurements are made from the top of the endocardial surface of the LV side of the septum to the top of the LV free wall. Therefore, a small amount of septal thickness is included in LV chamber dimension measurements.

Question 122

Free wall and septal thciknesses are measured along the same lines that chamber dimensions are obtained. The inter ventricular septum is measured from ........................to the................ during both systole and diastole.

Answer 122

Free wall and septal thciknesses are measured along the same lines that chamber dimensions are obtained. The inter ventricular septum is measured from the top of the septum to the top of the endocardial surface at the bottom of the septum during both systole and diastole.

Question 123

The LV free wall measurement starts at ............. and goes down to ...............defining the .....................

Answer 123

The LV free wall measurement starts at the top of the LV wall and goes down to the top of the bright line defining the pericardial sac.

Question 124

Wall and septal excursion measurements are sometimes made from M-mode images. These measure the greatest distance the wall makes upward during systole and the septum

Answer 124

Wall and septal excursion measurements are sometimes made from M-mode images. These measure the greatest distance the wall makes upward during systole and the septum makes downward during systole.

Question 125

Fig 4.31 shows an appropriate M-mode image for measurement. Clear boundaries are present as well as some chordae within the LV chamber.

Answer 125

M-mode image for measurement. Clear boundaries are present as well as some chordae within the LV chamber.

Question 126

Measuring pitfalls: Whenever images are not ideal or you are not comfortable with the M-mode cursor angle through the heart, it is better not to make the measurement than to base a diagnosis on potentially erroneous information.

Answer 126

Whenever images are not ideal or you are not comfortable with the M-mode cursor angle through the heart, it is better not to make the measurement than to base a diagnosis on potentially erroneous information.

Question 127

Breathening can create many artifactual motion abnormalities on the M-mode image.

Answer 127

Fig 4.32 shows how wall and septal motions are altered secondary to respiration. This kind of motion is seen even if the animal is not panting. Momentarily placing a hand over the animal's nostrils while 3 or 4 cardiac cycles are recorded on the M-mode can usually eliminate this artifact.

Question 128

Which is the most common problem during measurement of LV M_modes?

Answer 128

Defining septal and wall boundaries.

Question 129

The .............. side of the septum is the hardest to define?

Answer 129

The right ventricular side of the septum is the hardest to define?

Question 130

Why is the right ventricular side difficult to define?

Answer 130

- Right ventricular hypertrophy with prominent papillary muscles and trabeculae - Left ventricular dilation - Poor technique ..all contricute to ambiguity in identifying the right side of the septum. Fig 4.33, 4.34 Take care to identify and separate the right ventricular papillary muscle from the septum.

Question 131

When an M-mode has an ill-defined inter ventricular septum, move the image into a more horizontal position across the sector by sliding the transducer dorsal and cranial on the thorax in order to define the right ventricle and the septal boundaries better.

Answer 131

When an M-mode has an ill-defined inter ventricular septum, move the image into a more horizontal position across the sector by sliding the transducer dorsal and cranial on the thorax in order to define the right ventricle and the septal boundaries better.

Question 132

The LV wall i usually easier to obtain on M-modes, but at times............. or ............. may create ambiguous measuring points.

Answer 132

The LV wall i usually easier to obtain on M-modes, but at times chordae tendinae or papillary muscles may create ambiguous measuring points. Papillary muscles appear as thick layers of muscles above the free wall, usually during systole, but sometimes throughout both phases of cardiac cycle. Fig 4.36. Fig 4.35.

Question 133

Chordae tendinae generally follow wall motion, but they have a ................ upward rate of motion during systole.

Answer 133

slower

Question 134

If wall thickness appears to be greater than septal thickness and 2D image do not support this finding, ........is probably included in LV wall thickness measurements.

Answer 134

papillary muscle Elongate the LV by rotating the transducer or by lifting the transducer into a more horizontal position, creating better mitral valve motion. This will generally eliminate papillary muscle from the 2D image.

Question 135

M-mode assessment. LV diastolic dimension is used to determine the presence or absence of LV volume overload. Can systolic dimensions be used to assess the presence or absence of dilation?

Answer 135

Systolic dimensions are a reflection of systolic function in the heart and should not be used to assess the presence or absence of dilation. The same principle applies to wall and septal thickness measurements.

Question 136

The presence or absence of hypertrophy should be determined from ......

Answer 136

diastolic measurements of thickness.

Question 137

Systolic measurements are a reflection of systolic function, so increased thickness during systole may simple reflect increased function as opposed to ......

Answer 137

hypertrophy. Hypertrophy does increase systolic thickness but the effect of increased systolic function cannot be separated from the effects of hypertrophy.

Question 138

Evaluation of chamber size: use......dimension

Answer 138

diastplic LV

Question 139

Assessment of wall thickness

Answer 139

Use diastolic VS and LVW thicknesses | Use LVW to LVd ratio

Question 140

Can right ventricular wall thickness and chamber size be measured from LV M-modes?

Answer 140

Yes, but there is a great variability in these measurements because of a low ratio of wall thickness to chamber size creating high wall stress.

Question 141

Hearts with aortic stenosis or systemic hypertension should have increased wall thickness to chamber size ratios. The hypertrophy is an appropriate compensatory mechanism in response to the high ............. thus normalizing wall stress.

Answer 141

The hypertrophy is an appropriate compensatory mechanism in response to the high after load thus normalizing wall stress.

Question 142

In the dog and cat, the inter ventricular septum is typically only slightly ............ than the free wall.

Answer 142

thicker

Question 143

...............have increased LV dimensions and wall thicknesses compared to other dogs of the same weight. This difference exists whether the greyhound is a racing or a non racing animal.

Answer 143

Greyhounds In man, the effects of exercise on the heart regress after several weeks of non exercising, but the increased dimensions and hypertrophy persist in these greyhounds despite a sedentary lifestyle.

Question 144

Measurements of wall and septal excursions are a reflection of volume changes within the ventricular chamber. Greater volume changes create ............. wall and septal excursion than smaller volume changes.

Answer 144

Greater volume changes create greater wall and septal excursion than smaller volume changes.

Question 145

When the LV is volume contracted for any reason, wall motion abnormalities become evident, which can mimic cardiac disease.

Answer 145

If measruemtnes of ventricular size are smaller than normal and the animal is possibly dehydrated, or has any reason to be volume contracted, repeat the echo exam after the volume depleted state has been corrected.

Question 146

Mitral valve: Before the advent of Doppler echo, the mitral valve M-mode was analyzed for rate of opening and closing as well as excursion distances. How are the normal ranges for these parameters. Why?

Answer 146

Very wide since the effects of HR and pressure differentials on how fast or slow the valve opens and closes are pronounced. 2D and Doppler echo have provided greater accuracy in assessing movement and flow through the valve. Mitral valve M-modes are still valuable however, for detecting subtle movement alterations created by altered flow through and around the valve.

Question 147

....................... and ................ are 2 findings that are easily seen on M-mode images and in the absence of Doppler provide important hemodynamic info.

Answer 147

Systolic anterior motion and diastolic flutter are 2 findings that are easily seen on M-mode images and in the absence of Doppler provide important hemodynamic info.

Question 148

One very consistent and popular mitral valve measurement is the EPSS

Answer 148

E point to septal separation = EPSS. | Fig 4.37.

Question 149

The EPSS is the shortest distance from the E point of the ............... to the .....................

Answer 149

The EPSS is the shortest distance from the E point of the mitral valve to the ventricular septum

Question 150

The EPSS measurement is easy to make and is an indicator of?

Answer 150

LV filling and function

Question 151

Cardiac pathology may increase, decrease, or not affect EPSS, but EPSS has strong negative correlation to .................... in the absence of aortic and mitral insufficiencies.

Answer 151

Cardiac pathology may increase, decrease, or not affect EPSS, but EPSS has strong negative correlation to ejection fraction in the absence of aortic and mitral insufficiencies. Fig 4.38

Question 152

The EPSS has strong negative correlation to EF in the absence of aortic and mitral insufficiencies, which is based upon the fact that flow into the ventricle is equal to flow leaving the ventricle. In the presence of high ................. LV filling pressure, such as in DCM, flow from the LA to the LV is reduced and consequently flow out of the LV is also reduced.

Answer 152

In the presence of high diastolic LV filling pressure, such as in DCM, flow from the LA to the LV is reduced and consequently flow out of the LV is also reduced.

Question 153

EPSS: Indicator of LV ...... and ..........

Answer 153

EPSS: Indicator of LV filling and function

Question 154

EPSS: Increased EPSS = ................... ejection ejection fraction.

Answer 154

EPSS: Increased EPSS = decreased ejection ejection fraction.

Question 155

Normal canine EPSS =

Question 156

Studies in man and dogs have shown that EPSS accurately separates normal from abnormal LV ...............regardless of LV size when dilation is present.

Answer 156

accurately separates normal from abnormal LV function regardless of LV size when dilation is present.

Question 157

................, however, restricts valve motion and may decrease EPSS-

Answer 157

Hypertrophy

Question 158

Is EPSS also valid for assessing LV function in the presence of abnormal septal motion?

Answer 158

Yes, EPSS is also valid for assessing LV function in the presence of abnormal septal motion.

Question 159

Is body size generally considered when assessing normal EPSS value?

Answer 159

EPSS shows a very weak correlation to BSA and weight in some studies and no correlation in other, so body size is generally not considered when assessing normal EPSS value.

Question 160

While an inverse correlation of EPSS to heart rate has been shown in one study, another shows no effects of breed, age, sex, mass, or HR on EPSS.

Answer 160

Any correlation is weak and is probably not significant enough to warrant adjustment of normal values for the animal's weight or HR.

Question 161

EPSS: E= ..... | A= ...........

Answer 161

``` E= early diastolic mitral valve motion, A= Late diastolic mitral valve motion. ```

Question 162

Left atrium and aorta measurement can be measured using M-mode: Left atrium is imaged on M-mode as the largest LA dimension at end-............... from the top of the posterior aortic wall to the top of the pericardium. Fig 4.39

Answer 162

Left atrium is imaged on M-mode as the largest LA dimension at end systole from the top of the posterior aortic wall to the top of the pericardium. Fig 4.39

Question 163

M-mode: Left atrial wall thickness is generally not recorded well, and the.............. provides a consistent easily visualized atrial boundary.

Answer 163

Left atrial wall thickness is generally not recorded well, and the pericardium provides a consistent easily visualized atrial boundary.

Question 164

Although the LA may enlarge in planes other than that recorded for M-mode images, it is generally a clinically useful indicator of LA size. Why is it so?

Answer 164

because the LA can dilate in planes other than the ones used for this M-mode measurement, the absence of dilation should not be based upon this number alone. Evaluate 2D as well

Question 165

The aorta is measured from the top of the anterior aortic wall to the top of the posterior wall at end-............... Ideally 2 aortic valve cusps should be seen in order to minimize angle problems.

Answer 165

The aorta is measured from the top of the anterior aortic wall to the top of the posterior wall at end-diastole. Ideally 2 aortic valve cusps should be seen in order to minimize angle problems.

Question 166

Left ventricular ejection time is measured at the aortic valve from the time it ............. to the time it ............... Fig 4.39.

Answer 166

Left ventricular ejection time is measured at the aortic valve from the time it opens to the time it closes. Fig 4.39. A perfect aortic valve is not required, but clear definition of when it opens and when it closes is necessary.

Question 167

Pre-ejection time can only be measured when an electrocardiogram is used on the echocardiogram. The measurement is made from the beginning of the ............... ............. to where the ................valve opens. This time period is very similar to the isovolumetric .............. period where both the aortic and mitral valves are closed and the ventricle is building up enough pressure to open the aortic valves.

Answer 167

Pre-ejection time can only be measured when an electrocardiogram is used on the echocardiogram. The measurement is made from the beginning of the QRS complex to where the aortic valve opens. Fig 4.39. This time period is very similar to the isovolumetric contraction period where both the aortic and mitral valves are closed and the ventricle is building up enough pressure to open the aortic valves.

Question 168

There is a positive correlation between aortic and LA dimensions with weight and BSA, in dogs and cats, and a ratio of LA to .............. size may be used as an indicator of how severe the atrial dilation is.

Answer 168

There is a positive correlation between aortic and LA dimensions with weight and BSA, in dogs and cats, and a ratio of LA to aortic root size may be used as an indicator of how severe the atrial dilation is.

Question 169

It is wise to assess aortic root size before using the ratio (LA/Ao). A small aorta may be seen in animals with ............. output failure, and the LA to aortic root ratio will reflect greater LA enlargement than is actually present.

Answer 169

A small aorta may be seen in animals with low output failure, and the LA to aortic root ratio will reflect greater LA enlargement than is actually present.

Question 170

Left atrial size is very similar to aortic root size in dogs (range LA/Ao= 0.83-1.13), while in cats the left atrium may be much larger than the aorta (range LA/Ao 0.88-1.79)

Answer 170

Left atrial size is very similar to aortic root size in dogs (range LA/Ao= 0.83-1.13), while in cats the left atrium may be much larger than the aorta (range LA/Ao 0.88-1.79)

Question 171

Ratio indices: There are instances when the subjective assessment of ventricular and atrial size do not match. This is especially true in ......? (3)

Answer 171

giant and small breeds and in overweight animals. M-mode ratio indices may be more accurate in such unusual body types.

Question 172

M-mode dimensions of each parameter are divided by either?

Answer 172

the pure aortic root M-mode measurement or a weight-based aortic value.

Question 173

The weight-based aortic index is calculated as follows:?

Answer 173

AOw = kW upphöjt i 1/3. where W = weight in kg k = a constant for each species (dogs 0 0.795, cats 0.567) The constant was derived from the average value in each species of the raw aortic root measurement divide by W upphöjt i 1/3.

Question 174

The weight-based aortic root measurement is similar to using BSA as a correlation except that it is a ............ assessment versus an ............... assessment.

Answer 174

The weight-based aortic root measurement is similar to using BSA as a correlation except that it is a linear assessment versus an area assessment.

Question 175

BSA is calculated as ....?

Answer 175

BSA = kW upphöjt i 2/3. where k is a constant in dogs equaling 0.101 and weight is in kg.

Question 176

Se s 185: ex of the weighed assessment method.

Answer 176

se s 185: ex of the weighed assessment method.

Question 177

The normal range for weighted LV size in diastole is?

Answer 177

1.305-1.861

Question 178

Se s 185 for an ex of the M-mode aortic measurement without consideration for weight.

Answer 178

This method of evaluation seems superior to raw M-mode measures when compared to studies that used linear regr analysis of parameter to BW or BSA. The study was published prior to logarithmic correlation f M-mode parameters to weight in dogs. In dogs, the weight-based aortic indices seem superior to raw aortic root rations in that smaller ranges and standard deviations are found. Using aortic root ratio indices in cats did not add any more accuracy to measurements, presumably because of the narrow weight range, but weight based ratios did result in good adjustments for size.

Question 179

Some advantages that ratio indices probably have over linear correlated M-mode parameters is that they may be more accurate for different somatotypes and even within breeds that vary greatly in weight but not body types. (i.e Irish Wolfhounds).

Answer 179

Some advantages that ratio indices probably have over linear correlated M-mode parameters is that they may be more accurate for different somatotypes and even within breeds that vary greatly in weight but not body types. (i.e Irish Wolfhounds). They may also allow direct comparison between patiens of differing size and body type in the same way that fractional shortening and volume indices are used. This method may also be more accurate in overweight animals and in the highly trained athletic dog.

Question 180

Measurement and assessment of spectral doppler flow: Doppler examination has the ability to provide info about?

Answer 180

Direction, velocity, character, and timing of blood flow. | Thereby allowing definitive diagnostics in most cardiac examinations.

Question 181

Although the measurements of Doppler may appear intimidating, the equipment performs most of the calculations. Remember to interrogate multiple views when possible for all valvular flows since the imaging planes for best Doppler alignment varies from animal to animal.

Answer 181

Although the measurements of Doppler may appear intimidating, the equipment performs most of the calculations. Remember to interrogate multiple views when possible for all valvular flows since the imaging planes for best Doppler alignment varies from animal to animal.

Question 182

Measurement: | Peak velocity is simply measured by placing a caliper at..?

Answer 182

the apex of maximal upward or downward motion. fig 4.40. | The velocity is displayed in cm per sec (cm/sec) or m7sec.

Question 183

What is the velocity time integral (VTI), flow velocity integral (FVI) or time velocity integral (TVI)?

Answer 183

Tracing the flow profile provides a measure of mean velocity throughout the flow period, and is called the velocity time integral VTI, flow velocity integral (FVI) or time velocity integral (TVI)? Fig 4.41

Question 184

Flow velocity integral is directly proportional to the?

Answer 184

stroke volume

Question 185

The flow integral is calculated by tracing the flow profile with a trackball or joystick. Fig 4.41. Once the entire flow profile is traced, the FVI is displayed on the monitor in cm. The area under the flow velocity curve represents the?

Answer 185

The distance a volume of blood travels. | It is used with the area of the vessel or valve the blood is flowing through in order to calculate stroke volume.

Question 186

Systolic time intervals can be measured from................?

Answer 186

Systolic time intervals can be measured from aortic and pulmonary flow profiles.

Question 187

Left and right ventricular ejection times (LVET and RVET) are measured from the ........... to the ............. at the baseline. This is also called?

Answer 187

Left and right ventricular ejection times (LVET and RVET) are measured from the onset of flow to the end of flow at the baseline (fig 4.42). This is also called flow time (FT).

Question 188

Time to peak (TTP) flow (also called acceleration time (AT) is measured from the .......... to the point of ........................

Answer 188

Time to peak (TTP) flow (also called acceleration time (AT) is measured from the onset of flow to the point of maximal velocity. Fig 4.43

Question 189

These 2 systolic time periods are then divided to yield a variable that indicated what ....................

Answer 189

These 2 systolic time periods are then divided to yield a variable that indicated what fraction of time is spent in reaching maximal velocity (TTP/FT).

Question 190

Pre-ejection periods are measured from the onset of .......... to the onset of ..................

Answer 190

Pre-ejection periods are measured from the onset of the QRS complex to the onset of systolic flow.

Question 191

Diastolic time intervals: The isovolumetric relaxation time (IVRT) is measured by placing a CW or PW signal in the ....................on apical 4 or 5 ch imaging planes near the ................... and recording part of both the ............ profile and the ..................flow profile.

Answer 191

Diastolic time intervals: The isovolumetric relaxation time (IVRT) is measured by placing a CW or PW signal in the left ventricular outflow tract on apical 4 or 5 ch imaging planes near the mitral valve and recording part of both the aortic flow profile and the transmittal flow profile. Fig 4.44

Question 192

The time interval from ........... flow to the .......................... flow corresponds to the isovolumetric relaxation time period.

Answer 192

The time interval from cessation of aortic flow to the beginning of transmittal flow corresponds to the isovolumetric relaxation time period. Fig 4.45.

Question 193

When left ventricular pressure drops below LA pressure, the mitral valve .......

Answer 193

When left ventricular pressure drops below LA pressure, the mitral valve opens.

Question 194

Evaluation: there is little or no correlation between peak velocities for flow across the 4 valves with age, sex, or breed in the dog. Several studies have found that HR and weight do affect flow velocities while others have not.

Answer 194

The studies that showed an effect of body mass and heart rate on flow velocities reveal than in general, decreases in mass and increases in HR increased flow velocity.

Question 195

Physical factors that increase Doppler flow velocities: (3)

Answer 195

Increasing HR Inspiration Decreasing weight Age, sex, and breed have no effect.

Question 196

Aortic flow profiles are negative and have a ........... acceleration compared to the ...............deceleration rate.

Answer 196

Aortic flow profiles are negative and have a rapid acceleration compared to the slower deceleration rate. This gives the normal aortic flow profile an asymmetric appearance. Fig 3.45.

Question 197

Aortic flow: Peak velocity should be reached during the first ....... of systole

Answer 197

Peak velocity should be reached during the first third of systole

Question 198

Peak velocities obtained from PW and CW examinations are only slightly different. The discrepancy may be secondary to Doppler angle.

Answer 198

Peak velocities obtained from PW and CW examinations are only slightly different. The discrepancy may be secondary to Doppler angle.

Question 199

Most normal healthy dogs ave aortic flow velocities less than 200 cm/sec. There is agreement that flows above 250 cm/sec are abnormal, but flows that fall within the 200 to 250 cm/sec range are equivocal.

Answer 199

Most normal healthy dogs ave aortic flow velocities less than 200 cm/sec. There is agreement that flows above 250 cm/sec are abnormal, but flows that fall within the 200 to 250 cm/sec range are equivocal. Other aspects of the echo exam will have to be used in order to determine if disease is present.

Question 200

Can flow velcotieis be affected be heart rate?

Answer 200

Yes. Fast heart rates will increase peak and mean velocities.

Question 201

Aortic flow is characterized by?

Answer 201

Rapid acceleration: -Early peaking max velocity Slower deceleration Shorter ejection time than PA Longer PEP than PA

Question 202

Pulmonary flow is characterized by?

Answer 202

More symmetrical profile | -peak velocity in middle third of ejection period.

Question 203

Pulmonary artery flow profiles are also negative in all the views that can be obtained in animals. It has a very ............. shape with very ................acceleration and deceleration rates.

Answer 203

Pulmonary artery flow profiles are also negative in all the views that can be obtained in animals. It has a very symmetrical shape with very similar acceleration and deceleration rates. Fig 3.48

Question 204

Often pulmonary flow displays a .............. peak as opposed to the ........ peak velocity of aortic flow.

Answer 204

Often pulmonary flow displays a rounded peak as opposed to the pointed peak velocity of aortic flow.

Question 205

Peak velocity of pulmonary flow is reached approximately ........ way through ejection, and in the dog the mean ratio of time to peak velocity to total ejection time is .................

Answer 205

Peak velocity of pulmonary flow is reached approximately half way through ejection, and in the dog the mean ratio of time to peak velocity to total ejection time is 0.43.

Question 206

Peak pulmonary flow velocity in the dog is typically less than 130 cm/sec. This is lower than aortic flow presumably because of .....

Answer 206

Because of lower resistance within the pulmonary vascular system.

Question 207

Pulmonary flow has a slightly ........ ejection time and ........ pre-ejection period compared to aortic flow because of the ........ after-load.

Answer 207

Pulmonary flow has a slightly longer ejection time and reduced pre-ejection period compared to aortic flow because of the reduced after-load.

Question 208

Increased venous return with .......... increases pulmonary flow velocity during ................

Answer 208

Respiration affecte flow within the right side of the heart. Increased venous return with inspiration increases pulmonary flow velocity during inspiration.

Question 209

HR affects maximal velocity as does aortic flow. Faster heart rates in the dog increase velocity.

Answer 209

HR affects maximal velocity as does aortic flow. Faster heart rates in the dog increase velocity.

Question 210

There is also a body mass effect on the right side of the heart. Increased body mass .......... the mean velocity.

Answer 210

Increased body mass decreases the mean velocity and is speculated to be secondary to decreased heart rate in larger dogs.

Question 211

Systolic time intervals: HR affects LVET, but the effect is minimized by normalizing the interval. The heart rate is multiplied by the slope of the regression line for heart rate versus the LVET, and this value is added to the measured LVET.

Answer 211

The heart rate is multiplied by the slope of the regression line for heart rate versus the LVET, and this value is added to the measured LVET. This in effect allows LVET to be extrapolated to a HR of zero.

Question 212

The slope of HR versus LVET is 0.55, and the resulting equation for HR corrected LVET, left ventricular ejection time index (LVETI) is as follows:

Answer 212

LVETI = LVET + (0.55 x HR) Where HR should be measured from the R to R interval on the beat preceding the measured LVET.

Question 213

The pre-ejection time period is very similar to the isovolumetric contration period where both the aortic and mitral valves are ........ and the ventricle is building up enough pressure to open the aortic valves.

Answer 213

closed

Question 214

A ratio of PEP to LVET is usually calculated in order to reduce the effects of ..............on LVET.

Answer 214

A ratio of PEP to LVET is usually calculated in order to reduce the effects of heart rate on LVET. This is considered to be a more accurate indicator of LV function.

Question 215

Velocity of circumferential fiber shortening is a calculation that incorporates the ejection time into the fractional shortening equation. This is a measure of how fast the LV shortens and is calculated as...?

Answer 215

Vcf = LVd-LVs/LVd x LVET Where LVET is measured in seconds and chamber sizes are measured in cm. Velocity of circumferential shortening (VCF) may be divided by HR and multiplied by 100 in order to reduce the effects of rate on this systolic time interval.

Question 216

Because of the strong effect of HR on systolic time intervals, several beats should be measured and averaged.

Answer 216

Because of the strong effect of HR on systolic time intervals, several beats should be measured and averaged. In animals with atrial fibrillation or marked sinus arrhythmia, many beats should be measured and more than 10 is recommended. Time intervals measured from the longest cardiac cycles tend to be the most accurate indicators of LV function when HR are variable. Avoid measuring during ventricular or supraventricular premature complexes of the beats that follow them.

Question 217

Mitral valve flow: transmitral flow profiles in all planes are ................., and when heart rates are slow enough, the ...... phases of LV filling are displayed.

Answer 217

Mitral valve flow: transmitral flow profiles in all planes are positive, and when heart rates are slow enough, the 2 phases of LV filling are displayed. Fig 3.52

Question 218

Once HR exceed ca ......., the 2 phases begin to overlap and rates greater than ......... beats per minute shown no separation of filling phases.

Answer 218

Once HR exceed ca 125, the 2 phases begin to overlap and rates greater than 200 beats per minute shown no separation of filling phases.

Question 219

The early phase of ventricular filling extends from mitral valve .............. to peak ventricular ................ and is called the E peak just as it is on M-mode images of the mitral valve.

Answer 219

The early phase of ventricular filling extends from mitral valve opening to peak ventricular filling and is called the E peak just as it is on M-mode images of the mitral valve.

Question 220

Flow into the left ventricle during atrial contraction is represented by the ...... point of the mitral inflow profile.

Answer 220

Flow into the left ventricle during atrial contraction is represented by the A point of the mitral inflow profile.

Question 221

The E-peak should have a higher velocity than the A peak in the normal heart. The E:A ratio is always greater than one in the normal canine heart, but both slow HR and high HR bring the E:A ratio closer to ...

Answer 221

1

Question 222

Increased volume associated with atrial contraction in animals with slow HR............ the A flow velocity ................ the difference in E and A velocities.

Answer 222

Increased volume associated with atrial contraction in animals with slow HR increases the A flow velocity minimizing the difference in E and A velocities.

Question 223

Rapid HR .............. the E velocity secondary to decreased early ventricular filling volume and .............. flow associated with the atrial contraction.

Answer 223

Rapid HR decrease the E velocity secondary to decreased early ventricular filling volume and increases flow associated with the atrial contraction.

Question 224

Transmitral flow velocity is measured at the peak of both E and A points. Fig 4.46. Transmitral flow is affected by?(3)

Answer 224

Preload Myocardial relaxation Heart rate Fig 4.46

Question 225

Deceleration time after rapid ventricular filling is ......?

Answer 225

Deceleration time after rapid ventricular filling is the time from point of maximal E velocity along its deceleration slope to the baseline. Fig 4.46

Question 226

The peak filling rare and flow deceleration are influenced by several factors including...?

Answer 226

Isovolumic relaxation The pressure gradient from LA to LV Ventricular compliance

Question 227

Changes in relaxation affect ...........filling of the LV chamber while changes in compliance affect ................. diastolic filling of the ventricle.

Answer 227

Changes in relaxation affect early filling of the LV chamber while changes in compliance affect late diastolic filling of the ventricle.

Question 228

E wave velocity is increased with increased ........ pressure, decreased ........ pressure secondary to increased rate of relaxation, and .......... mitral valve area.

Answer 228

E wave velocity is increased with increased LA pressure, decreased LV pressure secondary to increased rate of relaxation, and small mitral valve area.

Question 229

Early filling is decreased by ....... atrial pressure, ......... rate of relaxation, and ......... compliance, or a .......... valve area.

Answer 229

Early filling is decreased by low atrial pressure, decreased rate of relaxation, and increased compliance, or a large valve area.

Question 230

Conditions that decrease early filling of the LV chamber, decreasing transmittal E wave amplitude, usually result in ..............A wave velocity because late diastole contributes more to total LV filling.

Answer 230

Conditions that decrease early filling of the LV chamber, decreasing transmittal E wave amplitude, usually result in increased A wave velocity because late diastole contributes more to total LV filling.

Question 231

MV E velocity increases with? (4)

Answer 231

Increased LA pressure Increased rate of LV relaxation Decreased LV compliance Small mitral valve area

Question 232

MV E velocity decreases with? (3)

Answer 232

Decreased LA pressure Impaired relaxation Increased LV compliance

Question 233

Increased HR is one of the factors resulting in a greater contribution to LV filing in ........ diastole during the atrial contraction

Answer 233

Increased HR is one of the factors resulting in a greater contribution to LV filing in late diastole during the atrial contraction

Question 234

Faster HR can also result in superimposed E and A waves as the ........... time period becomes shorted.

Answer 234

Faster HR can also result in superimposed E and A waves as the diastolic time period becomes shorted.

Question 235

BW and BSA do not affect transmitral flow, but ....... is a major factor in altering transmittal flow profiles.

Answer 235

BW and BSA do not affect transmitral flow, but age is a major factor in altering transmittal flow profiles.

Question 236

While E deceleration time does not change with age in cats as it does in man, there are weak correlations with age and other transmittal flow parameters.

Answer 236

While E deceleration time does not change with age in cats as it does in man, there are weak correlations with age and other transmittal flow parameters.

Question 237

Mitral valve E wave velocity ............ and A wave velocity .............. with age and the E/A ratio ............ as a result.

Answer 237

Mitral valve E wave velocity decreases and A wave velocity increases with age and the E/A ratio decreases as a result.

Question 238

Transmitral valve E dec time increases and E/A .........in dogs over the age of 10 when compared to dogs less than 6 years of age.

Answer 238

Transmitral valve E dec time increases and E/A decreases in dogs over the age of 10 when compared to dogs less than 6 years of age.

Question 239

BW ................ transmitral valve E deceleration time and A duration.

Answer 239

BW increases transmitral valve E deceleration time and A duration.

Question 240

Increases in heart rate ........ mitral valve E deceleration time in dogs. Sex has no effect on mitral valve flow velocity or time intervals.

Answer 240

Increases in heart rate increase mitral valve E deceleration time in dogs. Sex has no effect on mitral valve flow velocity or time intervals.

Question 241

Trans tricuspid flow profiles are similar to mitral flow profiles with 2 phases to ventricular filling and is always ............ in the planes used for Doppler interrogation.

Answer 241

Trans tricuspid flow profiles are similar to mitral flow profiles with 2 phases to ventricular filling and is always positive in the planes used for Doppler interrogation.

Question 242

Tricupsid flow velocities are lower than mitral flow velocities, probably because of ?

Answer 242

Tricupsid flow velocities are lower than mitral flow velocities, probably because of the reduced pressure drop from right atrium to right ventricle when compared to the pressure change from the LA to the LV.

Question 243

Peak tricuspid E velocity varies with respiration. Inspiration ......... peak flow velocity while expiration .......... E flow velocities.

Answer 243

Peak tricuspid E velocity varies with respiration. Inspiration increases peak flow velocity while expiration decreases E flow velocities. The E/A ratio therefore increases with inspiration and decreases with expiration.

Question 244

The E/A ratio can even be less than 1 under appropriate conditions in a normal heart with ratios ranging from 0.69 to 3.08 in the dog

Answer 244

The ratio can even be less than 1 under appropriate conditions in a normal heart with ratios ranging from 0.69 to 3.08 in the dog

Question 245

As with LV inflow rapid heart rate........ A velocity

Answer 245

increase

Question 246

TV E velcotity: E .............. with inspiration E ............. with expiration

Answer 246

E increases with inspiration | E decreases with expiration

Question 247

Pulmonary venous flow is continuous and phasic into the LA chamber

Answer 247

Pulmonary venous flow is continuous and phasic into the LA chamber. Fig 3.59

Question 248

LA filling occurs predominantly during ............. when the mitral valve is closed. .

Answer 248

LA filling occurs predominantly during systole when the mitral valve is closed. The velocity of this systolic flow is directly related to mean LA pressure.

Question 249

During diastole when the mitral valve is open, blood flow into the ..... is directly related to flow moving into the .... and occurs at the same time as early transmittal valve flow (E wave)

Answer 249

During diastole when the mitral valve is open, blood flow into the LA is directly related to flow moving into the LV and occurs at the same time as early transmittal valve flow (E wave)

Question 250

During atrial contraction there is reverse flow into the pulmonary veins, and the degree of this is affected by ........

Answer 250

During atrial contraction there is reverse flow into the pulmonary veins, and the degree of this is affected by: End diastolic LA pressure, LA function, LV compliance, and Heart rate and rhythm. Fig 4.47

Question 251

The ratio of transmittal valve A duration to pulmonary vein Ar is correlated to ...... filling pressure and ventricular compliance.

Answer 251

The ratio of transmittal valve A duration to pulmonary vein Ar is correlated to LV filling pressure and ventricular compliance. Partial fusion of the mitral valve E and A waves does not invalidate this correlation.

Question 252

Pulmonary vein: D occurs at the same time as MV ............ Ar occurs at the same time as MV .......

Answer 252

D occurs at the same time as MV E Ar occurs at the same time as MV A

Question 253

There is a significant positive correlation between pulmonary venous S wave peak velocity and systolic fraction with ......... in cats.

Answer 253

There is a significant positive correlation between pulmonary venous S wave peak velocity and systolic fraction with age in cats There is also a sign positive correlation between age and HR and pulmonary vein S velocity in cats. There is no association between age and pulmonary D or Ar velocity in cats. There is however a positive correlation between age and pulmonary vein Ar velocity in cats.

Question 254

Dogs have a significant positive association between ..... and pulmonary vein Ar velocity and a negative correlation between age and Ar duration. These relationships were only present in dogs greater than 10 years.

Answer 254

Dogs have a significant positive association between age and pulmonary vein Ar velocity and a negative correlation between age and Ar duration. These relationships were only present in dogs greater than 10 years.

Question 255

Increased ........ increases S and Ar velocity, and increased BW increases Ar duration in dogs.

Answer 255

Increased heart rate increases S and Ar velocity, and increased BW increases Ar duration in dogs.

Question 256

Pulmonary vein flow-feline: S wave velocity ......... with increased HR and age Ar wave duration ........... with age

Answer 256

S wave velocity increases with increased HR and age Ar wave duration increases with age

Question 257

Pulmonary vein flow-canine (

Answer 257

Ar velocity increases with increased age Ar duration decreases with increased age.

Question 258

Isovolumetric relaxation time: Ventricular relaxation is indirectly measured from IVRT. Delayed relaxation is reflected in ........ IVRT.

Answer 258

Ventricular relaxation is indirectly measured from IVRT. Delayed relaxation is reflected in longer IVRT.

Question 259

As atrial pressure increase however, the IVRT parameter will become less useful as it becomes "...............

Answer 259

As atrial pressure increase however, the IVRT parameter will become less useful as it becomes "normalized".

Question 260

IVRT is also affected by increased systolic aortic pressure and decreased LA pressure, both of which will ...........the IVRT and not truly reflect impaired relaxation.

Answer 260

IVRT is also affected by increased systolic aortic pressure and decreased LA pressure, both of which will prolong the IVRT and not truly reflect impaired relaxation.

Question 261

HR is positively correlated with IVRT in man, but its effects on IVRT are variable in dogs and cats.

Answer 261

HR is positively correlated with IVRT in man, but its effects on IVRT are variable in dogs and cats. BW and age do not significantly affect this parameter in cats. The relationship between age and increasing IVRT in cats has an r2 value of 0.18.

Question 262

IVRT increases with? (3)

Answer 262

Decreased LA pressure Increased AO pressure Delayed relaxation

Question 263

The left auricle fills during ventricular .......... and empties during atrial ............. late in diastole.

Answer 263

The left auricle fills during ventricular systole and empties during atrial contraction late in diastole. Fig 3.64 There are other flows recoded at the PW Doppler site at the junction of the left auricle and atrium, but they are inconsistently recorded.

Question 264

Feline auricular emptying velocity ranges from 0.19-1.0 m/sec, and filling velocity ranges from 0.24-0.93 m/sec

Answer 264

Feline auricular emptying velocity ranges from 0.19-1.0 m/sec, and filling velocity ranges from 0.24-0.93 m/sec

Question 265

There is a very weak correlation between left auricular flow and LA area or diameter in cats. Age, HR, weight, sex, and blood pressure have no effect on left auricular flow. Stasis of blood flow is associated with lower than normal auricular flow and predisposition toward thrombus formation.

Answer 265

There is a very weak correlation between left auricular flow and LA area or diameter in cats. Age, HR, weight, sex, and blood pressure have no effect on left auricular flow. Stasis of blood flow is associated with lower than normal auricular flow and predisposition toward thrombus formation.

Question 266

Measurement and assessment of TDI: TDI provides info regarding myocardial velocity in selected areas of the myocardium. A PW gate placed over the myocardium shows ............?

Answer 266

TDI provides info regarding myocardial velocity in selected areas of the myocardium. A PW gate placed over the myocardium shows both systolic and diastolic myocardial motion, which i sussed to evaluate diastolic and systolic function. Fig 3.67

Question 267

Using either color-tissue Doppler or PW tissue Doppler yields the same myocardial motions: which ones?

Answer 267

- A positive systolic motion: Sm or S´ - An early diastolic motion: Em or E´ - A late diastolic motion: Am or A´ - They also provide measurements of IVRT and IVCT

Question 268

Color TDI must be analyzed off line. One or more PW gates may be placed anywhere over the color sector on the stored TDI video loop and wall motion is displayed.

Answer 268

Color TDI must be analyzed off line. One or more PW gates may be placed anywhere over the color sector on the stored TDI video loop and wall motion is displayed.

Question 269

....... TDI is instantaneously generated during the exam by placing the PW gates over the color TDI sector.

Answer 269

PW TDI is instantaneously generated during the exam by placing the PW gates over the color TDI sector.

Question 270

Peak Sm, Em, and Am velocity are measured. Fig 4.48

Answer 270

Peak Sm, Em, and Am velocity are measured. Fig 4.48

Question 271

Color TDI also allows multiple PW gates to be placed over the color TDI sector during off-line analysis. Gradients of color TDI Sm, Em, and Am can be obtained between basal and apical sections of myocardium on apical views or between epicardial and endocardial locations on transverse and parasternal long-axis views.

Answer 271

Gradients of color TDI Sm, Em, and Am can be obtained between basal and apical sections of myocardium on apical views or between epicardial and endocardial locations on transverse and parasternal long-axis views. Fig 4.49

Question 272

Isovolumic relaxation time is measured from the end of .... to the beginning of ....

Answer 272

Isovolumic relaxation time is measured from the end of Sm to the beginning of Em.

Question 273

Isovolumic contraction time is measured from the end of ..... to the beginning of ........

Answer 273

Isovolumic contraction time is measured from the end of Am to the beginning of Sm. Fig 4.50

Question 274

Assessment: | Are Color TDI and PW TDI measurements interchangeable?

Answer 274

No, each modality has its own set of reference values.

Question 275

Color TDI evaluates .......... myocardial velocity while PW TDI measures .......... myocardial velocity in a segment of myocardium.

Answer 275

Color TDI evaluates mean myocardial velocity while PW TDI measures peak myocardial velocity in a segment of myocardium.

Question 276

Color TDI is also recorded at ....... fram rates than PW TDI: These factors cause color TDI values to be lower than PW TDI values.

Answer 276

Color TDI is also recorded at lower fram rates than PW TDI: These factors cause color TDI values to be lower than PW TDI values.

Question 277

Color TDI velocities are therefore .....than PW TDI velocities.

Answer 277

lower

Question 278

Reference values are not interchangeable.

Answer 278

Reference values are not interchangeable.

Question 279

There is a gradient from high to low tissue velocities from the base of the heart to the apex on apical 4 ch views in all walls.

Answer 279

There is a gradient from high to low tissue velocities from the base of the heart to the apex on apical 4 ch views in all walls. Fig 4.48

Question 280

.............. color tissue velocity is higher than ............ velocity obtained on radial fibers on both long- and short-axis right parasternal imaging planes.

Answer 280

Endocardial color tissue velocity is higher than epicardial velocity obtained on radial fibers on both long- and short-axis right parasternal imaging planes. Fig 4.49 These gradients exist throughout the cardiac cycle in cats and dogs for systolic and diastolic waves.

Question 281

The motion is .......... in that all points along the long or short axis of the heart exhibit coordinated motion with no lag in time.

Answer 281

The motion is synchronous in that all points along the long r short axis of the heart exhibit coordinated motion with no lag in time. Fig 4.49

Question 282

There is a breed effect on several TDI variables in both cats and dogs.

Answer 282

Breeds with specific ranges are listed in the appendices.

Question 283

Color TDI show the following myocardial motions; a positive systolic motion (.........´), an early diastolic negative motion (........), a late diastolic negative motion (.........).

Answer 283

Color TDI show the following myocardial motions; a positive systolic motion (Sm or S´), an early diastolic negative motion (Em or E´), a late diastolic negative motion (Am or A´). Fig 4.48

Question 284

The colored lines correspond to the color gates placed over the TDI color sector on the 2D image in fig 4.48

Answer 284

The colored lines correspond to the color gates placed over the TDI color sector on the 2D image in fig 4.48

Question 285

Gradients of color TDI Sm, Em and Am can be obtained between basal and apical .......... views, or between epicardial and endocardial locations on ......... and ............. views.

Answer 285

Gradients of color TDI Sm, Em and Am can be obtained between balsa and apical sections of myocardium on apical views, or between epicardial and endocardial locations on transverse and parasternal long-axis views.

Question 286

There is less variability between observers and daily examinations when TDI is applied to ............. fibers on apical images versus radial fibers on ............. images in man. This may be because of less translational and rotational motion on apical views.

Answer 286

There is less variability between observers and daily examinations when TDI is applied to longitudinal fibers on apical images versus radial fibers on transverse images in man. This may be because of less translational and rotational motion on apical views.

Question 287

In dogs, day-to-day variability of longitudinal E´ is less than 3.5 and 5.6 % in basal segments of both the right and left ventricular lateral wall, respectively. Other TDI values in dogs obtained at the base of the right and left ventricular wall on apical views have intra day an inter day variability of less than 15%.

Answer 287

In dogs, day-to-day variability of longitudinal E´ is less than 3.5 and 5.6 % in basal segments of both the right and left ventricular lateral wall, respectively. Other TDI values in dogs obtained at the base of the right and left ventricular wall on apical views have intra day an inter day variability of less than 15%.

Question 288

Color TDI: Gradients from high to low: -Base to apex on all ..........l walls -Endicardium to epicardium on ........ fibers

Answer 288

Gradients from high to low: -Base to apex on all longitudinal walls -Endicardium to epicardium on radial fibers

Question 289

Color TDI: | RV velocity greater than LV .........velocity

Answer 289

longitudinal

Question 290

One study in cats found repeatability of radial TDI values for the LV wall had an unacceptable degree of variability at >20% when obtained from right parasternal transverse and long-axis planes.

Answer 290

This study also showed longitudinal velocity measured by TDI on left apical 4 ch imaging planes were much more repeatable with variation of approximately 20% with the exception of TDI measurements at the lateral tricuspid annulus.

Question 291

Chetbould and other however found good repeatability and acceptable variations of less than 20% in all TDI parameters from both right parasternal radial analysis of wall motion and from left apical assessment of longitudinal fibers with the exception of velocity recorded at the apex of the heart.

Answer 291

Chetbould and other however found good repeatability and acceptable variations of less than 20% in all TDI parameters from both right parasternal radial analysis of wall motion and from left apical assessment of longitudinal fibers with the exception of velocity recorded at the apex of the heart.

Question 292

Greater variability is seen between observers than with one observer in almost all studies.

Answer 292

Greater variability is seen between observers than with one observer in almost all studies.

Question 293

Parameters that reflect diastolic function include:?

Answer 293

Peak early diastolic motion (Em), Peak late diastolic annular motion (A´), Isovolumic relaxation time (IVRT), Deceleration rate of the early diastolic motion (Em dec rate), and the Em:Am ratio. Fig 4,50

Question 294

There is a weak but significant inverse relationship between peak early diastolic velocity ... and age in both cats and dogs.

Answer 294

There is a weak but significant inverse relationship between peak early diastolic velocity Em and age in both cats and dogs. This is thought to be related to an age-related increase in cardiac mass, wall thickness, and intracellular matrix in man and is potentially also the case in animals.

Question 295

Late RV diastolic velocity, Am, and the ratio of Em/Am, IVRT are minimally affected by age in cats or dogs, but is affected by weight in dogs.

Answer 295

Late RV diastolic velocity, Am, and the ratio of Em/Am, IVRT are minimally affected by age in cats or dogs, but is affected by weight in dogs. These parameters are also unaffected by HR.

Question 296

Early diastolic deceleration rate, Em dec rate, in the cat is dry weakly correlated to HR but is not affected by age.

Answer 296

Early diastolic deceleration rate, Em dec rate, in the cat is dry weakly correlated to HR but is not affected by age.

Question 297

Increased IVRT is a sensitive indicator of ............ myocardial failure (impaired ...............) in man, and since it is not affected by age or HR, it has the potential to do so int eh cat as well.

Answer 297

Increased IVRT is a sensitive indicator of diastolic myocardial failure (impaired relaxation) in man, and since it is not affected by age or HR, it has the potential to do so int eh cat as well.

Question 298

TDI evaluation of mitral annular motion on the lateral LV wall is less load dependent than PW Doppler of transmitral flow. The ratio of E:Em correlates with .......... pressure.

Answer 298

TDI evaluation of mitral annular motion on the lateral LV wall is less load dependent than PW Doppler of transmitral flow. The ratio of E:Em correlates with LA pressure.

Question 299

Preload affects PW TDI variables in clinically healthy dogs. Increased right ventricular diastolic pressure secondary to iv infusion of volume results in ............ Em, Am, Em:Am ratio and Sm velocities and .............. in TDI measured myocardial performance index (MPI) and TDI derived isovolumic relaxation time (IVRT).

Answer 299

Increased right ventricular diastolic pressure secondary to iv infusion of volume results in increased Em, Am, Em:Am ratio and Sm velocities and decreases in TDI measured myocardial performance index (MPI) and TDI derived isovolumic relaxation time (IVRT).

Question 300

Right ventricular end diastolic pressure correlates significantly with ......?

Answer 300

Em, Am, Sm, TDI-derived IVRT, TDI calculated MPI, E:En (trans tricuspid E wave to Em), with the PW TDI derived IVRT, Sm, and Em being predictive of pressure.

Question 301

RV PW TDI: Increased preload:

Answer 301

Increased SM, Em and Am velocities Decreased MPI Decreased IVRT

Question 302

Right ventricular longitudinal color TDI vairbales in systole and both phases of diastole are higher than those in the LV. This is presumably because....?

Answer 302

This is presumably because the RV is dominated by longitudinal fibers whereas the LV has a predominance of radial fibers.

Question 303

Evaluation of CF Doppler provides ....... and semi ......... flow information.

Answer 303

Evaluation of CF Doppler provides qualitative and semi quantitative flow information.

Question 304

Is aliasing always abnormal?

Answer 304

No, aliasing may not always be abnormal because a low Nyquist limit may be exceed, and spectral Doppler is often required in order to determine if flow velocity is truly high, turbulent, or reversed.

Question 305

Can insufficiencies be commonly seen?

Answer 305

It is common to see insufficiencies at several of the valves. The leaks are trivial to mild and not hemodynamically significant. These insignificant regurgitant jets in man never extend more than 1 cm from the closed valves. The same insufficiencies are found in dogs, however, the timing and descriptions of the jets are only reported in horse.

Question 306

PI is reported in .......... % of normal dogs

Answer 306

PI is reported in 25-75% of normal dogs

Question 307

AI is seen in approximately ........ % of dogs.

Answer 307

AI is seen in approximately 10-11% of dogs.

Question 308

TR is reported in .......% of dogs

Answer 308

TR is reported in 50% of dogs

Question 309

MR is reported in .......% of dogs.

Answer 309

MR is reported in 15% of dogs. Fig 4.51, 4,52, 4,53, 4,54

Question 310

Combined AI and PI are reported in only ......% of normal dogs.

Answer 310

Combined AI and PI are reported in only 4% of normal dogs.

Question 311

Trivail to mild insufficiencies may be seen at al valves in normal animals. The jets do not extend more than ..... cm past the annulus.

Answer 311

The jets do not extend more than 1 cm past the annulus.

Question 312

When spectral Doppler was used to interrogate the small regurgitant jets in beagles, the velocities were less than those seen with regurgitation secondary to pathology and less than would be expected from normal pressure gradient within the heart.

Answer 312

Signal strength is also weak when interrogating these small jets. There is usually no corresponding murmur to identify the presence of these clinically insignificant leaks.

Question 313

Pathological regurgitation can be semi-quantitatively assessed by measuring the size of the color-flow jet within the atrial in the case of AV valvular insufficiency or within the outflow tract or ventricle in the case of aortic or pulmonic insufficiency.

Answer 313

Pathological regurgitation can be semi-quantitatively assessed by measuring the size of the color-flow jet within the atrial in the case of AV valvular insufficiency or within the outflow tract or ventricle in the case of aortic or pulmonic insufficiency.

Question 314

Color M-mode can be obtained during a color-flow exam. Value of this:

Answer 314

This helps separate the events of diastole and systole in order ro better time the color flow information. After turning on CF Doppler, place an M-mode cursor over the area of interest and activate M-mode. Fig 4.55

Question 315

Evaluation of ventricular function: In order to understand the evaluation and application of Doppler, a brief overview of systolic and diastolic function precedes each discussion on the echo evaluation of function.

Answer 315

Evaluation of ventricular function: In order to understand the evaluation and application of Doppler, a brief overview of systolic and diastolic function precedes each discussion on the echo evaluation of function.

Question 316

Systolic function: | The pumping ability or systolic function of the heart is dependent upon several factors including....?

Answer 316

``` Preload Afterload Contractility Distensibility Coordinated contraction Heart rate ```

Question 317

Systolic dysfunction is characterized by ......

Answer 317

Impaired pumping ability and Reduced ejection fraction.

Question 318

Abnormalities involving coordinated contraction are primarily the result of myocardial infarction. Although myocardial infarction is recognized more often in animals as echo plays a more important role in diagnostic work up of potential cardiac patients, its effect on systolic function will not be considered in this discussion.

Answer 318

Abnormalities involving coordinated contraction are primarily the result of myocardial infarction. Although myocardial infarction is recognized more often in animals as echo plays a more important role in diagnostic work up of potential cardiac patients, its effect on systolic function will not be considered in this discussion.

Question 319

What is preload?

Answer 319

The force stretching the myocardium.

Question 320

What is preload dependent upon?

Answer 320

The amount of blood distending the ventricles at end-diastole.

Question 321

Starling's law states that the greater the ..........., the greater the force of ............

Answer 321

Starling's law states that the greater the stretch, the greater the force of contraction. Increases in LV diastolic volume, all other factors remain ing constant, would therefore increase ventricular systolic function.

Question 322

What is afterload?

Answer 322

Afterload is the force against which the heart must contract.

Question 323

Normally the heart will hypertrophy in response to increases on preload in order to normalize wall stress. Which factors determines wall stress?.

Answer 323

The relationship of wall thickness to chamber size determines wall stress. Equation 4.3

Question 324

The type of hypertrophy pattern seen in response to increased preload is .........., in that wall thickness and overall LV mass increases in response to the increase in volume.

Answer 324

eccentric

Question 325

In the absence of hypertrophy, .......... is increased within the volume overloaded LV. The peripheral pressure that the LV must pump against is also ........

Answer 325

In the absence of hypertrophy, afterload is increased within the volume overloaded LV. The peripheral pressure that the LV must pump against is also afterload.

Question 326

What else will elevate the afterload?

Answer 326

Increased systemic or pulmonary pressure, Vasoconstriction, and Obstruction to ventricular outflow will also elevate the afterload in the left or right side of the heart.

Question 327

The compensatory hypertrophy pattern seen with increased after load is ....

Answer 327

concentric; where wall thicknesses increase with no increase in volume, and if the afterload is sever and chronic, hypertrophy may be at the expense of chamber size.

Question 328

Increases in after load without adequate compensatory hypertrophy decrease the ability of?

Answer 328

the heart to contract effectively when all other factors are kept constant.

Question 329

Contractility is dependent upon mechanisms within the myocardial cell. These involve?

Answer 329

the contractile proteins (actin and myosin), transport mechanisms for calcium, and regulatory proteins (troponin and tropomyosin)

Question 330

cardiac output can be calculated by?

Answer 330

Multiplying heart rate and stroke volume.

Question 331

Increases in HR with no other changes will result in greater ........

Answer 331

Increases in HR with no other changes will result in greater cardiac output.

Question 332

Generally the body regulates HR to meet the metabolic demands of its tissues. Very high heart rates however can be detrimental to the heart itself and induce myocardial failure.

Answer 332

Generally the body regulates HR to meet the metabolic demands of its tissues. Very high heart rates however can be detrimental to the heart itself and induce myocardial failure.

Question 333

Optimal right ventricular function allows the right atrium to maintain a low pressure for adeate .......... return and to provide low-pressure perfusion of the ............. vasculature.

Answer 333

Optimal right ventricular function allows the right atrium to maintain a low pressure for adequate venous return and to provide low-pressure perfusion of the pulmonary vasculature.

Question 334

RV Systole has 3 phases: which ones?

Answer 334

1. Contraction of the papillary muscles 2. Movement of the RV free wall toward the septum 3. Wringing of the RV secondary to contraction of the LV

Question 335

Contraction starts at the ........ and moves toward the thin walled and compliant upper region of the RV chamber resulting in slow continuous movement of blood into the lungs. RV pressure remains ........ throughout systole as a result.

Answer 335

Contraction starts at the apex and moves toward the thin walled and compliant upper region of the RV chamber resulting in slow continuous movement of blood into the lungs RV pressure remains low throughout systole as a result.

Question 336

IVRT and IVCT are ........... and ejection is ............. than in the LV and continues even after pressure starts to decline.

Answer 336

IVRT and IVCT are shorter and ejection is longer than in the LV and continues even after pressure starts to decline.

Question 337

Acutely increased afterload results in ....... on order to maintain forward flow.

Answer 337

Acutely increased afterload results in dilation on order to maintain forward flow.

Question 338

Increased afterload also increases .............. and ejection times.

Answer 338

Increased afterload also increases IVCT and ejection times.

Question 339

Chronic increases in pulmonary vascular pressure result in adaptive .............., but the right ventricle is still highly susceptible to acute on chronic increases in pressure.

Answer 339

Chronic increases in pulmonary vascular pressure result in adaptive hypertrophy, but the right ventricle is still highly susceptible to acute on chronic increases in pressure.

Question 340

Elevated RV filling pressure under either condition causes a ............ shift in the inter ventricular septum affecting LV function. The ............. in pulmonary flow ............. LV preload and function.

Answer 340

Elevated RV filling pressure under either condition causes a left ward shift in the inter ventricular septum affecting LV function. The decrease in pulmonary flow decreases LV preload and function.

Question 341

M-mode evaluation of systolic function Fractional shortening--left ventricle: probably the most common echo measurement of LV function. How is it calculated?

Answer 341

By subtracting the LV systolic dimension from the diastolic dimension and dividing by the diastolic dimension in order to obtain a percent change in LV size between filling and emptying. FS = LVd-LVs/LVd x 100

Question 342

Is FS a measure of contractility?

Answer 342

No, it is a measure of function.

Question 343

Which 3 primary factors affect FS the most?

Answer 343

Preload Afterload Contractility Each one of these may individually or together affect FS

Question 344

When fractional shortening is low it may be secondary to?

Answer 344

Poor preload Increased afterload Decreased contractility Increased preload on the other hand tends to increase function (increased FS) as does decreased afterload. Fig 4.56

Question 345

FS is not only a measure of contractility

Answer 345

FS is not only a measure of contractility

Question 346

The factors affecting FS (preload, afterload, contractility) may be hard to differentiate, but the M-mode measurements of ...... and .......flow analysis often aid in the determination.

Answer 346

The factors affecting FS (preload, afterload, contractility) may be hard to differentiate, but the M-mode measurements of size and Doppler flow analysis often aid in the determination.

Question 347

Increased LV diastolic size stretches the myofibers and according to Frank Starling should increase the ability to ........ and ................. FS.

Answer 347

Increased LV diastolic size stretches the myofibers and according to Frank Starling should increase the ability to shorten and increase FS.

Question 348

If the FS is normal in the presence of increased preload, either increased ...... is inhibiting the ability to shorten or ........ is a problem.

Answer 348

If the FS is normal in the presence of increased preload, either increased afterload is inhibiting the ability to shorten or contractility is a problem. Fig 4.57

Question 349

.................. preload puts less stretch on the myofibers resulting in decreased ability to shorten and a poor FS.

Answer 349

Decreased preload puts less stretch on the myofibers resulting in decreased ability to shorten and a poor FS.

Question 350

Hypertrophy that exceeds the normal chamber size to wall thickness ratio is consistent with chronically increased ......... (usually hypertension) or significantly decreased ........, which created the appearance of hypertrophy (pseudo hypertrophy) simply due to a lack of distension.

Answer 350

Hypertrophy that exceeds the normal chamber size to wall thickness ratio is consistent with chronically increased afterload (usually hypertension) or significantly decreased preload, which created the appearance of hypertrophy (pseudo hypertrophy) simply due to a lack of distension. If hypertension is acute or acute on chronic there may be a decrease in FS, which is unrelated to contractility.

Question 351

Increased preload = ...FS

Answer 351

Increased FS

Question 352

Decreased preload = ...FS

Answer 352

Decreased FS

Question 353

Increased afterload = ....FS

Answer 353

Decreased FS

Question 354

Decreased afterload = .....FS

Answer 354

Increased FS

Question 355

Is FS correlated to BSA or weight?

Answer 355

No.

Question 356

LV volume measurement: The problem with most of the equations is that they are not always applicable in the diseased heart, but work well in the normal heart.

Answer 356

LV volume measurement: The problem with most of the equations is that they are not always applicable in the diseased heart, but work well in the normal heart.

Question 357

2D assessment of volume and output is more accurate, but it is also more time consuming.

Answer 357

2D assessment of volume and output is more accurate, but it is also more time consuming.

Question 358

2D echo is recommended by the ASE because of the limited view of the heart in M-mode views. The 1D may not be representative of the LV chamber as a whole.

Answer 358

2D echo is recommended by the ASE because of the limited view of the heart in M-mode views. The 1D may not be representative of the LV chamber as a whole.

Question 359

There are several studies that show a high correlation between M-mode derived volumes and ................ when using the Teicholz method in normal dogs.

Answer 359

There are several studies that show a high correlation between M-mode derived volumes and cardiac output when using the Teicholz method in normal dogs.

Question 360

The Teicholz equation and its use to calculate EF and stroke volume (SV) is based upon the assumption that the LV chamber is an ........

Answer 360

ellipse

Question 361

Teicholz equation se 4.9

Answer 361

4.9 s 203

Question 362

LV stroke volume =

Answer 362

LVVd-LVVs

Question 363

LV ejection fraction =

Answer 363

LVVd-LVVs/LVVd x 100

Question 364

Correlation to invasive methods for deriving volume with this formula (Teicholz) from the M-mode LV image are high at 0.93 and 0.87.

Answer 364

Correlation to invasive methods for deriving volume with this formula (Teicholz) from the M-mode LV image are high at 0.93 and 0.87. Uehara found better correlation to true EF when using M-modes derived transverse LV 2D images as opposed to long-axis views. This view is easer to obtain and the M-mode cursor is also easier to place correctly on this view.

Question 365

LV volume overload changes the geometry of the LV chamber making it more ............l, and the M-mode derived LV volume calculations are no longer accurate since the Teicholz equation does not take into account these ................

Answer 365

LV volume overload changes the geometry of the LV chamber making it more spherical, and the M-mode derived LV volume calculations are no longer accurate since the Teicholz equation does not take into account these geometric alterations.

Question 366

Calculation of systolic volume using the Teicholz equation results in a ............. estimation of volume compared to methods that use 2D images.

Answer 366

Calculation of systolic volume using the Teicholz equation results in a larger estimation of volume compared to methods that use 2D images. Similar results are not found in normal cats. Although correlations using the Teicholz equation are not terrible under resting conditions with the cat under anesthesia (r = 0.89), when varying drugs were used to enhance or diminish cardiac output, the correlation diminished considerably to 0.71 and 0.84, respectively. The small dimensions of the feline heart provide little room for error and probably play a role in these results.

Question 367

Systolic and diastolic volume indices are used to unify ventricular size with respect to body size. Divide the systolic and diastolic volume by ...?

Answer 367

by the animal's body surface area to derive the index. The index ca be used to compare the ventricular diastolic or systolic volume between dogs irrespective of size.

Question 368

An M-mode derived systolic volume index

Answer 368

An M-mode derived systolic volume index

Question 369

Length may be obtained from the 2D long-axis image and measured from apex to mitral annulus or length may be calculated as a ratio of diameter to length developed form in vitro studies and is derived as follows:

Answer 369

LVLd = 1.46 LVd LVLs = 1.46 LVs LVLd and LVLs = LV length during diastole and systole, respectively. Bara för häst? Lite oklart i boken.

Question 370

The crescent-shaped RV chamber is hard to see completely in echo imaging planes. Most evaluation of RV function is .......in both man and animals.

Answer 370

qualitative

Question 371

Estimates of volume and ejection fraction in the RV are inaccurate. RV function has been assessed by calculating fractional area percent change (FAC) in man. This is obtained from apical 4 ch views and correlates well with MRI ejection fraction in people with normal and diseased hearts.

Answer 371

Estimates of volume and ejection fraction in the RV are inaccurate. RV function has been assessed by calculating fractional area percent change (FAC) in man. This is obtained from apical 4 ch views and correlates well with MRI ejection fraction in people with normal and diseased hearts.

Question 372

Tricuspid annular motion and myocardial performance indices, imaging of the vena cava, and pulmonary artery pressure assessment using tricuspid regurgitant velocity are all more commonly used to assess RV function.

Answer 372

Tricuspid annular motion and myocardial performance indices, imaging of the vena cava, and pulmonary artery pressure assessment using tricuspid regurgitant velocity are all more commonly used to assess RV function.

Question 373

Systolic time intervals reflect?

Answer 373

Systolic function

Question 374

M-mode systolic time intervals (STI) include?

Answer 374

LV ejection time (LVET) LV pre-ejection period (PEP) Velocity of circumferential shortening (VCF) LV ejection time to pre-ejection period ratio (LVET/PEP). Fig 4.39 and 4.42

Question 375

STI may be better indicators of LV systolic function than FS and have been shown to be as accurate as invasive methodology in humans for the assessment of LV performance.

Answer 375

STI may be better indicators of LV systolic function than FS and have been shown to be as accurate as invasive methodology in humans for the assessment of LV performance.

Question 376

Are STI indicators of contractility?

Answer 376

No, rather function. Just like FS

Question 377

STI are affected by preload, afterload, and contractility.

Answer 377

STI are affected by preload, afterload, and contractility. Table 4.1 summarizes how preload and afterload affect the systolic time intervals.

Question 378

STI: PEP and LVET in the normal heart: Preload dependent: Increased preload ......... PEP and ................. LVET

Answer 378

Increased preload decreases PEP and increases LVET High preload or volume within the LV allows the Frank Starling mechanism to come into play as fibers are elongated and function is enhanced. This shortens PEP and increases LVET.

Question 379

STI: PEP and LVET in the normal heart: Preload dependent: Decreased preload ........... PEP and ................... LVET

Answer 379

Decreased preload increases PEP and decreases LVET Decreased preload does not allow enough force to be generated by fibers that are not at optimum length, and PEP is increased. By the same token, volume within the LV affects LVET and a reduction in volume and force of contraction will decrease LVET.

Question 380

STI: PEP and LVET in the normal heart: Afterload dependent: Increased afterload increases PEP and increases LVET

Answer 380

Increased afterload ..............PEP and .............. LVET When afterload is increased, th heart's workload is increased, and as a result, the time it takes to generate enough pressure within the LV before the aortic valve can open is longer. This time corresponds to the pre-ejection period. The rate at which the heart can contract in the face of high afterload is also reduced, which results in reduced VCF.

Question 381

STI: PEP and LVET in the normal heart: Afterload dependent: Decreased afterload ............ PEP and ............... LVET

Answer 381

Decreased afterload decreases PEP and increases LVET Decreases in afterload allow the LV to function with greater ease, and the force necessary to open the aortic valve is reached sooner resulting in decreased PEP. The rate at which the heart can contract is also faster when the workload is reduced and VCF is increased.

Question 382

There are many applications for systolic time intervals within the diseased heart. See Table 4.2. There are limitation to their use, however. Why?

Answer 382

There are limitations since HR and loading conditions do affect them significantly. Contractility cannot be evaluated accurately without first analyzing the effects of preload and afterload on the heart.

Question 383

Mitral annular motion (MAM) is correlated with ejection fraction. Obtained from apical 4 ch views using M-mode of the septal side of the mitral annulus, this measurement shows a strong nonlinear correlation with ejection fraction in healthy people and dogs and in individuals with heart disease.

Answer 383

Mitral annular motion (MAM) is correlated with ejection fraction. Obtained from apical 4 ch views using M-mode of the septal side of the mitral annulus, this measurement shows a strong nonlinear correlation with ejection fraction in healthy people and dogs and in individuals with heart disease. Fig 4.58

Question 384

Does MAM change with age?

Answer 384

Decreases with age but does so only in patients with normal ejection fractions, while age does not affect MAM in patient with depressed EF.

Question 385

MAM in normal dogs ranges from ?

Answer 385

0.46-1.74 cm There is a strong relationship with BW: This parameter may be more useful indexed to BW because of theis strong linear relationship between body size and annular motion.

Question 386

The regression equation for the relationship between MAM and BW is?

Answer 386

MAM = 0.579 + (0.0167 x kg BW)

Question 387

Trying to overcome the strong relationship to BW, MAM can also be indexed to BW by dividing MAM by BSA.

Answer 387

Dogs less than 15 kg have statistically higher indexed MAM than larger dogs, but the index does not show any advantage over using absolute MAM values.

Question 388

MAM....with decreases EF

Answer 388

decreases

Question 389

Calculating a MAM percent by using FS of the long and short axis is another effort to normalize this index. MAM percent has an insignificant relationship with BW and is between 40 and 45% in all dogs. The equation is as follows:

Answer 389

MAM% = MAM / (LVd-LVs) + MAM x 100% where LVd and LVs are M-mode dimensions.

Question 390

Tricuspid annular motion or tricuspid annular plane systolic excursion (..........) using M-mode on apical 4 ch imaging planes has been evaluated in man.

Answer 390

Tricuspid annular motion or tricuspid annular plane systolic excursion (TAPSE) using M-mode on apical 4 ch imaging planes has been evaluated in man. The normal range in man is 1.5-2.0 cm. An excursion of less than 1.5 cm is associated with a poorer prognosis in human patients in left-sided congestive heart failure secondary to DCM and in patients with pulmonary hypertension.

Question 391

2D measurement of systolic function Volume determination using2D echo is a labor intensive process and requires precise identification of LV planes and evaluation through at least 5 cardiac cycles. It is not a calculation that is routinely done during a clinical examination. Formulas are used that determine the ventricular volume at end diastole and end systole. A percent change is then calculated that equals the EF.

Answer 391

2D measurement of systolic function Volume determination using2D echo is a labor intensive process and requires precise identification of LV planes and evaluation through at least 5 cardiac cycles. It is not a calculation that is routinely done during a clinical examination. Formulas are used that determine the ventricular volume at end diastole and end systole. A percent change is then calculated that equals the EF.

Question 392

While M-mode methods of volume determination with heart disease have poor correlation with more invasive methods of volume determination and is not thought to be clinically useful in the setting of heart disease, volume determination using 2D echo images is shown to be accurate in normal and abnormal human hearts. Factors that affect the accuracy of 2D volume calculations include?

Answer 392

1. Endocardial dropout 2. The type of cardiac disease present 3. The use of foreshortened ventricular chamber 4. Mathematical assumptions 5. The use of more advanced technology such as tissue harmonic imaging.

Question 393

These 2 D equations are based upon the fact that the normal LV is ......

Answer 393

elliptical.

Question 394

The Simpson's rule formula shows the best correlation with actual LV volumes in the diseased heart appearing to be relatively unaffected by changes in ventricular geometry. Even if volume is not accurate in some diseased heart, the calculation may be used in an individual to follow progression or regression of LV volume.

Answer 394

The Simpson's rule formula shows the best correlation with actual LV volumes in the diseased heart appearing to be relatively unaffected by changes in ventricular geometry. Even if volume is not accurate in some diseased heart, the calculation may be used in an individual to follow progression or regression of LV volume.

Question 395

Does EF imply forward stroke volume?

Answer 395

EF does not imply forward stroke volume. EF is a measure of volume leaving the LV regardless of if it flows through the aorta, a shunt, or the mitral valve.

Question 396

EDV and ESV planes are used for volume calculations. End diastolic frames are defined as?

Answer 396

The frame just before the mitral valve closes or the first frame into the QRS complex

Question 397

End systolic frames are identified as?

Answer 397

End systolic frames are identified as the frame just before the mitral valve opens or the smallest chamber size.

Question 398

The modified Simpon's rule involves ...?

Answer 398

Tracing the LV endiocardial border, and computerized calculations treat the ventricle as a stack of discs. Fig 4.59 A volume for each disc is calculated and summated for the total LV volume

Question 399

Other terms for this method of volume measurements?

Answer 399

The method of discs | The disc summation method

Question 400

Which planes should be used for the Simpons?

Answer 400

2 long-axis apical planes; the apical 4 ch and the apical 2 ch planes. 2 imaging planes will more accurately account for any irregularities of the LV chamber. The planes should maximize length and width

Question 401

An optimal LC length is usually about ..... times its width

Answer 401

2

Question 402

When ventricular size is maximized, the small amount of volume not accounted for is minimal and negligible. After tracing along the endocardial surface of the LV chamber in both planes, following the mitral annulus at the heart base, computation packages in the ultrasound equipment will divide the ventricle into discs and perform the volume calculation shown in fig 4.59.

Answer 402

When ventricular size is maximized, the small amount of volume not accounted for is minimal and negligible. After tracing along the endocardial surface of the LV chamber in both planes, following the mitral annulus at the heart base, computation packages in the ultrasound equipment will divide the ventricle into discs and perform the volume calculation shown in fig 4.59.

Question 403

When 2 views are not possible, a single apical plane may be used.

Answer 403

Fig 4.59 An area length computation is used to calculate volume when one apical image is used. The area of the LV is determined by tracing the endocardial surface, and the length is measured from the mitral annulus to the apex. The equation is as follow: Volume = 0.85 A upphöjt i 2/L where a= area of the LV chamber and L = LV length, both measured on the apical 4 ch image.

Question 404

A study in dogs using the bullet formula for volume determination found good correlation between echo determined EF in anesthetized dogs and gated equilibrium radionuclide ventriculography. The correlation to invasive measures of volume is high at 0.97. Why is it called the bullet method?

Answer 404

Because it assumes a bullet-shaped LV chamber with a wider base and rounded apex.

Question 405

The bullet method utilizes transverse LV dimensions and LV length. Transverse images at the level of the chordae are traced in diastole and systole in order to calculate areas. Fig 4.60. LV lenght (L) is measured on the right parasternal long axis from the apex of the vernacular to the mitral aorta junction. Fig. 4.20. The bullet formaula is?

Answer 405

LVV = 5/6 x area x length = 5/6 AL where LVV is LV volume

Question 406

Systolic and diastolic volume index calculation using both area length and Simpson's rule methods yield similar results and take into account the changing geometry encountered with volume overload.

Answer 406

Systolic and diastolic volume index calculation using both area length and Simpson's rule methods yield similar results and take into account the changing geometry encountered with volume overload.

Question 407

A systolic or diastolic volume index is derived by dividing the volume calculated by either of these methods by the dog's BSA. A systolic volume index of

Answer 407

A systolic volume index of

Question 408

Spectral Doppler Evaluation of Systolic Function: Conservation of mass is a physical principle used in Doppler to calculate volumetric flow. This principle states that mass in equals mass out. Since mass is equal to ..........., and density is constant, the equation can be modified to?

Answer 408

Since mass is equal to density (D) x volume (V) x area (A), and density is constant, the equation can be modified to: Vi x Ai = Vo x Ao Where Vi = volume in, Vo= volume out, Ai= area in, and Ao = area out.

Question 409

The continuity equation is derived from the above mentioned principle:

Answer 409

Q1 = ViAi = Q2 = VoAo Where Q = flow. In other words, flow into the heart equals flow out of the heart.

Question 410

Volume of flow is calculated by tracing the flow profile and determining the flow velocity integral (FVI) (area under the curve, also called ............and..................

Answer 410

Volume of flow is calculated by tracing the flow profile and determining the flow velocity integral (FVI) (area under the curve, also called time velocity integral (TVI), and velocity time integral (VTI). Fig 4.41

Question 411

FVI is multiplied by the area of the vessel, valve, or orifice through which flow volume is being calculated. The result is ........... through that path in the heart. This measurement can be done at any of the 4 valves.

Answer 411

FVI is multiplied by the area of the vessel, valve, or orifice through which flow volume is being calculated. The result is stroke volume through that path in the heart. This measurement can be done at any of the 4 valves.

Question 412

Flow velocity integrals at the mitral valve should use profiles that maximize peak .... and .... velocities.

Answer 412

Flow velocity integrals at the mitral valve should use profiles that maximize peak E and A velocities. Fig 4.62

Question 413

the FVI is directly proportional to ........, and its value is calculated by the machine once the flow profile is traced.

Answer 413

the FVI is directly proportional to stroke volume

Question 414

The FVI can be measured manually by applying the Equation .......

Answer 414

FVI = V x ET/2 where V = peak velocity and ET = ejection time

Question 415

VTI is directly proportional to .....?

Answer 415

Stroke volume

Question 416

The other part of the continuity equation states that the area of the vessel or orifice must be calculated. Measurement of volumetric flow assumes that the blood is flowing thorough a circular orifice since area calculations are based on a circle.

Answer 416

The other part of the continuity equation states that the area of the vessel or orifice must be calculated. Measurement of volumetric flow assumes that the blood is flowing thorough a circular orifice since area calculations are based on a circle.

Question 417

CSA is calculated by using equation.....

Answer 417

se Equation 4.25 s 211 CSA = pi x r upphöjt i 2 where r = radius and pi = 3.14 The radius is obtained by measuring the diameter of the vessel or annuli involved in the flow calculation. Studies have tried to determine which location is the best for measuring valve areas and still this is the greatest source of error in this method of calculating stroke volume and cardiac output. Although aortic flow has been studied and validated in dogs, pulmonary, mitral, and tricuspid flows need more evaluation.

Question 418

Studies in dogs have measured cardiac output by measuring area of the aorta from several imaging planes using both trace and diameter methods. Calculations based upon the same FVI and areas calculated from the 3 views for aorta showed that the highest correlation (r= 0.93) when compared to thermodilution-derived cardiac output was when aortic area was measured by...?

Answer 418

BY tracing the lumen of the aorta of a right parasternal transverse plane of the heart base. Fig 4.63. This makes Doppler derived LV stroke volume calculations a fairly valid assessment of LV function.

Question 419

Cross-sectional areas: Trace right parasternal aortic root cross sections Use apical 4 ch for mitral annulus Use diameter of PA on transverse planes.

Answer 419

Trace right parasternal aortic root cross sections Use apical 4 ch for mitral annulus Use diameter of PA on transverse planes.

Question 420

How is the validity of measurement of output form the right side? Why so?

Answer 420

Measurement of output from the right side is variable and has poor correlation (r = 0.31). This is primarily due to variability in diameter measurements of the pulmonary artery because of poor resolution of the lateral walls. Fig 4.64. Averaging several beats is important in order to account for the variation in flow caused by respiration.

Question 421

There is great variability in stroke volume calculation at the mitral valve. Why?

Answer 421

Because of error introduced while measuring the mitral annular area.

Question 422

Stroke volume calculation at the mitral valve: The annulus can be measured by either?

Answer 422

1. Tracing the orifice from transverse views or | 2. by measuring the diameter of the annulus.

Question 423

Tracing the area of the orifice the largest mitral valve area is used on transverse views of the LV. Fig 4.65. Unfortunately, mitral flow is.......and a mean flow area as opposed to maximal flow area should be calculated.

Answer 423

biphasic This is done by tracing the transmittal flow profile and determining a ratio of mean to maximal leaflet separation. The 2D area is multiplied by ratio area in order to obtain the mean mitral area for diastole. Drawback; it is difficult to apply however, and varying results are seen.

Question 424

The mitral annulus can be measured from apical 4 ch views. Fig 4.66. To account for changes in annular size during diastole, several frames red to be measured and averaged after the valve opens.

Answer 424

The circular equations and elliptical equations when 2 planes for diameter are interrogated, have been applied to area calculations. equations 4.25 och 4.26 Both show good correlations (r=0.99 in circular method) with actual area. At this time the diameter measurement using the circular equation appears to be the easiest and no less accurate than any other method.

Question 425

Stroke volume (SV) is finally calculated by multiplying the ....... by the ........ of the vessel or annulus.

Answer 425

SV = FVI x area

Question 426

Flow measurement at the tricuspid valve is not well studied, and results are variable enough that it is not routinely used in people or reported in animals.

Answer 426

Flow measurement at the tricuspid valve is not well studied, and results are variable enough that it is not routinely used in people or reported in animals.

Question 427

Errors in measuring diameter are squared when inserted into area calculations. Using the ..... itself is a valid assessment of increased or decreased flow in situations where diameter measurements are questionable.

Answer 427

FVI

Question 428

Increases in FVI may sugget ...... volume, as in a shunt, while decreases in FVI can represent ......... flow.

Answer 428

Increases in FVI may sugget increased volume, as in a shunt, while decreases in FVI can represent poor flow.

Question 429

Systolic time intervals: Research in animals has shown that the rate of acceleration during ventricular ejection is an indicator of ...................

Answer 429

Research in animals has shown that the rate of acceleration during ventricular ejection is an indicator of systolic function. Fig 4.43

Question 430

The force created within the LV in order to open the aortic valve affects the rate at which maximum velocity is reached. This variable has been studied in dogs and in man, it is thought to be one of the better indicators of systolic function. It has been used to chart changes in LV function. It is dependent upon ....... and ........... however.

Answer 430

It is dependent upon heart rate and systolic load however.

Question 431

Mean aortic flow acceleration is .... cm/sec2 in dogs.

Answer 431

32 cm/sec2

Question 432

Ejection time or flow time and pre-ejection period may both be measured from ........ or ............. flow profiles. Their application is the same as when the values are derived from M-mode images.

Answer 432

Ejection time or flow time and pre-ejection period may both be measured from aortic or pulmonary flow profiles. Their application is the same as when the values are derived from M-mode images.

Question 433

Myocardial performance index (MPI), also called Tei index, is an index of?

Answer 433

Global myocardial function

Question 434

MPI/Tei index includes both ....... and .......... time intervals.

Answer 434

Includes both diastolic and systolic time intervals.

Question 435

In man, the MPI index can provide prognostic info in patients with ..........(3)

Answer 435

In man, this index can provide prognostic info in patients with valvular aortic stenosis, DCM and mitral regurgitation.

Question 436

The Tei index correlates well with both systolic and diastolic function of the right and left ventricle in dogs, and can be used to assess overall global function.

Answer 436

The Tei index correlates well with both systolic and diastolic function of the right and left ventricle in dogs, and can be used to assess overall global function.

Question 437

The MPI can identify subclinical DCM in the Newfoundland dog and identifies dysfunction on dogs with tricuspid regurgitation, mitral regurgitation and pulmonary hypertension.

Answer 437

The MPI can identify subclinical DCM in the Newfoundland dog and identifies dysfunction on dogs with tricuspid regurgitation, mitral regurgitation and pulmonary hypertension.

Question 438

The MPI uses ventricular ejection time and the isovolumetric periods (contraction and relaxation) to derive an overall assessment of global ventricular function.

Answer 438

The MPI uses ventricular ejection time and the isovolumetric periods (contraction and relaxation) to derive an overall assessment of global ventricular function.

Question 439

Isovolumic relaxation time and isovolumic contraction time are added together and divided by the .............

Answer 439

Isovolumic relaxation time and isovolumic contraction time are added together and divided by the ejection time. Fig 4.67.

Question 440

Using PW Doppler, the time intervals are derived from different cardiac cycles. The time from closure of the AV valve to opening is the sum of?

Answer 440

Using PW Doppler, the time intervals are derived from different cardiac cycles. The time from closure of the AV valve to opening is the sum of the systolic time period and the two isovolumic time periods. Fig 4.68

Question 441

Ejection time is obtained from trans aortic or pulmonary flow from ...?

Answer 441

from beginning of flow to the end of flow using the spectral trace. Fig 4.68

Question 442

Subtracting the ......... from the closure to opening time of the AV valve provide the sum of the isovolumic relaxation and contraction time periods.

Answer 442

Subtracting the ejection time from the closure to opening time of the AV valve provide the sum of the isovolumic relaxation and contraction time periods.

Question 443

Equation 4.28 and 4.29 are used to calculate the myocardial performance index. LV MPI =

Answer 443

IVRT + IVCT/ LVET = MCO - LVET/LVET where MCO is mitral valve closing to opening time and LVET is LV ejection time

Question 444

RV MPI =

Answer 444

IVRT + IVCT/ RVET = TCO - RVET/RVET where TCO is mitral valve closing to opening time and RVET is RV ejection time

Question 445

MPI (Tei index)

Answer 445

Assesses global ventricular function Using PW Doppler or TDI Color TDI-derived MPI higher than PW-derived MPI

Question 446

Fig 4.67 MPI (Tei index) uses ventricular ejection time and the isovolumic periods (contraction and relaxation) to derive an overall assessment of global ventricular function.

Answer 446

IVRT and IVCT are added together and divided by the ejection time (LVET). Often mitral closure to opening (MCO) is measured and ejection time is subtracted from this time period in order to derive the sum of the isovolumic time intervals.

Question 447

Myocardial performance index can alos be calculated from tissue Doppler evaluation of the longitudinal free wall or septum on ......... ch views of the heart.

Answer 447

Myocardial performance index can alos be calculated from tissue Doppler evaluation of the longitudinal free wall or septum on apical 4 ch views of the heart.

Question 448

What is the advantage to derive the MPI using TDI?

Answer 448

The same cardiac cycle can be used since TDI records myocardial motion during systole and diastole wherever the PW gate is placed. Fig 4.69 TDI MPI may help overcome errors in evaluation secondary to variations in HR when PW is used at different points in time.

Question 449

Differences between color-tissue Doppler derived LV MPI and PW TDI derived LV MPI?

Answer 449

Color-tissue Doppler derived LV MPI is slightly higher than PW TDI even though they have similar values with a significant correlation between them. 0.70 r value.

Question 450

The Tei index correlates ...... with systolic and diastolic function of the right and left ventricle in dogs and cats.

Answer 450

The Tei index correlates well with systolic and diastolic function of the right and left ventricle in dogs and cats.

Question 451

Studies in anesthetized dogs and cats have shown that increases in systolic function after inotropic infusion can be detected by .......... myocardial performance index derived from PW Doppler and TDI at both the free wall and at the septum.

Answer 451

increases in systolic function after inotropic infusion can be detected by decreased myocardial performance index derived from PW Doppler and TDI at both the free wall and at the septum. Septal TDI-derived MPI had better correlation with LV systolic function than free wall TDI derived MPI

Question 452

Both TDI-and PW derived MPI correlate significantly with ventricular filling pressure and may be useful in the assessment of global cardiac function in dogs with LV failure.

Answer 452

Both TDI-and PW derived MPI correlate significantly with ventricular filling pressure and may be useful in the assessment of global cardiac function in dogs with LV failure.

Question 453

Decreases in preload decrease ejection times but increase the isovolumic time periods, resulting in increased MPI.

Answer 453

Decreases in preload decrease ejection times but increase the isovolumic time periods, resulting in increased MPI.

Question 454

Acute increases in preload that increase ejection time will ...... MPI

Answer 454

decrease

Question 455

TDI derived MPI appears to be more accurate than PW-derived Tei index in assessing changes in function caused by changes in preload.

Answer 455

TDI derived MPI appears to be more accurate than PW-derived Tei index in assessing changes in function caused by changes in preload.

Question 456

Most studies have shown PW derived LV MPI to be ........... of HR, blood pressure, BW, BSA, sex and age in dogs and cat.

Answer 456

Most studies have shown PW derived LV MPI to be independent of HR, blood pressure, BW, BSA, sex and age in dogs and cat.

Question 457

One study showed the PW-derived LV MPI to increase with advancing age in dogs. This is thought to be secondary to age-related increases in ventricular relaxation time.

Answer 457

One study showed the PW-derived LV MPI to increase with advancing age in dogs. This is thought to be secondary to age-related increases in ventricular relaxation time. Right ventricular Tei index is also unaffected by age, HR, and BW

Question 458

The Tei index appears to be preload and BP independent but is significantly affected by acute changes in ......... ........

Answer 458

The Tei index appears to be preload and BP independent but is significantly affected by acute changes in loading conditions.

Question 459

In dogs with mitral regurgitation secondary to degenerative valve disease, the Tei index remained normal unless ........dysfunction was present.

Answer 459

systolic

Question 460

Volume overloading of the RV chamber does not affect TDI derived MPI in dogs, and the presence of TR does not affect the MPI in children.

Answer 460

Volume overloading of the RV chamber does not affect TDI derived MPI in dogs, and the presence of TR does not affect the MPI in children.

Question 461

Can MPI be an indicator of acute increases in afterload?

Answer 461

Yes, it is a sensitive indicator of acute increases in afterload, which causes the Tei index to increase.

Question 462

Increased values for both right and left ventricular MPI are indicative of?

Answer 462

Myocardial dysfunction when changes in load are chronic.

Question 463

Increased MPI indicates?

Answer 463

poor function

Question 464

MPI: Independent of?

Answer 464

HR, BP, weight and age

Question 465

MPI: Sensitive to acute changes in ?

Answer 465

afterload

Question 466

Is MPI preload dependent?

Answer 466

No

Question 467

TDI evaluation of systolic function: LV TD provides info regarding?myocardial

Answer 467

Myocardial velocity in very specific selected areas of the myocardium

Question 468

A pulsed-wave gate placed over the myocardium shows both systolic (...) and diastolic myocardial motion (.......and....)

Answer 468

A pulsed-wave gate placed over the myocardium shows both systolic (Sm) and diastolic myocardial motion (Em and Am), which is used to evaluate function. Fig 4.70

Question 469

When color TDI is used, systolic and diastolic gradients along the septum and lateral wall on apical views and between the epicardium and endocardium on transverse view can be evaluated.

Answer 469

When color TDI is used, systolic and diastolic gradients along the septum and lateral wall on apical views and between the epicardium and endocardium on transverse view can be evaluated.

Question 470

TDI time intervals associated with systolic myocardial function include Q-Sm (......), Q-peak Sm (......), Q-end Sm (...) and duration of Sm

Answer 470

TDI time intervals associated with systolic myocardial function include Q-Sm (The time interval from the beginning of the QRS complex to the beginning of Sm), Q-peak Sm (beginning of the QRS complex to peak velocity of Sm), Q-end Sm (the time interval from the beginning of the QRS complex to the end of Sm), and duration of Sm. Fig 4.70

Question 471

TDI time intervals associated with systolic myocardial function are measured on ....... of the mitral annulus on the apical 4 ch imaging plane.

Answer 471

both sides

Question 472

There are significant .........relationships between Q-Sm and EF and between Q-end Sm and EF, and a sign .......... relationship between EF and duration of Sm.

Answer 472

There are significant inverse relationships between Q-Sm and EF and between Q-end Sm and EF, and a sign positive relationship between EF and duration of Sm.

Question 473

These TDI indices are HR affected and all of these time intervals should be corrected for HR by dividing the parameter by ...........?

Answer 473

These TDI indices are HR affected and all of these time intervals should be corrected for HR by dividing the parameter by the square root of the R-to-R interval

Question 474

Systolic failure in dogs and man with DCM results in a decreased ............ gradient using color TDI between the subendocardium and subepicardium on ....... images and a decreased gradient between basal and apical free-wall systolic motion on ......... ch planes.

Answer 474

Systolic failure in dogs and man with DCM results in a decreased systolic gradient using color TDI between the subendocardium and subepicardium on transverse images and a decreased gradient between basal and apical free-wall systolic motion on apical 4 ch planes.

Question 475

Color TDI in a Great Dane with subclinical myopathy revealed a depressed radial .......... to .......... Sm gradient.

Answer 475

Color TDI in a Great Dane with subclinical myopathy revealed a depressed radial epicardial to endocardial Sm gradient. This was detected before any definitive 2D, M-mode or clinical signs of DCM were present.

Question 476

A Golden Retriever with subclinical DCM associated with muscular dystrophy showed .......... color TDI Sm gradients along both longitudinal and radial myocardial segments.

Answer 476

A Golden Retriever with subclinical DCM associated with muscular dystrophy showed decreased color TDI Sm gradients along both longitudinal and radial myocardial segments.

Question 477

PW TDI shows ................ longitudinal Sm at the base of the LV wall in both subclinical and overt DCM in Doberman Pinschers.

Answer 477

PW TDI shows decreased longitudinal Sm at the base of the LV wall in both subclinical and overt DCM in Doberman Pinschers.

Question 478

Peak systolic annular motion of the myocardium along the longitudinal axis at both the free wall and septal mitral annulus ............ with even mildly depressed systolic function in dogs.

Answer 478

Peak systolic annular motion of the myocardium along the longitudinal axis at both the free wall and septal mitral annulus decreases with even mildly depressed systolic function in dogs.

Question 479

In man, depressed Sm annular velocity is a senstive indicator of depressed systolic funciton despite echo derived normal EF.

Answer 479

n man, depressed Sm annular velocity is a senstive indicator of depressed systolic funciton despite echo derived normal EF.

Question 480

Mitral annular systolic velocity correlates well with LV systolic function even in human patients with severe MR and can be used as a predictor of postoperative development of reduced EF.

Answer 480

Mitral annular systolic velocity correlates well with LV systolic function even in human patients with severe MR and can be used as a predictor of postoperative development of reduced EF.

Question 481

Studies in dogs show that increases in systolic function after inotropic infusion can be detected by increases in annular Sm and decreases in myocardial performance index derived from PW TDI at both the free wall and at the septum.

Answer 481

Septal Sm had better regresson correlation with systolic function than the free wall Sm.

Question 482

Experimental studies have shown that decreases in systolic function after pacing induced heart failure correlates well with systolic annular motion (Sm). In dogs, subclinical DCM can be diagnosed by ....in Sm

Answer 482

Decreases in Sm

Question 483

Can systolic failure be seen in cats with HCM using TDI?

Answer 483

Yes, depressed color TDI Sm all along the LV lateral wall and septum on apical 4 ch views has been documented. There is also decreased acceleration of systolic myocardial motion in these cats. This is seen in cats with HCM depute normal to elevated FS

Question 484

Color TDI documented postsystolic contraction may be seen with systolic failure. This late systolic motion occurs after the ...wave during the isovolumic relaxation time period.

Answer 484

T wave

Question 485

This late delayed contraction velocity (post systolic contraction) is usually greater than twice the normal systolic velocity. As a result, ...... is not present. The underlying cause of this postsytolic contraction is poorly understood, but it is indicative of systolic dysfunction.

Answer 485

This late delayed contraction velocity is usually greater than twice the normal systolic velocity. As a result, Em is not present. The underlying cause of this postsytolic contraction is poorly understood, but it is indicative of systolic dysfunction.

Question 486

TDI imaging: decreased systolic function: Decreases ..... Decreases ............ gradient Decreases .......... gradient Post.... ......... may be present.

Answer 486

Decreases Sm Decreases radial gradient Decreases longitudinal gradient Postsystolic contraction may be present.

Question 487

Right ventricle: Decreased PW TDI systolic annular velocity correlates well with decreased RV EF in man. Assessment of longitudinal systolic function using 2D color TDI of the RV involves placing a PW gate at the lateral tricuspid valve annulus on a modified left parasternal apical 4 ch view of the heart.

Answer 487

Decreased PW TDI systolic annular velocity correlates well with decreased RV EF in man. Assessment of longitudinal systolic function using 2D color TDI of the RV involves placing a PW gate at the lateral tricuspid valve annulus on a modified left parasternal apical 4 ch view of the heart. Fig 3.67

Question 488

parameters that reflect systolic function include?

Answer 488

Peak systolic annular motion (Sm), isovolumic contraction time (ICT), ejection time (RVET) and the myocardial performance index (MPI or Tei)

Question 489

Reduced systolic annular velocity is associated with RV systolic failure, myocardial infarction, and pulmonary hypertension in man. What about in dogs?

Answer 489

Color TDI imaging of the RV wall has been shown to be useful in diagnosing the presence of pulmonary hypertension when a pressure gradient cannot be obtained form tricuspid regurgitant flow.

Question 490

Global TDI (Sm x Em:Am), Sm, and Em:Am are significantly ........ in dogs with pulmonary hypertension.

Answer 490

Global TDI (Sm x Em:Am), Sm, and Em:Am are significantly reduced in dogs with pulmonary hypertension.

Question 491

Evaluation of diastolic function: Normal diastolic function allows the heart to fill appropriately at normal filling pressure. Diastolic failure is the result of?

Answer 491

Increased resistance to filling and increased LV filling pressure.

Question 492

Diastolic dysfunction simply refers to?

Answer 492

presence of myocardial alterations from normal during diastole but does not indicate anything regarding the patient's clinical status.

Question 493

Diastolic function of the heart is very complex and involves several interactive components. These include...?

Answer 493

``` Myocardial relaxation, arterial contraction, rapid and slow filling phases, loading conditions, the pericardial sac, and elastic properties of the heart. ```

Question 494

The echocardigraphic assessment of diastolic function as it applies to the clinical situation will be presented here and will incorporate the evaluation of isovolumic relaxation, transmittal valve flow, pulmonary venous flow, and tissue Doppler imaging.

Answer 494

isovolumic relaxation, transmittal valve flow, pulmonary venous flow, and tissue Doppler imaging.

Question 495

Parameters of diastolic function: (4)

Answer 495

Isovolumic relaxation time Pulmonary vein flow Transmitral valve flow TDI-Em, Am

Question 496

Diastole extends from?

Answer 496

Closure of the semilunar valves to closure of the atrioventricular valves. This roughly corresponds to the time period from the T wave on an electrocardiogram to the beginning of the QRS complex.

Question 497

LV relaxation is an active process requiring energy expenditure. After peak systole, LV pressure drops, and once it drops below...... pressure, the semilunar valve closes. At this point, a period of ............. begins.

Answer 497

LV relaxation is an active process requiring energy expenditure. After peak systole, LV pressure drops, and once it drops below aortic pressure, the semilunar valve closes. At this point, a period of isovolumic relaxation begins. Fig 4.71 No change in volume occurs and all valves are closed, but pressure decreases and the myocardium relaxes. Relaxation continues even after the mitral valve opens.

Question 498

Filling of the LV chamber has several phases; a rapid ventricular filling phase, as low ventricular filling phase, and filling secondary to atrial contraction. The peak flow velocity between the LA and LV is determined by the ...................... between the 2 chambers.

Answer 498

The peak flow velocity between the LA and LV is determined by the pressure gradient between the 2 chambers.

Question 499

The Bernoulli equation cannot be directly applied to flow across the mitral annulus because of?

Answer 499

various factors including viscous forces, internal forces, and flow acceleration But the pressure differentials during the various phases of diastole are reflected in the LV inflow profile.

Question 500

At the beginning of diastole, LV pressure is lower than LA pressure, and there is a rapid inflow of blood into the LV. Fig 4.72

Answer 500

This creates an increase in LV pressure, and as LV pressure equilibrates or even slightly exceeds LA pressure, flow velocity decelerates.

Question 501

During mid-diastole, blood passively flows into the LV at a very low velocity. Is there a measurable change in pressure during this phase of diastole?.

Answer 501

During mid-diastole, blood passively flows into the LV at a very low velocity. There is no measurable change in pressure during this phase of diastole.

Question 502

During the atrial contraction at the ................diastole, flow velocity ................ but not to the degree of the rapid ventricular filling phase of early diastole.

Answer 502

During the atrial contraction at the end of diastole, flow velocity accelerates but not to the degree of the rapid ventricular filling phase of early diastole.

Question 503

Most of LV filling is completed by the end of the rapid ventricular filling phase (end of the mitral valve ...... peak) in the normal heart.

Answer 503

Most of LV filling is completed by the end of the rapid ventricular filling phase (end of the mitral valve E peak) in the normal heart. Thus, peak E wave of the mitral valve reflects the pressure gradient between the LA and LV at the beginning of diastole.

Question 504

As pressure equilibrate between the 2 chambers, a period of ......... occurs and the time for pressures to equilibrate is reflected by the ............... time of the E wave.

Answer 504

As pressure equilibrate between the 2 chambers, a period of diastasis occurs and the time for pressures to equilibrate is reflected by the deceleration time of the E wave

Question 505

Valve motion with atrial systole (A wave) reflects the ............. ............. between the LA and LV at the end of .................

Answer 505

Valve motion with atrial systole (A wave) reflects the pressure gradient between the LA and LV at the end of diastole.

Question 506

Diastolic filling abnormalities may be secondary to impaired or delayed ............. or decreased ................ within the LV.

Answer 506

Diastolic filling abnormalities may be secondary to impaired or delayed relaxation or decreased compliance within the LV.

Question 507

When relaxation is impaired, LV pressure remains high ........ in diastole, and LV filling is delayed until later in the diastolic time period resulting in a greater contribution to LV filling from ..........................

Answer 507

When relaxation is impaired, LV pressure remains high early in diastole, and LV filling is delayed until later in the diastolic time period resulting in a greater contribution to LV filling from atrial contraction.

Question 508

Compliance of the heart is a reflection ot its distensibility. A compliant ventricular chamber allows proper ............ at normal ............. while a noncompliant ventricular chamber is stiff, and pressure elevates ............. as the chamber fills.

Answer 508

Compliance of the heart is a reflection ot its distensibility. A compliant ventricular chamber allows proper filling at normal pressure while a noncompliant ventricular chamber is stiff, and pressure elevates rapidly as the chamber fills.

Question 509

Compliance plays a larger role in ....... diastole when the ventricular chamber is ...............

Answer 509

Compliance plays a larger role in late diastole when the ventricular chamber is already partially filled.

Question 510

Hypertrophy and ischemia are primary factors affecting .................., while fibrosis, infiltrative processes, hypertrophy, and other structural abnormalities are the primary factors affecting ................. of the heart.

Answer 510

Hypertrophy and ischemia are primary factors affecting relaxation, while fibrosis, infiltrative processes, hypertrophy, and other structural abnormalities are the primary factors affecting compliance of the heart.

Question 511

Impairment of diastolic function can produce backward or forward heart failure. Forward failure results from?

Answer 511

Decreased ventricular volume secondary to restricte filling.

Question 512

Impairment of diastolic function can produce backward or forward heart failure. Backward failure is the result of?

Answer 512

Backward failure is the result of high LV filling pressure reflected back into the LA.

Question 513

Other factors affecting ventricular filling include?

Answer 513

Heart rate and rhythm | Left atrial function

Question 514

Rapid heart rates limit adequate LV filling since .......................coincide.

Answer 514

Rapid heart rates limit adequate LV filling since early rapid filling and late diastolic filling phases coincide.

Question 515

Poor atrial function also diminishes .................... filling.

Answer 515

Poor atrial function also diminishes late diastolic filling.

Question 516

Impaired relaxation: Abnormal myocardial relaxation results in?

Answer 516

``` Decreased peak velocities in early diastole (E peak), Increased A velocities, a low E:A ratio, Increased deceleration times, Increased isovolumic relaxation times. ``` Fig 4.73, 4.74

Question 517

These changes in LV filling secondary to impaired relaxation can be seen in patients with?

Answer 517

HCM | Hypertension.

Question 518

Impaired relaxation: ............. E:A ratio ........... MV deceleration ........... IVRT

Answer 518

Reverse E:A ratio Slow MV deceleration Long IVRT

Question 519

Impaired relaxation: | Decreased peak E velocity occurs because LV diastolic pressure does not .............. as much as in normal hearts.

Answer 519

LV diastolic pressure does not decrease as much as in normal hearts.

Question 520

Impaired relaxation: | The smaller pressure gradient between the LA and the LV results in a ........... peak E velocity.

Answer 520

The smaller pressure gradient between the LA and the LV results in a lower peak E velocity.

Question 521

Impaired relaxation: Deceleration time is also prolonged as the LV takes longer to ......... thus taking longer for ventricular and atrial pressures to ................, and filling time is slower.

Answer 521

Deceleration time is also prolonged as the LV takes longer to relax thus taking longer for ventricular and atrial pressures to equilibrate, and filling time is slower.

Question 522

Impaired relaxation: Because the ventricle may not completely relax until late in diastole often the atrial contraction contributes more to ventricular filling than the early filling phase does. This results in a high peak ...... velocity and an E:A ratio of .................. Prolonged isovolemic ............. time is also seen with impaired relaxation

Answer 522

This results in a high peak A velocity and an E:A ratio of less than 1. Prolonged isovolemic relaxation time is also seen with impaired relaxation

Question 523

Decreased compliance Restriction to LV filling results in a short isovolemic ........., increased ........... velocity (fig 4.75)

Answer 523

Restriction to LV filling results in a short IVRT, increased E velocity (fig 4.75)

Question 524

LV filling into a stiff noncompliant chamber produces a large increase in LV pressure per unit volume. This kind of diastolic dysfunction is present in patients with ........................where high filling pressures are predominant

Answer 524

This kind of diastolic dysfunction is present in patients with restrictive, dilated, hypertrophy, or ischemic cardiomyopathy where high filling pressures are predominant

Question 525

Decreased compliance: Most of ventricular filling occurs early in diastole and less occurs with atrial systole since pressure within the left ventricle elevates rapidly in early diastole, resulting in a high ................

Answer 525

Most of ventricular filling occurs early in diastole and less occurs with atrial systole since pressure within the left ventricle elevates rapidly in early diastole, resulting in a high E:A ratio.

Question 526

Decreased compliance: Low A velocity may also be seen if atrial function is compromised. Deceleration times are typically ............ in these hearts secondary to rapid .......... of atrial and ventricular pressures.

Answer 526

Low A velocity may also be seen if atrial function is compromised. Deceleration times are typically reduced in these hearts secondary to rapid equalization of atrial and ventricular pressures.

Question 527

Decreased compliance: ......... IVRT ......... E:A ratio .............. MV deceleration

Answer 527

Short IVRT High E:A ratio Rapid MV deceleration

Question 528

Elevated LA pressure seen with any of the cardiomyopathies results in higher E wave velocity and a more rapid equilibration between LV and LA pressure that can be seen in the reduced E deceleration time. This is referred to as a

Answer 528

Restrictive filling pattern. Fig 4.76

Question 529

There is an inverse relationship between deceleration time and LV filling pressure in human patients with systolic myocardial failure. This parameter is considered to be one of the more specific indications of high LV filling pressure, and studies in both man and dogs show a strong correlation between ......... E wave deceleration and mortality.

Answer 529

A strong correlation between rapid E wave deceleration and mortality.

Question 530

Restriction to ventricular filling result in high ............... velocities and decreased ....... velocities.

Answer 530

Restriction to ventricular filling result in high peak E velocities and decreased A velocities.

Question 531

Deceleration time is typically ......... in hearts with restrictive physiology as the atrial and ventricular pressured equalize rapidly.

Answer 531

Deceleration time is typically rapid in hearts with restrictive physiology as the atrial and ventricular pressured equalize rapidly.

Question 532

Elevated LA pressure, which can be seen with any of the cardiomyopathies, results in .......... E wave velocity and rapid pressure equilibration between the LV and LA that can be seen in the ........... E deceleration tim (MV DecT). This is referred to as?

Answer 532

higher E wave velocity reduced E deceleration A restrictive filling pattern.

Question 533

The IVRT may be ........... or ........... in heart with restriction to filling since atrial pressures are higher.

Answer 533

The IVRT may be reduced or normal in heart with restriction to filling since atrial pressures are higher.

Question 534

Isovolumic relaxation time .......... as LA pressure increases. Sinus tachycardia causes the E and A waves to fuse, which may result in a falsely ................ IVRT.

Answer 534

Isovolumic relaxation time decreases as LA pressure increases. Sinus tachycardia causes the E and A waves to fuse, which may result in a falsely shortened IVRT.

Question 535

Pulmonary venous flow during systole is .......... in the presence of elevated LA pressure.

Answer 535

Pulmonary venous flow during systole is blunted in the presence of elevated LA pressure. Fig 4.77

Question 536

Pulmonary vein systolic flow velocity may also be ...............in the presence of significant mitral regurgitation, atrial fibrillation, and severe LV systolic failure.

Answer 536

Pulmonary vein systolic flow velocity may also be decreased in the presence of significant mitral regurgitation, atrial fibrillation, and severe LV systolic failure.

Question 537

As LV filling pressure increases, .................... flow during atrial contraction is accentuated. Velocity and duration are ........

Answer 537

As LV filling pressure increases, reverse flow during atrial contraction is accentuated. Velocity and duration are increased . Fig 4.78

Question 538

A pulmonary venous atrial reverse flow duration longer than transmitral atrial flow duration indicates?

Answer 538

Decreased compliance as well as high LV filling pressure.

Question 539

Increased LA pressure: ``` ...... E:A ratio ........ MV deceleration ......... IVRT ........pulmonary vein S ........... pulmonary vein Ar duration and velocity ``` ............ E:Em

Answer 539

Increased LA pressure: ``` High E:A ratio Rapid MV deceleration Decreased IVRT Decreased pulmonary vein S Increased pulmonary vein Ar duration and velocity ``` Increased E:Em

Question 540

TDI diastolic motion is less ............. dependent than conventional PW Doppler of transmittal valve low in cats and people with hypertrophic heart disease.

Answer 540

TDI diastolic motion is less preload dependent than conventional PW Doppler of transmittal valve low in cats and people with hypertrophic heart disease.

Question 541

TDI diastolic annular motion appears to be a good predictor of mortality and development of congestive heart failure in man. When both annular Sm and Em are lower than 3 cm/sec in man, it is predictive of significant mortality. This was even more useful predictor when combined with a restrictive filling pattern (rapid E wave deceleration and high E:Em ratios)

Answer 541

TDI diastolic annular motion appears to be a good predictor of mortality and development of congestive heart failure in man. When both annular Sm and Em are lower than 3 cm/sec in man, it is predictive of significant mortality. This was even more useful predictor when combined with a restrictive filling pattern (rapid E wave deceleration and high E:Em ratios)

Question 542

Diminished Em velocity then indicates impaired ................ function.

Answer 542

Diminished Em velocity then indicates impaired diastolic function. Fig 4.79.

Question 543

Normal feline PW TDI Em values should be greater than .....?

Answer 543

7,2 cm/sec

Question 544

In normal heart, annular Em increases with ...?

Answer 544

Exercise, | Increased preload, and Increased transmittal pressure gradient.

Question 545

Hearts with increased LA pressure show ............... in early transmittal flow velocity, and since Em .......... at all stages of diastolic failure, the E:Em (als0 written as E:E´) ..........

Answer 545

Hearts with increased LA pressure show increases in early transmittal flow velocity, and since Em decreases at all stages of diastolic failure, the E:Em (also written as E:E´) increases.

Question 546

E:Em in normal cats should be less than...? Increases in this ratio are consistent with ......?

Answer 546

8,07. Increases in this ratio are consistent with high LV filling pressure. The ratio of E:Em is a powerful negative prognostic indicator in man when its value exceeds 15.

Question 547

An animal model of tachycardia -induced cardiomyopathy showed a progression of impaired relaxation pattern to a restrictive filling pattern as heart failure progressed. This means that transmittal E wave velocity was ........., went through a pseudonormal phase, and progressed to a restrictive filling pattern.

Answer 547

low

Question 548

EM is reduced from early on in the progression of the disease process and remained low even as left atrial pressure increased and can be used to discriminate normal from pseudonormal transmittal flow velocities.

Answer 548

EM is reduced from early on in the progression of the disease process and remained low even as left atrial pressure increased and can be used to discriminate normal from pseudonormal transmittal flow velocities.

Question 549

When combined with transmittal flow early deceleration time (EDT), the more rapid the DT and the ........ the E:Em the worse the prognosis.

Answer 549

When combined with transmittal flow early deceleration time (EDT), the more rapid the DT and the higher the E:Em the worse the prognosis.

Question 550

During treatment for congestive heart failure, it has been shown that persistence of a restrictive filling pattern (........ mitral valve deceleration time, ...... mitral valve E) indicated a poorer prognosis as well.

Answer 550

During treatment for congestive heart failure, it has been shown that persistence of a restrictive filling pattern (rapid mitral valve deceleration time, high mitral valve E) indicated a poorer prognosis as well. A reversible restrictive pattern is consistent with a better prognosis and longer survival time.

Question 551

Normal feline: E:Em

Answer 551

increased LV filling pressure

Question 552

Normal feline: Em > 0.72 cm/sec An decrease in the ratio indicates?

Answer 552

Impaired diastolic function

Question 553

Pseudonormalization: Diastolic function is not a static thing, and various diseases create a continuum of changes in LV preload and atrial pressure. A mitral valve flow profile may appear normal despite impaired diastolic function. This is referred to as?

Answer 553

Pseudonormalization. Fig 4.80

Question 554

As left atrial pressure increases with advancing ............ dysfunction, early transmitral flow velocity ...............secondary to the increase in LA pressure. This changes the low transmittal valve E:A ratio back to normal (psudonormal).

Answer 554

As left atrial pressure increases with advancing diastolic dysfunction, early transmitral flow velocity increases secondary to the increase in LA pressure. This changes the low transmittal valve E:A ratio back to normal (psudonormal).

Question 555

As left atrial pressure increases even further, the restrictive filling pattern develops and the E:A ratio becomes significantly greater than .....

Answer 555

1

Question 556

During the time that LA pressures are just high enough to return the transmittal flow appearance to normal, isovolumic ............. time also returns to normal. It does not take as long for LV pressure to drop to LA pressure in this situation creating a .................. isovolumic relaxation time period.

Answer 556

During the time that LA pressures are just high enough to return the transmittal flow appearance to normal, isovolumic relaxation time also returns to normal. It does not take as long for LV pressure to drop to LA pressure in this situation creating a pseudonormal isovolumic relaxation time period.

Question 557

Normal from abnormal diastolic function can sometimes be differentiated by looking at pulmonary ...... flow.

Answer 557

vein

Question 558

Reversal of flow within the pulmonary veins is normally seen during atrial contraction. High velocity flow, which encompasses the entire time period of atrial contraction, is seen when LV ........... pressure increases abnormally during atrial contraction regardless of mitral valve flow profiles.

Answer 558

High velocity flow, which encompasses the entire time period of atrial contraction, is seen when LV diastolic pressure increases abnormally during atrial contraction regardless of mitral valve flow profiles. Fig 4.78 This may be used to evaluate diastolic function when heart rates are too high to separate the 2 phases of diastolic LV inflow.

Question 559

Valvular insufficiencies will alter the mitral inflow profiles. Significant ...........insufficiency will elevate LV diastolic pressure quickly during early diastole. The gradient from LA to LV will decrease rapidly, and deceleration time will decrease.

Answer 559

Valvular insufficiencies will alter the mitral inflow profiles. Significant aortic insufficiency will elevate LV diastolic pressure quickly during early diastole. The gradient from LA to LV will decrease rapidly, and deceleration time will decrease.

Question 560

Moderate to severe mitral insufficiency typically produces a ...... pressure gradient between the LA and LV.

Answer 560

Moderate to severe mitral insufficiency typically produces a large pressure gradient between the LA and LV. Peak E velocity will increase accordingly. Fig 4.81

Question 561

The presence of significant mitral insufficiency in hearts with hypertophic or dilated cardiomyopathy may alter the expected flow profile. Increased atrial pressure for instance, would ........ peak E inflow velocities by ........... the pressure gradient between the 2 chambers.

Answer 561

Increased atrial pressure for instance, would increase peak E inflow velocities by increasing the pressure gradient between the 2 chambers.

Question 562

A low LV filling pressure secondary to decreased preload can intensify the changes seen with impaired relation simply due to lack of volume.

Answer 562

A low LV filling pressure secondary to decreased preload can intensify the changes seen with impaired relation simply due to lack of volume.

Question 563

Peak E velocities increase for reasons other than .....

Answer 563

reasons other than impaired relaxation. Fig 4.81

Question 564

Grading of diastolic function: | Diastolic function can be categorized into 4 grades. What can be used to assign the grade of diastolic failure?

Answer 564

Altered transmitral flow Altered pulmonary vein flow Isovolumic relaxation time Tissue Doppler velocity Table 4.3

Question 565

Grade 1 diastolic failure is?

Answer 565

Impaired or delayed ventricular relaxation.

Question 566

Grade 1 diastolic failure: During this phase muscle relaxation is ...... so early ventricular filling is impaired resulting in diminished transmittal valve .... velocity and ....... rate as all as a possible increased pulmonary vein ...... ratio.

Answer 566

During this phase muscle relaxation is slower so early ventricular filling is impaired resulting in diminished transmittal valve E velocity and deceleration rate as all as a possible increased pulmonary vein S:D ratio.

Question 567

Diastolic filling of the atrium (which occurs at the same time as mitral E) is not optimal when ...... filling of the LV is reduced.

Answer 567

Diastolic filling of the atrium (which occurs at the same time as mitral E) is not optimal when early filling of the LV is reduced.

Question 568

Grade 2 diastolic dysfunction is present when?

Answer 568

LA pressure has increased enough to create the pseudo normalization phase. Mitral E:A and isovolumic relaxation time are normal. Pulmonary venous flow however shows increased Ar velocity and duration. Tissue Doppler E:EM is increased during this time period as it reflects the increase in LA pressure.

Question 569

Diastolic dysfunction that has progressed to the stage where LA pressure is significantly increased and LV filling pressure is high is grade.....

Answer 569

Grade 3 diastolic dysfunction

Question 570

In grade 3 diastolic dysfunction, transmitral E:A is significantly higher than 1.0 (often greater than 2.0), pulmonary Ar is ........ in duration and velocity, pulmonary vein D is significantly .........., and S is significantly .......... secondary to the elevated LA pressure. Tissue Doppler E:Em remains .......

Answer 570

In grade 3 diastolic dysfunction, transmitral E:A is significantly higher than 1.0 (often greater than 2.0), pulmonary Ar is increased in duration and velocity, pulmonary vein D is significantly increased, and S is significantly reduced secondary to the elevated LA pressure. Tissue Doppler E:Em remains elevated.

Question 571

.................. diastolic dysfunction is grade 4.

Answer 571

Irreversible diastolic dysfunction is grade 4.

Question 572

Hemodynamic information obtained from echocardiographic exams: Doppler hemodynamic information = non-invasiev cardiac catheterization. The peak velocity of vascular regurgitations and shunts are dependent upon the pressure difference between the 2 chambers or vessels involved. When a pressure gradient is calculated, it means that?

Answer 572

The pressure within the driving chamber or vessel is that much higher than the pressure within the receiving chamber or vessel.

Question 573

The pressure in the ................. chamber is estimated and added to the calculated gradient in order to determine pressure within the .............. chamber. These are of course based on estimates of pressure within the ................. chamber, and som error is inherent within the application.

Answer 573

The pressure in the receiving chamber is estimated and added to the calculated gradient in order to determine pressure within the driving chamber. These are of course based on estimates of pressure within the receiving chamber, and som error is inherent within the application.

Question 574

Pressure gradients: This is probably the most common application of Doppler echo in veterinary medicine. The physical principle of Conservation of Energy is the basis of the Bernoulli equation, which is used to calculate...?

Answer 574

Calculate the pressure gradient between 2 areas of the heart.

Question 575

The principle of Bernoulli equation states that when a constant volume of blood flows through a narrow area, its velocity must increase by an amount equal to ........

Answer 575

equal to the pressure drop. | fig 4.82

Question 576

When a constant volume of blood is moved through an orifice or vessel, the pressure increase proximal to the obstruction creates a proportional increase in blood velocity through the obstruction. The greater the degree of obstruction between the driving chamber and the receiving chamber or vessel, the greater the pressure differential and the higher the velocity of blood will be. The Bernoulli equation is as follows:

Answer 576

Pressure gradient = convective acceleration + flow acceleration + viscous friction (equation 4.30) The forces of viscous friction and flow acceleration are negligible in most causes of heart disease.

Question 577

The value of 1/2 p, the mass density of blood, is about 4, so the Bernoulli equation is simplified as?

Answer 577

The pressure gradient = 4 (blood velocity proximal to the obstruction or orifice - blood velocity distal to the obstruction or orifice. Se Equation 4.31

Question 578

The velocity is measured in m/s and the pressure gradient is mm mercury (Hg)

Answer 578

The velocity is measured in m/s and the pressure gradient is mm mercury (Hg)

Question 579

Modified Bernoulli Equation

Answer 579

PG=4V upphöjt i 2

Question 580

If a PW sample gate placed at a subvalvular aortic stenosis within the LV outflow tract produces a velocity of 1,2 m/sec, and velocity distal to the obstruction in the aorta is 3 m/sec, the following pressure gradient is calculated:

Answer 580

4 (3 upphöjt i 2 - 1.2 upphöjt i 2) = 30.3 mmHg

Question 581

Most normal flows within the heart are close to 1 m/sec, so the effect of V1 is ineligible and an even more simplified form of the equation is usually used:

Answer 581

Se equation 4.32 s 227 using the previous example, 4 (3 upphöjt i 2) = 36 mmHg Therefore, using the modified Bernoulli equation usually overestimated the pressure gradient to a small degree.

Question 582

Mean pressure gradients calculated from Doppler flow profiles can be determined by calculation packages with the ultrasound machine. The flow profile is traced and digitized. An arithmetic mean gradient is calculated that has a high correlation with catheterization-derived mean gradients.

Answer 582

Mean and peak pressure gradient calculation is shown in. fig 4.83

Question 583

Blood volume, tunnel lesions, and blood viscosity all place limitations to the application of the Bernoulli equation.

Answer 583

Blood volume, tunnel lesions, and blood viscosity all place limitations to the application of the Bernoulli equation.

Question 584

Since flow velocity is also dependent upon the .......... of blood moving through a vessel or orifice, pressure gradient calculations will be inaccurate when there is high ........ state.

Answer 584

Since flow velocity is also dependent upon the volume of blood moving through a vessel or orifice, pressure gradient calculations will be inaccurate when there is high flow state. (V1 will be elevated) Such conditions will exist when there is severe valvular insufficiency through a valve or through a stenotic area (i.e aortic insufficiency and aortic stenosis), a coexisting shunt, anemia, or sepsis).

Question 585

In the presence of conduit type of lesions as in tunnel subvalvular aortic stenosis, the Bernoulli equation will ............... the pressure gradient since the effects of are no longer insignificant.

Answer 585

overestimate

Question 586

Pressure gradients may also be overestimated when the viscosity of blood is ...............

Answer 586

Pressure gradients may also be overestimated when the viscosity of blood is decreased.

Question 587

.................... blood viscosity may underestimate the pressure gradient

Answer 587

Increased blood viscosity may underestimate the pressure gradient

Question 588

Since the sample site for measuring aortic flow velocity proximal to an aortic stenotic lesion within the LV outflow tract is often very deep, the signal may ............ even with low frequency transducers.

Answer 588

alias It would not be possible to determine V1 accurately, and the calculated pressure gradient will be higher than it actually is

Question 589

Pressure gradients not accurate when...?

Answer 589

The intercept angle is large Conduit-type obstruction is present There is valvular insufficiency at the obstruction V1 is not negligible.

Question 590

Although there is very good correlation between catheter-and Doppler-derived pressure gradients, there is a difference in the way the gradients are measured, which makes it appear that the Doppler-derived gradient overestimates the gradient when compared to gradients derived during cardiac catheterization.

Answer 590

Although there is very good correlation between catheter-and Doppler-derived pressure gradients, there is a difference in the way the gradients are measured, which makes it appear that the Doppler-derived gradient overestimates the gradient when compared to gradients derived during cardiac catheterization.

Question 591

Doppler-derived pressure gradients calculate .............. instantaneous pressure differentials across the stenotic lesion while catheterization-derived pressure gradients are ................ differentials.

Answer 591

Doppler-derived pressure gradients calculate maximal instantaneous pressure differentials across the stenotic lesion while catheterization-derived pressure gradients are peak-to-peak differentials. Fig 4.84.

Question 592

Catheterization: Peak-to-peak pressure gradients in aortic stenosis for example, are determined by calculating the difference between maximal LV pressure and maximal aortic pressure. These two pressure .......... occur at the same time.

Answer 592

Peak-to-peak pressure gradients in aortic stenosis for example, are determined by calculating the difference between maximal LV pressure and maximal aortic pressure. These two pressure do not occur at the same time.

Question 593

Doppler derived pressure gradients are calculated from the .............................. between ventricular and aortic pressure.

Answer 593

Doppler derived pressure gradients are calculated from the maximal instantaneous pressure difference between ventricular and aortic pressure. This creates a discrepancy between invasive-versus noninvasive-derived gradients since instantaneous gradients may be as much as 30 to 40% higher than peak-to-peak gradients.

Question 594

The more severe the stenosis, the closer peak-to-peak and instantaneous pressures are, since the highest LV pressures are generated later in ....................

Answer 594

The more severe the stenosis, the closer peak-to-peak and instantaneous pressures are, since the highest LV pressures are generated later in systole

Question 595

Fig 4.83. Dynamic outflow obstruction is evident by ..............

Answer 595

Dynamic outflow obstruction is evident by the late peaking flow profile.

Question 596

Tracing the aortic flow velocity profile yields both...?

Answer 596

``` maximum velocity (Max V) mean velocity (Mean V) Velocity time integral (VTI) Peak pressure gradient (Max PG) Mean pressure gradient (Mean PG). ```

Question 597

The arithmetic mean gradient calculated from Doppler flow profiles has a high correlation with cauterization derived mean gradients.

Answer 597

The arithmetic mean gradient calculated from Doppler flow profiles has a high correlation with cauterization derived mean gradients.

Question 598

In order to fully apply Doppler echo, estimates of intracardiac pressure are necessary.

Answer 598

In order to fully apply Doppler echo, estimates of intracardiac pressure are necessary. Fig 4.85 shows typical pressures within the cardiac chambers an great vessels. Disease processes may change these pressures somewhat, but unless invasive procedures are available, they are a good estimate, and using these representative pressures will not diminish the usefulness of Doppler-derived information in most applications.

Question 599

Intracardiac pressure determination from Doppler flows and pressure gradients are based on estimates of pressure within the receiving .......... or ............., and some error is inherent within the application.

Answer 599

Intracardiac pressure determination from Doppler flows and pressure gradients are based on estimates of pressure within the receiving chamber or vessel, and some error is inherent within the application.

Question 600

The pressure gradient can always be used as an "at least" pressure. For example, if the pressure gradient from LV to LA is calculated as 130 mmHg, the LV pressure is "at least 130 mmHg" regardless of what the LA pressures are.

Answer 600

The pressure gradient can always be used as an "at least" pressure. For ex if the pressure gradient from LV to LA is calculated as 130 mmHg, the LV pressure is "at least 130 mmHg" regardless of what the LA pressures are.

Question 601

The simplified Bernoulli equation is used in many applications. For example?

Answer 601

It is applied to stenotic lesions involving the great vessels or atrioventricular valves, ventricular and atrial septal defects, and intracardiac pressure determination by regurgitant jets.

Question 602

Mathematical software packages within the ultrasound equipment will calculate pressure gradients after peak velocity through the stenosis, shunt, or leak is identified and mean pressure gradient when the FVI is traced.

Answer 602

Mathematical software packages within the ultrasound equipment will calculate pressure gradients after peak velocity through the stenosis, shunt, or leak is identified and mean pressure gradient when the FVI is traced.

Question 603

Fig 4.83. from a dog with subvalvular aortic stenosis. The pressure gradient of 130 mmHg means that?

Answer 603

The LV is 130 mmHg higher than pressure beyond the obstruction in the aorta.

Question 604

Systolic pressures within the LV is fairly equal to peripheral systolic pressure in the absence of LV outflow obstruction. The driving pressure of a MR jet therefore would equal both

Answer 604

ventricular systolic pressure and systolic blood pressure.

Question 605

Since LV pressure is typically at least 100 to 110 mmHg, and LA pressure is usually less than 10 mmHg, a pressure gradient close to ........ is expected when the Bernoulli equation is applied to the peak velocity of a mitral regurgitation.

Answer 605

100

Question 606

This means that velocities of close to ....... m/sec should be recorded from a mitral regurgitant jet

Answer 606

This means that velocities of close to 5 m/sec should be recorded from a mitral regurgitant jet (4 x 5 upphöjt i 2 = 100)

Question 607

LA pressure can be estimated and added to the pressure gradient in order to calculate LV pressure, but even if LA pressure is not estimated and assumed to be zero, LV and systemic pressures are at least equal to the pressure.

Answer 607

LA pressure can be estimated and added to the pressure gradient in order to calculate LV pressure, but even if LA pressure is not estimated and assumed to be zero, LV and systemic pressures are at least equal to the pressure.

Question 608

As systemic pressure increases the driving pressure from LV to atrium will also increase, and peak velocity will ........ accordingly.

Answer 608

As systemic pressure increases the driving pressure from LV to atrium will also increase, and peak velocity will increase accordingly. Fig 4.86

Question 609

An animal with a regurgitant jet velocity of 6,8 m/sec (4 x 6,8 upphöjt i 2 = 185), would have ......... systemic pressures of at least 185 mmHg.

Answer 609

An animal with a regurgitant jet velocity of 6,8 m/sec (4 x 6,8 upphöjt i 2 = 185), would have systolic systemic pressures of at least 185 mmHg.

Question 610

Many cases of systemic hypertension have been found inadvertently by interrogating MR jets. Often Doppler assessment of high blood pressure is easier to obtain than good peripheral measurements of blood pressure especially in smaller animals.

Answer 610

Many cases of systemic hypertension have been found inadvertently by interrogating MR jets. Often Doppler assessment of high blood pressure is easier to obtain than good peripheral measurements of blood pressure especially in smaller animals.

Question 611

A "white coat" effect similar to that seen in people may be seen in animals, and pressure may only be elevated secondary to the stress of the clinical environment.

Answer 611

A "white coat" effect similar to that seen in people may be seen in animals, and pressure may only be elevated secondary to the stress of the clinical environment.

Question 612

Severe mitral regurgitation with a significant degree of flow acceleration proximal to the mitral valve will overestimate the pressure gradient because ....... is no longer negligible.

Answer 612

Severe mitral regurgitation with a significant degree of flow acceleration proximal to the mitral valve will overestimate the pressure gradient because V1 is no longer negligible.

Question 613

Use mitral or tricuspid insufficiencies to double check a pulmonic or aortic ...................

Answer 613

Use mitral or tricuspid insufficiencies to double check a pulmonic or aortic pressure gradient.

Question 614

Systolic RV and pulmonary pressures: The same principles described for the mitral valve are applied to the right side of the heart and have been studied in the dog. Right ventricular systolic pressure approximates ................. .......... systolic pressure in the normal heart.

Answer 614

Right ventricular systolic pressure approximates pulmonary artery systolic pressure in the normal heart. Therefore, the driving pressure behind a tricuspid regurgitant jet will equal both ventricular systolic pressures and pulmonary systolic pressure in the absence of pulmonic stenosis.

Question 615

se fig 4.86! Peak MR velocity jet of 695 cm/sec is inserted into the Bernoulli equation to yield a calculated pressure gradient of ....... mmHg. LV pressure is at least ...... mmHg. In the absence of aortic stenosis this is also a reflection of systemic pressure. In the presence of aortic stenosis, it suggests a pressure gradient of approximately 73 across the obstruction since ventricular pressure is at least ...... and aortic pressure is approximately 120.

Answer 615

Peak velocity of 695 cm/sec from the MR jet is inserted into the bernoulli equation to yield a calculated pressure gradient of 193 mmHg. LV pressure is at least 193 mmHg. In the absence of aortic stenosis this is also a reflection of systemic pressure. In the presence of aortic stenosis, it suggests a pressure gradient of approximately 73 across the obstruction since ventricular pressure is at least 193 and aortic pressure is approximately 120.

Question 616

Fig 4.87. Peak velocities from tricuspid regurgitant jets are used to determine RV systolic pressure. A velocity of 455 cm/sec and a pressure gradient of 82,8 suggest right ventricular systolic pressures are at least.....

Answer 616

83 mmHg In the absence of pulmonic stenosis, this is a reflection of pulmonary systolic pressures. In the presence of pulmonic stenosis, it suggests a pressure gradient of approximately 63 across the obstruction since ventricular pressures are at least 83 and pulmonary pressures are approximately 20

Question 617

RV and pulmonary systolic pressures are typically about ..... to ..... mmHg, and RA pressure is normally less than ..... mmHg.

Answer 617

RV and pulmonary systolic pressures are typically about 20 to 25 mmHg, and RA pressure is normally less than 5 mmHg.

Question 618

A normal pressure gradient between the RV and RA would be about .............

Answer 618

15 to 20 mmHg.

Question 619

If a tricuspid regurgitant jet with a velocity of 2,3 m/sec is receded, the calculated pressure is .... indicative of normal RV and pulmonary systolic pressures.

Answer 619

21 mmHg Regurgitant jets with higher velocities are suggestive of elevated RV and pulmonary systolic pressures. Fig 4.87.

Question 620

When aortic stenosis and MR are both present, the LV pressure affects both the aortic flow velocity and the MR velocity. Fig 4.85. A pressure gradient of 100 mmHg calculated from the aortic flow velocity in the presence of aortic stenosis tells us that LV pressure is 100 mmHg greater than ................pressure. If systolic blood pressure is 100 mmHg then LV pressure is approximately ........ mmHg.

Answer 620

A pressure gradient of 100 mmHg calculated from the aortic flow velocity in the presence of aortic stenosis tells us that LV pressure is 100 mmHg greater than systemic pressure. If systolic blood pressure is 100 mmHg then LV pressure is approximately 200 mmHg.

Question 621

If systolic blood pressure is 100 mmHg then LV pressure is approximately 200 mmHg. Doppler interrogation of MR should show a peak velocity of about ...... m/sec if aortic flow profiles were accurately recorded .

Answer 621

Doppler interrogation of MR should show a peak velocity of about 7 m/sec if aortic flow profiles were accurately recorded . (4 x 7 upphöjt i 2 = 196). This can be used to double check the Doppler results. MR can often be used to verify or help determine a LV to aorta pressure gradient in the presence of subvalvular or valvular aortic stenosis

Question 622

If there is a discrepancy between the 2 determinations of LV pressure then the highest estimate should be used since Doppler rarely ............... a pressure gradient but often ............ a gradient when the interrogation angle with respect to flow becomes large.

Answer 622

If there is a discrepancy between the 2 determinations of LV pressure then the highest estimate should be used since Doppler rarely overestimates a pressure gradient but often underestimates a gradient when the interrogation angle with respect to flow becomes large.

Question 623

Doppler often underestimates a gradient when the interrogation angle with respect to flow becomes large. For ex, with a systolic blood pressure of 120, if a gradient of 60 is obtained for a subvalvular aortic stenosis (suggesting ventricular pressure of approximately 180 mmHG) and a gradient of 220 is obtained from a small MR jet (suggesting LV pressure of approximately 220 mmHg), then the pressure gradient across the aortic valve is underestimated and should be closer to and at least ...... mmHg.

Answer 623

For ex, with a systolic blood pressure of 120, if a gradient of 60 is obtained for a subvalvular aortic stenosis (suggesting ventricular pressure of approximately 180 mmHG) and a gradient of 220 isobtiante from a small MR jet (suggesting LV pressure of approximately 220 mmHg), then the pressure gradient across the aortic valve is underestimated and should be closer to and at least 100 mmHg. The same process can be applied to right sided pressure calculations when both tricuspid insufficiency and pulmonary stenosis is present. The pressure gradient measured from the tricuspid regurgitant jet ma be used to determine or verify the severity of the pulmonic stenosis.

Question 624

............ systemic pressure can be determined non invasively if aortic insufficiency is present.

Answer 624

Diastolic systemic pressure can be determined non invasively if aortic insufficiency is present.

Question 625

Peak velocity of the aortic insufficiency can be used to determine the pressure gradient between the aorta and LV during diastole. A normal diastolic systemic pressure of 60 and a normal LV end diastolic pressure of 10 yield a pressure gradient of ......

Answer 625

50.

Question 626

A peak aortic insufficiency velocity of 3,5 m/sec would suggest a .......... systemic diastolic pressure (4 x 3.5 upphöjt i 2 = 49).

Answer 626

A peak aortic insufficiency velocity of 3,5 m/sec would suggest a normal systemic diastolic pressure (4 x 3.5 upphöjt i 2 = 49).

Question 627

As diastolic systemic pressure increases with hypertension, the driving pressure into the LV becomes greater, and higher peak aortic regurgitant velocity is expected. Fig 4.88

Answer 627

As diastolic systemic pressure increases with hypertension, the driving pressure into the LV becomes greater, and higher peak aortic regurgitant velocity is expected. Fig 4.88

Question 628

Aortic insufficiency with a peak velocity of 4.8 m/sec suggest diastolic blood pressure of at least ......mmHg

Answer 628

92 mmHg (4 x 4.8 upphöjt i 2 = 92)

Question 629

As with systolic pressure estimation, animals do display a "white coat effect", and blood pressure may only be temporarily elevated due to the clinical environment.

Answer 629

As with systolic pressure estimation, animals do display a "white coat effect", and blood pressure may only be temporarily elevated due to the clinical environment.

Question 630

Diastolic pulmonary pressure: Pulmonary hypertension elevates .................. pressures. Since a large number of normal animals have pulmonary insufficiency, this jet may be used to determine pulmonary ...............pressure.

Answer 630

Pulmonary hypertension elevates both systolic and diastolic pressures. Since a large number of normal animals have pulmonary insufficiency, this jet may be used to determine pulmonary diastolic pressure.

Question 631

The presence of elevated diastolic pulmonary pressure confirms the presence of pulmonary hypertension even if systolic pulmonary pressure cannot be derived fem a tricuspid regurgitant jet.

Answer 631

The presence of elevated diastolic pulmonary pressure confirms the presence of pulmonary hypertension even if systolic pulmonary pressure cannot be derived fem a tricuspid regurgitant jet.

Question 632

Since normal pulmonary diastolic pressure is approximately 10 to 15 mmHg, and right ventricular diastolic pressure is less than 5 mmHg, a pressure gradient of about ........ to ...... mmHg is expected in the normal heart from the pulmonary artery to the right ventricle.

Answer 632

Since normal pulmonary diastolic pressure is approximately 10 to 15 mmHg, and right ventricular diastolic pressure is less than 5 mmHg, a pressure gradient of about 10 to 15 mmHg is expected in the normal heart from the pulmonary artery to the right ventricle.

Question 633

Pulmonic insufficincy jets should have velocities no greater than ........to ...... m/sec in animals with normal pulmonary pressures

Answer 633

Pulmonic insufficincy jets should have velocities no greater than 2 to 2.5 m/sec in animals with normal pulmonary pressures (4 x 2 upphöjt i 2 = 16)

Question 634

Peak early diastolic regurgitant pressure gradient represents ......pulmonary artery pressure. The pressure gradient obtained at end diastole is used to calculate ..... diastolic pulmonary artery pressure.

Answer 634

Peak early diastolic regurgitant pressure gradient represents mean pulmonary artery pressure. The pressure gradient obtained at end diastole is used to calculate end diastolic pulmonary artery pressure. Fig 4.90

Question 635

Adding an estimated .................. pressure to the end diastolic pressure gradient obtained from the pulmonary regurgitant jet represents the end diastolic pressure i the pulmonary artery.

Answer 635

Adding an estimated RV end diastolic pressure to the end diastolic pressure gradient obtained from the pulmonary regurgitant jet represents the end diastolic pressure i the pulmonary artery.

Question 636

RV diastolic pressure is estimated from ........collapse during respiration.

Answer 636

RV diastolic pressure is estimated from vena cava collapse during respiration. See chapter 5

Question 637

Pulmonary insufficiency: Peak early pressure gradient: = ...... PA pressure En diastolic pressure gradient = PA ......... pressure.

Answer 637

Peak early pressure gradient: = mean PA pressure En diastolic pressure gradient = PA diastolic pressure.

Question 638

Regurgitant fraction: Flow through the mitral annulus is equal to flow out the aorta in a normal heart as is flow through the mitral and tricuspid valves and flow through the aortic and pulmonary valves and flow through the tricuspid and pulmonary valves.

Answer 638

Flow through the mitral annulus is equal to flow out the aorta in a normal heart as is flow through the mitral and tricuspid valves and flow through the aortic and pulmonary valves and flow through the tricuspid and pulmonary valves. This of course is true over the course of several cardiac cycles since there are variations in stroke volume related to HR and respiration on a beat to beat basis.

Question 639

Only when there are insufficiencies or ........ will there be more volume flowing through one valve than other.

Answer 639

Only when there are insufficiencies or shunts will there be more volume flowing through one valve than other.

Question 640

In the case of mitral insufficiency, flow through the mitral valve will be ....... than flow through the aortic valve. The regurgitant volume plus the normal forward stroke volume moves past the mitral valve and then as the normal forward stroke volume goes throughout the aorta, the regurgitant volume flows back into the LA. Based on this, regurgitant fraction (RF) can be calculated by applying the following equation:

Answer 640

In the case of mitral insufficiency, flow through the mitral valve will be greater than flow through the aortic valve. Mitral RF= Mitral SV - aortic SV/ mitral SV Where SV = stroke volume, which is calculated using equations 4.25, 4.26 and 4.27

Question 641

Limitations to the calculation of mitral RF application?

Answer 641

Inaccuracies in the area calculations for the aorta and mitral annuluses as well as the fact that the stroke volume at each valve is not measured at the same cardiac cycle. Measure five or more cardiac cycles for area measurements in order to eliminate as much technical error as possible as well as beat-to beat flow differences. All the information available inducing the degree of volume overload, function, flow velocities, and profiles as well as the clinical picture should be evaluated.

Question 642

Regurgitant fractions are just one way of assessing regurgitation, and this area of echo needs further investigation in veterinary medicine.

Answer 642

Regurgitant fractions are just one way of assessing regurgitation, and this area of echo needs further investigation in veterinary medicine.

Question 643

Shunt ratios: Analysis of cardiac shunts should involve analysis of the shunt pathway. Only the chambers and vessels of the heart that are in the pathway will show enlargement or increased flow volume. A ventricle septal defect therefore has increased volume within the....?

Answer 643

Left ventricle Right ventricle Pulmonary artery Left atrium The right atrium and aorta never see the shunted volume

Question 644

With atrial septal defect, the shunt volume flows through the?

Answer 644

Left atrium Right atrium, Right ventricle Pulmonary artery The LV and aorta never see the shunt volume.

Question 645

Patent ductus artery (PDA) volume overloads the ...?

Answer 645

pulmonary artery, the left atrium, the left ventricle, and ascending aorta. The right side of the heart is not affected by a typical L-R flowing PDA

Question 646

Based on the flow pathway then the severity of a ventricular septal defect, atrial septal defect, or PDA can be assessed by analyzing flow through an area that should not see the shunted volume versus an area that does. This is done by determining

Answer 646

Qp/Qs where Qp = pulmonary flow Qs = systemic flow

Question 647

The greater the volume of blood shunting across a VSD for instance the greater the amount of flow out of the pulmonary artery versus the ....... where the shunted blood nerver passes.

Answer 647

aorta

Question 648

Calculation of a shunt ratio for ventricular septal defect or atrial septal defect can be done by applying equation:

Answer 648

Qp/Qs = PAsv/AOsv where PAsv= pulmonary artery stroke volume AOsv= aortic stroke volume Stroke volume is calculated using equations 4.25, 4.26, 4.27

Question 649

Qp:Qs= shunt ratio for?

Answer 649

shunt ratio for VSD and ASD

Question 650

Qs:Qp= shunt ratio for?

Answer 650

shunt ratio for PDA

Question 651

PDA is different in that the increased flow is seen in the ascending aorta, and normal stroke volume is seen i the pulmonary artery. Its shunt ratio is therefore calculated as follows:

Answer 651

Qs/Qp = AOsv/PAsv

Question 652

As with regurgitant fractions there are limitations to this technique. The most limiting factor is?

Answer 652

Area calculations for the aorta and pulmonary artery. Shunt severity should never be assessed by one method alone. The entire exam should be considered including cardiac size, flow velocities, as well as the clinical picture.

Question 653

Pressure half-time: Aortic regurgitation: The effects of AI on LV diastolic pressure can be assessed from the shape of the AI flow profile. At any point during diastole, the instantaneous pressure difference between the aorta and LV is reflected upon the ...................profile.

Answer 653

At any point during diastole, the instantaneous pressure difference between the aorta and LV is reflected upon the regurgitant jet flow profile.

Question 654

When AI is severe, there will be a rapid ......... in aortic diastolic pressure because of runoff into the LV, and there will be a dramatic ........... in LV pressures. Both of these factors produce a rapid ......... in regurgitant velocity as the driving pressure into the LV declines and the receiving pressure increases creating less of a pressure gradient. The flow profile becomes ........... in shape as opposed to the flat plateau-shaped flow profiles seen in mild aortic insufficiency.

Answer 654

When AI is severe, there will be a rapid decline in aortic diastolic pressure because of runoff into the LV, and there will be a dramatic increase in LV pressures. Both of these factors produce a rapid decline in regurgitant velocity as the driving pressure into the LV declines and the receiving pressure increases creating less of a pressure gradient. The flow profile becomes triangular in shape as opposed to the flat plateau-shaped flow profiles seen in mild aortic insufficiency. Fig 4.91

Question 655

Mild aortic insufficiency does not elevate LV diastolic pressure significantly and neither does it decrease aortic diastolic pressures dramatically. The result is a flow profile that is ........ shaped because the pressure gradient remains similar throughout diastole.

Answer 655

Mild aortic insufficiency does not elevate LV diastolic pressure significantly and neither does it decrease aortic diastolic pressures dramatically. The result is a flow profile that is plateau shaped because the pressure gradient remains similar throughout diastole. Fig 4.92

Question 656

Pressure half-time (PHT) =

Answer 656

= time for peak velocity to decline by half

Question 657

Aortic regurgitation: Hemodynamically insignificant: ``` PHT= ........ PHT= ...... shaped ```

Answer 657

``` PHT= long PHT= plateau shaped ```

Question 658

Aortic regurgitation: Hemodynamically significant: PHT=........ PHT= .......... slope

Answer 658

PHT=short | PHT= steep slope

Question 659

The rapid decline in aortic regurgitation velocity can be measured, and the measurement is referred to as?

Answer 659

The diastolic half-time

Question 660

What is the diastolic half-time?

Answer 660

The time it takes for the peal gradient (not velocity) to decrease by half

Question 661

How is the diastolic half-time measured?

Answer 661

By extending the deceleration slope to the baseline and measuring the deceleration time. This deceleration time is multiplied by 0.29. Fig 4.93. The calculations are performed by the equipment automatically.

Question 662

There are no standards for measurement of diastolic half-times in animals, and even in man, there are problems in applying half-time measurements.

Answer 662

There are no standards for measurement of diastolic half-times in animals, and even in man, there are problems in applying half-time measurements.

Question 663

Diastolic half-times less than ....... m/sec are suggestive of hemodynamically significant aortic regurgitation.

Answer 663

Diastolic half-times less than 300 m/sec are suggestive of hemodynamically significant aortic regurgitation. The measurement cannot separate groups of patients into mild, moderate, and severe insufficiency consistently however, and there is much overlap. Part of the problem may lie in the fact that several flows affect aortic and ventricular pressures including transmittal flow into the ventricle while the aortic valve is leaking, and forward flow into the system at the same time as the regurgitant flow. Nevertheless, a subjective assessment of flow profile is easy enough to apply, and significant aortic insufficiency as well as a rapid increase in LV diastolic pressure can be assumed from a sharp decline in AI velocity during diastole.

Question 664

Mitral and tricuspid stenosis The severity of mitral or tricuspid stenosis correlates directly with pressure half-time. The longer the pressure half-time the ........ the stenosis.

Answer 664

The severity of mitral or tricuspid stenosis correlates directly with pressure half-time. The longer the pressure half-time the more severe the stenosis. Fig 4.94

Question 665

Mitral and tricuspid stenosis The velocity across the stenosis is directly dependent upon........... This is in contrast to the pressure half-times seen i aortic and pulmonary regurgitation. The ...............slope reflects delayed normal early diastolic ............ because of a persistent pressure differential between the LA and LV

Answer 665

The velocity across the stenosis is directly dependent upon LV pressures. This is in contrast to the pressure half-times seen i aortic and pulmonary regurgitation. The reduced slope reflects delayed normal early diastolic closure because of a persistent pressure differential between the LA and LV

Question 666

Normal mitral valve pressure half-time in the dog are? An in the cat?

Answer 666

29 +/- 8 m/sec (

Question 667

Normally during early ventricular filling, the left ventricular pressure rises and LA pressure decreases resulting in a rapid deceleration of the E peak on transmitral flow profiles when the pressure gradient between the 2 chambers rapidly equalizes.

Answer 667

Normally during early ventricular filling, the left ventricular pressure rises and LA pressure decreases resulting in a rapid declaration of the E peak on transmitral flow profiles when the pressure gradient between the 2 chambers rapidly equalizes.

Question 668

With mitral or tricuspid stenosis, the more severe the restriction to ventricular inflow the ........ the pressure gradient is maintained between the 2 chambers and the .......... the decline of the MV or TV E peak during early diastolic filling.

Answer 668

With mitral or tricuspid stenosis, the more severe the restriction to ventricular inflow the longer the pressure gradient is maintained between the 2 chambers and the slower the decline of the MV or TV E peak during early diastolic filling.

Question 669

M-mode hemodymanic information: Doppler echocardiography provides direct assessment of blood flow within the heart and is the primary method used to assess the hemodynamics of flow within the ventricles and atria. However, even without the quantitative information available through Doppler, the following M-mode features can provide very definite information about flow within the heart.

Answer 669

Doppler echocardiography provides direct assessment of blood flow within the heart and is the primary method used to assess the hemodynamics of flow within the ventricles and atria. However, even without the quantitative information available through Doppler, the following M-mode features can provide very definite information about flow within the heart. See the following questions.

Question 670

Aortic valve motion on M-mode images reflects ............... Normally the aortic valve opens rapidly, and the leaflets parallel each other as they lie along the aortic wall during systole. The end of systole produces rapid ...... of these cusps.

Answer 670

Aortic valve motion on M-mode images reflects cardiac output. Normally the aortic valve opens rapidly, and the leaflets parallel each other as they lie along the aortic wall during systole. The end of systole produces rapid closure of these cusps.

Question 671

M-mode images that show normal opening at the onset of systole, but then show gradual closure of the cusps throughout systole, suggest that blood flowing through the aorta is ........as systole progresses. When is this typically seen?

Answer 671

M-mode images that show normal opening at the onset of systole, but then show gradual closure of the cusps throughout systole, suggest that blood flowing through the aorta is decreasing as systole progresses. Fig 4.95 This is typically seen when systolic function is impaired and cardiac output cannot be maintained throughout systole. It is also a frequent finding is patients with severe mitral insufficiency and low output failure where blood flows into the low pressure LA as opposed to the high-pressure aorta.

Question 672

Systolic aortic valve fluttering is often seen in diseases that create turbulent and rapid blood flow through the aorta as in ......

Answer 672

Subvalvular aortic stenosis or hypertophic obstructive cardiomyopathy. Fig 4.96

Question 673

When the aortic valve exhibit mid systolic closure or notching, it is an indication that ....?

Answer 673

An indication that flow has been abruptly reduced at that point in time. Fig 4.97.

Question 674

When does the aortic valve exhibit mid systolic closure or notching?

Answer 674

This is usually seen with dynamic obstruction to LV outflow.

Question 675

Dynamic obstruction including ...?

Answer 675

subvalvular muscular obstruction that increases with contraction of the ventricular septum, and systolic anterior mitral valve motion.

Question 676

Systolic aortic valve closure can also be seen with discrete aortic stenosis. It is typically seen .......... in the systolic time period however.

Answer 676

Systolic aortic valve closure can also be seen with discrete aortic stenosis. It is typically seen earlier in the systolic time period however. This is not specific to obstructive disease, but is is rarely seen otherwise. It has been reported with MI, VSD, aortic root dilation, and DCM.

Question 677

Mitral valve motion: There are 2 phases to LV filling, a rapid passive filling phase, and a slower active phase secondary to atrial contraction. These 2 phases create eh classic ....shape of the mitral valve.

Answer 677

M shape

Question 678

Mitral valve motion: A reduction i deceleration after peak E velocity has been reached is generally associated with?

Answer 678

Associated with a decrease in the rate of filling secondary to delayed ventricular relaxation or increased stiffness of ventricular walls. Fig 4.98 This is not a specific firing and may occasionally be seen in normal hearts and in patients with pulmonary hypertension or other volume contracted states.

Question 679

Patients in which LV filling pressure is high will show ...... ......... closure of the mitral valve. Typically the valve closes ....... after the beginning of the QRS complex.

Answer 679

Patients in which LV filling pressure is high will show early rapid closure of the mitral valve. Typically the valve closes shortly after the beginning of the QRS complex. This is a subtle and nonspecific finding.

Question 680

Mitral valve closure may also be delayed producing what is called the "......" bump. This is also found with elevated LV pressure and and is thought by some to reflect ......... ........ secondary to the high filling pressure.

Answer 680

Mitral valve closure may also be delayed producing what is called the "B" bump. Fig 4.99 This is also found with elevated LV pressure and and is thought by some to reflect diastolic MR secondary to the high filling pressure.

Question 681

The E point to septal separation (EPSS) correlates with? The EPSS may also be affected by .........

Answer 681

LV EF. Fig 4.38 The EPSS may also be affected by aortic insufficiency, however, as the regurgitant jet within the LV outflow tract prevents the valve from moving completely up toward the septum. Fig 4.100.

Question 682

The turbulence associated with AI will also create vibration of the mitral valve during ....... This vibration may sometimes also be seen of the inter ventricular septum.

Answer 682

The turbulence associated with AI will also create vibration of the mitral valve during diastole. This vibration may sometimes also be seen of the inter ventricular septum.

Question 683

The worse the AI the greater the EPSS, the coarser the mitral valve diastolic flutter, and the more abnormal the "...." appears.

Answer 683

The worse the AI the greater the EPSS, the coarser the mitral valve diastolic flutter, and the more abnormal the "M" appears.

Question 684

Mitral valve motion also changes with LV outflow obstruction. The mitral valve moves up toward the septum and LV outflow tract creating what is referred to as systolic anterior mitral valve motion (SAM)

Answer 684

Fig 4.101

Question 685

Several theories exist for the underlying cause of SAM. Such as?

Answer 685

High velocity flow within an outflow tract narrowed by a hypertrophied septum may create a Venturi effect and tends to pull one or both mitral valve leaflets along with it toward the septum. The presence of abnormal ventricular architecture and papillary muscle misalignment may allow the anterior or posterior mitral valve to be pushed into the outflow tract during systole. Alignment of the sub auricular papillary muscle into the middle of a hypertophic ventricular chamber may also play a role in the development of SAM:

Question 686

The SAM itself adds to the obstruction to flow as the leaflet is pulled into the outflow tract. The greater the upward motion and the more apposition the mitral leaflet has with the septum during systole, the greater the degree of obstruction.

Answer 686

This is a sensitive finding in moderate to severe dynamic LV outflow obstruction but may occasionally be seen in hearts with transposition of the greats vessels, coronary artery disease, systemic hypertension, discrete aortic stenosis, tunnel aortic stenosis, and mitral stenosis. There are other less frequently reported incidences of SAM in patients with glycogen storage diseases, and Friedreich's ataxia.

Question 687

LV wall: Restriction to ventricular fillins as seen with restrictive pericarditis or restrictive cardiomyopathy is difficult to assess with M-mode or even 2D images. In some cases, however, there are alterations in LV wall motion. Normally the LV gradually fills and there is concomitant downward motion of the free wall during diastole. With restriction to filling, LV wall motion is .... with ..... increase in LV dimension toward the latter part of diastole since filling is impaired.. This is a subtle and not a very sensitive finding but when present is specific.

Answer 687

In some cases, however, there are alterations in LV wall motion. Normally the LV gradually fills and there is concomitant downward motion of the free wall during diastole. With restriction to filling, LV wall motion is flat with no increase in LV dimension toward the latter part of diastole since filling is impaired.. This is a subtle and not a very sensitive finding but when present is specific.

Question 688

Interventricular septum: Animals with right-sided pressure or volume overload show paradoxical and flattened septal motion. This motion appears to be specific for?

Answer 688

Specific for right-sided disease and is not seen in left-sided cardiac disease.

Question 689

Normally the septum moves downward during .......... systole with peak downward motion occurring just before peak upward motion of the LV free wall. The septum begins to move upward again at the end of .......... and may show a ....... dip. (Fig 4.102). The dip may be associated with early LV filling or when RV filling occurs slightly before LV filling.

Answer 689

Normally the septum moves downward during early systole with peak downward motion occurring just before peak upward motion of the LV free wall. The septum begins to move upward again at the end of systole and may show a diastolic dip. (Fig 4.102). The dip may be associated with early LV filling or when RV filling occurs slightly before LV filling.

Question 690

In the presence of RV systolic pressure overload, RV systole ............, despite a possibly shortened ejection time.

Answer 690

In the presence of RV systolic pressure overload, RV systole lengthens, despite a possibly shortened ejection time.

Question 691

RV systolic pressure overload: The lengthened RV systolic period extends into the time when the LV starts to relax. As a result, the interventricular septum moves down to the ........early in diastole. With the onset of LV ..............., LV pressure becomes higher than right sided pressure again, and the septal motion moves to the right. This results in .................... septal motion. When there is also elevated RV filling pressure, then the septum remains deviated toward the left throughout the ......... time period with upward motion occurring only at peak LV c...........

Answer 691

The lengthened RV systolic period extends into the time when the LV starts to relax. As a result, the inter ventricular septum moves down to the left early in diastole. With the onset of LV contraction, LV pressure becomes higher than right-sided pressure again, and the septal motion moves to the right. This results in paradoxical septal motion. When there is also elevated RV filling pressure, then the septum remains deviated toward the left throughout the diastolic time period with upward motion occurring only at peak LV contraction. Fig 4.103

Question 692

The right-sided volume overload must be ...................... before paradoxical septal motion is seen.

Answer 692

The right-sided volume overload must be moderate to severe before paradoxical septal motion is seen.

Question 693

Animals with right-sided volume overload, which elevates RV diastolic pressure but which does not exceed .............. pressure, did not show paradoxical and flattened septal motion but do show a flatter septal appearance.

Answer 693

Animals with right-sided volume overload, which elevates RV diastolic pressure but which does not exceed left side pressure, did not show paradoxical and flatten red septal motion but do show a flatter septal appearance.

Question 694

In all cases of paradoxical and flattened septal motion, systolic ............. of the septum still occurs at the appropriate time in the cardiac cycle despite the abnormal motion.

Answer 694

In all cases of paradoxical and flattened septal motion, systolic thickening of the septum still occurs at the appropriate time in the cardiac cycle despite the abnormal motion.

Question 695

The 2D manifestation of paradoxical septal motion is ?

Answer 695

The 2D manifestation of paradoxical septal motion is a flattened septum on transverse LV imaging planes. Fig 4.12, 4.104

Question 696

The normally circular LV chamber has a ......................... shape secondary to elevated RV pressure.

Answer 696

triangular Studies have shown that the degree of curvature of the septum correlates with the degree of RV volume overload.

Question 697

Paradoxical septal motion may be seen with?

Answer 697

Paradoxical septal motion may be seen with left bundle branch block, pericarditis, mitral stenosis, aortic insufficiency, infarction, and after cardiac surgery.