Term
| Identify the different fields, zones, and dimensions of the ultrasound beam |
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Definition
Fields and Zones:
-Near Field(p.16): Fresnel zone, proximal or cylindrical portion of the beam, optimal imaging occurs here, thus maximizing the length of the near field is an important goal.
-Far Field (p.16): Where the beam begins to diverge, Fraunhofer zone.
Dimensions: (p. 17) The ultrasound beam is a three-dimensional structure that, in the case of a phased array transducer, is roughly rectangular in cross section. The dimensions of the beam are referred to as axial and lateral.
-Axial- along the axis of wave propagation
-Lateral- parallel to the face of the transducer, sometimes called azimuthal. The lateral dimension is further divided into a vertical and horizontal component.
-Acoustic focusing through a lens will change the shape in the vertical and horizontal dimensions equally. Electronic focusing will narrow the beam in one and in one of these two dimensions, resulting in a thinner sector slice.
-Transducers that employ anular phased-array technology have the capacity to focus in both dimensions, resulting in a compact, high-intensity beam profile. |
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Term
| What are the principles of Doppler echocardiography |
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Definition
alignment
pitch and motion
frequency
Doppler shift
pulsed wave
continuous wave
color flow imaging
tissue Doppler imaging |
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Term
| Discuss the principle Alignment |
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Definition
| Whereas echocardiography functions optimally when the beam and the target are at right angles, doppler equations rely on a more parallel alignment between the beam and the flow of blood |
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Term
| Discuss the principle Pitch and Motion |
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Definition
-If the source of sound is stationary, then the pitch or frequency of that sound was constant,
-Sound moved toward the listener, the frequency increased and the pitch appeared to rise.
-If the sound source was moving away from the listener; the frequency of the sound decreased relative to the listener and the pitch appeared lower. |
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Term
| Discuss the principle Frequency |
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Definition
-If the target is stationary, the frequency and wavelength of the emitted and reflected ultrasound are identical.
-If the target is moving toward the transducer, the reflected frequency is shifted upward proportional to the velocity of the target relative to the transducer.
-Movement of the target away from the transducer results in reflected ultrasound having a lower frequency than the emitted ultrasound, a downward shift in frequency.
-The increase or the decrease in frequency due to relative motion between the transducer and the target is referred as Doppler shift |
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Term
| Discuss the principle Doppler shift |
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Definition
-Depends on the transmitted frequency of the ultrasound, the speed of sound, the intercept angle between the interrogating beam and the flow, and, finally, the velocity of the target.
-The angle of incidence ()- only becomes significant beyond approximately 20 degrees.
-Doppler imaging is the opposite of echocardiographic imaging, because in echo a higher transducer frequency is desirable because it is associated with higher resolution. With Doppler imaging, a lower frequency is advantageous because it allows high flow velocity to be recorded.
-The primary job of the Doppler instrument is to measure the Doppler shift, and from this measurement, velocity can be calculated.
-The Doppler shift is defined as the difference in frequency between the transmitted and received or backscattered signal. |
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Term
| Discuss the principle of Pulsed Wave Doppler |
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Definition
| short intermittent bursts of ultrasound, only listens at the fixed and very brief time interval after transmission of the pulse, important limitation of the pulsed Doppler imaging is the maximal velocity that can be accurately resolved. (aliasing occurs) |
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Term
| Discuss the principle of Continuous Wave Doppler |
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Definition
| Simultaneously transmits and receives ultrasound signals continuously. This can be accomplished one of two ways. One type of transducer employs two distinct elements: one to transmit and one to receive. Major advantage of CW is that aliasing does not occur and very high velocities can accurately be resolved. |
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Term
| Discuss the principle of Color Flow Doppler |
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Definition
| is a form of PW Doppler imaging that uses multiple sample volumes along multiple raster lines to record the Doppler shift based on principles of PW and high PRF Doppler imaging. The direction of flow can be displayed using red (toward) and blue (away). |
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Term
| Discuss the principle of Tissue Doppler |
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Definition
-records the motion of the myocardium rather than the blood.
-Two important differences must be recognized: 1. because the velocity of the tissue is much lower than blood flow, the machine must be adjusted to record a much lower range of velocities. 2. because the tissue is a much stronger reflector of the Doppler signal compared with the blood, additional adjustments are required to avoid over saturation.
-Limitation: the incident angle between the beam and the direction of the target motion varies from region to region- this limits the ability of the technique of the technique to provide absolute velocity information, although direction and relative changes in tissue velocity are displayed. Measures strain (strain rate imaging)-measure of deformation that occurs when force is applied to tissue. |
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Term
| Discuss the methods for determining Stroke Volume |
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Definition
| Stroke volume:(p. 218-222) In the absence of valvular regurgitation or intracardiac shunt, flow through all four valves should be equal. Stroke volume is a fundamental measure of global LV systolic performance and can be readily converted in to cardiac output by multiplying by heart rate. |
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Term
| Discuss the methods for Regurgitant fraction |
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Definition
Regurgitant Fraction: (p. 222) In patients with valvular regurgitation, differences in stroke volume across different valves provide a quantitative assessment of severity. This type of calculation can be used for any valve of the heart. It assumes that the valve used as the standard for flow is not regurgitant and that a similar degree of accuracy can be achieved at each location. Calculation is complicated by the presence of valve stenosis.
Ao Regurgitant volume:
Regurgitant Volume= Aortic systolic flow- Mitral diastolic flow
or
Regurgitant fraction (%)= (Regurgitant Volume / Aortic outflow volume) x 100% |
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Term
| Discuss the methods for Shunt ratios |
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Definition
| Quantitation of Intracardiac Shunts: (p. 223) Determining the pulmonary-to-systemic flow ratio, or Qp:Qs, is the principal way to quantitate the size of the shunt. In most cases, the shunt ratio is determined by calculating pulmonary stroke volume and comparing it with aortic stroke volume. The difference equals the net shunt volume in the absence of semilunar valve stenosis or regurgitation. |
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Term
| Discuss the use of the modified Bernoulli’s equation |
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Definition
(Application - Clinical Utility)
Peak velocity through a stenotic valve - AS max gradient
TR jet velocity - RVSP
LVOT contour and velocity - HOCM gradient
Peak velocity across a VSD - RVSP
End- diastolic velocity or PR jet - PADP
Velocity through a PDA - PASP
MR contour and velocity - LV dP/dt |
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Term
| List echocardiographic findings for pulmonary hypertension |
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Definition
Doppler: (p. 208-209)
*Pulmonary Valve Flow: As pulmonary pressure increases, peak velocity occurs earlier in systole and late systolic notching is often present. The shorter the accerleration time, the higher the pulmonary artery pressure
*Tricuspid Regurgitation: Max TR velocity and estimated RA pressure are used in the Bernoulli equation to calculate RVSP which is similar to PASP RVSP=4(TRVelocity)2 + PRA
*Pulmonary Regurgitation: An increased end-diastolic regurgitant velocity
M-mode:(p. 355, Fig. 12.7)
*Loss of the pulmonic valve A-Wave
*Mid systolic notching of the pulmonic valve (this was not called flying “W” but is the same thing)
2-D:
-Elevated RVSP 2-D: (p. 206-208. Fig 7.57)
*A flattened and displaced septum toward the LV throughout the cardiac cycle
*RVH
-RV volume overload:(p. 209-210)
*Flattened septum during diastole
*RV dilation |
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Term
| Describe how right atrial pressure is often determined |
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Definition
-A useful way to estimate right atrial pressure relies on visualization of the IVC.
-By observing the degree of dilation and the respiratory variability in inferior vena cava caliber, RA pressure can be estimated with reasonable accuracy.
-If the vessel is normal in size and collapses in response to a “sniff,” RA pressure is less than 10 mm Hg. Mildly elevated RA pressure (10-15mmHg) is associated with a normal to mildly dilated IVC (>2.5cm), with no response to sniffing, suggests a RA pressure greater than 15mmHg. |
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Term
| Compare the advantages and disadvantages of M-mode and Two-dimensional echocardiography |
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Definition
M-Mode:
-Advantage- (p.47) High temporal resolution and the spatial resolution along the single line of interrogation is higher than that of two-dimensional echo. High temporal resolution is suited to identify brief rapid motion or fine oscillatory motion.
-Disadvantage-(p. 25) No information about motion in the orthogonal direction is provided and a complete recording of the object’s shape is lacking.
2-D:
-Advantage- (p.47)Provides an expanded view of cardiac anatomy by imaging not along a single line of interrogation but along a series of lines typically spanning a 90 degree arc. (p.25-26) Provides a more precise understanding of the true motion pattern compared to M-mode. |
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Term
| Discuss atrial fibrillation in echocardiography |
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Definition
-Patients classified as having valvular verses non-valvular atrial fibrillation. Most noted with rheumatic mitral stenosis (Enlarged LA)
-Guidelines for long-term anticoagulation in patients with chronic A-fib are based in large part on patient age and evidence of underlying structural heart disease, which can be easily assessed with transthoracic echo.
-Detection of Thrombus: Thromboembolism occurs in patients with A-Fib because of the stasis of blood in the left atrium. 90% of thrombi forms in the LA appendage. Appears as dense “smoke” in the LA or LA appendage. If thrombus is present, cardioversion is deferred.
-PW doppler can measure atrial appendage velocity- Subjects with more well preserved velocities apppear less likely to have spontaneous echo contrast or to form atrial thrombus and may represent a group with a lower likelihood of embolic events (Fig. 22.49)
-Earlier cardioversion may result in more successful long-term maintenance of sinus rhythm. |
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Term
| Discuss the evaluation of mitral stenosis in echocardiography |
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Definition
2-D:
-Commissural fusion- Leaflets open with “doming” motion
-Rheumatic Heart Disease- Open anterior leaflet has also been descrived as having a “hockey stick” appearance
-Orifice Area- funnel-shaped orifice. Orifice area can accurately be planimetered and correlates well with that determined from hemodynamic data. Actual limiting orfice at the tips, and careful scanning must be performed to ensure that the image is frozen and planimetered at the mitral valve tips and not more proximally where the orifice would be overstated. Instrumentation settings also affect the ability to accurately visualize the limiting orifice. Made in the parasternal short-axis view, allows optimal recording of mitral leaflet excursion (p. 113)
Doppler:
-Transvalvular gradient from LA to LV
-Pressure half time
M-Mode:
-Only provides qualitative assesment of MS
-Reduced diastolic E-F slope, no longer used to quantitate MS
-Increase echogenicity of the leaflets with decreased excursion and reduced separation of the anterior and posterior leaflets.
-“Paradoxical” anterior diastolic motion of the posterior mitral valve leaflet |
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Term
| List the consequences found with mitral stenosis |
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Definition
-LA and LA appendage dilation
-LA and LA appendage thrombus or clot
-PHTN
-RV Dilation |
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Term
| Discuss the evaluation of mitral valve prolapse |
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Definition
Two Forms:
1.MVP associated with myxomatous thickening of the MV leaflets
2.Mild buckling of an otherwise anatomically normal valve
M-Mode:
-Leaflet thickening with posterior bowing of the MV apparatus during systole
-Beam should be alligned to encompass the area just behind the mitral annulus to show buckling into the LA.
2-D:
-Appreciate the presence or absence of valve thickening and the symmetry versus asymmetry with which the valve “prolapses.”
-Parasternal Long-axis or Apical 2 chamber specific for detection of buckling.
-Diagnosis of MVP made when one or both leaflets breaks the plane of the mitral annulus in a nonsymmetric manner, typically taking on a buckling apperance.
-Once diagnosis of MVP is made it is important to further characterize other areas of the cardiovascular system that may also be involved.(such as the complications and for Marfans) |
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Term
| Discuss the evaluation of mitral regurgitation in echocardiography |
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Definition
Doppler:
1.Color Flow Doppler: The primary echo tool for detection and quantitation of MR. The severity of MR is directly proportional to the area of the regurgitation jet in the LA.
-Jet area
-Jet area to atrium
-Central vs. eccentric jets
-Vena contracta width
-PISA- size/qualitative, volumetric flow/regurgitant volume, Effective regurgitant orfice
2. Pulmonary vein flow reversal
3. Spectral:
-Forward flow calculation at the mitral annulus
-Signal Density
-Elevated E/A ratio with normal LV function |
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Term
| List the complications associated with mitral valve prolapse |
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Definition
-Individuals with thickening of the leaflets in association with prolapse who are most prone to complications such as progressive mitral regurgitation, spontaneous chordal rupture, neurologic events, and endocarditis.
-Several sequelae and complications of MVP can be identified from the echocardiogram. These include MR, ruptured chordae and flail leaflets as well as endocarditis |
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Term
| Describe the etiologies of mitral regurgitation in relation to ischemia |
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Definition
MR
Papillary muscle rupture/ Flail leaflet (p. 342-346)
Restricted Leaflet Motion
-Necrosis and subsequent scarring of a papillary muscle may result in retraction of either the anterior or posterior leaflet (most common in posterior leaflet)
-The papillary muscle and the wall supporting it are apically and posteriorly displaced. This has the effect of functionally shortening the mitral valve apparatus for that leaflet, thus restricting it’s ability to fully close.
-Can be accompanied with dilation of the mitral annulus. |
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Term
| Discuss the evaluation of aortic stenosis in echocardiography |
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Definition
Diagnosis
*Congenital(p. 577, Table 18.5)
-Unicuspid
-Bicuspid
-Dysplastic
Acquired: (degenerative, rhematic and infective)
*2-D:
-Short-axis perspective is most helpful to determine the number of cusps and whether fusion of one or more commissures is present.
-Thick and restricted cusps
-No longer parallel to aortic walls in systole, and often point toward the center of the Ao.
Quantifying Severity
*Doppler:
-Bernoulli equation- pressure gradient across valve
•Maximal jet velocity through the stenotic valve (usually occurs mid-systole, becomes later based on severity, late peaking jets are also characteristic of dynamic subaortic stenosis)
•CW parallel to direction of flow
-Continuity Equation- Aortic valve area, unaffected by LV dysfunction and AR
1. The cross-sectional area of the LVOT
2. TVI of the outflow tract
3. TVI of the AS jet
Assessing LV Function
-Reduced LV function is important because of its prognostic and management implications.
-In addition, reduced LV function alters the relationship between transvalvular pressure gradient and AV area, thereby complicating the quantitative determination of severity. |
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Term
| Discuss how Doppler is used to evaluate the severity of aortic regurgitation |
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Definition
-PW-(p. 299)Assesses diastolic flow reversal in the descending Ao. As AR becomes worse, a greater degree of flow reversal occurs and retrograde velocities can be recorded throughout diastole. The presence of holodiastolic flow reversal in the descending Ao has been correlated with severe AR.
-CW- (p.299) Compares the density or darkness of the envelope of the antegrade aortic flow and the regurgitant jet. The larger the regurgitant volume is, the darker the regurgitant jet. The shape of the envelope also contains information. The velocity of the jet is simply a reflection of the pressure gradient between the Ao and LV throughout diastole. A pressure half-time of less than 250 milliseconds or a slope greater than 400 cm/sec2 are indicators of severe AR.
-CF- (p. 296-297) Most commonly used technique to assess AR. The size or extent of the AR within the LV, the effective regurgitant orifice area and the volume or fraction of regurgitant flow. The most commonly used approach relies on the relationship between the size of the regurgitant jet, visualized by color flow imaging, and the regurgitant volume. The jet height just below the aortic valve can be measured and compared with the dimension of the LVOT |
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Term
| Discuss how tricuspid regurgitation is evaluated in echocardiography |
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Definition
2-D: RA and RV dilation and detection of a RV volume overload (with TR implies at least moderate TR). Dilation and systolic pulsation of the IVC.
-CF: Used to quantify TR in a manner analogous to that for the MV. Retrograde systolic flow in IVC on pts with significant TR.
-Contrast: remains confined in the RA; systolic appearance of contrast in the IVC is another indirect marker of TR.
-TRV: can be used to determine RVSP. |
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Term
| Describe the primary goals and challenges of evaluating prosthetic valves complications that can result from prosthetic valves |
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Definition
-Goals: (p.408) The primary goals of 2-D echo of prosthetic valves are to confirm stability of the sewing ring, determine the specific type of prosthesis, confirm the opening and closing motion of the structural abnormalities such as vegetations and thrombi
-Challenges:(407) The high reflectance of the prosthetic material creates challenges for the echocardiographer. Because the speed of sound changes as it passes through prosthetic materials, size and appearance can be distorted. The high reflectance also leads to shadowing behind the prostheses. Reverberations frequently appear behind the prostheses which may obscure targets of interest. |
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Term
| List the causes of prosthetic valve dysfunction |
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Definition
-Obstruction: Mismatch between the valve and the patient, Technical difficulties, Thrombus, Fibrocalcific degeneration
-Infective Endocarditis: Vegetations, Abscesses
-Mechanical Failure: Defect in manufacturing |
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Term
| Define endocarditis and discuss how it is evaluated by transesophageal echocardiography |
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Definition
-Endocarditis:(p. 375) a localized infection anywhere on the endocardium, including the chamber walls, vessels and within congenital defects.
-TEE: (p.381) Smaller vegetations, those associated with prosthetic valves, and those in locations that would be shadowed or obscured during TTE are some of the areas in which TEE is superior. It’s ability to identify other manifestations of endocarditis, such as ring abscesses and fistulae. |
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Term
| Describe how mitral annular calcification is recognized in echocardiography |
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Definition
| This is most often appreciated in the posterior mitral valve annulus and can range from limited degrees of focal deposits to nearly circumferential heavy calcification. Echo Densities (Fig. 11.87, 11.88) |
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Term
| Discuss the conditions associated with mitral annular calcification |
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Definition
-MR
-LVOT obstruction (rare)
-Can result in MS that is not amenable to balloon valvuloplasty |
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Term
| List the findings (M-mode, Two-dimensional, and Doppler) for Bundle Branch Block. |
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Definition
| M-Mode - Abnormal IVS motion, LBBB- initial downward motion of the ventricular septum followed by anterior or paradoxial septal motion and the subsequent full thickening of the ventricular septum and posterior motion toward the center of the heart. |
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Term
| List the findings (M-mode, Two-dimensional, and Doppler) for Mitral stenosis |
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Definition
M-Mode: Thickened MV leaflets; Decr. E-F slope; Anterior motion of the posterior MV leaflets; Decr. A-wave; Decr. MV excursion; Steep A-C slope; Decr. Diastolic separation of MV leaflets; Pseudo-pansystolic MVP; LA dilation; pHTN; RV hypertrophy/dilation; Early diastolic dip of IVS; Abnormal IVS motion due to pressure/ volume overload.
2-D:
Thickened MV leaflets w/ restricted valve motion; LA dilation; LA contrast/smoke; RV hypertrophy/dilation; pHTN; Diastolic doming of anterior leaflet (hockey stick); Fibrosis and shortening of chordae; Commissural fusion; LA thrombus; PHTN; RV hypertrophy dilation; RA dilation; Small/protected LV
Doppler:
Turbulent flow; Incr. E velocity; Decr. E-F slope; pulmonary venous flow pattern (decreased systolci flow with a prolonged duration and increased pressure half time of diastolic flow); pressure ½ time; MV area; MV pressure gradient; MV EDP gradient; Coexisting valvular regurg; Turbulent jet |
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Term
| List the findings (M-mode, Two-dimensional, and Doppler) for Mitral valve proplapse |
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Definition
M-Mode:
Thickened MV leaflets (5mm or greater); LA dilation; pHTN; Holosystolic or Mid to Late systolic “sagging” of one or both MV leaflets from the C-D points; Abnormal late systolic dip LVPW; LV volume overload
2-D:
Any portion of one or both leaflets protruding beyond the mitral annular plane; Scalloped appearance of the MV leaflets in the PSAX veiw, Elongation of chordae
Doppler - MR |
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Term
| List the findings (M-mode, Two-dimensional, and Doppler) for Mitral regurgitation |
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Definition
M-Mode:
LV volume overload; pHTN; Increased D-E amplitude of Ant. MV leaflet; Steep E-F Slope; LA dilation; LV dilation; Gradual systolic closure of AV; Increased posterior Ao root wall excursion, Systolic flutter of IVS
2D:
Anatomic basis for MR; Bowing of IVS; LA systolic expansion; LA dilation; LV volume overload; pHTN; LV dilation; LV diastolic expansion; Incr. LA/RA ratio; Dilation of mitral annulus;
Doppler:
PW- Increased MB E velocity >1.2m/s; Decreased MV deceleration time <150 msec; Pulmonary venous flow, blunted <.3m/s or reversed S wave and increased D wave; Mitral VTI; LVOT velocity.
CW- Spectral strength indicates severity, Decreased MR velocity; Asymetrical shape of MR Velocity |
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Term
| List the findings (M-mode, Two-dimensional, and Doppler) for Flail Mitral Valve Leaflet |
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Definition
M-Mode:
Abnormal diastolic anterior and posterior leaflet motion; Systolic LA echoes; Systolic flutter of closure lines
2-D:
Diastolic inversion of anterior/posterior leaflet toward LA; Systolic inversion of MV leaflet(s); Systolic whipping of leaflet(s) toward LA; Floating chordae tendinae
Doppler:
MR; La systolic antegrade flow; LAW of MR jet |
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Term
| List the findings (M-mode, Two-dimensional, and Doppler) for Aortic Regurgiation |
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Definition
M-Mode:
Fine diastolic flutter of anterior MV leaflet; Incr. EPSS; Thickened aortic valve; Flail aortic valve; Lack of aortic valve coaptation; Premature closure of MV; Color size/timing of aortic jet; LV volume overload; LA dilation;
2-D:
LA dilation; LV dilation; LV volume overload; Incomplete closure of aortic cusps
Doppler:
Incr. LVOT velocity;
Law of aortic jet; Duration/direction of jet |
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Term
| List the findings (M-mode, Two-dimensional, and Doppler) for Aortic Stenosis |
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Definition
M-Mode:
Thickened aortic valve leaflets; LV hypertrophy; LA dilation; LV dilation; Decr. excursion of aortic valve; Dilated aortic root; Mitral annular calcification; Decr. E-F slope
2-D:
Thickened aortic valve leaflets; Systolic doming; Football-shaped aortic opening; Bicuspid aortic valve; Coexisting VSD; MR; AR; PDA; Commissural Fusion; Dilation of ascending aorta
Doppler:
Aortic valve velocity; AVA; Instantaneous gradient; LV stroke volume; mean pressure gradient |
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Term
| List the findings (M-mode, Two-dimensional, and Doppler) for Tricuspid regurgitation |
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Definition
M-Mode:
RV dilation; Abnormal IVS motion; Incr. E-F slope; Incr. RV end-diastolic pressure
2-D:
RA dilation; RV diastolic expansion; RV dilation; RV volume overload; Abnormal IVS motion; D-shaped LV; Dilated tricuspid valve annulus; Dilated IVC w/ no collapse; Dilated hepatic veins
Doppler:
LAW of TR jet; Tricuspid valve TVI; RVOT velocity; Flow reversal in IVC and/or hepatic vein; PFO |
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Term
| List the findings (M-mode, Two-dimensional, and Doppler) for Pulmonary regurgiation |
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Definition
M-Mode:
RV dilation; RV volume overload; Diastolic flutter of PV and TV; pHTN; Abnormal IVS motion
2-D:
RV dilation; RV volume overload; Abnormal IVS motion; RA dilation; RV diastolic expansion; D-shaped LV; PV ring/artery dilation
Doppler:
RVOT peak velocity; PV peak velocity; LAW of PI jet; Slope of PV flow |
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Term
| List the findings (M-mode, Two-dimensional, and Doppler) for Wolf-Parkinson White syndrome |
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Definition
M-Mode:
Abnormal IVS & PW motion, Early systolic motion of the ventricular septum or PW before the QRS. |
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Term
| List the effects of aging |
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Definition
-Progressive angulation between the ascending A and LVOT often in conjuction with localized proximal septal hypertrophy. This results in a "sigmoid" shape to the proximal IVS.
-The hypertrophy may be quite focal and result in localized area of turbulence in the outflow tract that may be the source of the ejection murmur often heard in elderly patients.
-Additionally, characteristic changes will be seen in the wall of the AO due to progressive thickening.
-Mild focal degrees of thickening are common in the AV and MV as well as the MV chordae.
-There is a progressive increase in the likelihood of anular calcium with age.
-With advanced age, even in the absence of sustained hypertension, myocardial stiffness increases, presumably due to mild degrees of fibrosis. This results in chronic diastolic dysfunction that can be detected with standard Doppler technique and that often results in modest LA dilation.
-Finally, with advanced age combined with long-standing hypertension (especially if poorly controlled), a pattern mimicking (genetically determined) hypertrophic cardiomyopathy may develop. |
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