Systolic function and Aortic valve Flashcards

1
Q

measures of systolic function

A

fractional shortening nml >30

fractional area change nml >50
ejection fraction >55
SV and CO
Dp/dt
V of circumferential shortening
End systolic elastance
preload recruitable stroke work
strain rate
tissue doppler peak systolic velocity

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2
Q

Fraction indices

A

all are (Diastolic - systolic) / diastolic

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3
Q

Qp/Qs

A

SVpa/SVlvot, helps to determine shunt

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4
Q

Inward radial motion of normal , hypokinetic, akinetic, dyskenitic function

A

normal - greater than 30%
hypokinetic - 10-30 %
Akinetic less than 10%
dyskinetic - paradoxical systolic motion

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5
Q

Dp/Dt

A

slope of LV pressure rise from 4-36 mmHg, need MR jet, measured at 1 and 3 m/s
Normal is 1610 +/- 290 mmHg/sec (around 1300 min)

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6
Q

velocity of circumferential shortening

A

FS with ET in denominator

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7
Q

end systolic elastance

A

Load Independent. Slope of PV loop at end systole points. Steeper slope is better systolic function

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8
Q

preload recruitable stroke work

A

Stroke work is the area under curve of PV loop. If this is plotted as function of end diastolic volume
Steeper slope is better systolic function

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9
Q

preload adjusted max power

A

Stroke work/EDV^2 or
stroke work/ EDA^(3/2)
load independent

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10
Q

tissue doppler peak systolic velocity

A

faster s’ is better systolic function, no normal values to be tested on
influenced by tethering and translation

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11
Q

strain rate

A

Strain is dimensionless, and change in length produced by application of stress
strain rate is strain/time
Translation and angle independent but limited by noise
load independent

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12
Q

Aortic root size

A

normally less than 4 cm in adult

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13
Q

Basic views of Aortic valve

A

ME AV SAX, LAX
Deep TG LAX
TG LAX
ME 5 chamber

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14
Q

AI acute vs chronic

A

acute- stroke work preserved, elevated end diastolic pressure
chronic - compensates by dilating and lower end diastolic pressure, larger stroke volumes. Eventually sarcomeres stretch too far and causes decompensation
Intervene before it becomes too dilated and decreased SV

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15
Q

Severity of AI

A

Jet height : LVOT diameter
mod 25-64%
Jet area : LVOT area
mod 5-59%
Jet depth
mod tip of AL
VC
greater than 6mm severe
Slope of jet decay
greater than 3 m/s severe
PHT
mod 200-500 ms, affected by diastolic function
Flow reversal in Aorta

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16
Q

3 things determine prognosis in AI.

A

LV dysfunction
LV dilation
Asc Ao dilation- sinus best predictor (normal 25-31mm)

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17
Q

High risk AI patients

A

symptomatic
Reduced EF
end systolic diameter indexed >25mm/m2 (81 vs 34% survival at 10 years)

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18
Q

Low risk group Marfan syndrome for AI

A

Indexed sinus / predicted sinus diameter that is less than 1.3 or less than 5% change annually

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19
Q

When to replace valve

A

symptomatic or
asymptomatic with severe chronic AR, or chronic AR with root dilation

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20
Q

Types of AI classes

A

type 1 a- 1 d is normal cusp motion
type 2 - cusp prolapse, common
type 3 - cusp restriction

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21
Q

Aortic stenosis assessment

A

peak velocity - mod 3-3.9 m/s
mean grad - 30-49 mmHg
max grad - 40-69 mmHg
DVI mod 0.25-0.5 independent of patient size, stroke volume (TVI LVOT/TVI AV) or ( A valve/ A LVOT)
AVA mod 1-1.5 cm2
Indexed AVA mod 0.6-0.85 cm2/m2

If mean gradient is high then you are done

If low, need to see if there is low flow and use cont eq or DVI

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22
Q

Modified gorlin equation

A

Shows how you can have low gradient but still have aortic stenosis

AVA = CO/ Peak grad

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23
Q

continuity equation

A

flow in equals flow out
can use Vpeak or VTI

24
Q

psuedoaortic stenosis

A

not enough stroke volume to pop valve open.

25
peak instantaneous vs peak to peak gradient
peak instantaneous > p 2 p gradient Echo is instantaneous, p2p is cardiac cath
26
In 3d en face view of mitral valve where is LAA and interatrial septum
LAA screen left, IAS screen right
27
Right heart views
4 C - FAC , Septal and post/ant leaflet RV I/O TG SAX TG RV inflow Deep TG RV outflow Asc AO SAX Ao Arch SAX ME bicaval and modified bicaval
28
Innominate vein
can be recognized on right hand side of aortic arch in upper esophageal aortic arch short axis view
29
RVSP calculation
4Vtr^2 + RAP Estimate pulmonic pressure assuming no pulmonic valve stenosis
30
RV function assessment
more qualitative than LV highly compliant, low resistance, sensitive to loading conditions 20% of post CPB failure due to RV
31
RV failure
can occur just by opening pericardium 2-3% of patients after heart transplant and 20-30% after LVAD retrograde cardioplegia doesnt protect because of thebesian veins draining into RV and not sinus. PVR increases after CPB
32
parameters of RV function
FAC >35% (mean 49) EF >45% TAPSE >15-17 mm (mean 23) IVA = 1.4 +/- 0.5 m/s (mean 3.7) most load independent for RV TV S' <10 abnormal strain >-20
33
Isovolumic acceleration
Peak velocity seen before s' on tissue doppler / time it takes to reach peak Should be somewhere around 2-3 m/s load independent!
34
RV volume overload
flattening of septum at end diastole to left hand side usually from PI, ASD, TR
35
eccentricity index
vertical dimension / horizontal dimension Index >1 = RV dysfunction
36
RV pressure overload
Shifts to left during end systole RVH thickness >5mm
37
Mcconell sign
apex moves but base does not indicates PE
38
RV inflow outlfow leaftlets seen
Posterior on lateral side and a/s on medial side
39
Tricuspid Regurgitation
Functional TR (normal leaflets) from annular dilation, pap muscle dysfunction, pressure/vol overload, PA cath structural TR ( abnormal leaflets) from rheumatic dz, myxomatous dz, ebsteins, carcinoid, endocarditis Jet area mod 5-10 cm2 vena contracta >7 severe hepatic flow reversal severe jet density = more volume
40
Rheumatic dz
most common cause of TS but less likely than TR , most commonly affects MV alone but can affect MV, AV and TV
41
Ebsteins anomaly
Large sail like anterior leaflet, TV funnel shaped and apically displaced p/s leaflets Associated with secundum ASD and SVT (WPW)
42
carcinoid syndrome
releases serotonin, bradykinin , histamine, prostaglandin RV valves damaged , thickened, fibrosed. Usually MAO protect LV (PFO can facilitate passage) can cause both TR and TS but TR more common
43
CVP and HV waveform timing
x descent which matches s wave on HV y descent which matches d wave on HV A and V waves match
44
Tricuspid stenosis
rare, but most commonly from rhuematic dz. Also from carcinoid or congenital Normal Peak velocity 30-70 cm/sec 190/PHT mean gradient >5 mmHg severe but dependent on HR and flow
45
Pulmonic valve
Hard to visualize Has anterior , right and left cusps valve leaflet closest to aortic valve is either left or right, farthest away from AV is anterior cusp
46
Pulmonic insufficiency
Mild PI is normal Significant PI usually congenital but can be caused by carcinoid, endocarditis, pHTN, myxomatous dz, radiation measured with jet area, width and holodiastolic flow reversal in main pa Early PI velocity used for PA mean pressure Late pi velocity used for pa diastolic pressure
47
pulmonic stenosis
usually congenital measured by peak and mean gradients seen in TOF ( subpulmonic) Hemodynamic goal includes maintaining aortic diastolic pressure. RVH and elevated RV pressure leads to coronary perfusion during diastole only. Does not drop o2 demand Pts frequently arrest
48
RV differences from LV
TV septal leaflet more apically placed than MV Anterior leaflet moderator band presence of TV presence of trabeculations absence of two well defined pap muscles
49
RV MPI
(IVRT + IVCT) / ET , lower is better Also can use TR signal time - PA signal time / PA signal time with PWD < 0.43 normal with TDI < 0.54 normal
50
RV dp/dt
12/time it takes TR jet to go from 1- 2 m/s. Affected by loading conditions <400 mmHg/s is abnormal Innacurate with severe TR
51
Things to look for assessing right heart function
CVP+CI position of IAS TR? Geometry Free wall motion and FAC RIMP
52
grading of endocardical thickening
grade 1 normal movement with thickening <30% grade 2 slightly decreased movement with 10-30% thickening grade 3 severe hypokinesis with <10% thickening grade 4 akinesis with no thickening grade 5 dyskinesis
53
How to calculate LVEDP using AR CWD
Using modified bernouli equation of the late AI velocity AoDP-LVEDP=4 Vailate^2
54
how and when to measure aortic annulus and root
aortic annulus - mid systole inner edge to inner edge all other measurements end diastole from leading edge to leading edge in perpendicular plane to long axis of aorta.
55
what is leading edge to leading edge in aorta
includes anterior wall but not posterior wall