Term
| Describe the normal pericardium |
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Definition
| The pericardium consists of two layers. The visceral pericardium is contiguous with the epicardium, and the parietal pericardium is the thicker fibrous sack surrounding the heart. Normally there is 5-10 ml of normal buffering fluid within the pericardial space. The pericardium extends 1-2cm up the great vessels. The pericardium similarly reflects around the pulmonary veins. The pericardium serves to restrain the four cardiac chambers within a relatively confined volume and space within the thorax. Because of the pericardial constraint, the total volume of the four cardiac chambers is limited and alterations in the volume of one chamber must, by necessity, be reflected in a change in volume in the opposite direction of another. |
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Term
| Describe how a pericardial effusion can be quantified |
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Definition
Most echocardiography laboratories visually quantify pericardial effusion as minimal, small, moderate, or large and further characterized as either free or locualted. The effusion should also be characterized as to the presence or absence of hemodynamic compromise.
Typically, minimal effusions represent the normal amount of pericardial fluid in a disease free state. It is visualized as a small echo free space in the posterior atrioventricular groove that may only be visible in systole when the heart has pulled away from pericardium. A small effusion is defined as one resulting in as much as 1 cm of posterior echo-free space, with or without fluid accumulation elsewhere. Moderate effusions have been described as 1 to 2 cm of echo free space and large effusions as more than 2 cm of maximal separation. |
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Term
| State where on 2-D Echo a pericardial effusion frequently appears maximal |
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Definition
| In the posterior AV groove |
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Term
| List the echocardiographic findings of a pericardial effusion(PE) |
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Definition
With M-mode the pericardial effusion appears as an echo free space both anterior and posterior to the heart.
In 2D pericardial effusion tends to be most prominent in the more dependent area and frequently appears maximal in the posterior atrioventricular groove.
Additional views including parasternal short axis, apical and subcostal views shows the circumferential extent of an effusion. |
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Term
| Given a list of echocardiographic findings, choose the ones that help differentiate pleural effusions from pericardial effusions |
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Definition
Pleural Effusion:
Fluid behind the LA
Fluid posterior to the descending thoracic aorta
Pericardial Effusion:
Fluid anterior to the aorta |
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Term
| Discuss the semiquantitative approach to judge the size of the pericardial effusion |
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Definition
Large effusion— 2cm of maximal separation.
Moderate effusion— 1-2 cm of echo free space
Small effusion— 1 cm of echo free space, without fluid accumulation elsewhere. |
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Term
| State the echocardiographic findings of cardiac tamponade |
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Definition
2D and M-mode Echo
-Diastolic RV collapse
-RA collapse/inversion
-Swinging Heart
Doppler
-Exaggerated respiratory variation inflow velocity
-Phasic variation in RV outflow tract/LV outflow tract
-Exaggerated respiratory variation in IVC flow |
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Term
| Given a list of exceptions to using right-sided collapsing of the heart when diagnosing cardiac tamponade, choose the ones that can lead to misdiagnosing |
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Definition
The most common is probably the patient with significant RV hypertrophy, usually due to pulmonary hypertension.
Thickening of the ventricular wall due to malignancy, an overlying inflammatory response or an overlying thrombus in hemorrhagic pericarditis may have the same effect.
Similarly, because ventricular interaction is directly related to ventricular volume, these signs maybe absent in low pressure tamponade, as may be seen in hypovolemic patients. |
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Term
| State the name of the electrocardiographic conditions caused by excessive motion of the heart during the presence of a large pericardial effusion |
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Definition
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Term
| List the findings of restrictive and constrictive pericarditis |
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Definition
Constrictive
-normal chamber sizes
-elevated E/A ratio with shortened deceleration time
-E wave velocity increase with respiratory variation
-LV isovolumic relaxation time show greater respiratory variation
-Systolic antegrade flow is enhanced with inspiration
-Using DTI, there is more rapid early relaxation when diastolic velocities are diminished to below normal
-Using velocity propagation of mitral inflow, the velocity with which the mitral flow moves towards the apex is exaggerated
Restrictive
- marked biatrial enlargement
- elevated E/A ratio with shortened deceleration time
- normal E wave velocity
- there is less respiratory variation and diastolic flow typically exceeds systolic flow.
- with velocity propagation of mitral inflow, the velocity with which the mitral flow moves towards the apex is reduced. |
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Term
| Describe the pericardium of a patient with constrictive pericarditis |
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Definition
| Typically, the parietal pericardium becomes the constricting force. In many instances, the pericardial space between the visceral and parietal pericardium may appear filled with vague echo dense substance representing a combination of actual pericardial thickening and organized inflammatory pericardial fluid |
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Term
| State the causes of constrictive pericarditis to include effusive constrictive pericarditis |
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Definition
Constrictive – self limited pericarditis, connective tissue disease or other inflammatory processes or after cardiac surgery, radiation therapy.
Effusive constrictive pericarditis – radiation therapy, malignancy |
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Term
| Discuss the echo evaluation of a patient with a post operative pericardial effusion |
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Definition
| In evaluating a critically ill patient with a suspected postoperative pericardial effusion or hematoma, it is important to evaluate the size and geometry of all four cardiac chambers and attempt to identify the inflow from the pulmonary veins and superior and inferior vena cava. Loculated effusions and hematoma after cardiac surgery can result in isolated compressions of one or more pulmonary veins or of vena cava inflow, either of which can compromise overall cardiac output. Identification of small, underfilled chambers that appear compressed may be indirect evidence of a compressive pericardial hematoma in this setting. |
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Term
| List the reasons for monitoring a pericardiocentesis via echocardiography |
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Definition
- Visualize the pericardiocentesis needle as it enters the pericardial cavity/ agitated saline can be injected to further define the location of the needle tip.
- Distribution and depth from the surface of the chest at which contact with the fluid is anticipated by the pericardiocentesis needle |
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Term
| State the major difficulty encountered with echocardiography when detecting a thickened pericardium |
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Definition
| In instances of marked fibrosis and calcification, it may be possible to infer substantial pericardial thickening, but actual measurement of thickness will remain problematic. In the presence of calcific pericarditis, there may be marked shadowing seen posterior to the pericardium. |
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Term
| Given a list of M-mode findings, choose the ones that are relative to constrictive pericarditis |
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Definition
-Abrupt relaxation of the posterior wall with subsequent flatting of endocardial motion in diastole.
-Abnormal septal motion.
-Steep propagation velocity (color M-Mode) |
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Term
| Given a list of anatomical cardiac structures, choose the one(s) in which pericardial cysts appear |
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Definition
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Term
| List the echocardiographic findings of an absent pericardium |
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Definition
- abnormal cardiac silhouette
- herniated LAA, less frequently RAA
- mild degrees of RA and RV dilation
- abnormal and frequent paradoxical IVS motion |
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Term
| Given a two-dimensional echocardiogram, identify the following disease states |
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Definition
Pericardial Effusion pg 248, 249, 250, 251
Pleural Effusion 251, 253
Cardiac Tamponade 258
Constrictive Pericarditis pg 262 |
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Term
| List the masses of questionable clinical significance that occur in the heart |
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Definition
RA
Chiari network
Eustachian valve
Crista Terminalis
Catheters/Pacemaker leads
Lipomatous hypertrophy of interatrial septum
Pectinate muscle
Fatty material
LA
Suture line
Fossa ovalis
Calcified mitral annulus
Coronary sinus
Ridge between LUPV and LAA
Lipomatous hypertrophy of interatrial septum
Pectinate muscle
Transverse sinus
RV
Moderator band
Muscle bundles/trabeculations
Catheters and pacemaker leads
LV
False chords
Papillary muscles
LV traebeculations
AO
Brachiocephalic vein
Innominate vein
Pleural effusion |
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Term
| State the most common benign cardiac tumor |
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Definition
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Term
| Describe left atrial myxoma and its location in the LA |
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Definition
| Their size, shape and texture can be quite varied. They may be smooth surfaced but more often irregularly shaped with filamentous fronds or have the appearance of a “cluster of grapes.” They are typically non-homogenous in texture with lucent centers or areas of calcification. The most important clue to their diagnosis is their location in the left atrium and origin from the mid portion of the atrial septum. |
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Term
| State the second most common location for a myxoma |
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Definition
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Term
| List the extracardiac masses that may impinge on or compress the heart |
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Definition
-mediastinal tumors
-coronary aneurysms
-hiatal hernias
- hematoma within the mediastinum or pericardial space
- myocardial cysts
- pericardial cysts |
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Term
| List the conditions predisposes a patient to LV thrombi. |
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Definition
- recent myocardial infarction/ thrombi usually involves the apex in the presence of akinesis or dyskinesis. Infarcts that do not result in an apical wall motion abnormality are less likely to be associated with thrombus formation.
- LV aneurysm
- Dilated cardiomyopathy |
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Term
| Given a list identify thrombi that are more likely to embolize |
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Definition
-thrombi that protrude into the LV cavity
-highly mobile
-large size
-hyperkinetic wall motion adjacent to the thrombus and an echo lucent center |
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Term
| List the potential sources of embolus and associated echocardiographic findings |
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Definition
-LV thrombus – apical aneurysm, presence of thrombus, dilated CM
-LA thrombus- presence of thrombus in LAA, spontaneous contrast, LAA emptying velocity, mitral stenosis, interatrial septal low aneurysm
-Pelvic veins or LE thrombus- ASD, atrial septal aneurysm, PFO
-Native valves- vegetation, tumor, MVP, MAC, sclerotic aortic valve
-Prosthetic valves- thrombus, vegetation
-Cardiac tumor- LA myxoma, papillary fibroelatoma
-Aorta- complex aortic plaque, atheroma |
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Term
| Given a list of several types of patients, choose the ones in which left atrial thrombi are particularly hazardous |
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Definition
| atrial fibrillation before cardioversion |
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Term
| List three scenarios in which thrombus may be found in the RA and the importance of their identification |
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Definition
precursors to pulmonary emboli
- Afib
- thrombi in transit from lower extremity or pelvic veins
- masses attached to catheters or pacemaker leads |
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Term
| Given a two-dimensional echocardiogram, identify the following cardiac masses |
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Definition
-Cardiac Neoplasm
-Intracardiac Thrombi |
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Term
| State what type of echocardiographic approach allows ultrasonic visualization of virtually the entire aorta |
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Definition
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Term
| List the two disease states that produce characteristic two-dimensional echocardiograms of aortic dilations |
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Definition
-cystic medial necrosis- as typified by Marfan’s Syndrome or other connective tissue disorders
-Secondary dilation of the aorta can occur in volume or pressure overlaod states such as hypertension or AI |
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Term
| Given a list of conditions and characteristics, choose the ones relative to Marfan’s syndrome |
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Definition
-Aortic insufficiency occurs in Marfan’s syndrome due to dilation of the sinotubular junction, which results in loss of normal aortic valve coaptation.
- High prevalence of MVP |
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Term
| State the conditions that predispose a person to an aortic dissection |
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Definition
-Preexisting aortic dilation
-Cystic medial fibrosis- Marfan’s syndrome
-Long-standing hypertension |
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Term
| State what types of aortic dissection are likely to result in lethal complications and why |
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Definition
| The crucial factor in aortic dissection is whether it involves the ascending aorta (Stanford A or Debakey I or II). These patients have a greater likelihood of subsequent rupture, pericardial effusion, aortic insufficiency, and coronary involvement, all of which may be lethal complications of acute dissection. |
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Term
| Discuss the echocardiographic technique used to distinguish the true lumen from a false lumen of an aortic dissection |
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Definition
- color flow imaging can be used to identify the communication points between the true and false lumen
- the true lumen will expand with systole as blood is ejected in to it.
- it often has a more regular shape, which may be either circular or oval.
- the true lumen is the smaller of the two lumens in the descending thoracic aorta.
- the false lumen is often filled with swirling homogeneous echoes, representing stasis of blood or occasionally with frank thrombus.
- the shearing of the intima from the media often results in small fibrinous tags of tissue in the false lumen, which represent small muscle remnants where the intima has been sheared from the media. |
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Term
| Given a picture of an aortic dissection determine the type |
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Definition
DeBakey Type I—dissection begins at the aortic root and involves the arch and the descending aorta
DeBakey Type II—limited only to the ascending aorta
DeBakey Type III—begins beyond the aortic arch, usually at the origin of the left subclavian artery |
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Term
| List the clues to artifacts that may lead to false identification of intimal flaps |
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Definition
Clues to artifact vs true dissection include random mobility of a true dissection flap as opposed to a more rigid and fixed location with respect to the aortic wall seen in artifact. Artifacts not infrequently will arise as a side lobe from the sinotubular junction, and their intensity will progressively diminish the lumen, where as a true dissection flap will not loose its echo intensity along its course. Color flow imaging can be useful for demonstrating margination of flow by a true dissection flap, whereas an artifact will not affect the distribution of the color flow signal.
The combination of left brrachiocephalic vein and the aorta creates a tubular echo, larger than that of the normal aorta. This can occasionally be confused with a dilated aorta with a dissection flap. |
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Term
| Define false aortic aneurysm |
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Definition
| Aortic pseudoaneurysm represents a contained rupture of the aorta and is characterized by an extraluminal aneurismal sack communicating with the true lumen by a relatively narrow neck. |
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Term
| State when false aortic aneurysms occur |
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Definition
-in spontaneous rupture of an aortic aneurysm with subsequent sealing off of the hemorrhage.
-As a sequelae of aortic dissection, in which there is further rupture through the adventitial layers.
-As a result of iatrogenic injury. |
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Term
| Given a list of cardiac structures, choose the most common location for sinus of valsalva aneurysm rupture |
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Definition
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Term
| List the abnormalities that may occur to the aorta as a result of trauma |
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Definition
Periadventitial hematoma
Thrombus within the medial space or in the lumen of the AO itself
AO transaction
Aortic psuedoaneurysm
Rupture of a Valsalva sinus
Aortovena-caval fistulae |
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Term
| State the echocardiographic approach that provides the best visualization of the aorta when measuring stiffness of the aorta and detecting aortic atherosclerosis |
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Definition
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Term
| Given a two-dimensional echocardiogram, identify the following disease processis |
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Definition
| Sinus of Valsalva Aneurysm, Aortic Dilatation, and Aortic Dissection |
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Term
| List the general categories and echo abnormalities of Dilated Cardiomyopathy |
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Definition
Dilated Cardiomyopathy: fall into the general categories of ischemic and nonischemic.
Echo Abnormalities:
LV dilation
Increasing sphericity of LV geometry
Apical and lateral displacement of papillary muscles
Functional MR
LV thrombus
LA dilation
Atrial fibrillation
LA thrombosis/stasis of blood
Pulmonary Hypertension
Tricuspid regurgitation
RV dilation |
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Term
| List the echo findings of Restrictive cardiomyopathy |
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Definition
The hallmark is normal ventricular size and systolic function with evidence of pathologic diastolic stiffening. Diastolic dysfunction may be often accompanied by varying degrees of increased wall thickness, whether due to LVH as in end-stage hypertensive cardiovascular disease, or infiltration. Biatrial enlargement
Varying degrees of concurrent systolic dysfunction may be noted in end-stage cases |
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Term
| List three types of Infiltrative Restrictive Cardiomyopathy |
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Definition
- Amyloidosis
- Glycogen storage diseases
- Hemachromatosis |
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Term
| Describe Hypertrophic Cardiomyopathy and list the echo findings of LVOT obstruction |
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Definition
Hypertrophic Cardioymyopathy: inappropriate left ventricular hypertrophy often with abnormal myofibril orientation. The classic form, idiopathic hypertrophic cardiomyopathy result in dynamic LVOT obstruction, MR, a high prevalency of arrhythmias, and sudden cardiac death.
M-Mode: The M-mode abnormalities associated with dynamic outflow tract obstruction were systolic anterior motion of the mitral valve, abnormal aortic valve motion in systole.
2-D: systolic anterior motion of the mitral valve abnormal aortic valve motion in systole. Should be characterized by the area of the mitral valve having abnormal motion (chordal or leaflet), the degree to which the systolic anterior motion results in contact of the valvular apparatus with the ventricular septum and the duration of contact with the ventricular septum.
The reduction in flow volume out the LVOT results in partial closure of the aortic valve, often with a secondary opening as final ejection occurs. This results in a single notch or occasionally several discrete high amplitude notches of aortic valve motion.
Doppler: CF-Dynamic LVOT obstruction results in marked turbulence in the outflow tract, which can be detected with color flow Doppler.
PW- Used to track the ejection velocities along the LVOT at which point, when significant dynamic outflow tract obstruction is present, the velocity will exceed the Nyquist limit and aliasing will occur.
CW- Provides a higher fidelity analysis of LVOT ejection dynamics and gradients, The late peaking of the outflow tract gradient is evidence of the dynamic nature of the gradient that develops toward mid-and end- systole rather than being related to a fixed obstruction in which the gradient occurs early in systole. |
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Term
| State the echo findings of myocarditis |
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Definition
-Near-normal ventricular dimensions with a global decrease in systolic function
-May be some regional variation in the degree to which function is diminished
-ventricular dilation may result in MR or TR
-Inflammation of the visceral pericardium may result in pericardial effusion |
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Term
| List the conditions that mimic hypertrophic cardiomyopathy |
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Definition
-Aquired hypertrophic cardiomyopathy of the hypertensive elderly
- Pts with intravascular volume depletion
-RV muscle bundle or trabeculation
RVH- with isolated septal hypertrophy |
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Term
| State the technical problem with using continuous wave Doppler on patients with hypertrophic cardiomyopathy |
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Definition
| -Occasionally confusion arises when looking for an outflow tract gradient if one mistakenly interrogates mitral regurgitation with a late peak and confuses it with the dynamic outflow tract obstruction. Often the mitral regurgitation signal will have a later onset than the outflow tract flow profile, and frequently the peak velocities are in a supraphysiologic range. When one encounters a hypertrophic cardiomyopathy with MR and a late peaking velocity of 6m/sec, confusion with the MR jet should be considered. |
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Term
| State the septal to posterior wall ratio that indicates septal hypertrophy and list two conditions that may have a similar ratio in the presence of LVH |
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Definition
Ratio: 1.3:1
Pulmonary Hypertension with RVH and Inferior wall infarction in the prescience of LVH |
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Term
| Given a two-dimensional echocardiogram, identify the following conditions |
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Definition
| Hypertrophic Cardiomyopathy, Dilated Cardiomyopathy, Restrictive Cardiomyopathy, Myocarditis |
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Term
| Given the LVID diastolic and the LVID systolic M-modes, calculate fractional shortening and ejection fraction |
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Definition
EF(%) = LVD(d)^3-LVD(s)^3/LVD(d)^3 X 100
FS% = LVD(d)-LVD(s)/LVD(d) X 100 |
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