Cardiac Imaging Teaching Files
The CardioPhiles
Topics 10-2013
Stage of diastolic function? nl LVEF with LAE; e/e' 10
​​
At rest Fig.1
Valsalva Fig 2.
Valsalva reduced LA pressure and converted a pseudonormal pattern into a impaired relaxation pattern thus helping with assessment of diastolic dysfunction stage.
Hold for 12 seconds if possible.
Adequate Valsalva decrease e wave >= 20%.
Annotate in screen.
Diastolic Assessment
–Critical measurements:
•LA volume (ideally use area length method (normal values); Simpson’s provides lower LA volumes);
•LV function;
•Mitral inflow vel profile;
•If normal LVEF: TDI (if no significant MR/MAC/MVP or ring and diagnostic no further testing).
–LV filling use steep portion on transmitral PW flow (red); for MS pressure 1/2t use gradual portion (blue);
–Strain phase of Valsalva: Pseudonormal – Valsalva lowers LAP and unmasks imparied relax pattern. Adequate effort (good effort decrease e wave 20 cm/s)
–Technical TDI: turn down receiver gain to prevent blooming, Improper alignement (need parallel alignement), suspend respiration in end expiration.
–Obtain both e’ medial and lat; Increased LV filling if E/e av >13, medial >15, or lateral >12
–Afib – E/e’ reliable; Afl no assessment can be made from mitral inflow vel as all LV filling is influenced by atrial contraction à best indicator RVSP
Stress Echo – Diastolic Functional Assessment
Rest:
–LA vol
–TR vel
–e/e’
Peak:
–WM assessment first
–TR vel
–e/e’
Right Atril Pressure (RAP) – Memorial
RAP: IVC measurement with sniff test (OPTIONAL: M-mode of the IVC):
•IVC <= 2.1 cm, collapse >=50% (low RAP) = RAP 5 mmHg;
•IVC >2.1 cm, collapse >=50% or IVC <=2.1 without collapse (Normal RAP) = 10;
•IVC >2.1 cm, collapse < 50% (increased RAP) = 15;
•IVC >> 2.5 cm, minimal collapse, particularly if associated with severe TR + at least 20;
•Athletes/young pts may have dilated IVC with normal RAP;
•In mechanically ventilated patients it is difficult to determine use 10 as default; 5 mmHg in case IVC < 1.2 cm.
2013 Memorial Echo Conference
MR Quantification
1. BP rule: If MR <= mild do not use PISA unless, b/o eccentricity of the jet, there is an impression of more severe MR; if in doubt do it.
2. Significant (> mild MR) if flow convergence is seen with Nyquist 50-60.
3. Critical measurements:
a. Vena Contracta (VC): Independent of pressure and less sensitive to color Doppler settings; measure width at narrowest portion; Best A4Ch, PLAX (A2Ch may overestimate); For central and eccentric.•
b. PISA: EROA (severity) & MR vol (severity + loading condition); Measure aliasing vel in direction of flow;
c. Rule for Severe MR: 4,5,6,7 (EROA >=0.4, RF 50%, RegVol 60 mL, VC 0.7).
Topics 11-2013
TR Quantification
1. Dependent on loading condition: Use TV annulus diam >= 35 mm during mitral repair as criteria for TV repair
Topics 11-2013
AR Quantification
1. Not as critcal as for MR.
2. PW at the descending aorta in the supra sternal notch view is critical if more than mild AR (Routine)
- Pandiastolic flow reversal at least mod-severe AR
- Most color mapping at 50-60 Nyquist
3. Pressure 1/2t
>500 ms Mild
>400 ms 1+ to 2+
300-400 uncertain
<300 3+ to 4+
<200 - severe
PW at the descending aorta in the supra sternal notch
•Sample volume placed just distal to origin of left subclavian artery
•Holodiastolic flow reversal may indicate at least moderate AR.
•End diastolic velocity >20cm/s, measured at peak R wave may suggest severe AR (see figure - courtesy Anne - severe perivalvular AR)
In severe, acute AR flow reversal will decrease rapidly with no end diastolic velocity
Significant holodiastolic reversal in abdominal aorta is also a specific
sign of severe AR
•http://www.bsecho.org/assessment-of-aortic-regurgitation/#!prettyPhoto
