Transcript Echo-Hemo Review - Grand Valley State University

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
[email protected]
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
Name the Wall Segments AND Typical
Perfusing Coronary Artery
Basal Anteroseptum
LAD
Name the Wall Segments AND Typical
Perfusing Coronary Artery
Apical Cap
LAD
Name the Wall Segments AND Typical
Perfusing Coronary Artery
Mid Anteroseptum
LAD
Name the Wall Segments AND Typical
Perfusing Coronary Artery
Basal Anteroseptum
LAD
1. _________
2. _________
3. ________
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 mediumsized 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 __________
>70%
percentage of luminal cross sectional area. This
causes blood flow to become inadequate to meet
demand with exercise, mental stress or
pharmacologic interventions.
T/F This spectral Doppler image of mitral
regurgitation is consistent with a reduced dP/dt
and is consistent with increased left ventricular enddiastolic 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
Name this complication of coronary
artery disease

Portion of papillary muscle seen in
transesophageal echocardiogram
Put the following in order.
Ischemic Cascade
A. Chest Pain
B. EKG changes
C. Perfusion defects
D. Wall motion abnormalities
E. 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:
A.
B.
C.
D.
E.
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:
A.
B.
C.
D.
E.
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?
A.
B.
C.
D.
E.
Old age
Heredity
Obesity
Diabetes mellitus
Atherosclerosis
What is the leading cause of coronary
artery disease?
A.
B.
C.
D.
E.
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?
A.
B.
C.
D.
E.
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?
A.
B.
C.
D.
E.
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?
A.
B.
C.
D.
E.
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?
A.
B.
C.
D.
E.
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.
Name this complication of coronary
artery disease

Basal inferior aneurysm
Which of the following mitral valve M-mode
findings might be visualized when LV
dysfunction is present?
A.
B.
C.
D.
E.
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%
Which of the following mitral valve M-mode
findings might be visualized when LV
dysfunction is present?
A.
B.
C.
D.
E.
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
Name this complication of coronary
artery disease

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. 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.

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.
Fill in the blank
Sound Waves are mechanical
_________________
vibrations which induce rarefractions and
compressions of any physical medium due
to an increase and decrease of density
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
What view is this? PLAX
Please label the following.
1IVS
RCC
4
NCC
5
2
Anterior Mitral Leaflet
3
Posterior Mitral Leaflet
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.
Posteriomedial
Papillary Muscle
Anterolateral
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
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.
Lower frequencies have:
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 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
How do you evaluate for pulmonary
hypertension using tricuspid
regurgitation?
4V2 + RAP (derived from IVC reactivity)
4 m/sec
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
Name the Wall Segments AND Typical
Perfusing Coronary Artery
Inferior Septum
RCA
The following definition describes
which modality?

Used primarily to examine the flow of blood.
Doppler
_________ imaging is concerned with direction,
velocity and then pattern of blood flow through
Doppler imaging
the heart and great vessels. ________
focuses on physiology and hemodynamics
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
Valsalva
the sinuses of ______________.
two
The mitral valve has ______
leaflets
two
and _______
commissures.
The interventricular septum normally
bows towards which cardiac
chamber?
Left
ventricle
What is being measured between the
arrows?
Define the following:

Translation
Movement in the chest as a whole

Rotation
Circular motion around the long axis of the left
ventricle

Torsion
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:
True
False,
Right
Side
 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)
93
Are these statements true according to the
American Society of Echocardiography
Guidelines for Image Orientation in Adults?
Recommended orientation:
True
 Short-axis
can be considered looking
for the apex toward the cardiac base
True
 Four
chamber and short axis: lateral
structures on the right side and the
medial structures on the left side
94
Which letter refers to the coronary sinus?
A
B
What is the region just proximal to the
pulmonic valve in the right ventricular outflow
tract called?
What valve is transected by the Mmode 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
Name the Wall Segments AND Typical
Perfusing Coronary Artery
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)
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
Name the Wall Segments AND Typical
Perfusing Coronary Artery
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
Name the Wall Segments AND Typical
Perfusing Coronary Artery
Apical Lateral
LAD
Name the Wall Segments AND Typical
Perfusing Coronary Artery
Apical Cap
LAD
Name the Wall Segments AND Typical
Perfusing Coronary Artery
Apical Anterior
LAD
Name the Wall Segments AND Typical
Perfusing Coronary Artery
Anterior Septum
LAD
Name the Wall Segments AND Typical
Perfusing Coronary Artery
Apical Lateral
LAD or CX
Name this complication of coronary
artery disease.

Anteroapical myocardial infarction and a pedunculated, slightly
mobile apical thrombus.
Name the Wall Segments AND Typical
Perfusing Coronary Artery
Apical Inferior
LAD
Name the Wall Segments AND Typical
Perfusing Coronary Artery
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 midventricular 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 fourchamber and two-chamber views with are used to
define a series of orthogonal diameters
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
Name the Wall Segments AND Typical
Perfusing Coronary Artery
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? Why?
Name the Wall Segments AND Typical
Perfusing Coronary Artery
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?

Right ventricular pressure overload


Increased mass (due to increased wall thickness) with nondilated 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 shorterparticularly 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
of E and A velocities at
approximately age 60 years
 Equalization



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
30_____percent of the ideal body
weight
After performing an echocardiogram
you calculate a wall motion score of
2.1. 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.
Name the Wall Segment AND the
Typical Perfusing Coronary Artery
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
Name the Wall Segments AND Typical
Perfusing Coronary Artery
Basal Inferoseptum
RCA
Where are red blood cells produced?
 Bone marrow
What percentage do red blood cells make up
of the formed elements in the blood?
 45%
Name the Wall Segments AND Typical
Perfusing Coronary Artery
Anterior
LAD
Name the Wall Segments AND Typical
Perfusing Coronary Artery
Mid Inferolateral
RCA or CX
Name the Wall Segments AND Typical
Perfusing Coronary Artery
Inferolateral
RCA or CX
Name the Wall Segments AND Typical
Perfusing Coronary Artery
Mid Inferoseptum
RCA or LAD
Anemia
______________
is the abnormal
decrease of red blood cells.
An abnormal increase in the
number of red blood cells is
called _____________________.

polycythemia
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.
Name the Wall Segments AND Typical
Perfusing Coronary Artery
Anterolateral
LAD or CX
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 Mmode has over B-mode.
True
 Superior temporal resolution and rapid
sampling frequency
Name the Wall Segment AND the
Typical Perfusing Coronary Artery
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.
What is this complication of
myocardial infarction called?
Ruptured
Papillary
Muscle
List two methods for evaluation
of LV mass.


Penn Cube
ASE
Which method for ejection fraction utilizes the
following traces?
Biplane method of discs (modified Simpson’s Rule)
What is the specific gravity of the
myocardial muscle?

1.04 g/ml
The word “Hemo” means:
a)
b)
c)
d)
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.
Name this complication of coronary
artery disease.

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?
Name the Wall Segments AND Typical
Perfusing Coronary Artery
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 Mmode.
2
4
3
1
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
1
2
3
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
What is this complication of myocardial
infarction called?
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
Gradual
pressure
•Highest
velocity
and
cath and echo
lowestrecovery:
pressure:
narrowest
gradients correlate
point of the orifice (vena
contracta)
Rapid pressure
•Pressure of
fluid decreases
as
recovery:
cath and echo
do not
the velocitygradients
increases
correlate. Echo will have
a higher gradient than
•After flow cardiac
passescatheterization
through orifice
pressure recovers and increases
toward its original valve
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?
Anterior
What is this diagram called? Wiggers
Is this a normal tracing? 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?
Name the Wall Segments AND Typical
Perfusing Coronary Artery
Basal Anterior
LAD
Name the Wall Segments AND Typical
Perfusing Coronary Artery
Mid Anterolateral
LAD or CX
Name the Wall Segments AND Typical
Perfusing Coronary Artery
Apical Anterior
LAD
Name the Wall Segments AND Typical
Perfusing Coronary Artery
Basal Inferolateral
LAD
Name the Wall Segments AND Typical
Perfusing Coronary Artery
Basal Anterolateral
LAD or CX
Name the Wall Segments AND Typical
Perfusing Coronary Artery
Inferior
RCA
Name this complication of coronary
artery disease.

Pseudo apical aneurysm with suggestion of
calcification along rim
Name the Wall Segments AND Typical
Perfusing Coronary Artery
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

What is this complication of myocardial
infarction called?
Pseudoaneurysm
The following formula may be used to
calculate valvular area. What is this
formula?
CSA1 x VTI1 = CSA2 x VTI2
CSA2 = CSA1 x VTI1
VTI2
Continuity Equation
Name the Wall Segment AND the
Typical Perfusing Coronary Artery
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.
Name the Wall Segment AND the
Typical Perfusing Coronary Artery
Apical Septum,
Apical Cap and
Apical Lateral: LAD
When a patient has aortic stenosis, the pressure in
the left ventricle will:
a) Decrease
b) Increase
c) Remain the same
What does this formula calculate?
(7*LVIDD3)
(2.4+LVIDD)
End diastole volume (EDV) ml
Teichholz method