M-Mode/Doppler

Increased LV end-diastolic pressures

A B-notch on the mitral M-Mode is associated with: atrial fibrillation increased pulmonary pressures first degree AV block Increased LV end-diastolic pressures

Reversal in color

Aliasing on color flow Doppler is shown by a mosaic of color display of green reversal in color reversal in intensity

aortic

An M-mode of a mitral hemograft valve resembles an M-Mode of which valve?

Low cardiac output

An underestimation of severity of aortic stenosis by CW Doppler may occur with - High gain settings, low cardiac output, aortic regurgitation, increased cardiac output

LVOT obstruction(SAM)

Aortic valve mid systolic closure on M-Mode is due to what?

The posterior displacement of the mitral leaflets during systole. This displacement can be either holosystolic or mid-to-late systolic. The prolapsing leaflet should extend more than 2-3 mm below a line connecting the echocardiographic C-D points

Define mitral valve prolapse as documented by M-mode

It will show the valve's cage which is fixed in position within the left ventricular cavity. The ventricular side of the ball is easily visualized as it moves within the cage. The atrial side of the ball appears within the left atrium. This artifact is caused by a delay that occurs when the ultrasound beam crosses the gas-filled ball. The slowing of the ultrasound beam causes the "other side" of the ball to appear incorrectly postioned in the left atrium.

Describe the 2D echo appearance of a caged-ball mitral valve, as seen in the parasternal long-axis view.

Left ventricular hypertrophy(symmetric or asymmetric) A small left ventricular cavity Systolic anterior motion of the mitral valve(SAM)

Describe the M-Mode appearance of hypertrophic obstructive cardiomyopathy

Type A(involving preexcitation of the posterior left ventricular wall)=characterized by early systolic contraction(notching) of the posterior left ventricular wall Type B(involving the preexcitation of the anterior right ventricular wall)=Characterized by abnormal septal motion, such as posterior motion(notching) during early systole.

Describe the appearance of Wolff-Parkinson_White syndrome(WPW) on M-Mode

It will show flow on both sides of the ball. If flow is detected only on one side, a thrombus or vegetative mass should be suspected.

Describe the appearance of color flow through a normal mitral caged-ball valve.

Yes

Do all mechanical valve have regurgitation?

All prosthetic valves have a transvalvular gradient

Do all prosthetic valves have a transvalvular gradient?

Peak instantaneous

Doppler measures a pressure drop(gradient) by the Bernoulli equation, This equation actually measures the ________________gradient across the valve.

aortic regurgitation

Doppler ultrasound may show retrograde flow velocities within the ascending aorta during diastole in the presence of?

Positioning the transducer in too high an intercostal space.

False overriding of the aorta may be produced on the M-Mode by: using a transducer with too low a frequency failure to turn the patient into a left decubitus position positioning the transducer in too high an intercostal space positioning the transducer in too low an intercostal space

Normal

High frequency systolic vibrations of the aortic valve on M-Mode are most consistent with: Mitral MR low cardiac output aortic valve stenosis normal findings

Irregularity of the length of the diastolic filling periods Absence of A wave Fibrillatory waves on the mitral leaflet during diastole

How does Afib the mital valve on M-Mode?

If the contracta is >.7 cm this indicates severe regurgitation in mitral and tricuspid Severe aortic regurgitation is >,6cm

How is the vena contracta used in evaluation of the regurgitation?

The transducer should be placed above the valve, either in the suprasternal or the right supraclavicular window. This placement will allow the balls excursion and timing to be documented.

If the caged-ball valve were in the aortic position, where would you place the M-Mode?

26mmHg gradient= 4v2

If the patient has a CW Doppler of the mitral valve and it shows a peak diastolic velocity of 2m/s. What is the peak pressure gradient across the valve?

Vascular resistance is lower

In normal patients, why does the peak velocity of flow in the pulmonary artery occur later than the peak velocity in the aorta?

Mitral valve prolapse

In patients, with larger pericardial effusions, what can a false positive diagnosis on M-Mode

The transducer should be placed at the left ventricular apex, so that the full excursion of the ball can be documented as it moves into the open position. This view also allows evaluation of the balls timing.

In using M-Mode to evaluate the function of a caged-ball(Starr-Edwards) prosthetic mitral valve, where should you place the transducer?

Pulmonary hypertension

M-mode echo demonstration of a mid-systolic closure of the pulmonary valve along with a decreased "a" wave is consistent with: pulmonary hypertension, pulmonary insufficiency, valvular pulmonary stenosis, infundibular pulmonary stenosis

Perivalvular leakage Bioprosthetic stenosis/degeneration Valve dehiscence(coming loose)/strut failure Ring abcess Thrombus Endocarditis Hemolysis

Name five complications of prosthetic valve dysfunction.

A decreased E-F wave A decreased "E" wave amplitude Multiple reverberant echoes during diastole Anterior displacement of the posterior mitral leaflets

Name four classic M-Mode findings associated with mitral stenosis

Dilated left ventricle Increased E-point septal separation(EPSS) Hypocontractile left ventricular wall motion A B-notch on the mitral valve A double-diamond mitral valve(when the valve closes in mid-diastole) Decreased aortic root motion

Name six classic M-Mode findings associated with dilated cardiomyopathy

Diastolic fluttering of the aortic leaflet Diastolic fluttering of the interventricular septum Dilatation and hypercontractility of the left ventricle Mitral valve preclosure

Name three classis M-Mode findings associated with aortic regurgitation

An infected mitral valve

On M-Mode, a flail mitral valve may have a similar appearance to a cleft mitral valve a stenotic mitral valve an infected mitral valve a parachute mitral valve

Mitral regurgitation

Premature closure of the aortic valve on M-Mode is most consistent with

aortic insufficiency

Premature mitral valve closure on M-Mode is a sign of high left ventricular diastolic pressure in aortic stenosis aortic insufficiency mitral insufficiency 1st degree block

Right atrium

The A-dip in the M-mode of the pulmonary valve is caused by the contraction of the

Aortic insufficiency

The Doppler jet of mitral stenosis obtained at the apex is sometimes confused with AI, MR, PI, TI

Continuous wave

The Doppler utilized to determine peak velocity

Placing the transducer too high on the chest

The false appearance of mitral valve prolapse on M-Mode can be created by: placing the transducer too high on the chest placing the transducer too low on the chest failure to roll the patient on their side failure to demonstrate aortic-mitral continuity

To accurately determine the direction and velocity of blood flow, a group of ultrasound pulses is transmitted, received and compared with respect to phase shift. This group of pulses is called a pulse packet The larger the pulse packet, the more accurate the flow-related information.

What are pulse packet in color flow Doppler?

Mitral and tricuspid regurgitation A decreased early mitral inflow velocity(>25%) during inspiration and mitral inflow pattern similar to restrictive cardiomyopathy (large E wave, short A-wave)

What are the Doppler findings associated with constrictive pericarditis?

Normal unrestricted valve motion An echogenic "shaggy" mass on any leaflet seen in systole.

What are the classis M-Mode findings of mitral Valve/or aortic endocarditis?

Vena Contracta Size of the jet by color flow Flow into the pulmonary veins Convergence zone

What are the four components that make up an MR jet?

Peak gradient mmHg Mild <36 Moderate 35-64 Severe > 64

What are the guidelines for peak gradient for pulmonic stenosis?

Peak velocity: m/s mild < 3.0 Moderate 3.0-4.0 Severe >4.0

What are the guidelines for pulmonary stenosis severity with peak velocity ?

1.5-2 m/sec=velocity 3-7 mmHg mean gradient

What are the normal gradient and velocity for a mitral prosthetic valve? (generally)

Velocity=2-3m/sec 14-20 mmHg mean gradient

What are the normal gradient and velocity for aortic prosthetic valve?(generally)

Multiple reververant echos during systole and diastole. Decreased separation of the valve leaflets. Left ventricular hypertrophy

What are the primary M-Mode findings associated with aortic valvular disease?

Left Bundle Branch Block=early systolic posterior deflection of the IVS. Right Bundle Branch Block=normal septal depolarization and no abnormal septal motion is present.

What are typical M-Mode findings associated with bundle branch block?

In patients with pulmonary hypertension, the pulmonary artery pressure is so high that, even during atrial contraction, the pulmonic leaflets do not move.

What causes the absence of the "a" wave?

Pulmonary hypertension

What condition causes an absent "a" wave and/or mid-systolic closure of the pulmonic valve in M-Mode?

Increased left ventricular end-diastolic pressure Dilated cardiomyopathy

What does a B-Notch on the mitral valve on M-Mode represent? What condition would cause this?

Pulmonic stenosis Exaggerated "a" dip

What does this M-Mode represent?

mitral stenosis

What does this M-Mode represent?

mitral valve prolapse

What does this m-Mode represent?

Diastolic Mitral valve fluttering from aortic regurgitation.

What does this represent in M-Mode?

Atrial contraction=represents atrial systole

What is A?

Diastolic inflow

What is D?

Systolic inflow

What is S?

RV diastolic collapse due to pericardial effusion. Check respiratory variation in flow to assess for tamponade.

What is a M-Mode of?

Pulmonary hypertension

What is a flying W in M-Mode significant for?

Flattened posterior wall motion during diastole Abnormal septal motion(early diastolic bounce) Two parallel within the pericardium

What is the M-Mode findings associated with constrictive pericarditis?

Possible eccentric closure of cusps(off midline)

What is the M-mode finding of a bicuspid aortic valve?

M-Mode-to visualize maximum poppet/disc motion.

What is the best method to evaluation mechanical valve motion?

TEE

What is the best way to evaluation of vegetations or thrombi?

<170msec

What is the normal pressure-half time for a mitral prosthetic valve?

An increase of more than 7 mm in the "a" dip

What is the primary M-Mode finding with pulmonic stenosis?

They tend to mask adjacent structures, regurgitations.

What is the problems with evaluation of prosthetic valves?

This is calculating the pulmonary artery pressure. The pulmonary artery pressure will be the same as the right ventricular systolic pressure.

What is the significance of calculating the RVSP?

Subcostal short-axis

What other view could you Doppler the pulmonic valve(other than short axis)?

Peak gradient or Peak instantaneous (for AS it's the highest gradient anytime during systole)

What type of pressure is obtained during Doppler?

An increase in the pulmonic "a" dip of more than 7mm.

What will M-mode show with pulmonic stenosis?

Underestimate the velocity.-you did not get a clear Doppler signal.

When obtaining a CW Doppler aortic profile from the apex through a heavily calcified aortic valve, you may: overestimate the velocity, underestimate the velocity, confuse the jet with mitral inflow, confuse the jet with pulmonic stenosis.

Aliasing

When the velocity of blood flow exceeds the Doppler nyquist limit, the following occurs? damping, aliasing, mirroring, contouring

the patient has a low EF or moderate to severe AI. You should then use the VTI measurements.

When using the continuity equation for aortic valve area, when should you not use the peak velocities for V1 and V2?

Diastolic flutter of the aortic valve

Which M-Mode finding is considered to be a specific indicator of a fenestrated aortic valve?

Apical four chamber

Which is the best placement of the Doppler transducer for recording maximum velocities for recordings of flow across a bioprosthetic valve in the mitral position?

M-Mode. It has a much higher sampling rate(temporal resolution), so it can record subtle or rapid changes in wall or valve motion.

Which method is best in assessing wall and valve motion irregularities caused by arrhythmias and conduction disturbances?

Systolic flow reversal in the pulmonary veins. This indicates severe MR>

Which of the components of the mitral regurgitation jet will give you the greatest hemodynamic information for severity of the regurgitation?

Transducer frequency

Which of the following parameters is least likely to affect serial left ventricular dimension measurements on M-Mode respiration patient position transducer position transducer frequency

Pulse walve (the better choice), you can "map the regurgitation into the left ventricle

Which technique would best allow you to assess the severity of aortic regurgitation? PW Doppler, CW Doppler, M-Mode, 2-D

To differentiate pericardial from pleural effusion.

Why is an M-Mode sweep from the LV to aorta used with a pericardial effusion?

The vena contracta is the narrowest part of a color Doppler jet (for regurgitation)

what is the vena contracta?