Echo-A Exam 5 (Parts 1&2)

To accurately diagnose systemic hypertension, how many times should blood pressure be checked?

Blood pressure should be checked at least three times in a row, in order to rule out error.

What are the grades of diastolic dysfunction that are associated with systemic hypertension?

Grade 1, impaired early relaxation usually associated with early stages of systemic hypertension. Grade 3 and 4 , restrictive filling usually associated with long-standing and maybe poorly controlled systemic hypertension. Grade 2 usually the period in between.

What is the normal range for left ventricle mass in both male and female patients?

For male patients left ventricle Mass should be 96 to 200 grams. For female patients, it should be 66 to 150 grams.

Once we know the pressure gradient described above and the RAP, what do we do with these two numbers?

We need to add them together to get RVSP.

Give the maximum normal measurements for the aorta (ascending, Arch, and descending / abdominal). What value specifically is being measured?

For the ascending aorta the maximum is 4.0 cm. For the transverse aorta (the arch), the maximum is 3.5 cm. For the DTA as well as the abdominal aorta, the maximum is 3.0 cm. In all cases we are measuring diameter.

Who is a good candidate for heart transplantation?

A patient with dilated cardiomyopathy (the end stage of many heart diseases) and severe Global systolic and diastolic dysfunction.

How will this waveform change in the case of pulmonary hypertension? Describe why these two things happen.

Acceleration time will become shorter, and we may see a notch in the systolic flow also called mid systolic notching or "flying W". The acceleration time gets shorter because the right ventricle contracts with more Force (overcompensates) to overcome the distal resistance. This distal resistance also causes a dicrotic notch during outflow the "flying W".

List some possible etiologies for pulmonary hypertension.

An access of blood flowing through the pulmonary artery. Reduction in the caliber of the pulmonary vasculature (vasoconstriction) either: (A)Primary- unknown cause (B)Secondary- due to long-standing pulmonary congestion due to left heart failure.

What are the two most dangerous complications from an aneurysm (especially an aortic aneurysm)?

Aneurysms can rupture resulting in Hemorrhage, and thrombus formation there can embolize. These will travel distally and lead to complete obstruction of smaller arteries.

Give the normal range for both IVS and PWLV thickness. When in the cardiac cycle is this measured? How thick do these need to be in order to be called hypertrophic?

Both of these should be 0.6 to 1.0 cm in thickness, measured at end diastole. In order to be called hypertrophic, the wall needs to be at least 1.2 cm in thickness.

List six effects systemic hypertension can have on the heart.

Concentric left ventricular hypertrophy, mitral annulus calcification, left atrium enlargement, diastolic dysfunction, aortic root dilation, aortic valve sclerosis.

What are the signs of rejection in a transplanted heart?

Excessive hypertrophy, decreased systolic dysfunction, excessive pericardial effusion, restrictive filling pattern (diastolic dysfunction grades three or four), Excessive mitral or tricuspid regurgitation.

If pulmonary hypertension is due to a shunt (allowing direct flow between the two sides of the heart), what can eventually happen if the pulmonary hypertension becomes severe enough? What is the syndrome called? What symptom will it usually cause?

If pulmonary hypertension becomes severe enough, the pressure in the right side will become higher than the pressure in the left. Once this happens the shunt will reverse Direction (beginning flow from right to left). This is called Eisenmenger's syndrome, and it usually results in cyanosis.

Once we have this measurement from The Continuous wave Doppler waveform, what formula do we use to calculate the pressure gradient? Do we need to add any other number to obtain PAEDP?

PAEDP= 4×V2 PIEDV+RAP We add RAP to the end diastolic 🔺P to get PAEDP.

What is the normal range for MPAP? Do we classify higher numbers as mild, moderate, and severe pulmonary hypertension like we do for PASP?

MPAP is normally 9-18mmHg Anything over 18mmHg is considered hypertensive. We don't have classifications for mild, moderate, or severe with this measurement.

What does MPAP stand for? What valve event do we look at to estimate MPAP? Specifically, what do we measure?

MPAP stands for mean pulmonary artery pressure. We do continuous wave Doppler on the pulmonic valve during diastole, so there must be a pulmonic insufficiency or regurg. When we get the pulmonic insufficiency waveform (above the Baseline), we measure the highest velocity near the beginning of the wave.

What pressures (average) are considered normal for the pulmonary artery in both systole and diastole? For systole, at what pressure do we begin to diagnose pulmonary?

Normal pressure in the pulmonary artery is 25 mmHg during systole, and 10 mmHg during diastole. During systole, any pressure more than 35 mmHg in the pulmonary arteries is considered hypertensive.

The IVS normally thickens during systole (unless there is ischemia), and the entire wall (anterior and inferior septum all levels) moves toward which chamber? If It Moves towards the other chamber, what do we call this type of motion? What are some things which can cause this?

Normally the entire IVS moves towards the left ventricle during systole. If however it moves towards the right ventricle we call it paradoxical septal motion. This can occur as a result of the right ventricular volume overload (RVVO), often as a result of pulmonary hypertension. It also occurs in patients with left bundle branch block, constrictive pericarditis, and those who have recently had heart surgery (first 6 months).

From the apical 4-chamber view, how should the right ventricle look compared to the left ventricle in a normal patient? How might that change in a patient with significant pulmonary hypertension?

Normally the right ventricle is a bit smaller than the left ventricle and is shaped differently. While the left ventricle is bullet-shaped, the right ventricle is more triangular or cone-shaped. With significant pulmonary hypertension, the right ventricle may become dilated and look more like the left ventricle in size or even larger.

Describe the shape seen when we do M-mode on the pulmonic valve of a normal patient. What are the parts of the wave called? What changes as the patient develops more severe pulmonary hypertension?

Normally we see the valve cusps moving downward during systole, creating a large V shape. Just before this, the cusp should bounce down a little bit, creating what is called an "A" dip. As pulmonary hypertension gets more severe, this "A" dip will disappear. Also, we may see mid systolic closure of the pulmonic valve.

From the apical 4-chamber view, how should the right atrium look compared to the left atrium in a normal patient?

Normally, the right atrium and left atrium should be roughly equal in shape and size.

How many types of heart transplantation are there? Briefly describe each.

Orthotopic, the old heart is removed in the new heart is put in its place. Heterotopic, the new heart is placed next to the old heart and they work together.

What is the normal range for PAEDP? Do we classify higher numbers as mild, moderate, and severe pulmonary hypertension like we do for PASP?

PAEDP should be 4 to 12 mmHg, and again it's only the high number we really care about. Anything over 12 mmHg indicate increased pulmonary artery diastolic pressure and there is no mild, moderate, or severe for this measurement either.

What does PAEDP stand for? What valve event do we look at to estimate PAEDP? Specifically, what would we measure?

PAEDP stands for pulmonary artery end diastolic pressure. We looked at PI for this as well. For PAEDP, we measure the highest velocity at the end of diastole (before the waveform drops back down to the Baseline).

What's the difference between primary and secondary systemic hypertension? Which is more common (give the percentages)?

Primary hypertension is when there is no other disease or condition causing the blood pressure to rise. Often it is idiopathic. Secondary hypertension is caused by other conditions (such as renal disease or pheochromocytoma). primary hypertension is far more common, making up 90 to 95% of cases.

What is the difference between primary and secondary pulmonary hypertension?

Primary pulmonary hypertension is when there is no other underlying disease or condition. The problem is simply too much resistance in the pulmonary arteries due to pulmonary vasoconstriction. Secondary pulmonary hypertension can be due to COPD, left heart failure, or congenital defects, or thoracic cage and Neromuscular system abnormalities, and acute or chronic pulmonary thromboembolism

Finally once we have found PASP, what values are associated with upper normal, mild, moderate, severe, and critical pulmonary hypertension?

Upper normal PA systolic pressure: 30-34 mmHg Mild pulmonary hypertension: 35-44 mmHg Moderate pulmonary hypertension: 45-59 mmHg Severe pulmonary hypertension: 60-80 mmHg Critical pulmonary hypertension: >80 mmHg

What might cause pulmonary congestion (other than the volume overload described above)?

Pulmonary congestion if not due to extra blood coming in, is do to left heart failure. This creates a pressure and volume overload to the lungs, which then become congested and overtime leads to pulmonary vasoconstriction and pulmonary hypertension.

If left untreated, pulmonary hypertension can lead to which sided heart failure? What are some complications of this type of heart failure?

Pulmonary hypertension will eventually lead to right heart failure (due to the pressure overload). Once the right heart fails, the chambers will dialate (Now volume overload) and cause the vessels leading to the right heart to become congested. Eventually fluid will build up in the tissues (edema, ascites, spleno- and hepatomegaly, Etc.).

Pulmonary hypertension will first cause what to the right ventricle? After a brief period, the right ventricle will then begin to fail. What might we see once this happens? Specifically, how might the tricuspid valve be affected?

Pulmonary hypertension will first cause the right ventricle to hypertrophy (muscle becomes thick). The myocardium will fail and then The ventricle will dilate. If the wall of the right ventricle and the annulus of the tricuspid valve becomes too stretched, it will lead to functional tricuspid regurge.

Give the definition of pulse pressure. What formula is used to calculate it? What value on average is considered normal for pulse pressure?

Pulse pressure is the difference between systolic and diastolic pressures. So it's calculated by subtraction systolic minus diastolic. A normal pulse pressure is approximately 40 mmHg.

What does RAP stand for? Why do we need to estimate this?

RAP stands for right atrial pressure, and we need this in order to find RVSP. If we know the pressure gradient from Bernoulli, then we know how much higher the right ventricle is compared to the right atrium. So we need to know the RAP in order to add the pressure gradient to get the RVSP.

What are some possible symptoms of pulmonary hypertension?

Shortness of breath without activity, cough, fatigue, dizziness, chest pain or pressure, rapid heartbeat, swelling of the ankles legs and abdomen, cyanosis.

List five possible complications (not in the heart itself) from systemic hypertension and briefly describe each.

Stroke, when small arteries in the brain rupture. CAD, the coronary arteries are damaged. Renal failure, high pressure can damage kidneys. Aneurysm, distention, high pressure damages walls of arteries. Retinopathy, pressure damages to the retina of the eye.

Give the systemic systolic and diastolic blood pressure numbers which signal the beginning of systemic hypertension. What is the range (again both systolic and diastolic) for pre-hypertension?

Systemic hypertension is defined as any systolic pressure greater than 140 mmHg and any diastolic pressure greater than 90 mmHg. Prehypertension is systolic pressure 120 - 140 mmHg and diastolic pressure is 80-90 mmHg.

How does the Atria appear by echocardiogram in a patient with heart transplantation and why?

The Atria appears larger than normal because the base of the old heart is usually kept in place. The new heart is attached at the Atria, as so not to disturb the venous connections.

Give the definition of narrow pulse pressure, and the value associated with it.

The pulse pressure is considered abnormally low if it is less than 40 mmHg differences between systolic and diastolic pressure. The most common cause of a low narrow pulse pressure is a drop of ventricular stroke volume, as in congestive heart failure and/or shock, also aortic valve stenosis and cardiac tamponade.

If we do pulse wave Doppler on the mid cavity of hypertensive hypertrophic cardiomyopathy patient, what would the waveform look like (give two specific features)? Which view of the heart would we normally use to get this Doppler waveform?

The waveform will be both late picking, dagger shaped (meaning it takes longer to accelerate the normal and systole) and high velocity (due to the narrowing of the mid cavity). Apical 4 chamber View.

List some medications used to help reduce the systemic hypertension.

These include beta blockers, calcium blockers, ACE inhibitors, diuretics, and vasodilators.

List some Lifestyle Changes which can help reduce systemic hypertension.

These include reducing alcohol consumption, quitting smoking, reducing caffeine consumption, reducing mental stress, maintaining a healthy weight, reducing salt intake.

List some symptoms associated with hypertensive crisis.

These include severe headache, bleeding from the nose, dyspnea and palpitations.

List some possible symptoms of systemic hypertension. Are symptoms always present?

These include tinnitus (a ringing in the ears), dyspnea, palpitations, headache, dizziness and pallor. However sometimes there are no symptoms.

Define hypertensive crisis. What medication is usually given to control it? What danger is associated with this medication if not administered properly?

This is systolic blood pressure systemic of over 240 mmHg or diastolic blood pressure of > 120 mmHg. The drug nitroprusside is given to control this, but it needs to be administered slowly. If not the blood pressure will drop rapidly, and is dangerous for the patient.

Why might there be a volume overload in the pulmonary arteries?

This is usually due to a shunt, where blood flows directly from the left side of the heart to the right. This results in an imbalance of stroke volume (more out of the right side than the left). These shunts are either septal defects (ASD, VSD) or a patient ductus arteriosus.

What effects does concentric left ventricular hypertrophy usually have on ejection fraction?

This will usually cause ejection fraction to increase in the early stages and the systolic cavity gets smaller.

How can we calculate an indexed left ventricle Mass? What is the normal range for index left ventricle mass in both male and female patients?

To calculate indexed mass, divide the actual mass by body surface area. For male patients, indexed left ventricle Mass should be 50-102 grams per square meter. for female patients, it should be 44 to 88 grams per square meter.

To measure this other pressure, we must first obtain a pressure gradient between which two Chambers? When in the cardiac cycle is this done? What valve condition must be present in order for us to get this pressure gradient?

To measure RVSP, we must obtain the pressure gradient (🔺P) between right ventricle and right atrium during systole. This is possible if the patient has tricuspid regurgitation.

In order to calculate pulmonary artery systolic pressure (PASP), we assume that it is equal to another pressure which we can measure. What is this other pressure? When would this other pressure not be equal to PASP?

We assume PASP is equal to right ventricle systolic pressure (RVSP). This is because the pulmonic valve should be wide open during systole, not allowing significant pressure gradient to remain between these two spaces (RV and MPA). If however the patient has RVOT obstruction or pulmonic stenosis (PS), then there would be a pressure gradient there. This would mean that PASP and RVSP are not equal.

List some echocardiography views or "Windows" for examining the main pulmonary artery.

We can see the main pulmonary artery from the following views: PSAX- aortic valve level RVOT Subcostal SAX aortic valve level We can also see the right pulmonary artery in transverse from the suprasternal notch View.

What two things do we assess in order to estimate RAP? Give the criteria used for estimating for different values for RAP.

We look at the IVC and access two things about it: Diameter (measured with calipers) Collapseability (using sniff test) if both are completely normal, then RAP = 3 mmHg. If one or the other is a little off, then RAP = 8 mmHg. If both are clearly abnormal, then RAP = 15 mmHg. If both are clearly abnormal and no collapse at all with sniff, then RAP is > or = 20 mmHg.

We can estimate PAP by looking at the pulse wave Doppler waveform of the RVOT flow. When in the cardiac cycle is this measured? Specifically what part of the waveform do we measure? What is considered normal for this measurement?

We need to look at pulmonary valve flow during systole below the bassline (normal direction outflow). We measure the acceleration time of the wave, which is the duration from the beginning (Baseline) to the peak.

In order to calculate left ventricle Mass, we need to measure which volume? Describe how this can be done.

We need to measure the volume of the left ventricle walls (not the chamber). We do this by first getting an area and cross-section (outer ring area-inner ring area to get area of walls). We then measure the length of the left ventricle (from apical 4 chamber) and multiply this area to get the volume.

Describe the procedure to obtain this pressure gradient.

We use continuous wave Doppler to get the peak velocity of the tricuspid regurg. This flow is away from the transducer, so it will show below the bassline (there for move Baseline up to make room for the waveform). Using the calc package, measure the peak velocity of the tricuspid regurge waveform. The machine will then do the math and give the pressure gradient.

Which formula is used to obtain this pressure gradient? Give the simplified version of this formula.

We use the simplified Bernoulli formula, which is: 🔺P=4×V2

Give the definition of wide pulse pressure in the value associated with it. What disease or condition often causes wide pulse pressure? Explain why.

Wide pulse pressure is when there is too large of a difference between systolic and diastolic pressures. This would be any pulse pressure greater than 60 mmHg. One common cause of wide pulse pressure is aortic insufficiency (regurge). During systolic blood pressure is normal. During diastole however the Artic valve leaks so the pressure in the aorta drops abnormally low and blood will not be forced into the coronary arteries.

Once we have this measurement from The Continuous wave Doppler waveform, what formula do we use to calculate the pressure gradient? Do we need to add any other number to obtain MPAP?

we use the simplified Bernoulli formula to get the pressure gradient. This pressure gradient is the difference in pressure between PA and RV in early diastole. Yes we need to add RAP to the 🔺P. MPAP = 4×V2 PIPDV+RAP