ECHOCARDIOGRAPHY AND HEMODYNAMICS REVIEW ECHO II

ECHOCARDIOGRAPHY AND HEMODYNAMICS REVIEW ECHO II
Susan A. Raaymakers, MPAS, PA-C, RDCS (AE,PE) Coordinator of Radiologic and Imaging Sciences - Echocardiography Grand Valley State University, Grand Rapids, Michigan

Anatomy Right Atrium SVC, CS, IVC Smooth walled
Derived from embryonic right atrium called the sinus venosus Right atrial appendage Sulcus terminalis Posterior external ridge that extends vertically from the SVC to the inferior vena cava Pectinate muscles

Name this complication of coronary artery disease
acute inferoseptal and inferior myocardial infarction resulting in ventricular septal defect

1. ______ 2. ______ 3. ______

Name the Wall Segments AND Typical Perfusing Coronary Artery
Apical Cap LAD

Basal Anteroseptum LAD

Apical Cap LAD

Mid Anteroseptum LAD

Basal Anteroseptum LAD

1. _________ 2. _________ 3. ________

What is this complication of myocardial infarction called
What is this complication of myocardial infarction called? When does it occur? Dressler’s Syndrome: delayed form of pericarditis: an immunologic reaction Occurs one to 12 weeks post MI Symptoms: fever, pleuropericaridial pain, malaise Cardiac tamponade is rare

What is polyarteritis? (Also called Kussmaul's disease, periarteritis nodosa) Systemic inflammation and necrosis occurring in medium-sized or small arteries. Kidneys, heart, liver, GI tract, pancreas, testes, skeletal muscular system, central nervous system (CNS), and skin are involved.

1. _________ 2. _________ 3. _________

Ischemia results in narrow of __________ percentage of luminal cross sectional area. This causes blood flow to become inadequate to meet demand with exercise, mental stress or pharmacologic interventions. >70%

T/F This spectral Doppler image of mitral regurgitation is consistent with a reduced dP/dt and is consistent with increased left ventricular end-diastolic pressure. True. The MR is quickly leaving the LV causing the LA to quickly increase in pressure.

Name four risk factors for coronary artery disease.
Increased LDL Smoking Diabetes Hypertension Genetics (hereditary) Type “A” personalities Aging Obesity Sedentary lifestyle Chronic stress

Portion of papillary muscle seen in transesophageal echocardiogram

Put the following in order.
Ischemic Cascade Chest Pain EKG changes Perfusion defects Wall motion abnormalities Diastolic dysfunction C, E, D, B, A

What is the term used for a myocardium that does not contract normally due to a brief period of ischemia following by a gradual return of contraction due to reperfusion? Stunning Hybernation

An acute myocardial infarction on an ECG may be indicated by:
Elevated ST segment Depressed ST segment Tall T waves Enlarged P waves Tall Q waves

An acute myocardial infarction on an ECG may be indicated by:
Elevated ST segment Depressed ST segment Tall T waves Enlarged P waves Tall Q waves ST-T segment changes: Depressed ST-segments suggest ischemia Elevated ST-segments suggest acute myocardial infarction

What is the leading cause of coronary artery disease?
Old age Heredity Obesity Diabetes mellitus Atherosclerosis

Although aneurysm formation may occur in any part of the ventricle, what is the most common site visualized 2D? Anterior left ventricle and apex Posterior left ventricular wall Right ventricular apex Basal portion of the left ventricle Lateral left ventricular wall

Although aneurysm formation may occur in any part of the ventricle, what is the most common site visualized 2D? Anterior left ventricle and apex Posterior left ventricular wall Right ventricular apex Basal portion of the left ventricle Lateral left ventricular wall After acute MI, 15% to 20% of patients develop LV aneurysm. Look for thrombus within aneurysm and patients often have persistent ST wave elevation

What is the term for systolic expansion of a segment that is thin and moves paradoxically compared to the surrounding myocardium? Hyopkinesis Akinesis Dyskinesis Hyperkinesis Paradoxical

What is the term for systolic expansion of a segment that is thin and moves paradoxically compared to the surrounding myocardium? Hyopkinesis Akinesis Dyskinesis Hyperkinesis Paradoxical You will hear both dyskinesis and paradoxical. You will also hear dyskinetic as a term referring to abnormal. For board exam purposes use dyskinetic.

Basal inferior aneurysm

Which of the following mitral valve M-mode findings might be visualized when LV dysfunction is present? Increased E point/septal separation with abnormal fractional shortening Decreased amplitude decreased E point septal separation with normal fractional shortening A point less than E point Ejection fraction of 65% Fraction thickening of 10%

T/F Myocardial rupture with acute electromechanical dissociation, hypotension and shock is usually fatal. True

Name this complication of coronary artery disease.
Large apical aneurysm

Basal inferior aneurysm with thrombus formation

Please describe this image.
Right ventricular infarction

Please describe this dynamic image.
Akinesis of anterior septum due to acute left anterior descending coronary artery occlusion.

Please describe this dynamic image.
Normal thickening and motion of the myocardium

You are asked to perform an echocardiogram due to a friction rub
You are asked to perform an echocardiogram due to a friction rub. What is a friction rub? Patients with pericarditis, an inflammation of the sac surrounding the heart may have an audible pericardial friction rub Pericardial friction rub: scratching, creaking, high pitched sound emanating from the rubbing of both layers of inflamed pericardium. Loudest in systole, but can often be heard also at the beginning and at the end of diastole. Dependent on body position and breathing, and changes from hour to hour.

T/F Lower viscosity equals higher velocity True

Name the Wall Segment AND the Typical Perfusing Coronary Artery
Anteroseptal LAD

Name this rhythm Ventricular Tachycardia

What supplies are missing for a TEE procedure?
Equipment, supplies Oximeter: continuous measurement of oxygen saturation is strongly recommended Suction equipment Oxygen delivery system Automated blood pressure monitoring device ECG monitoring (present on the ultrasound machine) Supplies for contrast administration (stopcocks, syringes, IV tubing) Bite Block

Does increased preload result in increased IVRT?
NO

List Indications for Stress Echocardiography Testing.
Detection of coronary artery disease Assessment of the area of myocardium at risk Risk stratification after myocardial infarction Evaluation after revascularization Detection of myocardial infarction Women with chest pain symptoms and/or cardiac risk factors Patients after heart transplantation Patients being considered for renal transplant Patients undergoing vascular surgery

How do you prepare the right ventricular opacification agent?
Rapidly agitate 5 mL of sterile saline, with a small amount (approximately 0.2 mL) of air between two syringes connected with a three-way stopcock. Results in production of large, highly variable sized microbubbles that do not pass through the pulmonary vascular bed. When the saline appears opaque, it is injected rapidly (to avoid coalescence) into a peripheral vein during echocardiographic imaging. The contrast effect may be enhanced by following the contrast injection with 10 mL of non-agitated saline. Coalescence: come together, combine

Fill in the blank _________________ are mechanical vibrations which induce rarefractions and compressions of any physical medium due to an increase and decrease of density Sound Waves

Which plane divides into superior and inferior?
In this image the transverse plane.

T/F Image resolution is no greater than 1 to 2 wavelengths (typically 1 mm) True

Name This Rhythm Atrial Flutter

Is this right ventricular volume or pressure overload?
Right ventricular volume overload Maximum reversal of curvature seen in mid-diastole with normalization in mid-systole

List two complications of TEEs
Complications of TEEs are rare: Aspiration Arrhythmia Perforation of the esophagus Laryngospasm Hematemesis Medication complications Hypotension Hypertension Hypoxia Death (very rare)

Which view is the following? Apical Four Chamber with Anterior Tilt
Apical 5 chamber

What view is this? Please label the following.
PLAX 1 IVS RCC 4 NCC 5 2 Anterior Mitral Leaflet Posterior Mitral Leaflet 3

Does increased preload result in increased E wave?
Yes

How long should a patient fast before undergoing a TEE?
4 to 6 hours

Which valve can be evaluated in this M-mode image?
Mitral

Which view is this? RVIT

Please Identify These Leaflets
Anterior Posterior/Septal The Medial Leaflet of the Tricuspid valve is not seen in this view.

What is the name of this view?
PSAX-Ao

Is there diastolic filling dysfunction? If so, qualify it.
Restrictive Filling Defect Doppler Values E/A >2 DT <150 ms S/D <1

Please identify the cusps.
Right Coronary Cusp Left Coronary Cusp Non Coronary Cusp

Please Label the Following
Anterior Mitral Leaflet

True/False A heart rate of 150 bpm allows adequate filling time in diastole and does not affect preload in any way. False. Tachycardia does not allow enough time for the left ventricle to fill in diastole and decreases preload.

Please Label the Following.
Anterolateral Papillary Muscle Posteriomedial Papillary Muscle

Please identify the following structure in this TEE.
Left Atrial Appendage

Please identify the following. Which view is this?
Subcostal Four Chamber

Please identify the following valve leaflets
2 1

What are two contraindications to TEE?
Esophageal pathology Severe dysphagia Esophageal stricture Esophageal diverticula Bleeding esophageal varices Esophageal cancer Cervical spine disorders Orthopedic conditions that prevent neck flexion

T/F M-mode and 2D images will be best if the sound wave is positioned perpendicular (90 degrees) True

Name two advantages of left hand scanning
Sonographer has eye contact with the patient Patient is able to watch the video monitor, which can help keep the patient occupied Sonographer can help explain various aspects of the procedures without providing any diagnostic information Sonographer can see if the patient is experiencing any distress during the exam Reduces the chance of back injury to the sonographer. When scanning from the right, the sonographer needs to reach around the patient potentially overextending back muscles. Sonographer is able to see where the transducer is being placed.

What is an advantage of scanning right-handed?
Many in-patient hospital situations dictate the scanning side Altering right and left hand scanning decreases repetitive motion injuries

Point of maximum impulse
What is the PMI? Point of maximum impulse

Where would you find the moderator band?
In the right ventricle

If this pulse is one second, what is the frequency?.
Frequency is defined as the number of complete variations (cycles) that an acoustic variable goes through in 1 sec. In this figure of complete variations (cycles), the frequency is 4 complete variations per second, or 4 Hz

T/F Lower frequencies have decreased penetration False.
1. Increased penetrations 2. Decreased resolution

Name this rhythm Torsades du Pointe

What is temporal resolution.
Temporal Resolution: The resolution of the image (quality) as it pertains to moving objects. The higher the frame rate the better the temporal resolution.

What is the frequency of ultrasound?
Ultrasound: > 20 KHz

What is the difference between these two images
What is the difference between these two images? What control on the echocardiography machine is being utilized? Too much gain is used, distorting the image, reducing resolution, and increasing noise.

What is this structure? An example of a false tendon (arrows) in the left ventricular (LV) apex is demonstrated.

Which valve is positioned most apically?
Tricuspid

4V2 + RAP (derived from IVC reactivity)
How do you evaluate for pulmonary hypertension using tricuspid regurgitation? 4V2 + RAP (derived from IVC reactivity)

The following definition describes which modality?
Motion can be introduced by plotting the B-Mode display against time. In other words, this allows a single dimension of anatomy to be graphed against time. Often described as the “ice-pick” view of the heart. This modality is obtained using a single interrogation beam. M-Mode

Inferior Septum RCA

The following definition describes which modality?
Used primarily to examine the flow of blood. _________ imaging is concerned with direction, velocity and then pattern of blood flow through the heart and great vessels. ________ imaging focuses on physiology and hemodynamics Doppler Doppler

What is the best view for evaluation of proximal coronary arteries?
PSAX-Ao

Which is the best view for assessing the length of inferior left ventricular wall?
Apical 2 Chamber Inferior

The tip of the heart is called the ___________.
Apex

The coronary arteries originate from the sinuses of ______________.
Valsalva

The mitral valve has ______ leaflets and _______ commissures.
two two

The interventricular septum normally bows towards which cardiac chamber?
Left ventricle

What is being measured between the arrows?

Translation Rotation Torsion Define the following:
Movement in the chest as a whole Circular motion around the long axis of the left ventricle NEED TO COME UP WITH WAY TO SHOW THIS!!!! Unequal rotation motion at the apex versus the base of the left ventricle 92

Are these statements true according to the American Society of Echocardiography Guidelines for Image Orientation in Adults? Recommended orientation: Transducer position (narrowest portion of sector scan) at the top of the screen Lateral cardiac structures displayed on the left side of the screen (similar to other tomographic imaging techniques) True False, Right Side Most laboratories use ASE 93

Are these statements true according to the American Society of Echocardiography Guidelines for Image Orientation in Adults? Recommended orientation: Short-axis can be considered looking for the apex toward the cardiac base Four chamber and short axis: lateral structures on the right side and the medial structures on the left side True Most laboratories use ASE True 94

Which letter refers to the coronary sinus?
B

What is the region just proximal to the pulmonic valve in the right ventricular outflow tract called?

What valve is transected by the M-mode line of interrogation?
Pulmonic

Which M-mode of the pulmonic valve depicts pulmonary hypertension?

What is the vessel entering at the arrow?
Superior Vena Cava

Which chordae originate at the tips of the papillary muscle, branch into several thinner stands and attach at the extreme edge of the leaflets? 1st order

Which papillary muscle is typically perfused only by the right coronary artery and therefore is more susceptible to rupture? Posterior medial

What does antegrade flow?
Forward flow in contradiction to retrograde flow such as regurgitation

Which regurgitation is present in 80 to 90 percent of healthy individuals?
Tricuspid

What opacification agent is used to evaluate for atrial shunts.
Agitated saline

Basal Inferolateral RCA or CX

List two advantages of using agitated saline.
Excellent safety profile Inexpensive Easily stored Widely available

A patient was referred to the echocardiography lab with suspicion of an pulmonary AVM. What is an pulmonary AVM? Pulmonary arteriovenous malformation Abnormal passageway (fistula) between an artery and vein that occurs in the blood vessels of the lungs. The result is a shunting of blood, and thus the blood is not oxygenated properly.

List three qualities of an ideal left ventricular opacification agent.
Ideal Contrast Agent Nontoxic (complete safety) Inert and poorly soluble gas Small size(for transcapillary passage) Excellent opacification (reflectivity) Capable of oscillation upon ultrasonic stimulation (to allow detection of harmonic images) Long half-life Intravenous administration Similar rheology to RBCs

What are ideal settings for the ultrasound machine using a left ventricular opacification agent? List two settings. Set mechanical index (MI): 0.4 to 0.6 Select harmonic imaging Optimize transmit focus location (usually far-field; may be apical) Optimize TGCs and gain Optimize compression Minimize near-field gain Use and modify contrast presets supplied by specific vendors

You are asked to assist in an ICE procedure in the cardiac catheterization lab. What is this?

What are complications of ICE?
Intracardiac thrombus formation Pericardial effusion Pulmonary vein obstruction

True/False If the goal a a test is to identify all patients with disease then prefer high sensitivity. True. Transversely if the goal is to determine those patients who do not have the disease then specificity is preferred.

What is a disadvantage of low yield screening?
Major negative impact use of this technique if only a limited number of echocardiograms can be performed (depends on number of instruments, physicians and sonographers)

Other testing modalities or intervention may be recommended
May the sonographer recommend other testing modalities on the worksheet? Worksheets should include: All measurements Reference to previous studies Degree of severity of findings Left ventricular systolic function is quantified Information is interpreted and correlated Often image quality is reported Other testing modalities or intervention may be recommended Report need for immediate care for patient

Mid Inferior RCA

How many echocardiographic studies should a physician be involved in annually to be considered competent in Level 3? Level 3 Additional qualifications to supervise an echocardiography laboratory 12 months 300 studies performed 750 studies interpreted 500 annual studies to maintain competence

How long must patient records be kept?
Seven years

Apical Lateral LAD

Apical Cap LAD

Apical Anterior LAD

Anterior Septum LAD

Apical Lateral LAD or CX

Anteroapical myocardial infarction and a pedunculated, slightly mobile apical thrombus.

Apical Inferior LAD

Mid Anterior LAD

Which occurs first, mitral stenosis or aortic stenosis in the cardiac cycle?
Aortic Regurgitation, AI occurs during isovolumic relaxation as well as during diastole. Mitral stenosis only occurs during diastole.

What does this m-mode tell you about the left ventricular function?
Poor anterior and posterior leaflet separation indicates poor transmitral flow. This most likely is due to elevated end systolic pressure in the left ventricle and therefore poor left ventricular function.

T/F During systolic contraction the cardiac base moves toward the apex.
True. Descent of Cardiac Base During ventricular contraction, the base of the heart moves toward the apex The magnitude of this motion is directly proportional to systolic function Typically, M-mode interrogation is undertaken at the lateral mitral valve annulus and the amount of excursion toward the transducer is determined This measurement is rarely used today but same principle is used in tissue Doppler imaging (DTI) for determination of diastolic and systolic function Normal >8 mm (98% specificity); mean 12±mm in both four and two chamber views

List one method of evaluating LV volumes
Biplane method of discs (modified Simpson’s rule) Single plane area-length Quick method (Hemisphere-cylinder)

Which method for evaluation of left ventricular volumes assumes that the left ventricle is approximated by a cylinder and the apex is an ellipsoid? “Bullet” Formula Short-axis endocardial area at the mid-ventricular level Am and a long-axis length Volume = 5/6 x Am x L

Which method of evaluating LV volumes most closely predicts angiographic volume?
Simpson’s Biplane Represents cavity as stack of discs and sums individual volumes of each disc Endocardial borders are traced in apical four-chamber and two-chamber views with are used to define a series of orthogonal diameters

Avoid aorta and coronary sinus
Using Simpson’s Rule how do you determine when to trace the diastolic volume? Image maximization Both AV valves imaged Avoid aorta and coronary sinus End-diastolic frame is largest LV cavity just after MV closure at electrocardiographic R wave

Which law states that as heart volume increases the length of the myocardial fiber increases resulting in a stronger recoil? Frank-Starling Law

Apical septum LAD

List three causations of increased wall tension.
Ventricular volume and pressure Arterial resistance Aortic impedance Mass of blood in aorta Viscosity of blood

What is indicated by these arrow?
Left bundle branch block causing septal contraction prior to inferolateral contraction.

T/F IVRT is affected by impaired left ventricular relaxation.
True Time interval between aortic valve closure and mitral valve opening Normal isovolumic relaxation time i.e. approximately 80 to 100 msec Normal range varies with age and heart rate Impaired relaxation is associated with prolonged IVRT Measured from A4 angulated anteriorly to show outflow tract and aortic valve midway between aortic valve and mitral valve

What is this complication of myocardial infarction called?
True apical aneurysm

Does the following m-mode indicate normal or abnormal stroke volume
Does the following m-mode indicate normal or abnormal stroke volume? Why?

Basal Inferior RCA

Name this rhythm 2nd Degree Block Mobitz I, Wenkebach
Note the gradual lengthening of the P-R with the eventual drop

Is this right ventricular pressure overload or volume overload?
Increased mass (due to increased wall thickness) with non-dilated chamber Leftward shift of septal motion throughout cardiac cycle with reversal curvature at end-systole

Is the left atrial pressure increased?

Is the left atrial pressure elevated?
Yes. Pseudonormal. E/A >1 Relatively normal decel time Pattern distinguished from normal by Em<Am and pulmonary venous inflow Pd>Pa, duration longer than mitral A duration suggestive of elevated left ventricular filling pressures

Explain what happens to right-sided murmurs with inspiration.
Right-sided murmurs generally increase in intensity with inspiration Inspiration causes a decrease in intrathroacic pressure allowing air to enter the lungs. This decrease in intrathoracic pressure allso causes an increase in the venous blood return to the right side of the heart.

How is pseudonormal diastolic filling patterns altered with a Valsalva maneuver?
Reduction in venous return during Valsalva maneuver results in an overall decrease of LV filling velocities without significant change in the E/A ratio in normal. Decrease in venous return does change in pseudonormal because atrial empting is abnormal. Due to reduced emptying in early diastole, emptying with atrial contraction will atrial increase

Is the left atrial pressure elevated?
No

How does increased heart rate affect diastasis?
At high heart rates diastole is shorter- particularly the period of diastasis When overlap of these two velocity curve occurs the A velocity is added to E velocity curve resulting in a higher A velocity

Approximately what age signifies equalization of the E and A waves?
Aging adults E velocity diminishes Atrial contribution becomes more prominent Equalization of E and A velocities at approximately age 60 years Reversal of E and A velocities post 60 years old Early diastolic deceleration time progressively prolonged Slight increase in isovolumic relaxation time with age

A patient is considered obese when he/she is overweight by _____percent of the ideal body weight
30

After performing an echocardiogram you calculate a wall motion score of Is this considered normal? Normal contracting has a wall motion score index of 1. Patients with a wall motion score index of >2.0 are abnormal.

Basal Inferolateral Cx or RCA

What is a NYHA classification IV mean?
A functional and therapeutic classification for prescription of physical activity for cardiac patients. Class I: patients with no limitation of activities; they suffer no symptoms from ordinary activities. Class II: patients with slight, mild limitation of activity; they are comfortable with rest or with mild exertion. Class III: patients with marked limitation of activity; they are comfortable only at rest. Class IV: patients who should be at complete rest, confined to bed or chair; any physical activity brings on discomfort and symptoms occur at rest.

What are the oxygen saturations?

Which plane divides into anterior and posterior?
Coronal Plane

At rest, what is the approximate stroke volume in mL?
70 mL at rest

Basal Inferoseptum RCA

Where are red blood cells produced
Where are red blood cells produced? What percentage do red blood cells make up of the formed elements in the blood? Bone marrow 45%

Anterior LAD

Mid Inferolateral RCA or CX

Inferolateral RCA or CX

Mid Inferoseptum RCA or LAD

Anemia polycythemia ______________ is the abnormal decrease of red blood cells. An abnormal increase in the number of red blood cells is called _____________________.

Which requires a higher myocardial contraction? Polycythemia or anemia
Polycythemia (Abnormal increase in the number of red blood cells) Greater viscocity requires greater force to move through vascular system.

Anterolateral LAD or CX

SaO2 value refers to arterial oxygen saturation.
You are asked to perform a cardiac ultrasound on a 90 year old female with an SaO2 of 79%. What does an SaO2 of 79% indicate? SaO2 value refers to arterial oxygen saturation. Below 90% is considered hypoxemic

On M-mode what is displayed on the horizontal axis (x)?
Motion or time displayed on horizontal axis (X)

True/False On M-mode echo strength is directly proportional to the strength of the reflected echoes
TRUE. Echo strength is represented as the brightness of structures on the image display Blood-filled cavities do not produce echoes Solid structures such as cardiac valves and walls produce strong echoes

True/False Temporal resolution is an advantage that M-mode has over B-mode.
Superior temporal resolution and rapid sampling frequency

Basal Inferior Wall: RCA

What does this Wiggers’ Diagram Indicate?

What modality(ies) is(are) used to create this image?
Color M-mode

Label this m-mode image of the pulmonic valve leaflet.
3 4 2 1 6 5 1

What does each letter indicate?
A: reflects small posterior deflection occurring at atrial systole B: notes small anterior deflection occurring at and of atrial systole and onset of ventricular systole C: large posterior deflection immediately following ventricular ejection D: gradual anterior motion of the leaflet during the ventricular ejection period E: closed position of the leaflet upon completion of ventricular ejection F: represents the slight posterior movement of the leaflet during diastole and is the point immediately prior to atrial contraction and the next A point.

Ruptured Papillary Muscle

List two methods for evaluation of LV mass.
Penn Cube ASE

Biplane method of discs (modified Simpson’s Rule)
Which method for ejection fraction utilizes the following traces? Biplane method of discs (modified Simpson’s Rule) Technique requires recording apical four and two chamber views from which the endocardial border is outline in end-diastole and end-systole Using both two and four chamber views increase accuracy Ventricle is mathematically divided along its long axis into a series of disks of equal height Individual disk volume is calculated as height x disk area where height is assumed to be the total length of the left ventricular long axis ÷ the number of segments or disks The surface area of each disk is determined from the diameter of the ventricle at that point Ventricular volume is represented by the sum of the volume of each of the disks

What is the specific gravity of the myocardial muscle?
1.04 g/ml

The word “Hemo” means: Blood Force or power Kinetic energy
Decreased pressure

What is the normal fractional shortening percentage?
21 to 40%

What is the first heart tone?
First heart tone, S1, caused by the closure of AV valves at the at the beginning of ventricular contraction, or systole.

True apical aneurysm

Where would you measure the sinotubular junction?
Answer: 3 1. Aortic annulus, 2 Trans-sinus or sinus of Valsalva, 4. Ascending aorta

Which set of images would you use to measure for stroke volume?

During which phase does the left ventricular pressure exceed the aortic pressure?

Apical Lateral LAD

During which phases are the semilunar valves open?

Assuming that this Wigger’s diagram was obtained from the right-sided pressures, what does this diagram indicate? Pulmonic stenosis

Name the points on this M-mode.
2 4 3 1 5

T/F In the autonomic nervous system, the FLIGHT OR FIGHT RESPONSE, refers to the parasympathetic division of the autonomic nervous system. False, The FLIGHT OR FIGHT RESPONSE refers to the sympathetic nervous system, in which the heart rate is increased, AV node conduction and increases irritability.

Label 3 1 2 4 5 6 8 7

Assuming that this Wigger’s diagram was obtained from pressures left atrium and left ventricle, what does this diagram indicate? Mitral stenosis

Acute anterior apical infarct with early thrombus formation. Regional dilation of the LV at apex and pedunculated, multilobulated mas protruding into the cavity of the LV

What is Pressure Recovery?
Hydrodynamic principle based on conservation of energy Highest velocity and lowest pressure: narrowest point of the orifice (vena contracta) Pressure of fluid decreases as the velocity increases After flow passes through orifice pressure recovers and increases toward its original valve Gradual pressure recovery: cath and echo gradients correlate Rapid pressure recovery: cath and echo gradients do not correlate. Echo will have a higher gradient than cardiac catheterization

The longer the interval between contractions, the ____________ the contraction.
A. shorter B. stronger C. weaker D. longer

In M-mode does the root of the aorta move anterior or posterior?

What is this diagram called? Is this a normal tracing?
Wiggers Yes

How does the cardiac catheterization laboratory calculate valvular area?
Gorlin formula

What velocity would you use in the calculation of the Effective Orifice of mitral regurgitation using PISA?

Basal Anterior LAD

Mid Anterolateral LAD or CX

Apical Anterior LAD

Basal Inferolateral LAD

Basal Anterolateral LAD or CX

Inferior RCA

Pseudo apical aneurysm with suggestion of calcification along rim

Mid Inferolateral RCA or CX

What information must you obtain to calculate the Tei Index?
Left ventricular ejection time Systolic time including isovolumic contraction

What is the second heart sound?
S2, second heart sound, caused by the closure of the aortic and pulmonic valves at the end of ventricular systole.

In a patient with a ventricular septal defect how might you determine the right ventricular pressure?

What is Pulmonary Artery Capillary Wedge Pressure?
Indirect assessment of left atrial pressure Useful in diagnosis of left ventricular heart failure Swan-Ganz catheter

Pseudoaneurysm

The following formula may be used to calculate valvular area
The following formula may be used to calculate valvular area. What is this formula? CSA1 x VTI1 = CSA2 x VTI2 CSA2 = CSA1 x VTI VTI2 Continuity Equation

Mid Inferoseptum: RCA

What does this Wiggers’ Diagram represent?

Name this Rhythm Atrial Flutter 4:1

Explain what happens to left-sided murmurs with inspiration.
Left-sided murmurs generally decrease in intensity with inspiration Increased volume of blood entering the right sided chambers of the heart restricts the amount of blood entering the left sided chambers.

Increased preload leads to _________.
A. increased contractility B. decreased contractility C. shorter contractility time D. none of the above.

T/F An example of afterload is hypertension True

T/F Standing decreases venous return, stroke volume True

T/F Amyl nitrate increases the heart rate True

What is the third heart sound?
Third Heart Tones, S3 Caused by vibration of the ventricular walls Resulting from the first rapid filling so it is heard just after S2 Low in frequency and intensity Commonly heard in child and young adults In older adults S3 often indicates heart failure

How do wall filters affect spectral Doppler?
On the left notice that the low velocity blood flow has been filtered out.

Apical Septum, Apical Cap and Apical Lateral: LAD

When a patient has aortic stenosis, the pressure in the left ventricle will:
Decrease Increase Remain the same

What does this formula calculate?
(7*LVIDD3) (2.4+LVIDD) End diastole volume (EDV) ml Teichholz method

ECHOCARDIOGRAPHY AND HEMODYNAMICS REVIEW ECHO II

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