Exam 4

Question 1

Cardiomyopathy

Answer 1

primary disease of the myocardium excluding myocardial dysfunction due to ischemia or chronic valvular disease

Question 2

Dilated Cardiomyopathy

Answer 2

all four chambers are enlarged with impaired systolic function of both the LV and RV due to a wide range of underlying causes

Question 3

Hypertrophic Cardiomyopathy

Answer 3

an autosomal dominant inherited disease of the myocardium related to abnormalities in gene coding for contractile proteins

Question 4

Restrictive Cardiomyopathy

Answer 4

fibrotic stiff ventricles due to altered myocardium with significantly impaired diastolic function

Question 5

Causes and symptoms of Dilated Cardiomyopathy

Answer 5

Causes: idiopathic, infections, toxins, metabolic, inherited, Tako-tsubo, autoimmune/systemic inflammatory disease
Symptoms: Dyspnea, orthopnea, DOE, cough, rales, crackles, sputum

Question 6

Causes and symptoms of Hypertrophic Cardiomyopathy

Answer 6

Causes: inherited
Symptoms: angina, syncope, DOE, Paroxysmal Nocturnal Dyspnea, pulmonary edema

Question 7

Causes and symptoms of Restrictive Cardiomyopathy

Answer 7

Causes: infiltrative, deposition or scarring to organs, endomyocardial fibrosis, myocardial fibrosis
Symptoms: heart failure due to impaired diastolic filling and inability to maintain cardiac output

Question 8

5 parameters of Diastolic Algorithm

Answer 8

1. Average E/e’ > 14
2. Septal e’ velocity < 7 cm/s
3. Lateral e’ velocity < 10 cm/s
4. TR velocity > 2.8 m/s
5. LA volume index > 34 ml/m^2

Question 9

E/A ratio for Grades 1, 2, and 3

Answer 9

Grade 1: E/A ≤ 0.8 and E ≤ 50 cm/s
Grade 2: E/A ≤ 0.8 and E > 50 cm/s OR E/A > 0.8 - < 2
Grade 3: ≥ 2

Question 10

Additional Parameters of Diastolic Dysfunction:
Normal

Answer 10

DT: 160-200 ms
E/e’: ≤ 14
AR-A: < 0 ms
IVRT: 50-100 ms
PVA: ≤ 35 cm/s
S~D
L Wave: < 20 cm/s
Propagation Velocity: > 50 cm/s

Question 11

Additional Parameters of Diastolic Dysfunction:
Grade 1

Answer 11

DT: > 200ms
E/e’: increasing ratio implies worsening
AR-A: < 0 ms
IVRT: > 100 ms
PVA: ≤ 35 cm/s
S significantly > D
L Wave: > 20 cm/s
Propagation Velocity: decreasing slope implies worsening

Question 12

Additional Parameters of Diastolic Dysfunction:
Grade 2

Answer 12

DT: 160-200 ms
E/e’: increasing ratio implies worsening
AR-A: ≥ 30 ms
IVRT: 50-100 ms
PVA: > 35 cm/s
S<D
L Wave: > 20 cm/s
Propagation Velocity: decreasing slope implies worsening

Question 13

Additional Parameters of Diastolic Dysfunction:
Grade 3

Answer 13

DT: < 160 ms
E/e’: increasing ratio implies worsening
AR-A: ≥ 30 ms
IVRT: < 50 ms
PVA: > 35 cm/s
S significantly < D
L Wave: > 20 cm/s
Propagation Velocity: decreasing slope implies worsening

Question 14

DD and age

Answer 14

~ 60 E/A ratio = 1
> 60 E/A ratio = < 1
> 60 increased decel time and IVRT
> 50 S > D

Question 15

Valsalva and DD

Answer 15

valsalva can convert restrictive LV inflow to a pseudonormal

Question 16

Corrective Treatments for Dilated Cardiomyopathy

Answer 16

-Periodic Echocardiograms
-Conventional Medications
-Sizing down annulus
-Implantable defibrillators
-BiVent pacemakers
-LVAD and transplant
-MV repair/ reopposing the chordae

Question 17

Corrective Treatments for Hypertrophic Cardiomyopathy

Answer 17

-Echo
-Medical Therapy
-AICD (Automatic Implanted Cardiac Defibrillator)
-PTSMA (Percutaneous Transluminal Septal Myocardial Ablation)
-Myotomy-Myectomy (cutting of the myocardium)

Question 18

Corrective Treatments for Restrictive Cardiomyopathy

Answer 18

-treat Underlying Etiology
-treat CHF
-transplant

Question 19

Patterns of Hypertrophy

Answer 19

Type 1: 10 %, hypertrophy confined to antero septum
Type 2: 20 %, hypertrophy of both antero and infero septum
Type 3: 52 %, hypertrophy of septum and anterolateral free wall
Type 4: 18 %, hypertrophy of other regions, apical hypertrophy “ace of spades”

Question 20

Doppler Evaluation of LVOT Obstruction

Answer 20

-A5
- PW mapping
- CW mid to late systolic high velocity jet > 1.1 m/s , dagger shaped LVOT envelope

Question 21

LVOT Obstructions

Answer 21

-Nonobstructive: PPG < 30 mmHg at rest with provocation
-Obstructive: PPG ≥ 30 mmHg at rest
-Inducible or latent: PPG < 30 mmHg at rest and ≥ 30 mmHg with provocation

Question 22

LVOT Obstruction vs. Midcavitary Obstruction

Answer 22

LVOT:
dagger shaped envelope
mid to late systolic high velocity jet

Midcavitary:
seen in dehydrated patients with LVH
late peaking and sawtooth waveform in PW
alleviated by giving volume

Question 23

RCM vs. Constrictive Pericarditis

Answer 23

RCM:
- reduced regional and global longitudinal strain
- low medial and septal TDI e’ velocities
- moderate to severe PHT
- low color m-mode propagation velocity

Constrictive Pericarditis:
- treatable
- normal medial strain
- preserved global longitudinal strain “hot septum”
- normal medial TDI e’
- demonstrates significant respiratory changes on doppler inflows

Question 24

Athletic vs Pathological Heart

Answer 24

Athletic:
-mild LVH or RVH
- mild RVE, LVE, LAE, or IVC enlargement
- reverses with deconditioning
- normal TDI and strain

Question 25

Common Conditions of Diastolic Dysfunction

Answer 25

-Primary Myocardial: Dilated, Restrictive, and Hypertrophic Cardiomyopathy -Secondary Myocardial: Hypertension, Aortic Stenosis, Congenital Heart Disease -Coronary Artery Disease: Ischemia, Infarction -Extrinsic Constraint: Pericardial Tamponade, Pericardial Constriction

Question 26

Typical Grade 1 of Diastolic Dysfunction (Impaired LV relaxation)

Answer 26

- decreased E/A ratio - prolonged deceleration time - reduced e' - increased LA volume - increased TR velocity - increased IVRT - S > D

Question 27

Typical Grade 2 of Diastolic Dysfunction (Pseudonormal Diastolic Dysfunction)

Answer 27

- Normal E/A ratio - Normal deceleration time - Normal IVRT - elevated E/e' - reduced E' - increased LA volume - increased TR velocity - S slightly less than D

Question 28

Typical Grade 3 of Diastolic Dysfunction (Abnormal Ventricular Compliance)

Answer 28

- increased E/A ratio - decreased deceleration time - reduced E' - increased LA volume - increased TR velocity - elevated E/e' - reduced IVRT - pulmonary vein AR wave prolonged - S significantly < D

Question 29

2D/M-mode/Doppler findings in Dilated Cardiomyopathy

Answer 29

2D: - significant 4 chamber enlargement, LVIDd > 112%, LVED > 75ml/m^2 , increased LV mass, spherical shaped LV M-mode: - increased EPSS, decreased aortic root motion, B bump, tapered aortic valve closure

Question 30

2D/M-mode/Doppler findings in Hypertrophic Cardiomyopathy

Answer 30

2D: asymmetric hypertrophy of LV, "ace of spades" appearance M-mode: systolic anterior motion of anterior mitral leaflet

Question 31

2D/M-mode/Doppler findings in Restrictive Cardiomyopathy

Answer 31

2D: thickened to fibrotic appearance of ventricular walls, biatrial enlargement, small ventricles Doppler: MR/TR envelopes may begin at end diastole

Question 32

2D/M-mode/Doppler findings in Amyloid

Answer 32

2D: myocardium, valves, and IAS appear thick and granular in appearance, biatrial enlargement

Question 33

2D/M-mode/Doppler findings in LVOT Obstruction

Answer 33

2D: systolic anterior motion of anterior mitral leaflet, contact lesion on septum, posterior jet of MR M-mode: mid-systolic fluttering and closing of AV Doppler: mid to late systolic high velocity jet, dagger shaped envelope, in PW mapping will determine location of obstruction

Question 34

2D/M-mode/Doppler findings in Hypertension

Answer 34

2D: LV dilation, aortic root dilation, aortic valve sclerosis, LAE, mitral annular calcification Doppler: mid cavitary obstruction = late systolic high velocity sawtooth signal

Question 35

2D/M-mode/Doppler findings in Diabetes

Answer 35

2D: thick ventricular walls, myocardium is reflective/hyperechoic, LVE, LVH Doppler: abnormal strain and TDI

Question 36

2D/M-mode/Doppler findings in Rejected Post transplanted heart

Answer 36

2D: RV/LV systolic dysfunction, increased LV mass, increased echogenicity of myocardium, evolving pericardial effusion