DMS 204- Week 3-7 LOs
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
