Ventricular Function Flashcards
(42 cards)
An increased mitral valve E point to septal-separation (EPSS) may indicate:
A. Increased left ventricular end-diastolic pressure
B. Pulmonary hypertension
C. Reduced ejection fraction
D. Left atrial myxoma
C. The anterior mitral valve normally makes contact or closely approaches the interventricular septum in early ventricular diastole. With reduced ejection fraction there is an increase in the EPSS independent of left ventricular size. An EPSS value of ≥ 20 mm represents an ejection fraction of < 30%.
Patients with mitral stenosis or significant aortic regurgitation should be excluded.
A mitral valve B-notch (bump) suggests increased left ventricular end-diastolic pressure (LVEDP).
Premature closure of the mitral valve (usually found in patients with severe acute aortic regurgitation) indicates increased left ventricular end-diastolic pressure (LVEDP).
The formula used to determine fractional shortening is:
A. EDV - ESV
B. (EDV - ESV) ÷ EDV x 100
C. (EDD - ESD) ÷ EDD x 100
D. CSA x VTI
EDV, end-diastolic volume;
ESV, End-systolic volume;
EDD, end-diastolic dimension;
ESD, end-systolic dimension;
CSA, cross-sectional area;
VTI, velocity time integral
C. A method used to evaluate global left ventricular systolic function is fractional shortening. The normal range for men: 25 to 43%; women: 27 to 45%.
The formula used to determine ejection fraction is:
A. EDV - ESV
B. (EDD - ESD) ÷ EDD x 100
C. (EDV - ESV) ÷ EDV × 100
D. CSA x VTI
EDV, end-diastolic volume;
ESV, end-systolic volume;
EDD, end-diastolic dimension;
ESD, end-systolic dimension,
CSA, cross-sectional area,
VTI, velocity time integral
C. The normal ejection fraction is ≥ 55% for men and women.
• Mildly abnormal: 45 to 54%
• Moderately abnormal: 30 to 44%
• Severely abnormal: < 30%
An ejection fraction of 42% is determined with two-dimensional echocardiography. This indicates ________ global left ventricular
systolic function.
A. Normal
B. Mildly abnormal
C. Moderately abnormal
D. Severely abnormal
C. A normal ejection fraction is ≥ 55% for men and women.
• Mildly abnormal is 45 to 54%
• Moderately abnormal is 30 to 44%
• Severely abnormal is < 30%
Which of the following methods is recommended to determine left ventricular volumes?
A. Biplane area-length
B. Biplane Simpson’s method of discs
C. Teichholtz
D. Cubed
B. Simpson’s method of discs (MOD) is the best method primarily because it does not assume a certain chamber geometry. The two views recommended to measure left ventricular ejection fraction are the apical four-chamber view and the apical two-chamber. Care must be taken not to foreshorten the ventricle.
Simpson’s method of discs (MOD) may also be used to determine right ventricular volumes, left atrial volumes and right atrial volumes.
Teichholtz is the M-mode method used to determine left ventricular volume.
The formula used to determine stroke volume by Doppler is:
A. EDV - ESV
B. (EDD - ESD) ÷ EDD × 100
C. (EDV - ESV) ÷ EDV x 100
D. CSA x VTI
EDV, end-diastolic volume;
ESV, end-systolic volume;
EDD, end-diastolic dimension;
ESD, end-systolic dimension,
CSA, cross-sectional area;
VTI, velocity time integral
D. Left ventricular stroke volume by Doppler is determined as the product of the left ventricular outflow tract cross-sectional area (CSA) multiplied by the left ventricular outflow tract velocity time integral (VTI) obtained with pulsed-wave Doppler in the apical five-chamber view or apical long-axis view.
End-diastolic volume (EDV) - end systolic volume (ESV) is the formula for stroke volume when using M-mode to two-dimensional echocardiography.
In patients with dilated cardiomyopathy, the index of myocardial performance (IMP) will be:
A. Normal
B. Increased
C. Decreased
D. Dependent upon blood pressure
B. IMP = (IVCT + IVRT) ÷ ET where IMP is IVCT is isovolumic contraction time; IVRT is isovolumic relaxation time; ET is ejection time.
With poor global ventricular systolic function, the IVCT increases, the IVRT increases and the ET shortens.
The normal value is 0.39 +/- 0.05 and is increased in patients with dilated cardiomyopathy ( > 0.59).
_________ is a direct measure of myocardial contractile function.
A. Strain
B. EPSS
C. E-F slope
D. Deceleration time
A. Strain is the change in length during myocardial contraction and is expressed as a percentage and is based on tissue Doppler imaging techniques.
Strain rate is the rate of deformation (change in length) and is expressed in 1/s.
Both strain and strain rate may be useful parameters when evaluating ventricular segmental and global systolic function and identifying myocardial disease processes (e.g., hypertrophic cardiomyopathy,
Fabry’s disease).
The rate at which the left ventricular pressure rises in ventricular systole is referred to as:
A. dv/dt
B. dP/dt
C. dt/dP
D. dd/tP
B. The rate at which the left ventricular pressure increases (dP/dt) is a measure of left ventricular contractility. A continuous-wave Doppler tracing of mitral regurgitation is obtained and one takes two points along the slope of the mitral regurgitation flow, calculates the pressure gradient between the left ventricle and the left atrium at each point and divides by the time between these two points. For convenience, one can make the first determination at 1 m/sec and the second at 3 m/sec.
Using the simplified Bernoulli equation, the 1 m/sec point is 4 mm Hg and the 3 m/sec is 36 mm Hg. Then, one can calculate dP/dt by dividing the difference, or 32 mm Hg, by dt in milliseconds. The normal value is > 1200 mm Hg/sec and the abnormal value is < 1000 mm Hg/sec.
A pulsed-wave Doppler tracing of the mitral valve inflow at the leaflet tips is obtained with the following information: E/A ratio is 0.7; deceleration time is 320 msec; a tissue Doppler at the mitral annulus demonstrated an E’ peak velocity of 6 cm/s and an E/E’ ratio is calculated to be 7. The diastolic grade is:
A. Normal diastolic function
B. I
С. ІІ
D. III or IV
B. A reduced E/A ratio ≤ 0.75, increased deceleration time > 220 msec, a tissue Doppler E’ velocity of < 8 cm/s and a E/E’ ratio of < 8 suggests Grade I. Grade I represents impaired relaxation and suggests normal diastolic filling pressures.
A pulsed-wave Doppler tracing of the mitral valve inflow at the leaflet tips is obtained with the following information: E/A ratio is 1.2, deceleration time is 200 msec, tissue Doppler of the mitral annulus peak E’ wave velocity is 7 cm/s, E’/A’ ratio is .6 and a E/E’ ratio of 12 is calculated. The diastolic grade is Grade:
A. I
В. II
С. ІІI
D. IV
B. Grade II is pseudonormalization and suggests impaired relaxation with mild to moderate reduction in ventricular compliance and mild to moderate increase in filling pressures. The strain phase of the Valsalva maneuver may be used to unmask the pseudonormalization flow pattern. Tissue Doppler of the mitral annulus is useful because it will demonstrate E’/A’ reversal (E/A’ ratio < 1) in patients with pseudonormalization.
A pulsed-wave Doppler tracing of the mitral valve inflow at the leaflet tips is obtained with the following information: E/A ratio is 2.3, deceleration time is 123 msec, Valsalva maneuver demonstrated no change in the E/A ratio, tissue Doppler of the mitral valve annulus demonstrates an E’ wave peak velocity of 3 cm/s and an E/E’ ratio of 33 is calculated. The diastolic grade is grade:
A. I
В. II
С. ІІI
D. IV
D. The restrictive filling pattern can be subdivided into reversible restrictive (grade III) and fixed restrictive Grade IV). If there is a change in the pulsed-wave Doppler E/A ratio to Grade II or Grade I during the Valsalva maneuver, then the diastolic grade is reversible restrictive (Grade III). If there is less than a 10% change in the E/A ratio, fixed restrictive (Grade IV) is reported out.
The restrictive filling pattern suggests impaired relaxation, marked reduction in ventricular compliance with significant elevation of filling pressures.
Which maneuver is most useful to use when trying to determine the presence of Grade II (pseudonormalization) or when determining between Grade III (reversible restrictive) and Grade
IV (fixed restrictive):
A. Valsalva
B. Mueller
C. Leg raising
D. Squatting
A. The strain phase of the Valsalva maneuver decreases venous return which reduces preload decreasing the filling pressures transiently.
Grade II will return to Grade I during the strain phase of the Valsalva maneuver. Grade III (reversible restrictive) will return to Grade II or Grade I during the strain phase of the Valsalva maneuver. Grade IV (fixed restrictive) E/A ratio will change less than 10% with the strain phase of the Valsalva maneuver.
The most common etiology for ischemic heart disease is coronary artery:
A. Aneurysm
B. Atherosclerosis
C. Embolus
D. Spasm
B. Atherosclerosis, the principal cause of death in Western civilization, is a progressive disease process that generally begins in childhood and has clinical manifestations in middle to late adulthood.
The most specific echocardiographic finding for ischemic heart muscle is:
A. Abnormal diastolic wall motion at the ischemic segment
B. Alterations in systolic wall thickening
C. Normal diastolic wall motion
D. Normal systolic wall motion
B. Probably the most specific finding for ischemic heart muscle is alteration in systolic thickening. Normal myocardial muscle increases in thickness with systolic contraction. When the blood supply to the heart muscle is disrupted as in acute myocardial ischemia or myocardial infarction the result is a reduction in systolic wall thickening.
A wall segment of the heart that is without systolic wall thickening is best described as:
A. Hypokinetic
B. Akinetic
C. Dyskinetic
D. Hyperkinetic
B. A qualitative assessment of left ventricular systolic segmental function can be made with echocardiography. Hyperkinetic refers to increased systolic wall thickening as compared with normal systolic wall thickening. (e.g., normal response to exercise). Hypokinetic refers to decreased systolic wall thickening. Akinetic is the absence of systolic wall thickening. Dyskinetic refers to a wall segment that moves the opposite of normal.
The correct term for describing decreased ventricular systolic wall thickening is:
A. Hyperkinetic
B. Hypokinetic
C. Akinetic
D. Dyskinetic
B. A qualitative method for analyzing systolic wall thickening uses the following numbers and descriptive terms:
1 - Normal or Hyperkinetic
2 - Hypokinetic (decreased systolic wall thickening)
3 - Akinetic (absence of systolic wall thickening)
4 - Dyskinetic (moving in the opposite direction of normal during ventricular systole)
5 - Aneurysmal (diastolic deformation)
A systolic wall motion score of 3 is assigned to a certain segment of left ventricular muscle indicates:
A. Normal
B. Hypokinetic
C. Akinetic
D. Dyskinetic
C. For segmental systolic wall function a wall motion score index has been proposed. Each segment is judged by a scheme that assigns a 1 for a normal (or hyperkinetic such as is seen in stress echocardiography post-exercise) segment, 2 for hypokinesis, 3 for akinesis, 4 for dyskinesis and 5 for aneurysmal.
The left ventricular wall motion score index is then derived by adding the scores and dividing by the number of segments evaluated. A normal wall motion score index is 1. A wall motion score index of 2 is significantly abnormal.
In determining the size of myocardial infarction echocardiography generally:
A. Is unpredictable
B. Overestimates recent myocardial infarction and underestimates old myocardial infarction
C. Predicts the exact size of infarct
D. Underestimates recent myocardial infarction and overestimates old myocardial infarction
B. As a general rule echocardiography tends to overestimate recent myocardial infarction and to underestimate old myocardial infarction. The explanation may be in part a result of stunning in the acute myocardial infarction setting. The tethering effect may explain the underestimation of old myocardial infarction.
The normal response of non-infarcted myocardium in a patient with acute myocardial infarction is:
A. Hyperkinesis
B. Hypokinesis
C. Akinesis
D. Dyskinesis
A. In acute myocardial infarction two-dimensional echocardiography will demonstrate abnormal systolic wall thickening of the affected wall segments) with hyperkinesis of the opposing walls).
The echocardiographic appearance of necrotic myocardium secondary to myocardial infarction includes all of the following EXCEPT:
A. Akinetic wall segment
B. Echogenic wall segment
C. Thin ventricular wall
D. Wall motion score of 1
D. After the initial myocardial infarction healing starts, the necrotic myocardium is replaced within a few weeks by a scar of fibrous tissue.
The resulting echocardiographic appearance of an old myocardial infarction is that of a thin, akinetic myocardial wall segment that is more echogenic (bright) than the surrounding healthy myocardium.
The definition of stunned myocardium is:
A. Myocardium after cardiopulmonary resuscitation
B. Myocardium after electrical cardioversion
C. Myocardium that is hyperkinetic post-myocardial infarction
D. Reperfused viable myocardium that is not functioning
D. Stunned myocardium is a term used to describe ischemic muscle that is reperfused and is still viable but not functioning
Hibernating myocardium is:
A. Myocardium that is hyperkinetic post-myocardial infarction
B. Reperfused viable myocardium that is functioning
C. Viable myocardium at rest but not functioning with exercise
D. Viable myocardium that is nonfunctioning because of chronic ischemia
D. Hibernating myocardium is viable muscle that is nonfunctioning because of chronic ischemia. Reperfusion may restore function.
Stress echocardiography methods that may be used to detect hibernating myocardium include:
A. Cold pressure
B. Handgrip
C. Low-dose dobutamine
D. Treadmill
C. It has been demonstrated that low-dose dobutamine improves hibernating myocardium but as the dose of dobutamine increases the hibernating wall motion decreases. (biphasic response).
