DMS 204- Week 3-7 LOs

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TV- inferior and medial to aortic root PV- superior and lateral to the aota TV moves anteriorly with atrial contraction and PV dips posteriorly

how do you differentiate the TV from the PV when scanning?

Mitral M-mode- fluttering of the anterior MV leaflet

how do you find AI with m-mode?

fluttering of the anterior MV leaflet on m-mode

how do you find aortic insufficiency in an m-mode?

pleural effusion will be seen only posterior to the descending thoracic aorta; PE is anterior to the descending thoracic aorta

how do you tell if an effusion is pericardial vs. pleural?

supine with knees bent

how is the patient positioned for subcostal views?

frequency

how many cycles per second going into our transducer in MHz

one

how may lines of focus does m-mode have?

truncated ellipse with a longer length than width and a tapered, but rounded, apex If you foreshorten the LV, you might make it look they have a disease when they really dont

how should the LV look in apical views? Why is it so important to get a true apical view?

aim transducer to bell button

how would you obtain the RVIT from the PLAX view?

aim the transducer head to the patient's left shoulder

how would you obtain the RVOT from the PLAX view?

1

if the CSA of the LVOT is 3 cm^2 and the VTI is 16 cm and the VTI of the aorta is 48 cm what is the CSA of the aorta in cm^2?

paradoxical septal motion

if the RV is pulling more than the LV, _________ septal motion occurs

.5

if the velocity of the LVOT is 1 m/s and the CSA is 2 and the velocity of the aorta is 4 m/s what is the CSA of the aorta in cm^2?

lower it

if you had 3 m/s trace with flow toward your transducer and a 2 m/s nyquist limit, how would you move your baseline

decrease

if you had a small velocity on your spectral trace, and 6 m/s for your PRF, what would you do to your scale/PRF?

overall 2D gain

if your entire picture does not have enough gain, which of the controls would you use first?

2 m/s

if your spectral trace display reads 2 m/s on the top of the baseline and 2 m/s on the bottom of the baseline, what is the nyquist limit?

4 m/s

if your spectral trace display reads 3 m/s on the top of the baseline and 1 m/s on the bottom of the baseline, what is the PRF?

LV and LA

in MS, the pressure gradient obtained by velocity reflects a pressure difference between:

LV and aorta

in aortic stenosis, the pressure gradient obtained by velocity reflects a pressure difference between

TV- above the septum MV- below the septum

in relation to the IVS, where does the TV sit on the M-mode and where does the MV sit?

yes

is it normal to have a moderator band in the RV?

500 cc or more >3.0 cm at diastole

large PE criteria

100-300 cc .5 to 1.5 cm at diastole

low end moderate PE criteria

25-35 mm/sec

mild MS slope

anterior (largest) septal (medial) posterior (lateral)

name the TV leaflets

RCC LCC NCC

name the aortic valve cusps

brachiocephalic/innominate left common carotid left subclavian

name the branches off the aortic arch in descending order

anterior and posterior MV leaflets

name the mitral valve leaflets

anteriolateral posteriomedial

name the mitral valve papillary muscles

right left anterior

name the pulmonic valve leaflets

posterior bowing of the posterior MV leaflet suggestive of midsystolic MVP of the posterior MV leaflet Reduced slope suggestive of decreased LV compliance

subjectively interpret

reduced slope and anterior movement of the posterior MV leaflet during diastole suggestive of MS

subjectively interpret

small PE on 2nd beat; insignificant PE for first beat

subjectively interpret

spongy anterior MV leaflet suggestive of vegetation of anterior leaflet

subjectively interpret

tachycardia with LVE or LVVO

subjectively interpret

NCC- no coronary artery RCC- right coronary artery LCC- left coronary artery

tell which coronary artery goes with each aortic cusp

RCC and NCC

the 2 aortic cusps seen in the PLAX view are what?

anterior wall of the aortic root

the IVS is continuous with _________

peak pressure is halved

the PHT is the time for what to occur?

mitral annulus

the __________ is an anatomically well-define fibrous structure, with an elliptical shape; it is the attachment between the mitral leaflets, left atrium, and left ventricle

flow

the continuity equation states what will be equal on both sides of a stenosis?

more

the deeper you go, the ______ time it takes

4(V)^2

the equation used to convert peak velocity to pressure difference is:

anterior MV leaflet

the posterior aortic root wall is continuous with ____________

pressure half time

the time it takes for the peak pressure to drop to half its original value

true

true/false: with a decreased, flatter slope you have decreased flow volume between the chambers

true

true/false: with an increased, steep slope you have a shorter PHT

15-25 mm/sec

unknown (gray) MS slope

V2

velocity where it pushes blood through aortic valve (1.5 to 2.2 m/s)

PHT- absent or <2mm a wave and flying W of PV in systole PS- A dip > 7 mm

what are the characteristic m-mode findings for pulmonary hypertension and pulmonic stenosis

ASH; IVSH

what besides SAM?

RVVO and LVVO combined

what causes flat septal motion

RVVO

what causes paradoxical septal motion

white

what color is high amplitude?

black

what color is low amplitude?

depth gain compensation

what does DGC stand for?

hockey stick of anterior MV leaflet

what does MS look like on 2d

hat or plateau with anterior movement of the posterior MV leaflet

what does MS look like on m-mode

time depth compensation

what does TGC stand for?

pressure half time

what equation is best used to measure the CSA of a stenotic MV?

LV dysfunction

what is EPSS greater than 1 cm suggestive of for MV

IAS and IVS IVC and hepatics

what is ideal to look at in subcostal views?

time

what is measured by the x axis on m-mode?

brightness

what is measured by the z axis on m-mode?

depth

what is measured on the y axis on m-mode?

LA

what is posterior to the aortic root in m-mode?

IVC should collapse with inspiration; sniff test

what is supposed to happen to the IVC with inspiration? if you are having trouble seeing this happen, what trick can you use to help?

220/PHT

what is the MVA equation?

190/PHT

what is the TVA equation?

eccentricity of closure line of aortic valve

what is the classic finding on a M-mode for a bicuspid aortic valve?

one is a velocity and one is a time?

what is the difference between the VPHT and the PHT?

in apical long axis, the LV apex is seen

what is the difference between the apical long axis and PLAX view?

.785 x diameter^2

what is the formula for CSA?

high temporal resolution

what is the hallmark of M-mode?

12 o'clock

what is the indicator orientation of suprasternal long?

3 o'clock

what is the indicator orientation of suprasternal short?

uniform brightness throughout the picutre

what is the main goal of adjusting TGCs?

RV

what is the most anterior chamber in the PLAX view?

myxoma (usually left atrial)

what is the most common atrial mass?

posterior MV leaflet

what is the most common mitral valve leaflet to prolapse?

2D imaging

what is the preferred method to detect loculated PE

TEE

what modality is used to best visualize the left atrial appendage

systole- triangular diastole- peace sign

what shapes do you see in PSAX for systole and diastole of the aortic valve

systole- crescent shaped diastole- football shaped

what shapes do you see in PSAX for systole and diastole of the mitral valve?

RPA

what structure is seen posterior to the aortic arch in the suprasternal long axis view?

anterior and posterior leaflets

what two mitral valve leaflets are seen in the PLAX?

VTI and Velocity

what two values could you use CSA in the continuity equation?

LVOT VTI

what value do you use along with LVOT CSA to calculate the SV?

if walls in diastole are >1.5

when does systolic thickening equation fail?

QRS to end of T wave

when is systole on the ECG?

top ones

when setting TGC gains, which slidepots are set low?

lower ones

when setting TGC slidepots, which ones are set higher?

narrowed

when velocity is increased in valves, valves may be ___________

increase

when you ________ the depth, you decrease the frequency

L/min

when you calculate the CO, what are the units in your answer?

1.4

when you calculate the PHT what number do you divide the peak velocity by to obtain the V PHT?

increase time resolution

when you decrease the sector width you:

decrease

when you increase the frequency, you _______ the penetration

increased line density

when you narrow the sector width what could increase your resolution?

increase

when you scan a stenosis, what should you do to the PRF scale?

it is doubled

when you use harmonics, what happens to the frequency of the returned signal to the transducer?

12-1 o'clock

where should your indicator be for IVC short axis?

3 o'clock

where should your indicator be for subcostal long?

12 o'clock

where should your indicator be for subcostal short?

AV cusp insertion points 1 mm back in systole

where/when is the diameter of the LVOT measured?

anterior

which MV leaflet is the longest?

RCC- anterior NCC-posterior

which cusps are seen anterior and posterior on aortic valve 2D PLAX and M-mode

higher

with _______ frequency, it goes shallower and has a clearer image

lower

with ________ frequency, it goes deeper but not as clear of image

double

with harmonics, you get ______ the frequency back that you send

color

with what modality do we most use our sector width control?

immobile anterior leaflet

< 1 cm MV excursion

inverse

frequency and penetration are _______ to each other

7 to 7.5

frequency of transducer for a newborn

2.0 to 2.5

frequency of transducer for a thick chested individual

3.5 or even a 5

frequency of transducer for a thin adult

3.5 or even a 5

frequency of transducer for a young child

extra bump between a and c indicative of increased LVEDP

B point on MV m-mode

from four chamber view, rotate transducer counterclockwise until indicator is at approximately 12 o'clock

give orientation for apical 2 chamber

300-500 cc 1.5 to 3.0 cm at diastole

high end moderate PE criteria

beginning of diastole just before valve opens

D point on MV m-mode

high V2

high pressure in LV and lower pressure in aorta

stenosis

high velocity typically means _______

normal TAPSE

subjectively interpret

paradoxical septum

subjectively interpret

maintaining same position as apical 2, continue rotating counterclockwise until transducer orientation is at about 10 or 11 o'clock

give orientation for apical 3 chamber

transducer lateral to left breast at 3 o'clock; from 4 chamber, angle the transducer anteriorly to open up the aorta

give orientation for apical five chamber

atrial contraction

A point on MV m-mode

IVSd/LVPWd greater than or equal to 1.3 cm

ASH criteria

closure of the MV and beginning of systole

C point on MV m-mode

maximal excursion of the valve

E point on MV m-mode

point to which the valve had closed following the passive filling phase

F point on MV m-mode

rotating the transducer between long and short axis views to ensure a true short axis measurement

How do you ensure that you are measuring perpendicular to the long axis when doing m-mode?

4(3)^2 = 36 100+36 = 136

If a patients BP is 100/60 mmHg and their aortic velocity is 3 m/s what is the pressure in the LV?

PV and RVOT VTI

If you were calculating the PV CSA what would you substitue for LVOT VTI and AV VTI values?

velocity 1

LV velocity

apex and then posterior, lateral, medial, anterior

PE collect most where?

loculated PE

PE fluid penned into a particular area; it can be rheumatic or caused by TB; the epicardium and pericardium are stuck together and therefore you can get loculated PE.

horizontal bands

TGCs alter the amplitude/strength of an image by altering the gain on a 2D picture by:

3 o'clock with transducer pointing towards patient's right shoulder; lateral to left breast

give orientation for apical four chamber

55-70 mm/sec

gray area MV slope

20-30%

gray area systolic thickening

dropout

absence of reflected signal

increase

as velocity increases, the pressure differences between chambers will ________

stenosis

as velocity really increases on a spectral trace through a valve, we most suspect?

end systole, end of T wave, because it is fullest then

at what point in the cardiac cycle do you measure the LA for 2D measurements? why?

early systole right when the cusps open because that is when the cusps are the most open

at what point in the cardiac cycle do you measure the aortic cusp opening for 2D measurements? why?

end diastole, Q wave, because it is perpendicular and clear to measure

at what point in the cardiac cycle do you measure the aortic root for 2D measures? Why?

2.5 to 3.5

average patient transducer frequency

AI MR VSDs

causes of LVVO

ASD with L to R shunt PR TR

causes of RVVO

LVPW or IVS greater than 1.5 cm at diastole

define gross hypertrophy

separation of the 2 ply walls dilated aortic roots greater than 5 cm dissected wall must be thicker than 1/2 mm to be picked up by ultrasound

describe aortic dissection on 2D and M-mode

hyperkinetic

describe septal motion

systole- aortic root moves anteriorly diastole- aortic root moves posteriorly

describe the movement of the aortic root in systole and diastole

systole- aortic root should move anteriorly diastole- aortic root should move posteriorly

describe the movement of the aortic root in systole and diastole

flat septal motion

describe the septal motion

paradoxical septal motion

describe the septal motion

C-chambers PE W- wall thickness TH-thickening EF-ejection fraction ASH WM- wall motion

explain how CoPE WiTH ElFs, ASHes, and WorMs can help you when interpreting LV M-modes

SL- slope E- Excursion EP-EPSS

explain how SLEEP can assist you when interpreting MV m-modes

mobile anterior leaflet

greater than 1 cm MV excursion

flat

no septal motion; it appears flat throughout diastole and systole

greater than or equal to 28%

normal EF

< 1 cm

normal EPSS of MV

normally ≤ 1.2 cm

normal IVS measurement

1.9 to 4.0 cm

normal LA measurements

3.5 to 5.7 cm

normal LV measurement

normally ≤ 1.2 cm

normal LVPW measurement

>70 mm/sec

normal MV slope

0.9 to 2.6 cm

normal RV measurement

1.5 to 2.6 cm

normal aortic cusp separation measurements

>.5 cm

normal aortic excursion measurement

2.0-3.7 cm

normal aortic root measurements

>30%

normal systolic thickening of IVS and LVPW

less than 30 cc 0 cm at diastole

normal/insignificant PE criteria

RA; LA

normally the IAS bulges toward _______; in RAE it bulges toward the ___________

Fo

not always present but lies between E and F if it is present on MV m-mode; the slope between the E and F points are not necessarily straight, and occasionally an Fo is indicated where a break in the diastolic E to F slope occurs

RCC and NCC

on aortic m-mode, what cusps are seen?

pressure gradient

pressure difference between two chambers

<28 %

reduced EF

<55 mm/sec

reduced MV slope

<20%

reduced systolic thickening

hyperdynamic (hyperkinetic)

septum pulls down extra hard and septal motion in systole is accentuated

<15 mm/sec

severe MS slope

4(velocity m/s)^2

simplified bernoulli equation

30-100cc <.5 cm at diastole

small PE criteria

High End Moderate PE

subjectively interpret

SAM of MV suggestive of IHSS

subjectively interpret

b-notching suggestive of increased LVEDP

subjectively interpret

concentric hypertrophy

subjectively interpret

echoes within the MV area during diastole suggestive of LA clot or mass holosystolic posterior bileaflet MV bowing during systole suggestive of holosystolic MVP

subjectively interpret

fluttering of the anterior MV leaflet may be suggestive of AI

subjectively interpret

multiple a kicks suggestive of atrial flutter

subjectively interpret

normal

subjectively interpret


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