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Gravity
Key Concepts:
Terms in this set (175)
<5.9cm male, <5.3cm female
Normal LVIDd size (cm)
>6.9cm male, >6.2cm female
Severely dilated LVIDd size (cm)
Normal <1.2cm, severe hypertrophy >2cm
Normal and severe LV wall thickness measurements (cm)
<200g male, <150g female
Normal LV mass (g)
<7mm
Normal EPSS
<3.1cm/m2 male, <3.2cm/m2 female
Normal LVIDd/BSA (cm/m2)
>3.8cm/m2 male, >3.7cm/m2 female
Severely dilated LVIDd/BSA (cm/m2)
1.2cm. <0.8cm severely reduced. Accounts for 30% LV function.
Normal MAPSE
18-22cm, trace VTI LVOT
Normal stroke distance and how measured
Measure LVOT. LVOT VTI trace.
Machine calculated cross sectional area — 0.75 x (LVOT diam)2.
SV = CSA LVOT x VTI LVOT
SV equation and how to measure.
>1200mmHg
Normal dP/dt
<800mmHg
Severely abnormal dP/dt
MR in A4C, measure CW between 1m/s and 3m/s.
At 1m/s PG will be 4mmHg (Bernoulli = gradient = 4x V2).
At 3m/s PG will be 36.
Therefore change in gradient is 36-4=32.
dP/dt in mmHg/s is therefore 32/time interval (s)
Inaccurate if acute MR or increased after load (AS/Htn)
How to calculate dP/dt
>25%
Normal FS
<15%
Severely abnormal FS
<0.4
Normal Tei index
67-155ml
Normal diastolic LV volume (Male)
35-75ml/m2
Normal diastolic LV volume index (male)
56-104ml/m2
Normal diastolic LV volume (female)
25-75ml/m2
Normal diastolic LV volume index (female)
22-58ml
Normal systolic LV volume (male)
19-49ml
Normal systolic LV volume (female)
12-30ml/m2
Normal systolic LV volume index (male)
12-30ml/m2
Normal systolic LV volume index (female)
>83ml
Severe systolic LV volume (male)
>70ml
Severe systolic LV volume (female)
>202
Severe diastolic LV volume (male)
>131ml
Severe diastolic LV volume (female)
>43ml/m2
Severe systolic LV volume index
>97ml/m2
Severe diastolic LV volume index
Normal <4.0cm
Severe >5.3cm
Normal and severe LA diameter (male)
Normal <3.8cm
Severe >4.7
Normal and severe LA diameter (female)
Normal <2.3
Severe >3.0
Normal and severe LA diameter index
Normal <58
Severe >79
Normal and severe LA volume (male)
Normal <52
Severe >73
Normal and severe LA volume (female)
Normal <28
Severe >40
Normal and severe LA volume index
Basal >4.2cm
Mid >3.5cm
Base to apex length >8.6cm
Dilated RV dimensions
AV level >3.5Cm
PV annulus >2.7cm
Dilated RVOT diameters
>2.2cm
Dilated MPA diameter
Diastolic - >25cm2
Systolic - >14cm2
Dilated RV systolic and diastolic areas
IVC size <1.5cm
Resp collapse
Normal RA/hep vein size
RAP 0-5mmHg
Size 1.5-2.5cm
Resp <50%
RA/hep normal
RAP 5-10mmHg
SIze 1.5-2.5cm
Resp <50%
RA size increased.
RAP 10-15mmHg
Size >2.5cm
Resp <50%
V large IVC
Large hep vein
RAP 15-20mmHg
Size >2.5cm
No resp variation
V enlarged RA and hep vein size.
RAP >20mmHg
PV >4m/s
Mean pressure drop >40mmHg
AVA <1.0 cm2
Velocity ratio <0.25m/s
Severe AS
PV <2.9m/s
Mean pressure drop <25mmHg
AVA 1.5-2.0
Velocity ratio >0.5cm2
Mild AS
VC >0.6cm
Jet width/LVOT diameter >65%
Regurg volume >60ml/beat
Regurg fraction >50ml/beat
Regurg orifice area >0.3cm2
VTI diastolic flow reversal 15cm
P half time <250ms
Severe AR
P half time >219s
Mean pressure drop >10mmHg
MVA <1.0cm2
Severe MS
Jet area/LA >40%
VC >0.7cm
PISA radius (nyquist 40) >1.0cm
Regurg vol >60ml
Regurg fraction >50%
Regurg orifice area >0.40
Severe MR
Jet size wide/large
Regurg fraction >60%
CW density/decel dense/steel
RVOTvti/LVOTvti high
Severe PR
Peak velocity >4m/s
Peak PG >75mmHg
Severe PS
Mean pressure drop >5mmHg
Inflow VTI >60cm
Valve area <1.0cm2
Severe TS
Jet area >10cm2
VC >0.7cm
PISA radius >0.9cm
CW dense, triangular
RA/IVC dilated
Reverse hepatic systolic flow
Severe TR
From base - basal inferoseptal, mid inferoseptal, apical septal, apical cap
Segments left of screen A4C
From base - basal anterolateral, mid anterolateral, apical lateral, apical cap
Segments right of screen A4C
From base - basal inferior, mid inferior, apical inferior, apical cap
Segments left of screen A2C
From base - basal anterior, mid anterior, apical anterior, apical cap
Segments right of screen A2C
From base - basal inferolateral, mid inferolateral, apical lateral, apical cap
Segments left of screen A3C
From base - basal anteroseptal, mid anteroseptal, apical anterior, apical cap.
Segments right of screen A3C
Basal anterior and anteroseptal, mid anterior and anteroseptal, apical anterior and septal and apical cap.
LAD segments
Basal inferoseptal and inferior, mid inferoseptal and inferior and apical inferior.
RCA segments
Basal anterolateral and inferolateral, mid anterolateral and inferolateral and apical lateral.
Cx segments
From base - basal inferoseptal (RCA), mid inferoseptal (RCA), apical septal (LAD). (+ apical cap LAD)
A4C - three LV segments left of screen & coronary artery supply
Basal anterolateral (Cx), mid anterolateral (Cx) and apical lateral (Cx)
A4C - three LV segments right of screen & coronary artery supply
Basal anterior (LAD), mid anterior (LAD), apical anterior (LAD)
A2C - three segments right of screen & coronary artery supply
Basal inferior (RCA), mid inferior (RCA), apical inferior (RCA).
A2C - three segments left of screen & coronary artery supply
Basal inferolateral (Cx), mid inferolateral (Cx) and apical lateral (Cx)
A3C - three segments on left of screen & coronary artery supply
Basal inferolateral (Cx), mid inferolateral (cx) and apical lateral (Cx)
PLAX - three segments at bottom of screen & coronary artery supply
Basal anteroseptal (LAD), mid anteroseptal (LAD) and apical anterior (LAD)
A3C - three segments on right of screen & coronary artery supply
Basal anteroseptal (LAD0, mid anteroseptal (LAD) and apical anterior (LAD)
PLAX - three septal segments & coronary artery supply
150-200ms
Normal E wave deceleration time
Septal <8
Lateral <10
Normal septal and lateral E/e'
<0.35m/s
Normal PVa
<0.65
Abnormal pulmonary vein S/D
1/100
Incidence of bicuspid AV
AVA x AV VTI = LVOT area x LVOT VTI
To so calculate:
3.14xLVOTdiam^2/4 x LVOT VTI / AV VTI
Continuity equation and how to calculate AVA from routine measures
3.14 x diameter ^2 / 4
OR
0.785 x diameter ^2 (probably easier).
Calculate CSA from diameter
Vmax >4.0m/s
Ppeak >65mmHg
Pmean >40mmHg
AVA <1.0cm2
Indexed AVA <0.6cm2/m2
DI <0.25
Waveform shape - arch
Severe AV stenosis
Vmax 2.6-2.9m/s
Ppeak <40mmHg
Pmean <20mmHg
AVA 1.5-2.0cm2
iAVA >0.85cm2/m2
DI >0.5
Waveform dagger shaped
Mild AV stenosis
LVOT VTI/AV VTI
Calculation of dimensionless index
Bernoulli equation
Gradient = 4 x (V2^2 - V1^2)
Where V1 is proximal to stenosis and V2 is distal
Can simplify and remove V1 if prox flow <1m/s
Measurement of pressure gradient
Nyquist limit = 0.5 x PRF
Nyquist limit equation
>20kHz
Ultrasound frequency
20Hz to 20,000Hz (kHz)
Audible sound frequency
1 million Hz
1 MHz in hertz
Velocity = frequency x wavelength
Velocity equation
Distance = speed x time
Distance equation
1540m/s
Average propagation velocity for the heart
330 m/s
Average propagation velocity for air
3500m/s
Average propagation velocity for bone
Velocity = frequency x wavelength.
Propagation velocity in tissue is fixed.
Reducing frequency will therefore lengthen wavelength
How to lengthen ultrasound wavelength
Transducer frequency and pulse length - higher frequency & shorter pulse length improves axial resolution.
What determines axial resolution
Distance from transducer - further away, less lateral resolution.
Narrower beam = better lateral resolution (Affected by focus)
Higher gain will reduce lateral resolution.
What determines lateral resolution
CSA x VTI
Flow volume equation
VC >0.6cm
Jet width/LVOT diameter >65%
P1/2T <200m/s
EDV >20
Dense CW signal
Holodiastolic flow reversal
LV dilatation +/- hypertrophy
Severe AR
VC <0.3cm
Jet/LVOT diameter <25%
P1/2T >500m/s
Incomplete CW signal.
Minimal diastolic flow reversal.
Mild AR
(PISA area x aliasing velocity) / MR peak velocity
Calculation of PISA area by radius measured = 2πR^2
Calculation of MR EROA
Regurg flow = 2π x r^2 x aliasing velocity
Calculation of MR regurgitant flow
Mild - <0.2
Severe - >0.4
Mild and severe MR EROA
Jet area >10cm2 or >40% LA area
VC >0.7cm
PISA radius >1cm
EROA >0.4
PV systolic reversal
Mitral inflow E wave >1.2m/s
CW trace dense and triangular
LV/LA enlarged
Severe MR
Jet are <4cm2 or <20% LA
VC <0.3cm
PISA radius <0.4cm (or none)
Normal PV flow (systolic dominant)
A-wave dominant mitral inflow
Soft parabolic CW trace
LV & LA normal (if chronic)
Mild MR
MVA (cm^2) = 220 / p1/2t (m/s)
How to measure MV area using pressure 1/2 time
pressure gradient = 4 x velocity ^2
Measure peak MV pressure gradient
MVA <1.0cm2
MV p1/2t >220
Pmean >10mmHg
TR velocity >3m/s
PAP >50mmHg
Severe MV stenosis
MVA 2.2-1.5cm2
P1/2t 100-150m/s
Pmean <5mmHg
TR velocity <2.7m/s
PAP <30mmHg
Mild MV stenosis
4-6cm2 with no measurable gradient.
Normal MV area
Pmax >75mmHg
Max velocity >4m/s
Severe PS
Pmax <40mmHg
Mild <3m/s
Mild PS
Pmean >5mmHg
TVA <1.0cm2
PHT >190m/s
Inflow VTI >60cm
Enlarged RA
Dilated IVC
Severe TS
TVA = 190 / tricuspid p1/2t
Calculate TVA
High estimated PASP
PLAX - RV:LV diastolic ratio >0.5:1
RVOT acceleration time <105m/s
Eccentricity index >1
TR Vmax >2.6m/s
TAPSE <1.5cm
IVRT >75ms
RVS' <12cm/s
RV MPI >0.32
RA >33ml/m2 (m)/>27ml/m2 (f)
Features suggestive of PHT
>20% fluid responsive
15-20% unclear
>20% fluid responsive
Caution if high intra-abdominal pressure, high vT/PAP or RH disease.
In a patient with no respiratory effort, ICVd variability index of what values suggest fluid responsiveness.
Measured <9cm2
Indexed <5.5cm2/BSA
What LVEDA suggests frank hypovolaemia (measured and indexed)
M<4.2cm, F<3.9
Indexed <2.2cm/BSA
Caution if pre-existing heart disease or LVH
What LVIDd suggests frank hypovolaemia (m/f, measured and indexed)
>15% fluid responsive
10-15% unclear
<10% NFR.
Caution if high vT/PAP, arrhythmia or LV impairment.
In mechanically ventilated patients with no resp effort, what VTI variation suggests fluid responsiveness.
>12% fluid responsive
8-12% not clear
<8% NFR
Caution if pain in position change, high dose pressers, high intra-abdominal pressure.
What VTI increment with PLR suggests fluid responsiveness
10-15% increase in CO 15-30m following delivery of a 500ml fluid bolus
Definition of fluid responsiveness
SVR = 80 x (MAP - RAP) / CO
MAP from BP, RA pressure from CVC/IVC.
Normal range 800-1200 dyne.s/cm5
How to measure SVR from echo. Normal range.
1.24 x (E/e') + 1.9
How to measure LVEDP
EDA - ESA / EDA x 100
How to measure LV fractional area change
IVCT + IVRT / ET
How to measure MPI
Tei index (most preload independent)
DP/dT (relatively)
Visual eyeball
Which LV ventricular performance measures are most load independent
BSE (m2) = Sq/ height (cm) x weight (kg) / 3600
How to calculate BSA
32 / time interval (s)
Calculation of dP/dt in mmHg
Isovolumetric relaxation - energy dependent prior to opening of MV
Early filling - passive. Accounts for 80%
Diastasis - equalisation of LA and LV pressure.
Atrial systole - 10-20%.
Four phases of diastolic function
Average E/e' >13
Average E/e' 8-13 + other parameters:
- Enlarged LA
- IAS bowing towards RA
- E/A >2
- E decel time <100ms
- PV S/D <0.65
Features suggesting raised LVEDP
Septal leaflet adjacent to septum
Anterior leaflet adjacent to RV free wall
Label the leaflets
Posterior leaflet adjacent to RV free wall
Leaflet adjacent to aorta is roughly split 50/50 between septal and anterior leaflet
Label the leaflets
Anterior towards probe
Posterior by septum.
If imaging and seeing the septum - may be the septal leaflet.
Label the leaflets
>2cm
>500ml
Depth and volume of large pericardial effusion
0.5 - 1cm
100 - 250ml
Depth and volume of small pericardial effusion
RA diastolic collapse
RV diastolic collapse
IVS shift towards LV
LA and LV last chambers to show diastolic collapse
Swinging heart.
Progression of tamponade echo features
>40%
<30% is normal
Abnormal TV inflow variability in tamponade
>25%
<20% is normal.
Abnormal MV inflow variability in tamponade
Thickened pericardium
Mild-moderate atrial enlargement
TV and MV E wave respiratory variation >25%
Ventricular septal bounce on insp.
Abrupt early diastolic motion
Features of pericardial constriction
Normal pericardium (vs constriction)
Moderate to severe atrial enlargement.
TV and MV E wave respiratory variation <15%
Normal septal motion.
Restrictive diastolic pattern.
Impaired long axis function
LVH with small LV cavity
Normal EF (by SV is actually low)
Features of restrictive cardiomyopathy
Apical Septal - LAD
Segment 1 + supply
Mid inferoseptal - RCA
Segment 2 + supply
Basal inferoseptal - RCA
Segment 3 + supply
Apical lateral - Cx
Segment 4 + supply
Mid anterolateral - Cx
Segment 5 + supply
Basal anterolateral - Cx
Segment 6 + supply
Apical interior - RCA
Segment 1 + supply
Mid inferior - RCA
Segment 2 + supply
Basal inferior - RCA
Segment 3 + supply
Apical anterior - LAD
Segment 4 + supply
Mid anterior - LAD
Segment 5 + supply
Basal anterior - LAD
Segment 6 + supply
Apical lateral - Cx
Segment 1 + supply
Mid inferolateral - Cx
Segment 2 + supply
Basal inferolateral - Cx
Segment 3 + supply
Apical anterior - LAD
Segment 4 + supply
Mid anteroseptal - LAD
Segment 5 + supply
Basal anteroseptal - LAD
Segment 6 + supply
>0.4
Abnormal right heart pulsed doppler MPI
>0.55
Abnormal right heart tissue doppler MPI
Ratio of RV SV to LV SV
RV SV - measure RVOT at PV and PW VTI
LV SV - measure LVOT (PLAX) and PW VTI (A5C)
How to measure shunt fraction
For PE
PAT of <60ms with PASP <60mmHg.
Can be ~94% specific for PE.
Describe the 60-60 sign
Regional RV dysfunction with apical sparing.
Commonly associated with PE.
Not specific - has been associated with regional RV infarction.
Describe McConnell's sign
>25%
What percentage of pulmonary tree obstruction will tend to result in acute cor pulmonale?
ΔP=4V2
Bernoulli Equation
EF(%) = (SV / EDV) × 100%
Ejection fraction equation
PAPsystolic = 4(VTR)2 + RAP
Pulmonary artery systolic pressure equation
PAPsystolic = [4(VTR)2 + RAP] - ΔPRV−PA
PASP equation when PS present
PAPdiastolic = 4 (VPR)2 + RAP
Diastolic PA pressure
PVR ≈ 10(VTR) / VTIRVOT
Calculate PVR
2.0 - 3.1cm
Normal aortic annulus diameter
2.9 - 4.5cm
Normal sinus of valsalva diameter
2.2 - 3.6cm
Normal sinotubular junction diameter
Time for LV ejection standardised against HR.
PW A5C, measure duration of forward flow in ms.
Formula FTc = FT + (1.29 x [HR-60])
LV corrected flow time & normal/abnormal measures
>0.27
<0.20 is normal
What MR Vmax/VTI suggests high SVR?
2.2 - 3.6cm
Normal ascending aorta and aortic arch diameters
2.0 - 3.0cm
Normal descending aorta diameter
Divide peak TR velocity by the RVOT VTI.
Normal value <0.15
How to rapidly estimate index of PVR
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