LA/RA/RV Flashcards
(99 cards)
1
Q
What is the function of the LA?
A
to collect blood from the lungs and push it into the left ventricle.
2
Q
How do I measure the LA?
PLAX
A
taken at end Systole just prior to the opening of the Mitral Valve
3
Q
What views is the LA measured using m-mode?
What are the disadvantage of measuring the LA in m-mode?
A
Can be do PLAX & PSAX
M-Mode can deform the natural contour
not always optimally positioned.
Lack of spatial orientation, oblique measurement line. Over estimation of LA size.
4
Q
Describe the two methods to measure the LA in the 4CH & 2CH views.
A
- area-length approach. The area is measured by planimetry of both apical views. Then linear/length dimension is measured from the center of the mitral annulus to the superior border of chamber.
- Simpsons Biplane- tracing area and transverse obtained automatically. Volume is derived and indexed with BSA
5
Q
What parameters are measured in the LA
A
The major and minor dimensions, area and volumes
6
Q
Why do we need to take measurements in more than one tomographic view.
A
No single tomographic view conveys complete information about a 3-D structure. It is recommended that a combination of two or more imaging planes be used.
7
Q
When do you measure LA Volume and in what views?
A
during end systole, just before mitral valve opening.
Apical 4CH & 2CH
8
Q
What part of the cardiac cycle do I measure the LA?
A
End Systole – end of T-wave
9
Q
What causes the IA septum to bow back and forth?
What causes it to stay bow out and what should we suspect?
A
Pressure gradient
a really high pressure
a PFO (patent foramen ovale)
10
Q
Define end-diastole. What wave are seen?
When does contraction occur?
What happens during late diastole?
A
MV closes after A wave. EKG R wave
Contraction occurs after the P wave – Late diastole which is the final phase of left ventricular filling
11
Q
What occurs on the EKG during A-FIB?
A
No p wave
here will be no A wave.
12
Q
What is a missing a wave on a echo PW mitral inflow an indication of? What type of rhythm will you see on the EKG
A
EKG rate will be irregularly irregular
A-FIB
13
Q
What does bowing of the atrial septum indicate? What view is it most easily appreciated in?
A
left atrial dilation (volume) and /or elevated left atrial pressure. Using the apical 4CH view.
14
Q
What does contraction of the LA correspond with on the EKG?
A
P-wave and occurs during late diastole
15
Q
On doppler of the mitral valve, what does the A-wave velocity and VTI determine?
A
The degree of contractility.
16
Q
What is the loss of LA contractility associated with?
A
A-FIB. Absence of the mitral a-wave and the p-wave on EKG.
17
Q
What is a PFO?
How does it occur.?
What % does it occur in adults?
A
Patent Foramen Ovale. Natural valve reopens because of increase pressure and volume in the LA or RA. 25 – 30% occurrence in Adults
18
Q
What are congenital PFO’s commonly caused by and what is seen when using color doppler or contrast?
A
The Primum and Secundum membranes not properly closing,
bidirectional flow - septum appears structurally intact.
Occasionally you will see tunneling between the membranes
19
Q
What is an ASD?
A
Atrial Septal defect. A hole in the septum.
20
Q
What two membranes make up the IAS?
A
The septum primum – left atrial side
The septum secundum – right atrial side
Together = the foramen ovale
21
Q
What happens to the foramen ovale at birth?
A
closes due to change in pressure also can reopen due to pressure change (PFO pressure overcomes and opens hole or the left atria gets over stretched.
22
Q
What is the best method for detecting a thrombus in the LAA?
A
TEE- appendage can be visualized from a variety of planes.
TTE is suboptimal
23
Q
What is used to distinguish the LAA from the PV?
A
Color doppler
24
Q
What can a thrombus in the LAA get confused with?
A
small pectinate muscles.
25
What three abnormalities (deformations) are seen in the IAS
ASD, PFO, and Aneurysm of the septum
26
Why can a tunnel like gap be occasionally intermittently visualized in a PFO?
How often do we evaluate it?
Due to trans-atrial pressure gradient changes with respiration. Evaluate every 3-4 cycles
27
What are PFO's frequently associated with?
Exaggerated mobility of the atrial septum and in the extreme form an atrial septal aneurysm.
28
What form of imaging is used to distinguish between an ASD and PFO and why?
TEE, because it is more sensitive and provides a more complete assessment.
29
What type of shunt is present when contrast crosses over > 4 sec from injection? What is the source?
transpulmonary shunting.
| Usually through a arteriovenous malformation.
30
What is a atrial septal aneurysm?
A redundancy of the mid-portion of the septum.
31
What are the visual characteristics of an atrial septal aneurysm?
Excessive mobility and billowing of the tissue in the region.
32
What is the threshold of IA septum movement before it becomes aneurysmal?
Which modality is better at detecting it?
10 mm from septal plane
| TEE is better at detecting the extent
33
What are the best views to see IA septum shunts?
septum subcostal viewShunts and blood flow across the
| – gaps in the wall- look for flow gaps
34
What views can IA billowing be seen? Which is the best view?
PSAX or A4CH best seen in TEE 4CH
35
What is the first view we see the IAS?
PSAX at the base
36
What does a lipomatous infiltration involve and what shape does it create?
What should be used to distinguish between lipomatous infiltration, a malignancy or thrombus?
A fatty infiltration of the superior and inferior portions of the septum, typically sparing the fossa ovalis, creating a dumbbell shape
If there is diffuse infiltration MRI should be used
37
What does the motion of the IA aneurysm reflect?
The relative pressure gradient between left and right atria and thus the out-pouching will usually occur in both directions over the course of the cardiac cycle.
38
What are atrial septal aneurysms associated with 75% of the time? What is the combination associated with?
PFO, Substantial risk of thromboembolism
39
What should be used to distinguish a diffuse septal infiltration of fatty tissue from a malignancy or a thrombus?
MRI
40
What is the crab view?
The view of the pulmonary arteries from the suprasternal notch using some posterior angulation.
41
What view can one or two PV into the LA be visulized?
4CH
42
What are the three phase of normal pulmonary venous flow
antegrade flow occurs in systole and early diastole
| retrograde flow occurs after atrial contraction in late diastole
43
What parameters of pulmonary venous flow are useful in the assessment of diastolic dysfunction.
The ratio of peak flow velocity in systole and diastole A wave duration time
44
What are the pulmonary venous waveforms?
S wave – antegrade Systolic – may have S1 & S2
D wave – diastolic
A reversal wave Ardur
45
What is the retrograde flow into the pulmonary veins in late systole used to observe?
mitral regurgitation.
46
What pathologic states are also associated with abnormal pulmonary venous flow that influence the wave form?
Mitral Stenosis, constrictive pericarditis and restrictive cardiomyopathy
47
What mode is the pulmonary vein documented in and why?
PW doppler with sample volume within the mouth of the vein as it enters the left atrium. To record pulmonary wave patterns/ inflow, which can access diastolic disfunction, MR, mitral stenosis
48
What accompanies dilation of the RA?
right ventricular volume and pressure overload as well as right ventricular heart failure.
49
What view is the RA measured from and how is it done? When is it measured?
Apical 4CH or subcostal
| linear dimensions and area planimetry for volume and size. Performed at end systole, prior to TV opening.
50
How is a quick assessment of the RA done?
compare the left and right atria in A4CH – If the right is larger than the left it is enlarged
51
What normal variants can be seen in the RA and are occasionally mistaken for pathologic structures?
Eustachian valve and Chiari network
52
What is the function of the eustachian valve?
A remnant of the embryologic valve responsible for directing blood from the IVC through the Foramen Ovale during fetal development. (Fossa Ovalis before birth)
A rigid structure that arises along the posterior margin of the IVC to the boarder of the fossa ovalis
53
What is the Chiari network and what does it look like?
A delicate appearing membranous structure near IVC orifice. Serves as a valve for the Coronary Sinus
This is highly mobile and fenestrated (filled with holes)
54
What is Cor Triatriatum Dexter? What does it create? Where can it occur?
A lack of normal regression of the eustachian tube that causes prominent eustachian to partial or complete separation of the right atrium. Creates three atria one left and two right. Sometimes there is a hole between to allow blood flow.
Can occur on the left side but dexter refers to right.
55
What can the eustachian tube be confused for ?
tumors, vegetations, or thrombi
56
What can occur when the eustachian tube is very large?
It can divert the flow of blood within the RA and result in false positive or false negative evidence of ASD
57
Where can Right Atrial thrombi occur? what is it usually a consequence of?
Can occur in the body or the atrial appendage of the right atrium, usually as a consequence of A-FIB
58
Why is it difficult to differentiate a right atrial thrombus?
The right is more trabeculated (pectinate muscles) than the left making it difficult to distinguish muscles form thrombi
59
Where is a thrombus Most commonly developed? What Name 3 things that contribute the the formation of a thrombus?
In the main body of the RA chamber. A consequence of low flow, atrial arrhythmia (AFIB), or the presence of foreign bodies
60
What are causes of a RA thrombus?
Low flow velocities, atrial arrhythmias and foreign bodies (catheters and pacemakers leads)
61
What types of thrombi are seen in the RA?
Thromboembolis and thrombi attached to indwelling catheters
62
What is a thromboemboli and what does it look like?
arises from the lower extremities or pelvic veins may occasionally be seen in the RA as a pulmonary embolus in transit. Multi-lobulated and freely mobile. wormlike” due to the shape of the vein it originated.
63
What pathology can mimic a thrombus extending into the RA? What appearance can they both have? How can you differentiate them?
renal cell carcinoma (RCC),
both can extend from the IVC into the RA and have a lobulated, mobile appearance.
A RCC will lead back to the kidney and there will be blood flow within the thrombus formation appearance. Not a thrombus, but a mass
64
What is almost impossible to distinguish from a RA throumbus? How is it detected?
vegetation, must be done together with blood work
65
What foreign objects pass through the RA and what effect to they have?
Tumor renal cell carcinoma:
thrombus from legs , gut or any venous source
embolism: Anything that does not belong in the venous system Plaque, fat, air bubble, ect.
*Block off blood supply
66
Where does the right atrial blood flow come from?
the IVC, SVC and Coronary Sinus
67
From what view will the IVC show variation with respiration?
From subcostal view long axis
68
What does the size of IVC correlated with and what can it be used to predict?
Changes in central venous pressure and the respiratory cycle. Predict right atrial pressure
69
What will cause the IVC size to increase?
| What is the normal % of diameter increase of the IVE during inspiration.
Increased central venous pressure and may accompany volume overload states.
The diameter of the IVC normally decreases > 50% during inspiration is noted –a blunted or absent decrease suggests increased right atrial pressure
70
With what modes is the IVC is evaluated?
Pulsed Wave and Color Doppler
71
Why do we substitute imaging of the IVC with hepatic vein?
| Which hepatic vein do we use?
Alignment can be difficult, so we use the hepatic veins instead
We us the hepatic vein to get the best doppler angle
Use the middle hepatic vein
72
What does the IVC/Hepatic vein Doppler look like?
Antegrade flow has S and D waves below baseline and A wave above (Opposite of pulmonary vein flow)
Velocities are increased with inspiration and decreased with expiration
73
What does severe TR do to the Hepatic vein waveform?
Severe Tricuspid Regurgitation will cause flow reversal during ventricular systole. Normal antegrade systolic flow is replaced by a prominent retrograde wave.
74
What kind of flow pattern will be seen with pulmonary HTN?
Pulmonary Hypertension will cause prominent flow reversal during atrial systole
75
In what views is the SVC seen?
In the Suprasternal Notch alongside the Aortic Arch as a vertical structure. (Better seen on TEE).
Subcostal
76
What is the shape of the Right Ventricle?
The right ventricle is crescent shaped in short axis
| The crescent shaped is only applicable to the short axis
77
What is the normal size of the Right Ventricle?
The right ventricle should be approximately two thirds the size of the left.
This estimation is based on a comparison to the right and left ventricles in multiple views
78
Why is the right ventricle difficult to quantify volume?
due to its unusual crescent shape,
irregular endocardial surface,
complex contraction mechanism
location almost directly behind the sternum.
Not a mathematically convenient shape to measure
minor axis - crescent
orthogonal axis - variable shape
79
What is a distinguishing landmark of the RV? What view can this landmark be seen in?
It has a moderator band within the apex and is seen in the apical 4 chamber view
80
Besides the Apical 4CH what view can linear measurements of the RV be obtained from?
the RV from the PLAX outflow area and PSAX at the base inflow area
3 linear dimensions can be obtained
81
How do you properly measure the RV from the 4 chamber view?
ASE: RV width: measure across the annulus
from Apex to the middle of the annular plane.
This can also be done with a trace
82
How to optimize the 4CH view for RV measurement
Try to get a view where you can best see the RV. Maybe coming more laterally and using the LV as a window or get on top of the RV apex.
83
What does RV volume and pressure overload result in?
hypertrophy of both the free wall and the IVS. Often associated with an increase trabeculations of the RV walls.
84
What finding of the RV often cause misinterpretation as evidence of ASH (Asymmetric septal hypertrophy)Which suggests HCM (hypertrophic cardiac myopathy?
RV volume and pressure overload, which leads to hypertrophy of both the free wall and the IVS and is associated with and INCREASE TRABECULATIONS of the RV wall
85
What affect does RV overload have on the IVS? What does it result in?
Distortion of the shape and motion IVS.
Flattening of the IVS in systole and diastole
“D” shaped left ventricle in short axis during systole and diastole
Should evaluate pulmonary and tricuspid valve flow.
resulting from an abnormal pressure gradient between the left and the right ventricles have?
86
What affect does RV pressure overload have?
It causes a distorted shape of the septum resulting in a D shaped LV. Due to instantaneous trans-septal pressure gradient. The greater the RVSP the greater the shift toward LV cavity. Can happen in Systole and diastole
87
What happens to the shape of the LV during a normal cardiac cycle?
The normal round shape is maintained, a reflection of the higher pressure within the left ventricular cavity.
88
What is the affect of RV Volume overload?
Septal flattening during diastole
89
What should be evaluated if there is both systole and diastole characteristic of pressure RV overload?
Pulmonary valve flow and tricuspid regurgitation should be evaluated
90
When does Normal Pulmonary valve flow peak?
During mid systole and has a parabolic shape
91
What happens to the peak velocity as pulmonary pressure increases?
peak velocity occurs earlier in systole and late systolic notching is often present.
92
Which pressure is normally greater PA or RV?
Normal PA diastolic pressure > RV diastolic pressure
93
What does high pulmonary pressure cause to the PW of the RVOT?
peak in early systole with systolic notching “flying W” in m-mode and spectral doppler.
A measure of the acceleration time.
94
How is the acceleration time effected?
Acceleration time decreases with higher pressure. It peaks early than it normally would with a notch in it.
95
What are two measurement changes that indicated signs of pulmonary HTN
diastolic pressure increases of the artery
disproportionately, creating a higher pressure gradient.
Increased end-diastolic regurgitant velocity > 2 m/sec
96
What is the normal pressure difference between the RV and the PA?
How does this effect the regurgitant jet velocity?
pulmonary artery diastolic pressure exceeds right ventricular diastolic pressure by only a few\w mmHg, so regurgitant jet velocity is low.
97
What affect does RV volume overload have on the RV and LV?
RV is visually greater than the LV. More fluid in the chamber. Thinner walls
“D” shape LV in Diastole only. (IVS is flat )
Crescent shape becomes spherical
M-Mode and 2D is normal shape during systole, but in diastole it is a lot bigger than it normally would be
Only diastolic septal displacement.
98
What is ARVD?
Arrhythmogenic RV dysplasia ARVD
Rare
Normal RV free wall myocardium replaced with adipose and or collagen containing tissue
causes malignant arrhythmias and sudden-death
May be echogenic walls ( brightness of the RV free wall)
99
What happens to the septal shape and pressure during systole when there is RV volume overload?
The normal transeptal pressure gradient is maintained. Normal septal shape and position are also maintained.
