Aortic Valve Stenosis
This is a secondary findings in aortic stenosis.
**What other findings may develop in late stage?
LVH
Post stenotic aorta dilation (ab turbulence and wall stress)
LA pressure increase, Ventricular dysfuction, endocarditis risk
Decribe sclerosis?
In aortic regurgitation the pulse pressure is wide or narrow?
Wide
Why?
How about aortic stenosis? Narrow or wide
what other symptoms? LV enlargement, LV dysfx, diastolic dysfx, shortness of breath and syncope
The most common cause of MS is ?
Rheumatic fever
**second to effect AV
Congenital - parachute
Aquired - MAC
Name at least two primary causes for MR and one secondary cause?
Primary - Rheumatic, prolapse , endocarditis, MS)
Secondary- ischemic or non ischemic CM (LV dilation), pap muscle rupture or chordae
Diastolic Rumble with an opening snap is caused by___
MS
Name 4 Causes of Aortic Stenosis
Calcific/Degenerative (50%)
Rheumatic
Congenital (Bicuspid 1-2%, unicuspid)
Supra and subvalvular obstructions
Which type of valve morphology is more likely to cause AI vs AS?
Quadricuspid
Describe a common feature/presentation noted on Echocardiogram in a patient with tethered MV (MS)
"hockey stick" appearance
Other common findings:
LA enlargment
PHTN
Calculate the RV and RF with the following...
When would this process of quantification not be applicable?
LVOTd 1.9 cm
LVOT VTI 21 cm
MVd 2.3 cm
MV VTI 35 cm
RV = 86 ml
RF=59%
If there is also AI
Severe:
>60 ml - RV
>50% - RF
>.7 Vena Contracta
>.4 EROA (from PISA)
Harsh systolic ejection murmur at RUSB (cresendo/Decresendo)
AS
also see a decreased or absent S2 or "A2", decreased and delayed carotid upstroke with bruit/thrill
Symptoms are dyspnea, angina, syncope
Describe two ways to find AVA
Continuity equation AVA= SV/AV VTI
AV planimetry
What are some limitations to each of these?
Describe two ways to semi quantitate AI? Which is the most common and what is normal vs. severe value?
PHT (<200 severe >500 mild)
Vena Contracta - >.6 severe
Jet height/width > 65% (JH/LVOT ratio)
PISA - RV and EROA >60ml
descending aorta and ab aorta (flow reversal or retrograde flow
Given a pressure half time of 400msec what would the MV area be?
0.5 cm2
220/PHT (PHT= DT x .29)
need to measure the second slope if it is bimodal
Normal valve area is 4-6 cm
If you suspect MR where else should you look? What would you expect to see on the Doppler if MR was significant?
Pulmonary Veins
Use PW doppler and look for systolic blunting or reversal
What is the physiologic advantage of LA dilation in face of MR?
Dilation allow the receiving chamber to accommodate more volume without experiencing a large increase in pressure (otherwise would result in increase PA pressures... think acute vs chronic)
When identifying a Aortic systolic signal vs MR/TR...
MR/TR starts _______ and lasts _________ than aortic systolic flow
Bicuspid AV M-Mode may show possible eccentric closure. T or F
And the orifice in SAX will be "_______" shaped?
The two underdeveloped leaflets turn into a malformed commissure called a ________.
True
Football
Raphe
Describe how you might identify if the AI is acute vs. Chronic?
LV contractility (hyper versus hypo)
LV dilation
Cause..(trauma etc)
What measurements/ values describes severe MS
MG: 8-10 mmHg (dependant on HR)
MVA: <1.0 cm2
PAP: > 50mmHg
**other echo findings (M-mode)
decrease E-F slope, decreased E wave
**Stress echo : >15 mmHg and >60 mmHg
Describe Barlow's syndrome, what is is associated with and where/how it is best evaluated on echocardiogram
Barlows - bileaflet redundant/myomatous(non inflammatory) leaflets) - associated with Marfans
One or more valve flaps buldge into the upper left atria great than 2mm and is best assessed from the PLAX view (not apical)
Holosystolic flow; Mid systolic click
Mitral regurgitation; MVP causing MR
What value is "severe" AS for each of the following:
Velocity
Mean Gradient
Valve Area
Dimensionless Index
>4.0 m/s
>40 mmHg
<1.0 cm2
<0.25
**we focus on mean gradient in Echo and Cath focus on peak to peak...echo gradients are usually higher than Cath lab because of this (peak instananeous vs peak to peak)
Which Anomaly causes aortic regurgitation and why?
Marfans - aortic dissection or aortic root enlargement
Other causes: primary cusp disease such as stenosis, Endocarditis, ankylosing spondilitis
Dilated ao annulus, trauma
Patient with mitral stenosis often develop _____ _______ putting them at risk for thrombus formation
atrial fibrillation
other signs/symptoms include : CHF, dyspena, fatigue orthopnea, edema hemoptysis
How many beats/velocities/waveforms should we measure with Afib?
The PISA is the most common method in assessment of MR - T or F
The greatest source of error in the PISA calculation is?
T
The radius of the flow convergence
How else can we calculate MR
Describe the process to get a PISA? Which direction should we shift the baseline when doing PISA?
Diastolic fluttering/vibration of the MV anterior leaflet is caused by _________ __________? This is called _______ ________ murmur.
aortic insufficiency
Austin Flint
** other murmur would be a diastolic "blowing" murmur