Embed Size (px)
DESCRIPTION
Citation preview
Basic Echocardiography
Selwyn Wong
Middlemore Hospital
Echocardiography Basics
Ultrasound waves sent from chest wall
Echocardiography Basics
Two-dimensional imaging
Echocardiography Basics
Echocardiography Basics
Echocardiography Basics
Echocardiography Basics
One-dimensional imaging (M-mode)
Echocardiography Basics
One-dimensional imaging (M-mode)
Echocardiography BasicsDoppler - Spectral
Pulse Continuous
Bernoulli equation P = 4V2
Echocardiography Basics
Doppler - Colour
Echocardiography Basics
Tissue velocity imaging
Echocardiography Basics
Tissue velocity imaging
Left ventricle - size
Normal
End-diastole 35-57cm
End-systole 21-40cm
Left ventricle - size
Normal
End-diastole 35-57cm
End-systole 21-40cm
Left ventricle - wall thickness
IVS and PW
06 -11cm
Left ventricle - systolic function
Fractional Shortening (FS)
FS = EDD-ESD EDD
Left ventricle - systolic function
Fractional Shortening (FS)
FS = EDD-ESD EDD
Left ventricle - systolic function
Left ventricle - systolic function
Ejection fraction ()
Normal gt55
Mild 40-50
Moderate 30-40
Moderate-severe 20-30
Severe lt20
Part OneA 67-year-old woman with congestive cardiac failure remains breathless on moderate exertion despite treatment with 40 mg frusemide and 20 mg enalapril daily On examination she has a pulse rate of 80minute blood pressure of 12570 mmHg and a jugular venous pressure (JVP) of +1 cm She has a soft systolic murmur with no added sounds her chest is clear and she has no oedema An ECG shows sinus rhythm A chest X-ray shows cardiomegaly with a cardiothoracic ratio of 15528 but no pulmonary congestion Echocardiography demonstrates systolic dysfunction with fractional shortening of 18 and mild mitral regurgitation Her serum creatinine level is normal
Which of the following is the most appropriate next step in treatment A Increase the frusemide dose B Add digoxin C Add an aldosterone antagonist D Add an angiotensin II receptor antagonist E Add a beta blocker
Left ventricle - diastolic function
Mitral inflow Pulmonary veins
Mitral TVI
LV diastolic function - mitral inflow
EA gt 1 EA lt 1 EA gtgt1
LV diastolic function - mitral TVI
EA gt 1 EA lt 1 EA gtgt1
Left ventricle - RWMAs
Left ventricle - RWMAs
Left ventricle - RWMAs
Left ventricle - thrombus
Left atrium - size
Diameter
Normal 20-40cm
Mild 40-50cm
Moderate 50-60cm
Severe gt60cm
Left atrium - size
Area
Normal lt20cm2
Mild 20-30cm2
Moderate 30-40cm2
Severe gt40cm2
Left atrium - thrombus
Cardiac Valves
Morphology
Valve dysfunction
aetiology
quantification
consequences
serial evaluation
Valve regurgitation - quantification
Colour - jet sizewidth
PISA
Spectral doppler
Consequences
AR - LV Response
bull Chronic AR - decompensated LV
bull LVEFlt55 LVESDgt55mm LVESV 60mlm2
Part OneA patient with aortic regurgitation has the following haemodynamic measurements cardiac output (CO) 75 Lminute heart rate (HR) 75minute left ventricular end-diastolic volume (LVEDV) 200 mL left ventricular end-systolic volume (LVESV) 50 mL The regurgitant fraction is defined as the ratio of the regurgitant volume to the total volume flowing through the valve with each beat
The regurgitant fraction in this patient is A 25 B 33 C 50 D 67 E 75
Part OneA 45-year-old asymptomatic man returns for follow-up He was diagnosed 10 years ago with aortic regurgitation due to a congenital bicuspid aortic valve He has never had endocarditis Which one of the following echocardiographic profiles most strongly indicates the need for aortic valve replacement
LVEDD (mm)[35-55] FS [030-040] LA size (mm) [lt40]
A 70 030 60
B 75 040 40
C 70 025 45
D 65 045 50
E 75 035 55
Key LVEDD Left ventricular end-diastolic diameter LVESD Left ventricular end-systolic diameter FS Fractional shortening = (LVEDD - LVESD) LVEDD LA Left atrial
MR- Quantification of LV contractility
LV systolic function - most important parameter
bullEjection fraction fractional shortening velocity of
circumferential fibre shortening - load dependent
bullMR allows supranormal values of EF etc
bullEarly systolic dysfunction if
bullEF lt 60 (severe MR)
bullES diameter lt 45mm (26mmm2)
Mitral stenosis - quantification
Severity MVA (cm2) LAP (mm Hg) CO
Mild gt20 lt10-12 NL
Moderate 11-20 ~10-17 NL
Severe lt10 gt18
Very Severe lt08 gt20-25
Part OneA 35-year-old woman has increasing breathlessness on exertion Her cardiac silhouette is slightly enlarged on a chest X-ray and an ECG demonstrates sinus rhythm The continuous wave Doppler flow signal through the mitral inflow tract (shown above) is most consistent with which one of the following A Severe pulmonary hypertension (cor pulmonale) B Aortic stenosis C Mitral regurgitation D Mitral stenosis E Aortic regurgitation
Part OneA 28-year-old woman who emigrated from Cambodia 10 years ago presents to the emergency department with a three-week history of increasing shortness of breath orthopnoea nocturnal dyspnoea and ankle oedema She is 25 weeks pregnant and has no significant past medical history The presence of pulmonary oedema is confirmed clinically and radiologically She responds well to intravenous frusemide but remains tachypnoeic with a heart rate of 120minute in sinus rhythm Her blood pressure is 12585 mmHg Echocardiography demonstrates mitral stenosis with an estimated valve area of 13 cm2 and a left atrial diameter of 50 mm [lt40 mm] There are no other abnormalities What is the most appropriate next step in management A Balloon valvotomy B Surgical valvotomy C Digoxin therapy D Beta-blocker therapy E Angiotensin converting enzyme (ACE) inhibitor therapy
Part OneA 55-year-old man presents with acute pulmonary oedema Five years earlier he has undergone a mitral valve replacement with a bileaflet tilting disk valve (St Jude) for mixed mitral valve disease He has been well with normal exercise tolerance prior to the day of admission Examination on admission reveals tachypnoea sinus tachycardia of 110minute blood pressure of 10560 mmHg elevated jugular venous pressure (+ 5 cm) and bilateral crepitations throughout the lung fields His prothrombin timeminusinternational normalised ratio (PT-INR) is 19 [desired therapeutic range 20-35] Serum urea creatinine and electrolytes are normal The cardiothoracic ratio on chest X-ray is normal but the presence of pulmonary oedema is confirmed Echocardiography reveals that one of the prosthetic valve leaflets is not moving and there is an increased flow rate in diastole across the valve orifice (2 metressecond) What is the most appropriate course of action A Administration of intravenous streptokinase B Administration of intravenous heparin C Administration of intravenous antibiotics D Addition of an antiplatelet agent E Immediate mitral valve replacement
Aortic stenosis - quantification
Aortic stenosis - quantification Mean gradient
(mmHg) Peak Ao velocity
AVA (cm2)
Normal 10-20 gt25
Mild lt20 25-29 gt17
Moderate 20-40 30-40 10-17
Severe gt40 gt40 lt10
Right ventricle - size amp function
Estimation of Pulmonary PressurePA systolic pressure
bull Tricuspid regurgitation jet velocity
Estimation of Pulmonary PressureRA pressure
bull IVC size
Part OneThe severity of pulmonary hypertension can be determined using continuous wave Doppler measurements of the velocity of tricuspid regurgitation This method uses the Bernoulli equation which states that 1048661P = 4v2 (where 1048661P = instantaneous pressure gradient and v = velocity across the valve) There is tricuspid regurgitation with a peak velocity of 4 metressecond and a mean velocity of 35 metressecond Assuming right atrial pressure is 5 mmHg the best estimate of the peak right ventricular systolic pressure (plusmn 2 mmHg) is
A 50 mmHg B 55 mmHg C 60 mmHg D 65 mmHg E 70 mmHg
Cardiac Tamponade
Cardiac Tamponade
Cardiac Tamponade
Part OneA 65-year-old woman presents with a one-week history of progressive dyspnoea On admission there are signs of shock a systolic murmur and an elevated jugular venous pressure The ECG shows sinus tachycardia but no other abnormality An antero-posterior chest X-ray shows cardiomegaly The serum troponin I level is 05 mgL [lt01] A computed tomography (CT) scan is shown below
What is the most likely diagnosis A Pulmonary embolism B Right ventricular infarction C Pericardial tamponade D Myocarditis E Acute mitral regurgitation
Endocarditis
Positive echocardiogram for IE Discrete echogenic oscillating intracardiac mass located at a site of endocardial injury (eg on a valve or supporting structure in pathway of regurgitant jet or site of implanted material) or Periannular abscess or
New dehiscence of a prosthetic valve
Cardiac Resynchronisation
Cardiac Resynchronisation
bullSevere heart failure treatment to restore co-ordination to LV contraction
bullNYHA 3-4bullEF lt 35bullQRS duration gt 120 msec
Echocardiography
bullUseful non-invasive tool
bullReports objective and subjective
bullLimitations
Echocardiography Basics
Ultrasound waves sent from chest wall
Echocardiography Basics
Two-dimensional imaging
Echocardiography Basics
Echocardiography Basics
Echocardiography Basics
Echocardiography Basics
One-dimensional imaging (M-mode)
Echocardiography Basics
One-dimensional imaging (M-mode)
Echocardiography BasicsDoppler - Spectral
Pulse Continuous
Bernoulli equation P = 4V2
Echocardiography Basics
Doppler - Colour
Echocardiography Basics
Tissue velocity imaging
Echocardiography Basics
Tissue velocity imaging
Left ventricle - size
Normal
End-diastole 35-57cm
End-systole 21-40cm
Left ventricle - size
Normal
End-diastole 35-57cm
End-systole 21-40cm
Left ventricle - wall thickness
IVS and PW
06 -11cm
Left ventricle - systolic function
Fractional Shortening (FS)
FS = EDD-ESD EDD
Left ventricle - systolic function
Fractional Shortening (FS)
FS = EDD-ESD EDD
Left ventricle - systolic function
Left ventricle - systolic function
Ejection fraction ()
Normal gt55
Mild 40-50
Moderate 30-40
Moderate-severe 20-30
Severe lt20
Part OneA 67-year-old woman with congestive cardiac failure remains breathless on moderate exertion despite treatment with 40 mg frusemide and 20 mg enalapril daily On examination she has a pulse rate of 80minute blood pressure of 12570 mmHg and a jugular venous pressure (JVP) of +1 cm She has a soft systolic murmur with no added sounds her chest is clear and she has no oedema An ECG shows sinus rhythm A chest X-ray shows cardiomegaly with a cardiothoracic ratio of 15528 but no pulmonary congestion Echocardiography demonstrates systolic dysfunction with fractional shortening of 18 and mild mitral regurgitation Her serum creatinine level is normal
Which of the following is the most appropriate next step in treatment A Increase the frusemide dose B Add digoxin C Add an aldosterone antagonist D Add an angiotensin II receptor antagonist E Add a beta blocker
Left ventricle - diastolic function
Mitral inflow Pulmonary veins
Mitral TVI
LV diastolic function - mitral inflow
EA gt 1 EA lt 1 EA gtgt1
LV diastolic function - mitral TVI
EA gt 1 EA lt 1 EA gtgt1
Left ventricle - RWMAs
Left ventricle - RWMAs
Left ventricle - RWMAs
Left ventricle - thrombus
Left atrium - size
Diameter
Normal 20-40cm
Mild 40-50cm
Moderate 50-60cm
Severe gt60cm
Left atrium - size
Area
Normal lt20cm2
Mild 20-30cm2
Moderate 30-40cm2
Severe gt40cm2
Left atrium - thrombus
Cardiac Valves
Morphology
Valve dysfunction
aetiology
quantification
consequences
serial evaluation
Valve regurgitation - quantification
Colour - jet sizewidth
PISA
Spectral doppler
Consequences
AR - LV Response
bull Chronic AR - decompensated LV
bull LVEFlt55 LVESDgt55mm LVESV 60mlm2
Part OneA patient with aortic regurgitation has the following haemodynamic measurements cardiac output (CO) 75 Lminute heart rate (HR) 75minute left ventricular end-diastolic volume (LVEDV) 200 mL left ventricular end-systolic volume (LVESV) 50 mL The regurgitant fraction is defined as the ratio of the regurgitant volume to the total volume flowing through the valve with each beat
The regurgitant fraction in this patient is A 25 B 33 C 50 D 67 E 75
Part OneA 45-year-old asymptomatic man returns for follow-up He was diagnosed 10 years ago with aortic regurgitation due to a congenital bicuspid aortic valve He has never had endocarditis Which one of the following echocardiographic profiles most strongly indicates the need for aortic valve replacement
LVEDD (mm)[35-55] FS [030-040] LA size (mm) [lt40]
A 70 030 60
B 75 040 40
C 70 025 45
D 65 045 50
E 75 035 55
Key LVEDD Left ventricular end-diastolic diameter LVESD Left ventricular end-systolic diameter FS Fractional shortening = (LVEDD - LVESD) LVEDD LA Left atrial
MR- Quantification of LV contractility
LV systolic function - most important parameter
bullEjection fraction fractional shortening velocity of
circumferential fibre shortening - load dependent
bullMR allows supranormal values of EF etc
bullEarly systolic dysfunction if
bullEF lt 60 (severe MR)
bullES diameter lt 45mm (26mmm2)
Mitral stenosis - quantification
Severity MVA (cm2) LAP (mm Hg) CO
Mild gt20 lt10-12 NL
Moderate 11-20 ~10-17 NL
Severe lt10 gt18
Very Severe lt08 gt20-25
Part OneA 35-year-old woman has increasing breathlessness on exertion Her cardiac silhouette is slightly enlarged on a chest X-ray and an ECG demonstrates sinus rhythm The continuous wave Doppler flow signal through the mitral inflow tract (shown above) is most consistent with which one of the following A Severe pulmonary hypertension (cor pulmonale) B Aortic stenosis C Mitral regurgitation D Mitral stenosis E Aortic regurgitation
Part OneA 28-year-old woman who emigrated from Cambodia 10 years ago presents to the emergency department with a three-week history of increasing shortness of breath orthopnoea nocturnal dyspnoea and ankle oedema She is 25 weeks pregnant and has no significant past medical history The presence of pulmonary oedema is confirmed clinically and radiologically She responds well to intravenous frusemide but remains tachypnoeic with a heart rate of 120minute in sinus rhythm Her blood pressure is 12585 mmHg Echocardiography demonstrates mitral stenosis with an estimated valve area of 13 cm2 and a left atrial diameter of 50 mm [lt40 mm] There are no other abnormalities What is the most appropriate next step in management A Balloon valvotomy B Surgical valvotomy C Digoxin therapy D Beta-blocker therapy E Angiotensin converting enzyme (ACE) inhibitor therapy
Part OneA 55-year-old man presents with acute pulmonary oedema Five years earlier he has undergone a mitral valve replacement with a bileaflet tilting disk valve (St Jude) for mixed mitral valve disease He has been well with normal exercise tolerance prior to the day of admission Examination on admission reveals tachypnoea sinus tachycardia of 110minute blood pressure of 10560 mmHg elevated jugular venous pressure (+ 5 cm) and bilateral crepitations throughout the lung fields His prothrombin timeminusinternational normalised ratio (PT-INR) is 19 [desired therapeutic range 20-35] Serum urea creatinine and electrolytes are normal The cardiothoracic ratio on chest X-ray is normal but the presence of pulmonary oedema is confirmed Echocardiography reveals that one of the prosthetic valve leaflets is not moving and there is an increased flow rate in diastole across the valve orifice (2 metressecond) What is the most appropriate course of action A Administration of intravenous streptokinase B Administration of intravenous heparin C Administration of intravenous antibiotics D Addition of an antiplatelet agent E Immediate mitral valve replacement
Aortic stenosis - quantification
Aortic stenosis - quantification Mean gradient
(mmHg) Peak Ao velocity
AVA (cm2)
Normal 10-20 gt25
Mild lt20 25-29 gt17
Moderate 20-40 30-40 10-17
Severe gt40 gt40 lt10
Right ventricle - size amp function
Estimation of Pulmonary PressurePA systolic pressure
bull Tricuspid regurgitation jet velocity
Estimation of Pulmonary PressureRA pressure
bull IVC size
Part OneThe severity of pulmonary hypertension can be determined using continuous wave Doppler measurements of the velocity of tricuspid regurgitation This method uses the Bernoulli equation which states that 1048661P = 4v2 (where 1048661P = instantaneous pressure gradient and v = velocity across the valve) There is tricuspid regurgitation with a peak velocity of 4 metressecond and a mean velocity of 35 metressecond Assuming right atrial pressure is 5 mmHg the best estimate of the peak right ventricular systolic pressure (plusmn 2 mmHg) is
A 50 mmHg B 55 mmHg C 60 mmHg D 65 mmHg E 70 mmHg
Cardiac Tamponade
Cardiac Tamponade
Cardiac Tamponade
Part OneA 65-year-old woman presents with a one-week history of progressive dyspnoea On admission there are signs of shock a systolic murmur and an elevated jugular venous pressure The ECG shows sinus tachycardia but no other abnormality An antero-posterior chest X-ray shows cardiomegaly The serum troponin I level is 05 mgL [lt01] A computed tomography (CT) scan is shown below
What is the most likely diagnosis A Pulmonary embolism B Right ventricular infarction C Pericardial tamponade D Myocarditis E Acute mitral regurgitation
Endocarditis
Positive echocardiogram for IE Discrete echogenic oscillating intracardiac mass located at a site of endocardial injury (eg on a valve or supporting structure in pathway of regurgitant jet or site of implanted material) or Periannular abscess or
New dehiscence of a prosthetic valve
Cardiac Resynchronisation
Cardiac Resynchronisation
bullSevere heart failure treatment to restore co-ordination to LV contraction
bullNYHA 3-4bullEF lt 35bullQRS duration gt 120 msec
Echocardiography
bullUseful non-invasive tool
bullReports objective and subjective
bullLimitations
Echocardiography Basics
Two-dimensional imaging
Echocardiography Basics
Echocardiography Basics
Echocardiography Basics
Echocardiography Basics
One-dimensional imaging (M-mode)
Echocardiography Basics
One-dimensional imaging (M-mode)
Echocardiography BasicsDoppler - Spectral
Pulse Continuous
Bernoulli equation P = 4V2
Echocardiography Basics
Doppler - Colour
Echocardiography Basics
Tissue velocity imaging
Echocardiography Basics
Tissue velocity imaging
Left ventricle - size
Normal
End-diastole 35-57cm
End-systole 21-40cm
Left ventricle - size
Normal
End-diastole 35-57cm
End-systole 21-40cm
Left ventricle - wall thickness
IVS and PW
06 -11cm
Left ventricle - systolic function
Fractional Shortening (FS)
FS = EDD-ESD EDD
Left ventricle - systolic function
Fractional Shortening (FS)
FS = EDD-ESD EDD
Left ventricle - systolic function
Left ventricle - systolic function
Ejection fraction ()
Normal gt55
Mild 40-50
Moderate 30-40
Moderate-severe 20-30
Severe lt20
Part OneA 67-year-old woman with congestive cardiac failure remains breathless on moderate exertion despite treatment with 40 mg frusemide and 20 mg enalapril daily On examination she has a pulse rate of 80minute blood pressure of 12570 mmHg and a jugular venous pressure (JVP) of +1 cm She has a soft systolic murmur with no added sounds her chest is clear and she has no oedema An ECG shows sinus rhythm A chest X-ray shows cardiomegaly with a cardiothoracic ratio of 15528 but no pulmonary congestion Echocardiography demonstrates systolic dysfunction with fractional shortening of 18 and mild mitral regurgitation Her serum creatinine level is normal
Which of the following is the most appropriate next step in treatment A Increase the frusemide dose B Add digoxin C Add an aldosterone antagonist D Add an angiotensin II receptor antagonist E Add a beta blocker
Left ventricle - diastolic function
Mitral inflow Pulmonary veins
Mitral TVI
LV diastolic function - mitral inflow
EA gt 1 EA lt 1 EA gtgt1
LV diastolic function - mitral TVI
EA gt 1 EA lt 1 EA gtgt1
Left ventricle - RWMAs
Left ventricle - RWMAs
Left ventricle - RWMAs
Left ventricle - thrombus
Left atrium - size
Diameter
Normal 20-40cm
Mild 40-50cm
Moderate 50-60cm
Severe gt60cm
Left atrium - size
Area
Normal lt20cm2
Mild 20-30cm2
Moderate 30-40cm2
Severe gt40cm2
Left atrium - thrombus
Cardiac Valves
Morphology
Valve dysfunction
aetiology
quantification
consequences
serial evaluation
Valve regurgitation - quantification
Colour - jet sizewidth
PISA
Spectral doppler
Consequences
AR - LV Response
bull Chronic AR - decompensated LV
bull LVEFlt55 LVESDgt55mm LVESV 60mlm2
Part OneA patient with aortic regurgitation has the following haemodynamic measurements cardiac output (CO) 75 Lminute heart rate (HR) 75minute left ventricular end-diastolic volume (LVEDV) 200 mL left ventricular end-systolic volume (LVESV) 50 mL The regurgitant fraction is defined as the ratio of the regurgitant volume to the total volume flowing through the valve with each beat
The regurgitant fraction in this patient is A 25 B 33 C 50 D 67 E 75
Part OneA 45-year-old asymptomatic man returns for follow-up He was diagnosed 10 years ago with aortic regurgitation due to a congenital bicuspid aortic valve He has never had endocarditis Which one of the following echocardiographic profiles most strongly indicates the need for aortic valve replacement
LVEDD (mm)[35-55] FS [030-040] LA size (mm) [lt40]
A 70 030 60
B 75 040 40
C 70 025 45
D 65 045 50
E 75 035 55
Key LVEDD Left ventricular end-diastolic diameter LVESD Left ventricular end-systolic diameter FS Fractional shortening = (LVEDD - LVESD) LVEDD LA Left atrial
MR- Quantification of LV contractility
LV systolic function - most important parameter
bullEjection fraction fractional shortening velocity of
circumferential fibre shortening - load dependent
bullMR allows supranormal values of EF etc
bullEarly systolic dysfunction if
bullEF lt 60 (severe MR)
bullES diameter lt 45mm (26mmm2)
Mitral stenosis - quantification
Severity MVA (cm2) LAP (mm Hg) CO
Mild gt20 lt10-12 NL
Moderate 11-20 ~10-17 NL
Severe lt10 gt18
Very Severe lt08 gt20-25
Part OneA 35-year-old woman has increasing breathlessness on exertion Her cardiac silhouette is slightly enlarged on a chest X-ray and an ECG demonstrates sinus rhythm The continuous wave Doppler flow signal through the mitral inflow tract (shown above) is most consistent with which one of the following A Severe pulmonary hypertension (cor pulmonale) B Aortic stenosis C Mitral regurgitation D Mitral stenosis E Aortic regurgitation
Part OneA 28-year-old woman who emigrated from Cambodia 10 years ago presents to the emergency department with a three-week history of increasing shortness of breath orthopnoea nocturnal dyspnoea and ankle oedema She is 25 weeks pregnant and has no significant past medical history The presence of pulmonary oedema is confirmed clinically and radiologically She responds well to intravenous frusemide but remains tachypnoeic with a heart rate of 120minute in sinus rhythm Her blood pressure is 12585 mmHg Echocardiography demonstrates mitral stenosis with an estimated valve area of 13 cm2 and a left atrial diameter of 50 mm [lt40 mm] There are no other abnormalities What is the most appropriate next step in management A Balloon valvotomy B Surgical valvotomy C Digoxin therapy D Beta-blocker therapy E Angiotensin converting enzyme (ACE) inhibitor therapy
Part OneA 55-year-old man presents with acute pulmonary oedema Five years earlier he has undergone a mitral valve replacement with a bileaflet tilting disk valve (St Jude) for mixed mitral valve disease He has been well with normal exercise tolerance prior to the day of admission Examination on admission reveals tachypnoea sinus tachycardia of 110minute blood pressure of 10560 mmHg elevated jugular venous pressure (+ 5 cm) and bilateral crepitations throughout the lung fields His prothrombin timeminusinternational normalised ratio (PT-INR) is 19 [desired therapeutic range 20-35] Serum urea creatinine and electrolytes are normal The cardiothoracic ratio on chest X-ray is normal but the presence of pulmonary oedema is confirmed Echocardiography reveals that one of the prosthetic valve leaflets is not moving and there is an increased flow rate in diastole across the valve orifice (2 metressecond) What is the most appropriate course of action A Administration of intravenous streptokinase B Administration of intravenous heparin C Administration of intravenous antibiotics D Addition of an antiplatelet agent E Immediate mitral valve replacement
Aortic stenosis - quantification
Aortic stenosis - quantification Mean gradient
(mmHg) Peak Ao velocity
AVA (cm2)
Normal 10-20 gt25
Mild lt20 25-29 gt17
Moderate 20-40 30-40 10-17
Severe gt40 gt40 lt10
Right ventricle - size amp function
Estimation of Pulmonary PressurePA systolic pressure
bull Tricuspid regurgitation jet velocity
Estimation of Pulmonary PressureRA pressure
bull IVC size
Part OneThe severity of pulmonary hypertension can be determined using continuous wave Doppler measurements of the velocity of tricuspid regurgitation This method uses the Bernoulli equation which states that 1048661P = 4v2 (where 1048661P = instantaneous pressure gradient and v = velocity across the valve) There is tricuspid regurgitation with a peak velocity of 4 metressecond and a mean velocity of 35 metressecond Assuming right atrial pressure is 5 mmHg the best estimate of the peak right ventricular systolic pressure (plusmn 2 mmHg) is
A 50 mmHg B 55 mmHg C 60 mmHg D 65 mmHg E 70 mmHg
Cardiac Tamponade
Cardiac Tamponade
Cardiac Tamponade
Part OneA 65-year-old woman presents with a one-week history of progressive dyspnoea On admission there are signs of shock a systolic murmur and an elevated jugular venous pressure The ECG shows sinus tachycardia but no other abnormality An antero-posterior chest X-ray shows cardiomegaly The serum troponin I level is 05 mgL [lt01] A computed tomography (CT) scan is shown below
What is the most likely diagnosis A Pulmonary embolism B Right ventricular infarction C Pericardial tamponade D Myocarditis E Acute mitral regurgitation
Endocarditis
Positive echocardiogram for IE Discrete echogenic oscillating intracardiac mass located at a site of endocardial injury (eg on a valve or supporting structure in pathway of regurgitant jet or site of implanted material) or Periannular abscess or
New dehiscence of a prosthetic valve
Cardiac Resynchronisation
Cardiac Resynchronisation
bullSevere heart failure treatment to restore co-ordination to LV contraction
bullNYHA 3-4bullEF lt 35bullQRS duration gt 120 msec
Echocardiography
bullUseful non-invasive tool
bullReports objective and subjective
bullLimitations
Echocardiography Basics
Echocardiography Basics
Echocardiography Basics
Echocardiography Basics
One-dimensional imaging (M-mode)
Echocardiography Basics
One-dimensional imaging (M-mode)
Echocardiography BasicsDoppler - Spectral
Pulse Continuous
Bernoulli equation P = 4V2
Echocardiography Basics
Doppler - Colour
Echocardiography Basics
Tissue velocity imaging
Echocardiography Basics
Tissue velocity imaging
Left ventricle - size
Normal
End-diastole 35-57cm
End-systole 21-40cm
Left ventricle - size
Normal
End-diastole 35-57cm
End-systole 21-40cm
Left ventricle - wall thickness
IVS and PW
06 -11cm
Left ventricle - systolic function
Fractional Shortening (FS)
FS = EDD-ESD EDD
Left ventricle - systolic function
Fractional Shortening (FS)
FS = EDD-ESD EDD
Left ventricle - systolic function
Left ventricle - systolic function
Ejection fraction ()
Normal gt55
Mild 40-50
Moderate 30-40
Moderate-severe 20-30
Severe lt20
Part OneA 67-year-old woman with congestive cardiac failure remains breathless on moderate exertion despite treatment with 40 mg frusemide and 20 mg enalapril daily On examination she has a pulse rate of 80minute blood pressure of 12570 mmHg and a jugular venous pressure (JVP) of +1 cm She has a soft systolic murmur with no added sounds her chest is clear and she has no oedema An ECG shows sinus rhythm A chest X-ray shows cardiomegaly with a cardiothoracic ratio of 15528 but no pulmonary congestion Echocardiography demonstrates systolic dysfunction with fractional shortening of 18 and mild mitral regurgitation Her serum creatinine level is normal
Which of the following is the most appropriate next step in treatment A Increase the frusemide dose B Add digoxin C Add an aldosterone antagonist D Add an angiotensin II receptor antagonist E Add a beta blocker
Left ventricle - diastolic function
Mitral inflow Pulmonary veins
Mitral TVI
LV diastolic function - mitral inflow
EA gt 1 EA lt 1 EA gtgt1
LV diastolic function - mitral TVI
EA gt 1 EA lt 1 EA gtgt1
Left ventricle - RWMAs
Left ventricle - RWMAs
Left ventricle - RWMAs
Left ventricle - thrombus
Left atrium - size
Diameter
Normal 20-40cm
Mild 40-50cm
Moderate 50-60cm
Severe gt60cm
Left atrium - size
Area
Normal lt20cm2
Mild 20-30cm2
Moderate 30-40cm2
Severe gt40cm2
Left atrium - thrombus
Cardiac Valves
Morphology
Valve dysfunction
aetiology
quantification
consequences
serial evaluation
Valve regurgitation - quantification
Colour - jet sizewidth
PISA
Spectral doppler
Consequences
AR - LV Response
bull Chronic AR - decompensated LV
bull LVEFlt55 LVESDgt55mm LVESV 60mlm2
Part OneA patient with aortic regurgitation has the following haemodynamic measurements cardiac output (CO) 75 Lminute heart rate (HR) 75minute left ventricular end-diastolic volume (LVEDV) 200 mL left ventricular end-systolic volume (LVESV) 50 mL The regurgitant fraction is defined as the ratio of the regurgitant volume to the total volume flowing through the valve with each beat
The regurgitant fraction in this patient is A 25 B 33 C 50 D 67 E 75
Part OneA 45-year-old asymptomatic man returns for follow-up He was diagnosed 10 years ago with aortic regurgitation due to a congenital bicuspid aortic valve He has never had endocarditis Which one of the following echocardiographic profiles most strongly indicates the need for aortic valve replacement
LVEDD (mm)[35-55] FS [030-040] LA size (mm) [lt40]
A 70 030 60
B 75 040 40
C 70 025 45
D 65 045 50
E 75 035 55
Key LVEDD Left ventricular end-diastolic diameter LVESD Left ventricular end-systolic diameter FS Fractional shortening = (LVEDD - LVESD) LVEDD LA Left atrial
MR- Quantification of LV contractility
LV systolic function - most important parameter
bullEjection fraction fractional shortening velocity of
circumferential fibre shortening - load dependent
bullMR allows supranormal values of EF etc
bullEarly systolic dysfunction if
bullEF lt 60 (severe MR)
bullES diameter lt 45mm (26mmm2)
Mitral stenosis - quantification
Severity MVA (cm2) LAP (mm Hg) CO
Mild gt20 lt10-12 NL
Moderate 11-20 ~10-17 NL
Severe lt10 gt18
Very Severe lt08 gt20-25
Part OneA 35-year-old woman has increasing breathlessness on exertion Her cardiac silhouette is slightly enlarged on a chest X-ray and an ECG demonstrates sinus rhythm The continuous wave Doppler flow signal through the mitral inflow tract (shown above) is most consistent with which one of the following A Severe pulmonary hypertension (cor pulmonale) B Aortic stenosis C Mitral regurgitation D Mitral stenosis E Aortic regurgitation
Part OneA 28-year-old woman who emigrated from Cambodia 10 years ago presents to the emergency department with a three-week history of increasing shortness of breath orthopnoea nocturnal dyspnoea and ankle oedema She is 25 weeks pregnant and has no significant past medical history The presence of pulmonary oedema is confirmed clinically and radiologically She responds well to intravenous frusemide but remains tachypnoeic with a heart rate of 120minute in sinus rhythm Her blood pressure is 12585 mmHg Echocardiography demonstrates mitral stenosis with an estimated valve area of 13 cm2 and a left atrial diameter of 50 mm [lt40 mm] There are no other abnormalities What is the most appropriate next step in management A Balloon valvotomy B Surgical valvotomy C Digoxin therapy D Beta-blocker therapy E Angiotensin converting enzyme (ACE) inhibitor therapy
Part OneA 55-year-old man presents with acute pulmonary oedema Five years earlier he has undergone a mitral valve replacement with a bileaflet tilting disk valve (St Jude) for mixed mitral valve disease He has been well with normal exercise tolerance prior to the day of admission Examination on admission reveals tachypnoea sinus tachycardia of 110minute blood pressure of 10560 mmHg elevated jugular venous pressure (+ 5 cm) and bilateral crepitations throughout the lung fields His prothrombin timeminusinternational normalised ratio (PT-INR) is 19 [desired therapeutic range 20-35] Serum urea creatinine and electrolytes are normal The cardiothoracic ratio on chest X-ray is normal but the presence of pulmonary oedema is confirmed Echocardiography reveals that one of the prosthetic valve leaflets is not moving and there is an increased flow rate in diastole across the valve orifice (2 metressecond) What is the most appropriate course of action A Administration of intravenous streptokinase B Administration of intravenous heparin C Administration of intravenous antibiotics D Addition of an antiplatelet agent E Immediate mitral valve replacement
Aortic stenosis - quantification
Aortic stenosis - quantification Mean gradient
(mmHg) Peak Ao velocity
AVA (cm2)
Normal 10-20 gt25
Mild lt20 25-29 gt17
Moderate 20-40 30-40 10-17
Severe gt40 gt40 lt10
Right ventricle - size amp function
Estimation of Pulmonary PressurePA systolic pressure
bull Tricuspid regurgitation jet velocity
Estimation of Pulmonary PressureRA pressure
bull IVC size
Part OneThe severity of pulmonary hypertension can be determined using continuous wave Doppler measurements of the velocity of tricuspid regurgitation This method uses the Bernoulli equation which states that 1048661P = 4v2 (where 1048661P = instantaneous pressure gradient and v = velocity across the valve) There is tricuspid regurgitation with a peak velocity of 4 metressecond and a mean velocity of 35 metressecond Assuming right atrial pressure is 5 mmHg the best estimate of the peak right ventricular systolic pressure (plusmn 2 mmHg) is
A 50 mmHg B 55 mmHg C 60 mmHg D 65 mmHg E 70 mmHg
Cardiac Tamponade
Cardiac Tamponade
Cardiac Tamponade
Part OneA 65-year-old woman presents with a one-week history of progressive dyspnoea On admission there are signs of shock a systolic murmur and an elevated jugular venous pressure The ECG shows sinus tachycardia but no other abnormality An antero-posterior chest X-ray shows cardiomegaly The serum troponin I level is 05 mgL [lt01] A computed tomography (CT) scan is shown below
What is the most likely diagnosis A Pulmonary embolism B Right ventricular infarction C Pericardial tamponade D Myocarditis E Acute mitral regurgitation
Endocarditis
Positive echocardiogram for IE Discrete echogenic oscillating intracardiac mass located at a site of endocardial injury (eg on a valve or supporting structure in pathway of regurgitant jet or site of implanted material) or Periannular abscess or
New dehiscence of a prosthetic valve
Cardiac Resynchronisation
Cardiac Resynchronisation
bullSevere heart failure treatment to restore co-ordination to LV contraction
bullNYHA 3-4bullEF lt 35bullQRS duration gt 120 msec
Echocardiography
bullUseful non-invasive tool
bullReports objective and subjective
bullLimitations
Echocardiography Basics
Echocardiography Basics
Echocardiography Basics
One-dimensional imaging (M-mode)
Echocardiography Basics
One-dimensional imaging (M-mode)
Echocardiography BasicsDoppler - Spectral
Pulse Continuous
Bernoulli equation P = 4V2
Echocardiography Basics
Doppler - Colour
Echocardiography Basics
Tissue velocity imaging
Echocardiography Basics
Tissue velocity imaging
Left ventricle - size
Normal
End-diastole 35-57cm
End-systole 21-40cm
Left ventricle - size
Normal
End-diastole 35-57cm
End-systole 21-40cm
Left ventricle - wall thickness
IVS and PW
06 -11cm
Left ventricle - systolic function
Fractional Shortening (FS)
FS = EDD-ESD EDD
Left ventricle - systolic function
Fractional Shortening (FS)
FS = EDD-ESD EDD
Left ventricle - systolic function
Left ventricle - systolic function
Ejection fraction ()
Normal gt55
Mild 40-50
Moderate 30-40
Moderate-severe 20-30
Severe lt20
Part OneA 67-year-old woman with congestive cardiac failure remains breathless on moderate exertion despite treatment with 40 mg frusemide and 20 mg enalapril daily On examination she has a pulse rate of 80minute blood pressure of 12570 mmHg and a jugular venous pressure (JVP) of +1 cm She has a soft systolic murmur with no added sounds her chest is clear and she has no oedema An ECG shows sinus rhythm A chest X-ray shows cardiomegaly with a cardiothoracic ratio of 15528 but no pulmonary congestion Echocardiography demonstrates systolic dysfunction with fractional shortening of 18 and mild mitral regurgitation Her serum creatinine level is normal
Which of the following is the most appropriate next step in treatment A Increase the frusemide dose B Add digoxin C Add an aldosterone antagonist D Add an angiotensin II receptor antagonist E Add a beta blocker
Left ventricle - diastolic function
Mitral inflow Pulmonary veins
Mitral TVI
LV diastolic function - mitral inflow
EA gt 1 EA lt 1 EA gtgt1
LV diastolic function - mitral TVI
EA gt 1 EA lt 1 EA gtgt1
Left ventricle - RWMAs
Left ventricle - RWMAs
Left ventricle - RWMAs
Left ventricle - thrombus
Left atrium - size
Diameter
Normal 20-40cm
Mild 40-50cm
Moderate 50-60cm
Severe gt60cm
Left atrium - size
Area
Normal lt20cm2
Mild 20-30cm2
Moderate 30-40cm2
Severe gt40cm2
Left atrium - thrombus
Cardiac Valves
Morphology
Valve dysfunction
aetiology
quantification
consequences
serial evaluation
Valve regurgitation - quantification
Colour - jet sizewidth
PISA
Spectral doppler
Consequences
AR - LV Response
bull Chronic AR - decompensated LV
bull LVEFlt55 LVESDgt55mm LVESV 60mlm2
Part OneA patient with aortic regurgitation has the following haemodynamic measurements cardiac output (CO) 75 Lminute heart rate (HR) 75minute left ventricular end-diastolic volume (LVEDV) 200 mL left ventricular end-systolic volume (LVESV) 50 mL The regurgitant fraction is defined as the ratio of the regurgitant volume to the total volume flowing through the valve with each beat
The regurgitant fraction in this patient is A 25 B 33 C 50 D 67 E 75
Part OneA 45-year-old asymptomatic man returns for follow-up He was diagnosed 10 years ago with aortic regurgitation due to a congenital bicuspid aortic valve He has never had endocarditis Which one of the following echocardiographic profiles most strongly indicates the need for aortic valve replacement
LVEDD (mm)[35-55] FS [030-040] LA size (mm) [lt40]
A 70 030 60
B 75 040 40
C 70 025 45
D 65 045 50
E 75 035 55
Key LVEDD Left ventricular end-diastolic diameter LVESD Left ventricular end-systolic diameter FS Fractional shortening = (LVEDD - LVESD) LVEDD LA Left atrial
MR- Quantification of LV contractility
LV systolic function - most important parameter
bullEjection fraction fractional shortening velocity of
circumferential fibre shortening - load dependent
bullMR allows supranormal values of EF etc
bullEarly systolic dysfunction if
bullEF lt 60 (severe MR)
bullES diameter lt 45mm (26mmm2)
Mitral stenosis - quantification
Severity MVA (cm2) LAP (mm Hg) CO
Mild gt20 lt10-12 NL
Moderate 11-20 ~10-17 NL
Severe lt10 gt18
Very Severe lt08 gt20-25
Part OneA 35-year-old woman has increasing breathlessness on exertion Her cardiac silhouette is slightly enlarged on a chest X-ray and an ECG demonstrates sinus rhythm The continuous wave Doppler flow signal through the mitral inflow tract (shown above) is most consistent with which one of the following A Severe pulmonary hypertension (cor pulmonale) B Aortic stenosis C Mitral regurgitation D Mitral stenosis E Aortic regurgitation
Part OneA 28-year-old woman who emigrated from Cambodia 10 years ago presents to the emergency department with a three-week history of increasing shortness of breath orthopnoea nocturnal dyspnoea and ankle oedema She is 25 weeks pregnant and has no significant past medical history The presence of pulmonary oedema is confirmed clinically and radiologically She responds well to intravenous frusemide but remains tachypnoeic with a heart rate of 120minute in sinus rhythm Her blood pressure is 12585 mmHg Echocardiography demonstrates mitral stenosis with an estimated valve area of 13 cm2 and a left atrial diameter of 50 mm [lt40 mm] There are no other abnormalities What is the most appropriate next step in management A Balloon valvotomy B Surgical valvotomy C Digoxin therapy D Beta-blocker therapy E Angiotensin converting enzyme (ACE) inhibitor therapy
Part OneA 55-year-old man presents with acute pulmonary oedema Five years earlier he has undergone a mitral valve replacement with a bileaflet tilting disk valve (St Jude) for mixed mitral valve disease He has been well with normal exercise tolerance prior to the day of admission Examination on admission reveals tachypnoea sinus tachycardia of 110minute blood pressure of 10560 mmHg elevated jugular venous pressure (+ 5 cm) and bilateral crepitations throughout the lung fields His prothrombin timeminusinternational normalised ratio (PT-INR) is 19 [desired therapeutic range 20-35] Serum urea creatinine and electrolytes are normal The cardiothoracic ratio on chest X-ray is normal but the presence of pulmonary oedema is confirmed Echocardiography reveals that one of the prosthetic valve leaflets is not moving and there is an increased flow rate in diastole across the valve orifice (2 metressecond) What is the most appropriate course of action A Administration of intravenous streptokinase B Administration of intravenous heparin C Administration of intravenous antibiotics D Addition of an antiplatelet agent E Immediate mitral valve replacement
Aortic stenosis - quantification
Aortic stenosis - quantification Mean gradient
(mmHg) Peak Ao velocity
AVA (cm2)
Normal 10-20 gt25
Mild lt20 25-29 gt17
Moderate 20-40 30-40 10-17
Severe gt40 gt40 lt10
Right ventricle - size amp function
Estimation of Pulmonary PressurePA systolic pressure
bull Tricuspid regurgitation jet velocity
Estimation of Pulmonary PressureRA pressure
bull IVC size
Part OneThe severity of pulmonary hypertension can be determined using continuous wave Doppler measurements of the velocity of tricuspid regurgitation This method uses the Bernoulli equation which states that 1048661P = 4v2 (where 1048661P = instantaneous pressure gradient and v = velocity across the valve) There is tricuspid regurgitation with a peak velocity of 4 metressecond and a mean velocity of 35 metressecond Assuming right atrial pressure is 5 mmHg the best estimate of the peak right ventricular systolic pressure (plusmn 2 mmHg) is
A 50 mmHg B 55 mmHg C 60 mmHg D 65 mmHg E 70 mmHg
Cardiac Tamponade
Cardiac Tamponade
Cardiac Tamponade
Part OneA 65-year-old woman presents with a one-week history of progressive dyspnoea On admission there are signs of shock a systolic murmur and an elevated jugular venous pressure The ECG shows sinus tachycardia but no other abnormality An antero-posterior chest X-ray shows cardiomegaly The serum troponin I level is 05 mgL [lt01] A computed tomography (CT) scan is shown below
What is the most likely diagnosis A Pulmonary embolism B Right ventricular infarction C Pericardial tamponade D Myocarditis E Acute mitral regurgitation
Endocarditis
Positive echocardiogram for IE Discrete echogenic oscillating intracardiac mass located at a site of endocardial injury (eg on a valve or supporting structure in pathway of regurgitant jet or site of implanted material) or Periannular abscess or
New dehiscence of a prosthetic valve
Cardiac Resynchronisation
Cardiac Resynchronisation
bullSevere heart failure treatment to restore co-ordination to LV contraction
bullNYHA 3-4bullEF lt 35bullQRS duration gt 120 msec
Echocardiography
bullUseful non-invasive tool
bullReports objective and subjective
bullLimitations
Echocardiography Basics
Echocardiography Basics
One-dimensional imaging (M-mode)
Echocardiography Basics
One-dimensional imaging (M-mode)
Echocardiography BasicsDoppler - Spectral
Pulse Continuous
Bernoulli equation P = 4V2
Echocardiography Basics
Doppler - Colour
Echocardiography Basics
Tissue velocity imaging
Echocardiography Basics
Tissue velocity imaging
Left ventricle - size
Normal
End-diastole 35-57cm
End-systole 21-40cm
Left ventricle - size
Normal
End-diastole 35-57cm
End-systole 21-40cm
Left ventricle - wall thickness
IVS and PW
06 -11cm
Left ventricle - systolic function
Fractional Shortening (FS)
FS = EDD-ESD EDD
Left ventricle - systolic function
Fractional Shortening (FS)
FS = EDD-ESD EDD
Left ventricle - systolic function
Left ventricle - systolic function
Ejection fraction ()
Normal gt55
Mild 40-50
Moderate 30-40
Moderate-severe 20-30
Severe lt20
Part OneA 67-year-old woman with congestive cardiac failure remains breathless on moderate exertion despite treatment with 40 mg frusemide and 20 mg enalapril daily On examination she has a pulse rate of 80minute blood pressure of 12570 mmHg and a jugular venous pressure (JVP) of +1 cm She has a soft systolic murmur with no added sounds her chest is clear and she has no oedema An ECG shows sinus rhythm A chest X-ray shows cardiomegaly with a cardiothoracic ratio of 15528 but no pulmonary congestion Echocardiography demonstrates systolic dysfunction with fractional shortening of 18 and mild mitral regurgitation Her serum creatinine level is normal
Which of the following is the most appropriate next step in treatment A Increase the frusemide dose B Add digoxin C Add an aldosterone antagonist D Add an angiotensin II receptor antagonist E Add a beta blocker
Left ventricle - diastolic function
Mitral inflow Pulmonary veins
Mitral TVI
LV diastolic function - mitral inflow
EA gt 1 EA lt 1 EA gtgt1
LV diastolic function - mitral TVI
EA gt 1 EA lt 1 EA gtgt1
Left ventricle - RWMAs
Left ventricle - RWMAs
Left ventricle - RWMAs
Left ventricle - thrombus
Left atrium - size
Diameter
Normal 20-40cm
Mild 40-50cm
Moderate 50-60cm
Severe gt60cm
Left atrium - size
Area
Normal lt20cm2
Mild 20-30cm2
Moderate 30-40cm2
Severe gt40cm2
Left atrium - thrombus
Cardiac Valves
Morphology
Valve dysfunction
aetiology
quantification
consequences
serial evaluation
Valve regurgitation - quantification
Colour - jet sizewidth
PISA
Spectral doppler
Consequences
AR - LV Response
bull Chronic AR - decompensated LV
bull LVEFlt55 LVESDgt55mm LVESV 60mlm2
Part OneA patient with aortic regurgitation has the following haemodynamic measurements cardiac output (CO) 75 Lminute heart rate (HR) 75minute left ventricular end-diastolic volume (LVEDV) 200 mL left ventricular end-systolic volume (LVESV) 50 mL The regurgitant fraction is defined as the ratio of the regurgitant volume to the total volume flowing through the valve with each beat
The regurgitant fraction in this patient is A 25 B 33 C 50 D 67 E 75
Part OneA 45-year-old asymptomatic man returns for follow-up He was diagnosed 10 years ago with aortic regurgitation due to a congenital bicuspid aortic valve He has never had endocarditis Which one of the following echocardiographic profiles most strongly indicates the need for aortic valve replacement
LVEDD (mm)[35-55] FS [030-040] LA size (mm) [lt40]
A 70 030 60
B 75 040 40
C 70 025 45
D 65 045 50
E 75 035 55
Key LVEDD Left ventricular end-diastolic diameter LVESD Left ventricular end-systolic diameter FS Fractional shortening = (LVEDD - LVESD) LVEDD LA Left atrial
MR- Quantification of LV contractility
LV systolic function - most important parameter
bullEjection fraction fractional shortening velocity of
circumferential fibre shortening - load dependent
bullMR allows supranormal values of EF etc
bullEarly systolic dysfunction if
bullEF lt 60 (severe MR)
bullES diameter lt 45mm (26mmm2)
Mitral stenosis - quantification
Severity MVA (cm2) LAP (mm Hg) CO
Mild gt20 lt10-12 NL
Moderate 11-20 ~10-17 NL
Severe lt10 gt18
Very Severe lt08 gt20-25
Part OneA 35-year-old woman has increasing breathlessness on exertion Her cardiac silhouette is slightly enlarged on a chest X-ray and an ECG demonstrates sinus rhythm The continuous wave Doppler flow signal through the mitral inflow tract (shown above) is most consistent with which one of the following A Severe pulmonary hypertension (cor pulmonale) B Aortic stenosis C Mitral regurgitation D Mitral stenosis E Aortic regurgitation
Part OneA 28-year-old woman who emigrated from Cambodia 10 years ago presents to the emergency department with a three-week history of increasing shortness of breath orthopnoea nocturnal dyspnoea and ankle oedema She is 25 weeks pregnant and has no significant past medical history The presence of pulmonary oedema is confirmed clinically and radiologically She responds well to intravenous frusemide but remains tachypnoeic with a heart rate of 120minute in sinus rhythm Her blood pressure is 12585 mmHg Echocardiography demonstrates mitral stenosis with an estimated valve area of 13 cm2 and a left atrial diameter of 50 mm [lt40 mm] There are no other abnormalities What is the most appropriate next step in management A Balloon valvotomy B Surgical valvotomy C Digoxin therapy D Beta-blocker therapy E Angiotensin converting enzyme (ACE) inhibitor therapy
Part OneA 55-year-old man presents with acute pulmonary oedema Five years earlier he has undergone a mitral valve replacement with a bileaflet tilting disk valve (St Jude) for mixed mitral valve disease He has been well with normal exercise tolerance prior to the day of admission Examination on admission reveals tachypnoea sinus tachycardia of 110minute blood pressure of 10560 mmHg elevated jugular venous pressure (+ 5 cm) and bilateral crepitations throughout the lung fields His prothrombin timeminusinternational normalised ratio (PT-INR) is 19 [desired therapeutic range 20-35] Serum urea creatinine and electrolytes are normal The cardiothoracic ratio on chest X-ray is normal but the presence of pulmonary oedema is confirmed Echocardiography reveals that one of the prosthetic valve leaflets is not moving and there is an increased flow rate in diastole across the valve orifice (2 metressecond) What is the most appropriate course of action A Administration of intravenous streptokinase B Administration of intravenous heparin C Administration of intravenous antibiotics D Addition of an antiplatelet agent E Immediate mitral valve replacement
Aortic stenosis - quantification
Aortic stenosis - quantification Mean gradient
(mmHg) Peak Ao velocity
AVA (cm2)
Normal 10-20 gt25
Mild lt20 25-29 gt17
Moderate 20-40 30-40 10-17
Severe gt40 gt40 lt10
Right ventricle - size amp function
Estimation of Pulmonary PressurePA systolic pressure
bull Tricuspid regurgitation jet velocity
Estimation of Pulmonary PressureRA pressure
bull IVC size
Part OneThe severity of pulmonary hypertension can be determined using continuous wave Doppler measurements of the velocity of tricuspid regurgitation This method uses the Bernoulli equation which states that 1048661P = 4v2 (where 1048661P = instantaneous pressure gradient and v = velocity across the valve) There is tricuspid regurgitation with a peak velocity of 4 metressecond and a mean velocity of 35 metressecond Assuming right atrial pressure is 5 mmHg the best estimate of the peak right ventricular systolic pressure (plusmn 2 mmHg) is
A 50 mmHg B 55 mmHg C 60 mmHg D 65 mmHg E 70 mmHg
Cardiac Tamponade
Cardiac Tamponade
Cardiac Tamponade
Part OneA 65-year-old woman presents with a one-week history of progressive dyspnoea On admission there are signs of shock a systolic murmur and an elevated jugular venous pressure The ECG shows sinus tachycardia but no other abnormality An antero-posterior chest X-ray shows cardiomegaly The serum troponin I level is 05 mgL [lt01] A computed tomography (CT) scan is shown below
What is the most likely diagnosis A Pulmonary embolism B Right ventricular infarction C Pericardial tamponade D Myocarditis E Acute mitral regurgitation
Endocarditis
Positive echocardiogram for IE Discrete echogenic oscillating intracardiac mass located at a site of endocardial injury (eg on a valve or supporting structure in pathway of regurgitant jet or site of implanted material) or Periannular abscess or
New dehiscence of a prosthetic valve
Cardiac Resynchronisation
Cardiac Resynchronisation
bullSevere heart failure treatment to restore co-ordination to LV contraction
bullNYHA 3-4bullEF lt 35bullQRS duration gt 120 msec
Echocardiography
bullUseful non-invasive tool
bullReports objective and subjective
bullLimitations
Echocardiography Basics
One-dimensional imaging (M-mode)
Echocardiography Basics
One-dimensional imaging (M-mode)
Echocardiography BasicsDoppler - Spectral
Pulse Continuous
Bernoulli equation P = 4V2
Echocardiography Basics
Doppler - Colour
Echocardiography Basics
Tissue velocity imaging
Echocardiography Basics
Tissue velocity imaging
Left ventricle - size
Normal
End-diastole 35-57cm
End-systole 21-40cm
Left ventricle - size
Normal
End-diastole 35-57cm
End-systole 21-40cm
Left ventricle - wall thickness
IVS and PW
06 -11cm
Left ventricle - systolic function
Fractional Shortening (FS)
FS = EDD-ESD EDD
Left ventricle - systolic function
Fractional Shortening (FS)
FS = EDD-ESD EDD
Left ventricle - systolic function
Left ventricle - systolic function
Ejection fraction ()
Normal gt55
Mild 40-50
Moderate 30-40
Moderate-severe 20-30
Severe lt20
Part OneA 67-year-old woman with congestive cardiac failure remains breathless on moderate exertion despite treatment with 40 mg frusemide and 20 mg enalapril daily On examination she has a pulse rate of 80minute blood pressure of 12570 mmHg and a jugular venous pressure (JVP) of +1 cm She has a soft systolic murmur with no added sounds her chest is clear and she has no oedema An ECG shows sinus rhythm A chest X-ray shows cardiomegaly with a cardiothoracic ratio of 15528 but no pulmonary congestion Echocardiography demonstrates systolic dysfunction with fractional shortening of 18 and mild mitral regurgitation Her serum creatinine level is normal
Which of the following is the most appropriate next step in treatment A Increase the frusemide dose B Add digoxin C Add an aldosterone antagonist D Add an angiotensin II receptor antagonist E Add a beta blocker
Left ventricle - diastolic function
Mitral inflow Pulmonary veins
Mitral TVI
LV diastolic function - mitral inflow
EA gt 1 EA lt 1 EA gtgt1
LV diastolic function - mitral TVI
EA gt 1 EA lt 1 EA gtgt1
Left ventricle - RWMAs
Left ventricle - RWMAs
Left ventricle - RWMAs
Left ventricle - thrombus
Left atrium - size
Diameter
Normal 20-40cm
Mild 40-50cm
Moderate 50-60cm
Severe gt60cm
Left atrium - size
Area
Normal lt20cm2
Mild 20-30cm2
Moderate 30-40cm2
Severe gt40cm2
Left atrium - thrombus
Cardiac Valves
Morphology
Valve dysfunction
aetiology
quantification
consequences
serial evaluation
Valve regurgitation - quantification
Colour - jet sizewidth
PISA
Spectral doppler
Consequences
AR - LV Response
bull Chronic AR - decompensated LV
bull LVEFlt55 LVESDgt55mm LVESV 60mlm2
Part OneA patient with aortic regurgitation has the following haemodynamic measurements cardiac output (CO) 75 Lminute heart rate (HR) 75minute left ventricular end-diastolic volume (LVEDV) 200 mL left ventricular end-systolic volume (LVESV) 50 mL The regurgitant fraction is defined as the ratio of the regurgitant volume to the total volume flowing through the valve with each beat
The regurgitant fraction in this patient is A 25 B 33 C 50 D 67 E 75
Part OneA 45-year-old asymptomatic man returns for follow-up He was diagnosed 10 years ago with aortic regurgitation due to a congenital bicuspid aortic valve He has never had endocarditis Which one of the following echocardiographic profiles most strongly indicates the need for aortic valve replacement
LVEDD (mm)[35-55] FS [030-040] LA size (mm) [lt40]
A 70 030 60
B 75 040 40
C 70 025 45
D 65 045 50
E 75 035 55
Key LVEDD Left ventricular end-diastolic diameter LVESD Left ventricular end-systolic diameter FS Fractional shortening = (LVEDD - LVESD) LVEDD LA Left atrial
MR- Quantification of LV contractility
LV systolic function - most important parameter
bullEjection fraction fractional shortening velocity of
circumferential fibre shortening - load dependent
bullMR allows supranormal values of EF etc
bullEarly systolic dysfunction if
bullEF lt 60 (severe MR)
bullES diameter lt 45mm (26mmm2)
Mitral stenosis - quantification
Severity MVA (cm2) LAP (mm Hg) CO
Mild gt20 lt10-12 NL
Moderate 11-20 ~10-17 NL
Severe lt10 gt18
Very Severe lt08 gt20-25
Part OneA 35-year-old woman has increasing breathlessness on exertion Her cardiac silhouette is slightly enlarged on a chest X-ray and an ECG demonstrates sinus rhythm The continuous wave Doppler flow signal through the mitral inflow tract (shown above) is most consistent with which one of the following A Severe pulmonary hypertension (cor pulmonale) B Aortic stenosis C Mitral regurgitation D Mitral stenosis E Aortic regurgitation
Part OneA 28-year-old woman who emigrated from Cambodia 10 years ago presents to the emergency department with a three-week history of increasing shortness of breath orthopnoea nocturnal dyspnoea and ankle oedema She is 25 weeks pregnant and has no significant past medical history The presence of pulmonary oedema is confirmed clinically and radiologically She responds well to intravenous frusemide but remains tachypnoeic with a heart rate of 120minute in sinus rhythm Her blood pressure is 12585 mmHg Echocardiography demonstrates mitral stenosis with an estimated valve area of 13 cm2 and a left atrial diameter of 50 mm [lt40 mm] There are no other abnormalities What is the most appropriate next step in management A Balloon valvotomy B Surgical valvotomy C Digoxin therapy D Beta-blocker therapy E Angiotensin converting enzyme (ACE) inhibitor therapy
Part OneA 55-year-old man presents with acute pulmonary oedema Five years earlier he has undergone a mitral valve replacement with a bileaflet tilting disk valve (St Jude) for mixed mitral valve disease He has been well with normal exercise tolerance prior to the day of admission Examination on admission reveals tachypnoea sinus tachycardia of 110minute blood pressure of 10560 mmHg elevated jugular venous pressure (+ 5 cm) and bilateral crepitations throughout the lung fields His prothrombin timeminusinternational normalised ratio (PT-INR) is 19 [desired therapeutic range 20-35] Serum urea creatinine and electrolytes are normal The cardiothoracic ratio on chest X-ray is normal but the presence of pulmonary oedema is confirmed Echocardiography reveals that one of the prosthetic valve leaflets is not moving and there is an increased flow rate in diastole across the valve orifice (2 metressecond) What is the most appropriate course of action A Administration of intravenous streptokinase B Administration of intravenous heparin C Administration of intravenous antibiotics D Addition of an antiplatelet agent E Immediate mitral valve replacement
Aortic stenosis - quantification
Aortic stenosis - quantification Mean gradient
(mmHg) Peak Ao velocity
AVA (cm2)
Normal 10-20 gt25
Mild lt20 25-29 gt17
Moderate 20-40 30-40 10-17
Severe gt40 gt40 lt10
Right ventricle - size amp function
Estimation of Pulmonary PressurePA systolic pressure
bull Tricuspid regurgitation jet velocity
Estimation of Pulmonary PressureRA pressure
bull IVC size
Part OneThe severity of pulmonary hypertension can be determined using continuous wave Doppler measurements of the velocity of tricuspid regurgitation This method uses the Bernoulli equation which states that 1048661P = 4v2 (where 1048661P = instantaneous pressure gradient and v = velocity across the valve) There is tricuspid regurgitation with a peak velocity of 4 metressecond and a mean velocity of 35 metressecond Assuming right atrial pressure is 5 mmHg the best estimate of the peak right ventricular systolic pressure (plusmn 2 mmHg) is
A 50 mmHg B 55 mmHg C 60 mmHg D 65 mmHg E 70 mmHg
Cardiac Tamponade
Cardiac Tamponade
Cardiac Tamponade
Part OneA 65-year-old woman presents with a one-week history of progressive dyspnoea On admission there are signs of shock a systolic murmur and an elevated jugular venous pressure The ECG shows sinus tachycardia but no other abnormality An antero-posterior chest X-ray shows cardiomegaly The serum troponin I level is 05 mgL [lt01] A computed tomography (CT) scan is shown below
What is the most likely diagnosis A Pulmonary embolism B Right ventricular infarction C Pericardial tamponade D Myocarditis E Acute mitral regurgitation
Endocarditis
Positive echocardiogram for IE Discrete echogenic oscillating intracardiac mass located at a site of endocardial injury (eg on a valve or supporting structure in pathway of regurgitant jet or site of implanted material) or Periannular abscess or
New dehiscence of a prosthetic valve
Cardiac Resynchronisation
Cardiac Resynchronisation
bullSevere heart failure treatment to restore co-ordination to LV contraction
bullNYHA 3-4bullEF lt 35bullQRS duration gt 120 msec
Echocardiography
bullUseful non-invasive tool
bullReports objective and subjective
bullLimitations
Echocardiography Basics
One-dimensional imaging (M-mode)
Echocardiography BasicsDoppler - Spectral
Pulse Continuous
Bernoulli equation P = 4V2
Echocardiography Basics
Doppler - Colour
Echocardiography Basics
Tissue velocity imaging
Echocardiography Basics
Tissue velocity imaging
Left ventricle - size
Normal
End-diastole 35-57cm
End-systole 21-40cm
Left ventricle - size
Normal
End-diastole 35-57cm
End-systole 21-40cm
Left ventricle - wall thickness
IVS and PW
06 -11cm
Left ventricle - systolic function
Fractional Shortening (FS)
FS = EDD-ESD EDD
Left ventricle - systolic function
Fractional Shortening (FS)
FS = EDD-ESD EDD
Left ventricle - systolic function
Left ventricle - systolic function
Ejection fraction ()
Normal gt55
Mild 40-50
Moderate 30-40
Moderate-severe 20-30
Severe lt20
Part OneA 67-year-old woman with congestive cardiac failure remains breathless on moderate exertion despite treatment with 40 mg frusemide and 20 mg enalapril daily On examination she has a pulse rate of 80minute blood pressure of 12570 mmHg and a jugular venous pressure (JVP) of +1 cm She has a soft systolic murmur with no added sounds her chest is clear and she has no oedema An ECG shows sinus rhythm A chest X-ray shows cardiomegaly with a cardiothoracic ratio of 15528 but no pulmonary congestion Echocardiography demonstrates systolic dysfunction with fractional shortening of 18 and mild mitral regurgitation Her serum creatinine level is normal
Which of the following is the most appropriate next step in treatment A Increase the frusemide dose B Add digoxin C Add an aldosterone antagonist D Add an angiotensin II receptor antagonist E Add a beta blocker
Left ventricle - diastolic function
Mitral inflow Pulmonary veins
Mitral TVI
LV diastolic function - mitral inflow
EA gt 1 EA lt 1 EA gtgt1
LV diastolic function - mitral TVI
EA gt 1 EA lt 1 EA gtgt1
Left ventricle - RWMAs
Left ventricle - RWMAs
Left ventricle - RWMAs
Left ventricle - thrombus
Left atrium - size
Diameter
Normal 20-40cm
Mild 40-50cm
Moderate 50-60cm
Severe gt60cm
Left atrium - size
Area
Normal lt20cm2
Mild 20-30cm2
Moderate 30-40cm2
Severe gt40cm2
Left atrium - thrombus
Cardiac Valves
Morphology
Valve dysfunction
aetiology
quantification
consequences
serial evaluation
Valve regurgitation - quantification
Colour - jet sizewidth
PISA
Spectral doppler
Consequences
AR - LV Response
bull Chronic AR - decompensated LV
bull LVEFlt55 LVESDgt55mm LVESV 60mlm2
Part OneA patient with aortic regurgitation has the following haemodynamic measurements cardiac output (CO) 75 Lminute heart rate (HR) 75minute left ventricular end-diastolic volume (LVEDV) 200 mL left ventricular end-systolic volume (LVESV) 50 mL The regurgitant fraction is defined as the ratio of the regurgitant volume to the total volume flowing through the valve with each beat
The regurgitant fraction in this patient is A 25 B 33 C 50 D 67 E 75
Part OneA 45-year-old asymptomatic man returns for follow-up He was diagnosed 10 years ago with aortic regurgitation due to a congenital bicuspid aortic valve He has never had endocarditis Which one of the following echocardiographic profiles most strongly indicates the need for aortic valve replacement
LVEDD (mm)[35-55] FS [030-040] LA size (mm) [lt40]
A 70 030 60
B 75 040 40
C 70 025 45
D 65 045 50
E 75 035 55
Key LVEDD Left ventricular end-diastolic diameter LVESD Left ventricular end-systolic diameter FS Fractional shortening = (LVEDD - LVESD) LVEDD LA Left atrial
MR- Quantification of LV contractility
LV systolic function - most important parameter
bullEjection fraction fractional shortening velocity of
circumferential fibre shortening - load dependent
bullMR allows supranormal values of EF etc
bullEarly systolic dysfunction if
bullEF lt 60 (severe MR)
bullES diameter lt 45mm (26mmm2)
Mitral stenosis - quantification
Severity MVA (cm2) LAP (mm Hg) CO
Mild gt20 lt10-12 NL
Moderate 11-20 ~10-17 NL
Severe lt10 gt18
Very Severe lt08 gt20-25
Part OneA 35-year-old woman has increasing breathlessness on exertion Her cardiac silhouette is slightly enlarged on a chest X-ray and an ECG demonstrates sinus rhythm The continuous wave Doppler flow signal through the mitral inflow tract (shown above) is most consistent with which one of the following A Severe pulmonary hypertension (cor pulmonale) B Aortic stenosis C Mitral regurgitation D Mitral stenosis E Aortic regurgitation
Part OneA 28-year-old woman who emigrated from Cambodia 10 years ago presents to the emergency department with a three-week history of increasing shortness of breath orthopnoea nocturnal dyspnoea and ankle oedema She is 25 weeks pregnant and has no significant past medical history The presence of pulmonary oedema is confirmed clinically and radiologically She responds well to intravenous frusemide but remains tachypnoeic with a heart rate of 120minute in sinus rhythm Her blood pressure is 12585 mmHg Echocardiography demonstrates mitral stenosis with an estimated valve area of 13 cm2 and a left atrial diameter of 50 mm [lt40 mm] There are no other abnormalities What is the most appropriate next step in management A Balloon valvotomy B Surgical valvotomy C Digoxin therapy D Beta-blocker therapy E Angiotensin converting enzyme (ACE) inhibitor therapy
Part OneA 55-year-old man presents with acute pulmonary oedema Five years earlier he has undergone a mitral valve replacement with a bileaflet tilting disk valve (St Jude) for mixed mitral valve disease He has been well with normal exercise tolerance prior to the day of admission Examination on admission reveals tachypnoea sinus tachycardia of 110minute blood pressure of 10560 mmHg elevated jugular venous pressure (+ 5 cm) and bilateral crepitations throughout the lung fields His prothrombin timeminusinternational normalised ratio (PT-INR) is 19 [desired therapeutic range 20-35] Serum urea creatinine and electrolytes are normal The cardiothoracic ratio on chest X-ray is normal but the presence of pulmonary oedema is confirmed Echocardiography reveals that one of the prosthetic valve leaflets is not moving and there is an increased flow rate in diastole across the valve orifice (2 metressecond) What is the most appropriate course of action A Administration of intravenous streptokinase B Administration of intravenous heparin C Administration of intravenous antibiotics D Addition of an antiplatelet agent E Immediate mitral valve replacement
Aortic stenosis - quantification
Aortic stenosis - quantification Mean gradient
(mmHg) Peak Ao velocity
AVA (cm2)
Normal 10-20 gt25
Mild lt20 25-29 gt17
Moderate 20-40 30-40 10-17
Severe gt40 gt40 lt10
Right ventricle - size amp function
Estimation of Pulmonary PressurePA systolic pressure
bull Tricuspid regurgitation jet velocity
Estimation of Pulmonary PressureRA pressure
bull IVC size
Part OneThe severity of pulmonary hypertension can be determined using continuous wave Doppler measurements of the velocity of tricuspid regurgitation This method uses the Bernoulli equation which states that 1048661P = 4v2 (where 1048661P = instantaneous pressure gradient and v = velocity across the valve) There is tricuspid regurgitation with a peak velocity of 4 metressecond and a mean velocity of 35 metressecond Assuming right atrial pressure is 5 mmHg the best estimate of the peak right ventricular systolic pressure (plusmn 2 mmHg) is
A 50 mmHg B 55 mmHg C 60 mmHg D 65 mmHg E 70 mmHg
Cardiac Tamponade
Cardiac Tamponade
Cardiac Tamponade
Part OneA 65-year-old woman presents with a one-week history of progressive dyspnoea On admission there are signs of shock a systolic murmur and an elevated jugular venous pressure The ECG shows sinus tachycardia but no other abnormality An antero-posterior chest X-ray shows cardiomegaly The serum troponin I level is 05 mgL [lt01] A computed tomography (CT) scan is shown below
What is the most likely diagnosis A Pulmonary embolism B Right ventricular infarction C Pericardial tamponade D Myocarditis E Acute mitral regurgitation
Endocarditis
Positive echocardiogram for IE Discrete echogenic oscillating intracardiac mass located at a site of endocardial injury (eg on a valve or supporting structure in pathway of regurgitant jet or site of implanted material) or Periannular abscess or
New dehiscence of a prosthetic valve
Cardiac Resynchronisation
Cardiac Resynchronisation
bullSevere heart failure treatment to restore co-ordination to LV contraction
bullNYHA 3-4bullEF lt 35bullQRS duration gt 120 msec
Echocardiography
bullUseful non-invasive tool
bullReports objective and subjective
bullLimitations
Echocardiography BasicsDoppler - Spectral
Pulse Continuous
Bernoulli equation P = 4V2
Echocardiography Basics
Doppler - Colour
Echocardiography Basics
Tissue velocity imaging
Echocardiography Basics
Tissue velocity imaging
Left ventricle - size
Normal
End-diastole 35-57cm
End-systole 21-40cm
Left ventricle - size
Normal
End-diastole 35-57cm
End-systole 21-40cm
Left ventricle - wall thickness
IVS and PW
06 -11cm
Left ventricle - systolic function
Fractional Shortening (FS)
FS = EDD-ESD EDD
Left ventricle - systolic function
Fractional Shortening (FS)
FS = EDD-ESD EDD
Left ventricle - systolic function
Left ventricle - systolic function
Ejection fraction ()
Normal gt55
Mild 40-50
Moderate 30-40
Moderate-severe 20-30
Severe lt20
Part OneA 67-year-old woman with congestive cardiac failure remains breathless on moderate exertion despite treatment with 40 mg frusemide and 20 mg enalapril daily On examination she has a pulse rate of 80minute blood pressure of 12570 mmHg and a jugular venous pressure (JVP) of +1 cm She has a soft systolic murmur with no added sounds her chest is clear and she has no oedema An ECG shows sinus rhythm A chest X-ray shows cardiomegaly with a cardiothoracic ratio of 15528 but no pulmonary congestion Echocardiography demonstrates systolic dysfunction with fractional shortening of 18 and mild mitral regurgitation Her serum creatinine level is normal
Which of the following is the most appropriate next step in treatment A Increase the frusemide dose B Add digoxin C Add an aldosterone antagonist D Add an angiotensin II receptor antagonist E Add a beta blocker
Left ventricle - diastolic function
Mitral inflow Pulmonary veins
Mitral TVI
LV diastolic function - mitral inflow
EA gt 1 EA lt 1 EA gtgt1
LV diastolic function - mitral TVI
EA gt 1 EA lt 1 EA gtgt1
Left ventricle - RWMAs
Left ventricle - RWMAs
Left ventricle - RWMAs
Left ventricle - thrombus
Left atrium - size
Diameter
Normal 20-40cm
Mild 40-50cm
Moderate 50-60cm
Severe gt60cm
Left atrium - size
Area
Normal lt20cm2
Mild 20-30cm2
Moderate 30-40cm2
Severe gt40cm2
Left atrium - thrombus
Cardiac Valves
Morphology
Valve dysfunction
aetiology
quantification
consequences
serial evaluation
Valve regurgitation - quantification
Colour - jet sizewidth
PISA
Spectral doppler
Consequences
AR - LV Response
bull Chronic AR - decompensated LV
bull LVEFlt55 LVESDgt55mm LVESV 60mlm2
Part OneA patient with aortic regurgitation has the following haemodynamic measurements cardiac output (CO) 75 Lminute heart rate (HR) 75minute left ventricular end-diastolic volume (LVEDV) 200 mL left ventricular end-systolic volume (LVESV) 50 mL The regurgitant fraction is defined as the ratio of the regurgitant volume to the total volume flowing through the valve with each beat
The regurgitant fraction in this patient is A 25 B 33 C 50 D 67 E 75
Part OneA 45-year-old asymptomatic man returns for follow-up He was diagnosed 10 years ago with aortic regurgitation due to a congenital bicuspid aortic valve He has never had endocarditis Which one of the following echocardiographic profiles most strongly indicates the need for aortic valve replacement
LVEDD (mm)[35-55] FS [030-040] LA size (mm) [lt40]
A 70 030 60
B 75 040 40
C 70 025 45
D 65 045 50
E 75 035 55
Key LVEDD Left ventricular end-diastolic diameter LVESD Left ventricular end-systolic diameter FS Fractional shortening = (LVEDD - LVESD) LVEDD LA Left atrial
MR- Quantification of LV contractility
LV systolic function - most important parameter
bullEjection fraction fractional shortening velocity of
circumferential fibre shortening - load dependent
bullMR allows supranormal values of EF etc
bullEarly systolic dysfunction if
bullEF lt 60 (severe MR)
bullES diameter lt 45mm (26mmm2)
Mitral stenosis - quantification
Severity MVA (cm2) LAP (mm Hg) CO
Mild gt20 lt10-12 NL
Moderate 11-20 ~10-17 NL
Severe lt10 gt18
Very Severe lt08 gt20-25
Part OneA 35-year-old woman has increasing breathlessness on exertion Her cardiac silhouette is slightly enlarged on a chest X-ray and an ECG demonstrates sinus rhythm The continuous wave Doppler flow signal through the mitral inflow tract (shown above) is most consistent with which one of the following A Severe pulmonary hypertension (cor pulmonale) B Aortic stenosis C Mitral regurgitation D Mitral stenosis E Aortic regurgitation
Part OneA 28-year-old woman who emigrated from Cambodia 10 years ago presents to the emergency department with a three-week history of increasing shortness of breath orthopnoea nocturnal dyspnoea and ankle oedema She is 25 weeks pregnant and has no significant past medical history The presence of pulmonary oedema is confirmed clinically and radiologically She responds well to intravenous frusemide but remains tachypnoeic with a heart rate of 120minute in sinus rhythm Her blood pressure is 12585 mmHg Echocardiography demonstrates mitral stenosis with an estimated valve area of 13 cm2 and a left atrial diameter of 50 mm [lt40 mm] There are no other abnormalities What is the most appropriate next step in management A Balloon valvotomy B Surgical valvotomy C Digoxin therapy D Beta-blocker therapy E Angiotensin converting enzyme (ACE) inhibitor therapy
Part OneA 55-year-old man presents with acute pulmonary oedema Five years earlier he has undergone a mitral valve replacement with a bileaflet tilting disk valve (St Jude) for mixed mitral valve disease He has been well with normal exercise tolerance prior to the day of admission Examination on admission reveals tachypnoea sinus tachycardia of 110minute blood pressure of 10560 mmHg elevated jugular venous pressure (+ 5 cm) and bilateral crepitations throughout the lung fields His prothrombin timeminusinternational normalised ratio (PT-INR) is 19 [desired therapeutic range 20-35] Serum urea creatinine and electrolytes are normal The cardiothoracic ratio on chest X-ray is normal but the presence of pulmonary oedema is confirmed Echocardiography reveals that one of the prosthetic valve leaflets is not moving and there is an increased flow rate in diastole across the valve orifice (2 metressecond) What is the most appropriate course of action A Administration of intravenous streptokinase B Administration of intravenous heparin C Administration of intravenous antibiotics D Addition of an antiplatelet agent E Immediate mitral valve replacement
Aortic stenosis - quantification
Aortic stenosis - quantification Mean gradient
(mmHg) Peak Ao velocity
AVA (cm2)
Normal 10-20 gt25
Mild lt20 25-29 gt17
Moderate 20-40 30-40 10-17
Severe gt40 gt40 lt10
Right ventricle - size amp function
Estimation of Pulmonary PressurePA systolic pressure
bull Tricuspid regurgitation jet velocity
Estimation of Pulmonary PressureRA pressure
bull IVC size
Part OneThe severity of pulmonary hypertension can be determined using continuous wave Doppler measurements of the velocity of tricuspid regurgitation This method uses the Bernoulli equation which states that 1048661P = 4v2 (where 1048661P = instantaneous pressure gradient and v = velocity across the valve) There is tricuspid regurgitation with a peak velocity of 4 metressecond and a mean velocity of 35 metressecond Assuming right atrial pressure is 5 mmHg the best estimate of the peak right ventricular systolic pressure (plusmn 2 mmHg) is
A 50 mmHg B 55 mmHg C 60 mmHg D 65 mmHg E 70 mmHg
Cardiac Tamponade
Cardiac Tamponade
Cardiac Tamponade
Part OneA 65-year-old woman presents with a one-week history of progressive dyspnoea On admission there are signs of shock a systolic murmur and an elevated jugular venous pressure The ECG shows sinus tachycardia but no other abnormality An antero-posterior chest X-ray shows cardiomegaly The serum troponin I level is 05 mgL [lt01] A computed tomography (CT) scan is shown below
What is the most likely diagnosis A Pulmonary embolism B Right ventricular infarction C Pericardial tamponade D Myocarditis E Acute mitral regurgitation
Endocarditis
Positive echocardiogram for IE Discrete echogenic oscillating intracardiac mass located at a site of endocardial injury (eg on a valve or supporting structure in pathway of regurgitant jet or site of implanted material) or Periannular abscess or
New dehiscence of a prosthetic valve
Cardiac Resynchronisation
Cardiac Resynchronisation
bullSevere heart failure treatment to restore co-ordination to LV contraction
bullNYHA 3-4bullEF lt 35bullQRS duration gt 120 msec
Echocardiography
bullUseful non-invasive tool
bullReports objective and subjective
bullLimitations
Echocardiography Basics
Doppler - Colour
Echocardiography Basics
Tissue velocity imaging
Echocardiography Basics
Tissue velocity imaging
Left ventricle - size
Normal
End-diastole 35-57cm
End-systole 21-40cm
Left ventricle - size
Normal
End-diastole 35-57cm
End-systole 21-40cm
Left ventricle - wall thickness
IVS and PW
06 -11cm
Left ventricle - systolic function
Fractional Shortening (FS)
FS = EDD-ESD EDD
Left ventricle - systolic function
Fractional Shortening (FS)
FS = EDD-ESD EDD
Left ventricle - systolic function
Left ventricle - systolic function
Ejection fraction ()
Normal gt55
Mild 40-50
Moderate 30-40
Moderate-severe 20-30
Severe lt20
Part OneA 67-year-old woman with congestive cardiac failure remains breathless on moderate exertion despite treatment with 40 mg frusemide and 20 mg enalapril daily On examination she has a pulse rate of 80minute blood pressure of 12570 mmHg and a jugular venous pressure (JVP) of +1 cm She has a soft systolic murmur with no added sounds her chest is clear and she has no oedema An ECG shows sinus rhythm A chest X-ray shows cardiomegaly with a cardiothoracic ratio of 15528 but no pulmonary congestion Echocardiography demonstrates systolic dysfunction with fractional shortening of 18 and mild mitral regurgitation Her serum creatinine level is normal
Which of the following is the most appropriate next step in treatment A Increase the frusemide dose B Add digoxin C Add an aldosterone antagonist D Add an angiotensin II receptor antagonist E Add a beta blocker
Left ventricle - diastolic function
Mitral inflow Pulmonary veins
Mitral TVI
LV diastolic function - mitral inflow
EA gt 1 EA lt 1 EA gtgt1
LV diastolic function - mitral TVI
EA gt 1 EA lt 1 EA gtgt1
Left ventricle - RWMAs
Left ventricle - RWMAs
Left ventricle - RWMAs
Left ventricle - thrombus
Left atrium - size
Diameter
Normal 20-40cm
Mild 40-50cm
Moderate 50-60cm
Severe gt60cm
Left atrium - size
Area
Normal lt20cm2
Mild 20-30cm2
Moderate 30-40cm2
Severe gt40cm2
Left atrium - thrombus
Cardiac Valves
Morphology
Valve dysfunction
aetiology
quantification
consequences
serial evaluation
Valve regurgitation - quantification
Colour - jet sizewidth
PISA
Spectral doppler
Consequences
AR - LV Response
bull Chronic AR - decompensated LV
bull LVEFlt55 LVESDgt55mm LVESV 60mlm2
Part OneA patient with aortic regurgitation has the following haemodynamic measurements cardiac output (CO) 75 Lminute heart rate (HR) 75minute left ventricular end-diastolic volume (LVEDV) 200 mL left ventricular end-systolic volume (LVESV) 50 mL The regurgitant fraction is defined as the ratio of the regurgitant volume to the total volume flowing through the valve with each beat
The regurgitant fraction in this patient is A 25 B 33 C 50 D 67 E 75
Part OneA 45-year-old asymptomatic man returns for follow-up He was diagnosed 10 years ago with aortic regurgitation due to a congenital bicuspid aortic valve He has never had endocarditis Which one of the following echocardiographic profiles most strongly indicates the need for aortic valve replacement
LVEDD (mm)[35-55] FS [030-040] LA size (mm) [lt40]
A 70 030 60
B 75 040 40
C 70 025 45
D 65 045 50
E 75 035 55
Key LVEDD Left ventricular end-diastolic diameter LVESD Left ventricular end-systolic diameter FS Fractional shortening = (LVEDD - LVESD) LVEDD LA Left atrial
MR- Quantification of LV contractility
LV systolic function - most important parameter
bullEjection fraction fractional shortening velocity of
circumferential fibre shortening - load dependent
bullMR allows supranormal values of EF etc
bullEarly systolic dysfunction if
bullEF lt 60 (severe MR)
bullES diameter lt 45mm (26mmm2)
Mitral stenosis - quantification
Severity MVA (cm2) LAP (mm Hg) CO
Mild gt20 lt10-12 NL
Moderate 11-20 ~10-17 NL
Severe lt10 gt18
Very Severe lt08 gt20-25
Part OneA 35-year-old woman has increasing breathlessness on exertion Her cardiac silhouette is slightly enlarged on a chest X-ray and an ECG demonstrates sinus rhythm The continuous wave Doppler flow signal through the mitral inflow tract (shown above) is most consistent with which one of the following A Severe pulmonary hypertension (cor pulmonale) B Aortic stenosis C Mitral regurgitation D Mitral stenosis E Aortic regurgitation
Part OneA 28-year-old woman who emigrated from Cambodia 10 years ago presents to the emergency department with a three-week history of increasing shortness of breath orthopnoea nocturnal dyspnoea and ankle oedema She is 25 weeks pregnant and has no significant past medical history The presence of pulmonary oedema is confirmed clinically and radiologically She responds well to intravenous frusemide but remains tachypnoeic with a heart rate of 120minute in sinus rhythm Her blood pressure is 12585 mmHg Echocardiography demonstrates mitral stenosis with an estimated valve area of 13 cm2 and a left atrial diameter of 50 mm [lt40 mm] There are no other abnormalities What is the most appropriate next step in management A Balloon valvotomy B Surgical valvotomy C Digoxin therapy D Beta-blocker therapy E Angiotensin converting enzyme (ACE) inhibitor therapy
Part OneA 55-year-old man presents with acute pulmonary oedema Five years earlier he has undergone a mitral valve replacement with a bileaflet tilting disk valve (St Jude) for mixed mitral valve disease He has been well with normal exercise tolerance prior to the day of admission Examination on admission reveals tachypnoea sinus tachycardia of 110minute blood pressure of 10560 mmHg elevated jugular venous pressure (+ 5 cm) and bilateral crepitations throughout the lung fields His prothrombin timeminusinternational normalised ratio (PT-INR) is 19 [desired therapeutic range 20-35] Serum urea creatinine and electrolytes are normal The cardiothoracic ratio on chest X-ray is normal but the presence of pulmonary oedema is confirmed Echocardiography reveals that one of the prosthetic valve leaflets is not moving and there is an increased flow rate in diastole across the valve orifice (2 metressecond) What is the most appropriate course of action A Administration of intravenous streptokinase B Administration of intravenous heparin C Administration of intravenous antibiotics D Addition of an antiplatelet agent E Immediate mitral valve replacement
Aortic stenosis - quantification
Aortic stenosis - quantification Mean gradient
(mmHg) Peak Ao velocity
AVA (cm2)
Normal 10-20 gt25
Mild lt20 25-29 gt17
Moderate 20-40 30-40 10-17
Severe gt40 gt40 lt10
Right ventricle - size amp function
Estimation of Pulmonary PressurePA systolic pressure
bull Tricuspid regurgitation jet velocity
Estimation of Pulmonary PressureRA pressure
bull IVC size
Part OneThe severity of pulmonary hypertension can be determined using continuous wave Doppler measurements of the velocity of tricuspid regurgitation This method uses the Bernoulli equation which states that 1048661P = 4v2 (where 1048661P = instantaneous pressure gradient and v = velocity across the valve) There is tricuspid regurgitation with a peak velocity of 4 metressecond and a mean velocity of 35 metressecond Assuming right atrial pressure is 5 mmHg the best estimate of the peak right ventricular systolic pressure (plusmn 2 mmHg) is
A 50 mmHg B 55 mmHg C 60 mmHg D 65 mmHg E 70 mmHg
Cardiac Tamponade
Cardiac Tamponade
Cardiac Tamponade
Part OneA 65-year-old woman presents with a one-week history of progressive dyspnoea On admission there are signs of shock a systolic murmur and an elevated jugular venous pressure The ECG shows sinus tachycardia but no other abnormality An antero-posterior chest X-ray shows cardiomegaly The serum troponin I level is 05 mgL [lt01] A computed tomography (CT) scan is shown below
What is the most likely diagnosis A Pulmonary embolism B Right ventricular infarction C Pericardial tamponade D Myocarditis E Acute mitral regurgitation
Endocarditis
Positive echocardiogram for IE Discrete echogenic oscillating intracardiac mass located at a site of endocardial injury (eg on a valve or supporting structure in pathway of regurgitant jet or site of implanted material) or Periannular abscess or
New dehiscence of a prosthetic valve
Cardiac Resynchronisation
Cardiac Resynchronisation
bullSevere heart failure treatment to restore co-ordination to LV contraction
bullNYHA 3-4bullEF lt 35bullQRS duration gt 120 msec
Echocardiography
bullUseful non-invasive tool
bullReports objective and subjective
bullLimitations
Echocardiography Basics
Tissue velocity imaging
Echocardiography Basics
Tissue velocity imaging
Left ventricle - size
Normal
End-diastole 35-57cm
End-systole 21-40cm
Left ventricle - size
Normal
End-diastole 35-57cm
End-systole 21-40cm
Left ventricle - wall thickness
IVS and PW
06 -11cm
Left ventricle - systolic function
Fractional Shortening (FS)
FS = EDD-ESD EDD
Left ventricle - systolic function
Fractional Shortening (FS)
FS = EDD-ESD EDD
Left ventricle - systolic function
Left ventricle - systolic function
Ejection fraction ()
Normal gt55
Mild 40-50
Moderate 30-40
Moderate-severe 20-30
Severe lt20
Part OneA 67-year-old woman with congestive cardiac failure remains breathless on moderate exertion despite treatment with 40 mg frusemide and 20 mg enalapril daily On examination she has a pulse rate of 80minute blood pressure of 12570 mmHg and a jugular venous pressure (JVP) of +1 cm She has a soft systolic murmur with no added sounds her chest is clear and she has no oedema An ECG shows sinus rhythm A chest X-ray shows cardiomegaly with a cardiothoracic ratio of 15528 but no pulmonary congestion Echocardiography demonstrates systolic dysfunction with fractional shortening of 18 and mild mitral regurgitation Her serum creatinine level is normal
Which of the following is the most appropriate next step in treatment A Increase the frusemide dose B Add digoxin C Add an aldosterone antagonist D Add an angiotensin II receptor antagonist E Add a beta blocker
Left ventricle - diastolic function
Mitral inflow Pulmonary veins
Mitral TVI
LV diastolic function - mitral inflow
EA gt 1 EA lt 1 EA gtgt1
LV diastolic function - mitral TVI
EA gt 1 EA lt 1 EA gtgt1
Left ventricle - RWMAs
Left ventricle - RWMAs
Left ventricle - RWMAs
Left ventricle - thrombus
Left atrium - size
Diameter
Normal 20-40cm
Mild 40-50cm
Moderate 50-60cm
Severe gt60cm
Left atrium - size
Area
Normal lt20cm2
Mild 20-30cm2
Moderate 30-40cm2
Severe gt40cm2
Left atrium - thrombus
Cardiac Valves
Morphology
Valve dysfunction
aetiology
quantification
consequences
serial evaluation
Valve regurgitation - quantification
Colour - jet sizewidth
PISA
Spectral doppler
Consequences
AR - LV Response
bull Chronic AR - decompensated LV
bull LVEFlt55 LVESDgt55mm LVESV 60mlm2
Part OneA patient with aortic regurgitation has the following haemodynamic measurements cardiac output (CO) 75 Lminute heart rate (HR) 75minute left ventricular end-diastolic volume (LVEDV) 200 mL left ventricular end-systolic volume (LVESV) 50 mL The regurgitant fraction is defined as the ratio of the regurgitant volume to the total volume flowing through the valve with each beat
The regurgitant fraction in this patient is A 25 B 33 C 50 D 67 E 75
Part OneA 45-year-old asymptomatic man returns for follow-up He was diagnosed 10 years ago with aortic regurgitation due to a congenital bicuspid aortic valve He has never had endocarditis Which one of the following echocardiographic profiles most strongly indicates the need for aortic valve replacement
LVEDD (mm)[35-55] FS [030-040] LA size (mm) [lt40]
A 70 030 60
B 75 040 40
C 70 025 45
D 65 045 50
E 75 035 55
Key LVEDD Left ventricular end-diastolic diameter LVESD Left ventricular end-systolic diameter FS Fractional shortening = (LVEDD - LVESD) LVEDD LA Left atrial
MR- Quantification of LV contractility
LV systolic function - most important parameter
bullEjection fraction fractional shortening velocity of
circumferential fibre shortening - load dependent
bullMR allows supranormal values of EF etc
bullEarly systolic dysfunction if
bullEF lt 60 (severe MR)
bullES diameter lt 45mm (26mmm2)
Mitral stenosis - quantification
Severity MVA (cm2) LAP (mm Hg) CO
Mild gt20 lt10-12 NL
Moderate 11-20 ~10-17 NL
Severe lt10 gt18
Very Severe lt08 gt20-25
Part OneA 35-year-old woman has increasing breathlessness on exertion Her cardiac silhouette is slightly enlarged on a chest X-ray and an ECG demonstrates sinus rhythm The continuous wave Doppler flow signal through the mitral inflow tract (shown above) is most consistent with which one of the following A Severe pulmonary hypertension (cor pulmonale) B Aortic stenosis C Mitral regurgitation D Mitral stenosis E Aortic regurgitation
Part OneA 28-year-old woman who emigrated from Cambodia 10 years ago presents to the emergency department with a three-week history of increasing shortness of breath orthopnoea nocturnal dyspnoea and ankle oedema She is 25 weeks pregnant and has no significant past medical history The presence of pulmonary oedema is confirmed clinically and radiologically She responds well to intravenous frusemide but remains tachypnoeic with a heart rate of 120minute in sinus rhythm Her blood pressure is 12585 mmHg Echocardiography demonstrates mitral stenosis with an estimated valve area of 13 cm2 and a left atrial diameter of 50 mm [lt40 mm] There are no other abnormalities What is the most appropriate next step in management A Balloon valvotomy B Surgical valvotomy C Digoxin therapy D Beta-blocker therapy E Angiotensin converting enzyme (ACE) inhibitor therapy
Part OneA 55-year-old man presents with acute pulmonary oedema Five years earlier he has undergone a mitral valve replacement with a bileaflet tilting disk valve (St Jude) for mixed mitral valve disease He has been well with normal exercise tolerance prior to the day of admission Examination on admission reveals tachypnoea sinus tachycardia of 110minute blood pressure of 10560 mmHg elevated jugular venous pressure (+ 5 cm) and bilateral crepitations throughout the lung fields His prothrombin timeminusinternational normalised ratio (PT-INR) is 19 [desired therapeutic range 20-35] Serum urea creatinine and electrolytes are normal The cardiothoracic ratio on chest X-ray is normal but the presence of pulmonary oedema is confirmed Echocardiography reveals that one of the prosthetic valve leaflets is not moving and there is an increased flow rate in diastole across the valve orifice (2 metressecond) What is the most appropriate course of action A Administration of intravenous streptokinase B Administration of intravenous heparin C Administration of intravenous antibiotics D Addition of an antiplatelet agent E Immediate mitral valve replacement
Aortic stenosis - quantification
Aortic stenosis - quantification Mean gradient
(mmHg) Peak Ao velocity
AVA (cm2)
Normal 10-20 gt25
Mild lt20 25-29 gt17
Moderate 20-40 30-40 10-17
Severe gt40 gt40 lt10
Right ventricle - size amp function
Estimation of Pulmonary PressurePA systolic pressure
bull Tricuspid regurgitation jet velocity
Estimation of Pulmonary PressureRA pressure
bull IVC size
Part OneThe severity of pulmonary hypertension can be determined using continuous wave Doppler measurements of the velocity of tricuspid regurgitation This method uses the Bernoulli equation which states that 1048661P = 4v2 (where 1048661P = instantaneous pressure gradient and v = velocity across the valve) There is tricuspid regurgitation with a peak velocity of 4 metressecond and a mean velocity of 35 metressecond Assuming right atrial pressure is 5 mmHg the best estimate of the peak right ventricular systolic pressure (plusmn 2 mmHg) is
A 50 mmHg B 55 mmHg C 60 mmHg D 65 mmHg E 70 mmHg
Cardiac Tamponade
Cardiac Tamponade
Cardiac Tamponade
Part OneA 65-year-old woman presents with a one-week history of progressive dyspnoea On admission there are signs of shock a systolic murmur and an elevated jugular venous pressure The ECG shows sinus tachycardia but no other abnormality An antero-posterior chest X-ray shows cardiomegaly The serum troponin I level is 05 mgL [lt01] A computed tomography (CT) scan is shown below
What is the most likely diagnosis A Pulmonary embolism B Right ventricular infarction C Pericardial tamponade D Myocarditis E Acute mitral regurgitation
Endocarditis
Positive echocardiogram for IE Discrete echogenic oscillating intracardiac mass located at a site of endocardial injury (eg on a valve or supporting structure in pathway of regurgitant jet or site of implanted material) or Periannular abscess or
New dehiscence of a prosthetic valve
Cardiac Resynchronisation
Cardiac Resynchronisation
bullSevere heart failure treatment to restore co-ordination to LV contraction
bullNYHA 3-4bullEF lt 35bullQRS duration gt 120 msec
Echocardiography
bullUseful non-invasive tool
bullReports objective and subjective
bullLimitations
Echocardiography Basics
Tissue velocity imaging
Left ventricle - size
Normal
End-diastole 35-57cm
End-systole 21-40cm
Left ventricle - size
Normal
End-diastole 35-57cm
End-systole 21-40cm
Left ventricle - wall thickness
IVS and PW
06 -11cm
Left ventricle - systolic function
Fractional Shortening (FS)
FS = EDD-ESD EDD
Left ventricle - systolic function
Fractional Shortening (FS)
FS = EDD-ESD EDD
Left ventricle - systolic function
Left ventricle - systolic function
Ejection fraction ()
Normal gt55
Mild 40-50
Moderate 30-40
Moderate-severe 20-30
Severe lt20
Part OneA 67-year-old woman with congestive cardiac failure remains breathless on moderate exertion despite treatment with 40 mg frusemide and 20 mg enalapril daily On examination she has a pulse rate of 80minute blood pressure of 12570 mmHg and a jugular venous pressure (JVP) of +1 cm She has a soft systolic murmur with no added sounds her chest is clear and she has no oedema An ECG shows sinus rhythm A chest X-ray shows cardiomegaly with a cardiothoracic ratio of 15528 but no pulmonary congestion Echocardiography demonstrates systolic dysfunction with fractional shortening of 18 and mild mitral regurgitation Her serum creatinine level is normal
Which of the following is the most appropriate next step in treatment A Increase the frusemide dose B Add digoxin C Add an aldosterone antagonist D Add an angiotensin II receptor antagonist E Add a beta blocker
Left ventricle - diastolic function
Mitral inflow Pulmonary veins
Mitral TVI
LV diastolic function - mitral inflow
EA gt 1 EA lt 1 EA gtgt1
LV diastolic function - mitral TVI
EA gt 1 EA lt 1 EA gtgt1
Left ventricle - RWMAs
Left ventricle - RWMAs
Left ventricle - RWMAs
Left ventricle - thrombus
Left atrium - size
Diameter
Normal 20-40cm
Mild 40-50cm
Moderate 50-60cm
Severe gt60cm
Left atrium - size
Area
Normal lt20cm2
Mild 20-30cm2
Moderate 30-40cm2
Severe gt40cm2
Left atrium - thrombus
Cardiac Valves
Morphology
Valve dysfunction
aetiology
quantification
consequences
serial evaluation
Valve regurgitation - quantification
Colour - jet sizewidth
PISA
Spectral doppler
Consequences
AR - LV Response
bull Chronic AR - decompensated LV
bull LVEFlt55 LVESDgt55mm LVESV 60mlm2
Part OneA patient with aortic regurgitation has the following haemodynamic measurements cardiac output (CO) 75 Lminute heart rate (HR) 75minute left ventricular end-diastolic volume (LVEDV) 200 mL left ventricular end-systolic volume (LVESV) 50 mL The regurgitant fraction is defined as the ratio of the regurgitant volume to the total volume flowing through the valve with each beat
The regurgitant fraction in this patient is A 25 B 33 C 50 D 67 E 75
Part OneA 45-year-old asymptomatic man returns for follow-up He was diagnosed 10 years ago with aortic regurgitation due to a congenital bicuspid aortic valve He has never had endocarditis Which one of the following echocardiographic profiles most strongly indicates the need for aortic valve replacement
LVEDD (mm)[35-55] FS [030-040] LA size (mm) [lt40]
A 70 030 60
B 75 040 40
C 70 025 45
D 65 045 50
E 75 035 55
Key LVEDD Left ventricular end-diastolic diameter LVESD Left ventricular end-systolic diameter FS Fractional shortening = (LVEDD - LVESD) LVEDD LA Left atrial
MR- Quantification of LV contractility
LV systolic function - most important parameter
bullEjection fraction fractional shortening velocity of
circumferential fibre shortening - load dependent
bullMR allows supranormal values of EF etc
bullEarly systolic dysfunction if
bullEF lt 60 (severe MR)
bullES diameter lt 45mm (26mmm2)
Mitral stenosis - quantification
Severity MVA (cm2) LAP (mm Hg) CO
Mild gt20 lt10-12 NL
Moderate 11-20 ~10-17 NL
Severe lt10 gt18
Very Severe lt08 gt20-25
Part OneA 35-year-old woman has increasing breathlessness on exertion Her cardiac silhouette is slightly enlarged on a chest X-ray and an ECG demonstrates sinus rhythm The continuous wave Doppler flow signal through the mitral inflow tract (shown above) is most consistent with which one of the following A Severe pulmonary hypertension (cor pulmonale) B Aortic stenosis C Mitral regurgitation D Mitral stenosis E Aortic regurgitation
Part OneA 28-year-old woman who emigrated from Cambodia 10 years ago presents to the emergency department with a three-week history of increasing shortness of breath orthopnoea nocturnal dyspnoea and ankle oedema She is 25 weeks pregnant and has no significant past medical history The presence of pulmonary oedema is confirmed clinically and radiologically She responds well to intravenous frusemide but remains tachypnoeic with a heart rate of 120minute in sinus rhythm Her blood pressure is 12585 mmHg Echocardiography demonstrates mitral stenosis with an estimated valve area of 13 cm2 and a left atrial diameter of 50 mm [lt40 mm] There are no other abnormalities What is the most appropriate next step in management A Balloon valvotomy B Surgical valvotomy C Digoxin therapy D Beta-blocker therapy E Angiotensin converting enzyme (ACE) inhibitor therapy
Part OneA 55-year-old man presents with acute pulmonary oedema Five years earlier he has undergone a mitral valve replacement with a bileaflet tilting disk valve (St Jude) for mixed mitral valve disease He has been well with normal exercise tolerance prior to the day of admission Examination on admission reveals tachypnoea sinus tachycardia of 110minute blood pressure of 10560 mmHg elevated jugular venous pressure (+ 5 cm) and bilateral crepitations throughout the lung fields His prothrombin timeminusinternational normalised ratio (PT-INR) is 19 [desired therapeutic range 20-35] Serum urea creatinine and electrolytes are normal The cardiothoracic ratio on chest X-ray is normal but the presence of pulmonary oedema is confirmed Echocardiography reveals that one of the prosthetic valve leaflets is not moving and there is an increased flow rate in diastole across the valve orifice (2 metressecond) What is the most appropriate course of action A Administration of intravenous streptokinase B Administration of intravenous heparin C Administration of intravenous antibiotics D Addition of an antiplatelet agent E Immediate mitral valve replacement
Aortic stenosis - quantification
Aortic stenosis - quantification Mean gradient
(mmHg) Peak Ao velocity
AVA (cm2)
Normal 10-20 gt25
Mild lt20 25-29 gt17
Moderate 20-40 30-40 10-17
Severe gt40 gt40 lt10
Right ventricle - size amp function
Estimation of Pulmonary PressurePA systolic pressure
bull Tricuspid regurgitation jet velocity
Estimation of Pulmonary PressureRA pressure
bull IVC size
Part OneThe severity of pulmonary hypertension can be determined using continuous wave Doppler measurements of the velocity of tricuspid regurgitation This method uses the Bernoulli equation which states that 1048661P = 4v2 (where 1048661P = instantaneous pressure gradient and v = velocity across the valve) There is tricuspid regurgitation with a peak velocity of 4 metressecond and a mean velocity of 35 metressecond Assuming right atrial pressure is 5 mmHg the best estimate of the peak right ventricular systolic pressure (plusmn 2 mmHg) is
A 50 mmHg B 55 mmHg C 60 mmHg D 65 mmHg E 70 mmHg
Cardiac Tamponade
Cardiac Tamponade
Cardiac Tamponade
Part OneA 65-year-old woman presents with a one-week history of progressive dyspnoea On admission there are signs of shock a systolic murmur and an elevated jugular venous pressure The ECG shows sinus tachycardia but no other abnormality An antero-posterior chest X-ray shows cardiomegaly The serum troponin I level is 05 mgL [lt01] A computed tomography (CT) scan is shown below
What is the most likely diagnosis A Pulmonary embolism B Right ventricular infarction C Pericardial tamponade D Myocarditis E Acute mitral regurgitation
Endocarditis
Positive echocardiogram for IE Discrete echogenic oscillating intracardiac mass located at a site of endocardial injury (eg on a valve or supporting structure in pathway of regurgitant jet or site of implanted material) or Periannular abscess or
New dehiscence of a prosthetic valve
Cardiac Resynchronisation
Cardiac Resynchronisation
bullSevere heart failure treatment to restore co-ordination to LV contraction
bullNYHA 3-4bullEF lt 35bullQRS duration gt 120 msec
Echocardiography
bullUseful non-invasive tool
bullReports objective and subjective
bullLimitations
Left ventricle - size
Normal
End-diastole 35-57cm
End-systole 21-40cm
Left ventricle - size
Normal
End-diastole 35-57cm
End-systole 21-40cm
Left ventricle - wall thickness
IVS and PW
06 -11cm
Left ventricle - systolic function
Fractional Shortening (FS)
FS = EDD-ESD EDD
Left ventricle - systolic function
Fractional Shortening (FS)
FS = EDD-ESD EDD
Left ventricle - systolic function
Left ventricle - systolic function
Ejection fraction ()
Normal gt55
Mild 40-50
Moderate 30-40
Moderate-severe 20-30
Severe lt20
Part OneA 67-year-old woman with congestive cardiac failure remains breathless on moderate exertion despite treatment with 40 mg frusemide and 20 mg enalapril daily On examination she has a pulse rate of 80minute blood pressure of 12570 mmHg and a jugular venous pressure (JVP) of +1 cm She has a soft systolic murmur with no added sounds her chest is clear and she has no oedema An ECG shows sinus rhythm A chest X-ray shows cardiomegaly with a cardiothoracic ratio of 15528 but no pulmonary congestion Echocardiography demonstrates systolic dysfunction with fractional shortening of 18 and mild mitral regurgitation Her serum creatinine level is normal
Which of the following is the most appropriate next step in treatment A Increase the frusemide dose B Add digoxin C Add an aldosterone antagonist D Add an angiotensin II receptor antagonist E Add a beta blocker
Left ventricle - diastolic function
Mitral inflow Pulmonary veins
Mitral TVI
LV diastolic function - mitral inflow
EA gt 1 EA lt 1 EA gtgt1
LV diastolic function - mitral TVI
EA gt 1 EA lt 1 EA gtgt1
Left ventricle - RWMAs
Left ventricle - RWMAs
Left ventricle - RWMAs
Left ventricle - thrombus
Left atrium - size
Diameter
Normal 20-40cm
Mild 40-50cm
Moderate 50-60cm
Severe gt60cm
Left atrium - size
Area
Normal lt20cm2
Mild 20-30cm2
Moderate 30-40cm2
Severe gt40cm2
Left atrium - thrombus
Cardiac Valves
Morphology
Valve dysfunction
aetiology
quantification
consequences
serial evaluation
Valve regurgitation - quantification
Colour - jet sizewidth
PISA
Spectral doppler
Consequences
AR - LV Response
bull Chronic AR - decompensated LV
bull LVEFlt55 LVESDgt55mm LVESV 60mlm2
Part OneA patient with aortic regurgitation has the following haemodynamic measurements cardiac output (CO) 75 Lminute heart rate (HR) 75minute left ventricular end-diastolic volume (LVEDV) 200 mL left ventricular end-systolic volume (LVESV) 50 mL The regurgitant fraction is defined as the ratio of the regurgitant volume to the total volume flowing through the valve with each beat
The regurgitant fraction in this patient is A 25 B 33 C 50 D 67 E 75
Part OneA 45-year-old asymptomatic man returns for follow-up He was diagnosed 10 years ago with aortic regurgitation due to a congenital bicuspid aortic valve He has never had endocarditis Which one of the following echocardiographic profiles most strongly indicates the need for aortic valve replacement
LVEDD (mm)[35-55] FS [030-040] LA size (mm) [lt40]
A 70 030 60
B 75 040 40
C 70 025 45
D 65 045 50
E 75 035 55
Key LVEDD Left ventricular end-diastolic diameter LVESD Left ventricular end-systolic diameter FS Fractional shortening = (LVEDD - LVESD) LVEDD LA Left atrial
MR- Quantification of LV contractility
LV systolic function - most important parameter
bullEjection fraction fractional shortening velocity of
circumferential fibre shortening - load dependent
bullMR allows supranormal values of EF etc
bullEarly systolic dysfunction if
bullEF lt 60 (severe MR)
bullES diameter lt 45mm (26mmm2)
Mitral stenosis - quantification
Severity MVA (cm2) LAP (mm Hg) CO
Mild gt20 lt10-12 NL
Moderate 11-20 ~10-17 NL
Severe lt10 gt18
Very Severe lt08 gt20-25
Part OneA 35-year-old woman has increasing breathlessness on exertion Her cardiac silhouette is slightly enlarged on a chest X-ray and an ECG demonstrates sinus rhythm The continuous wave Doppler flow signal through the mitral inflow tract (shown above) is most consistent with which one of the following A Severe pulmonary hypertension (cor pulmonale) B Aortic stenosis C Mitral regurgitation D Mitral stenosis E Aortic regurgitation
Part OneA 28-year-old woman who emigrated from Cambodia 10 years ago presents to the emergency department with a three-week history of increasing shortness of breath orthopnoea nocturnal dyspnoea and ankle oedema She is 25 weeks pregnant and has no significant past medical history The presence of pulmonary oedema is confirmed clinically and radiologically She responds well to intravenous frusemide but remains tachypnoeic with a heart rate of 120minute in sinus rhythm Her blood pressure is 12585 mmHg Echocardiography demonstrates mitral stenosis with an estimated valve area of 13 cm2 and a left atrial diameter of 50 mm [lt40 mm] There are no other abnormalities What is the most appropriate next step in management A Balloon valvotomy B Surgical valvotomy C Digoxin therapy D Beta-blocker therapy E Angiotensin converting enzyme (ACE) inhibitor therapy
Part OneA 55-year-old man presents with acute pulmonary oedema Five years earlier he has undergone a mitral valve replacement with a bileaflet tilting disk valve (St Jude) for mixed mitral valve disease He has been well with normal exercise tolerance prior to the day of admission Examination on admission reveals tachypnoea sinus tachycardia of 110minute blood pressure of 10560 mmHg elevated jugular venous pressure (+ 5 cm) and bilateral crepitations throughout the lung fields His prothrombin timeminusinternational normalised ratio (PT-INR) is 19 [desired therapeutic range 20-35] Serum urea creatinine and electrolytes are normal The cardiothoracic ratio on chest X-ray is normal but the presence of pulmonary oedema is confirmed Echocardiography reveals that one of the prosthetic valve leaflets is not moving and there is an increased flow rate in diastole across the valve orifice (2 metressecond) What is the most appropriate course of action A Administration of intravenous streptokinase B Administration of intravenous heparin C Administration of intravenous antibiotics D Addition of an antiplatelet agent E Immediate mitral valve replacement
Aortic stenosis - quantification
Aortic stenosis - quantification Mean gradient
(mmHg) Peak Ao velocity
AVA (cm2)
Normal 10-20 gt25
Mild lt20 25-29 gt17
Moderate 20-40 30-40 10-17
Severe gt40 gt40 lt10
Right ventricle - size amp function
Estimation of Pulmonary PressurePA systolic pressure
bull Tricuspid regurgitation jet velocity
Estimation of Pulmonary PressureRA pressure
bull IVC size
Part OneThe severity of pulmonary hypertension can be determined using continuous wave Doppler measurements of the velocity of tricuspid regurgitation This method uses the Bernoulli equation which states that 1048661P = 4v2 (where 1048661P = instantaneous pressure gradient and v = velocity across the valve) There is tricuspid regurgitation with a peak velocity of 4 metressecond and a mean velocity of 35 metressecond Assuming right atrial pressure is 5 mmHg the best estimate of the peak right ventricular systolic pressure (plusmn 2 mmHg) is
A 50 mmHg B 55 mmHg C 60 mmHg D 65 mmHg E 70 mmHg
Cardiac Tamponade
Cardiac Tamponade
Cardiac Tamponade
Part OneA 65-year-old woman presents with a one-week history of progressive dyspnoea On admission there are signs of shock a systolic murmur and an elevated jugular venous pressure The ECG shows sinus tachycardia but no other abnormality An antero-posterior chest X-ray shows cardiomegaly The serum troponin I level is 05 mgL [lt01] A computed tomography (CT) scan is shown below
What is the most likely diagnosis A Pulmonary embolism B Right ventricular infarction C Pericardial tamponade D Myocarditis E Acute mitral regurgitation
Endocarditis
Positive echocardiogram for IE Discrete echogenic oscillating intracardiac mass located at a site of endocardial injury (eg on a valve or supporting structure in pathway of regurgitant jet or site of implanted material) or Periannular abscess or
New dehiscence of a prosthetic valve
Cardiac Resynchronisation
Cardiac Resynchronisation
bullSevere heart failure treatment to restore co-ordination to LV contraction
bullNYHA 3-4bullEF lt 35bullQRS duration gt 120 msec
Echocardiography
bullUseful non-invasive tool
bullReports objective and subjective
bullLimitations
Left ventricle - size
Normal
End-diastole 35-57cm
End-systole 21-40cm
Left ventricle - wall thickness
IVS and PW
06 -11cm
Left ventricle - systolic function
Fractional Shortening (FS)
FS = EDD-ESD EDD
Left ventricle - systolic function
Fractional Shortening (FS)
FS = EDD-ESD EDD
Left ventricle - systolic function
Left ventricle - systolic function
Ejection fraction ()
Normal gt55
Mild 40-50
Moderate 30-40
Moderate-severe 20-30
Severe lt20
Part OneA 67-year-old woman with congestive cardiac failure remains breathless on moderate exertion despite treatment with 40 mg frusemide and 20 mg enalapril daily On examination she has a pulse rate of 80minute blood pressure of 12570 mmHg and a jugular venous pressure (JVP) of +1 cm She has a soft systolic murmur with no added sounds her chest is clear and she has no oedema An ECG shows sinus rhythm A chest X-ray shows cardiomegaly with a cardiothoracic ratio of 15528 but no pulmonary congestion Echocardiography demonstrates systolic dysfunction with fractional shortening of 18 and mild mitral regurgitation Her serum creatinine level is normal
Which of the following is the most appropriate next step in treatment A Increase the frusemide dose B Add digoxin C Add an aldosterone antagonist D Add an angiotensin II receptor antagonist E Add a beta blocker
Left ventricle - diastolic function
Mitral inflow Pulmonary veins
Mitral TVI
LV diastolic function - mitral inflow
EA gt 1 EA lt 1 EA gtgt1
LV diastolic function - mitral TVI
EA gt 1 EA lt 1 EA gtgt1
Left ventricle - RWMAs
Left ventricle - RWMAs
Left ventricle - RWMAs
Left ventricle - thrombus
Left atrium - size
Diameter
Normal 20-40cm
Mild 40-50cm
Moderate 50-60cm
Severe gt60cm
Left atrium - size
Area
Normal lt20cm2
Mild 20-30cm2
Moderate 30-40cm2
Severe gt40cm2
Left atrium - thrombus
Cardiac Valves
Morphology
Valve dysfunction
aetiology
quantification
consequences
serial evaluation
Valve regurgitation - quantification
Colour - jet sizewidth
PISA
Spectral doppler
Consequences
AR - LV Response
bull Chronic AR - decompensated LV
bull LVEFlt55 LVESDgt55mm LVESV 60mlm2
Part OneA patient with aortic regurgitation has the following haemodynamic measurements cardiac output (CO) 75 Lminute heart rate (HR) 75minute left ventricular end-diastolic volume (LVEDV) 200 mL left ventricular end-systolic volume (LVESV) 50 mL The regurgitant fraction is defined as the ratio of the regurgitant volume to the total volume flowing through the valve with each beat
The regurgitant fraction in this patient is A 25 B 33 C 50 D 67 E 75
Part OneA 45-year-old asymptomatic man returns for follow-up He was diagnosed 10 years ago with aortic regurgitation due to a congenital bicuspid aortic valve He has never had endocarditis Which one of the following echocardiographic profiles most strongly indicates the need for aortic valve replacement
LVEDD (mm)[35-55] FS [030-040] LA size (mm) [lt40]
A 70 030 60
B 75 040 40
C 70 025 45
D 65 045 50
E 75 035 55
Key LVEDD Left ventricular end-diastolic diameter LVESD Left ventricular end-systolic diameter FS Fractional shortening = (LVEDD - LVESD) LVEDD LA Left atrial
MR- Quantification of LV contractility
LV systolic function - most important parameter
bullEjection fraction fractional shortening velocity of
circumferential fibre shortening - load dependent
bullMR allows supranormal values of EF etc
bullEarly systolic dysfunction if
bullEF lt 60 (severe MR)
bullES diameter lt 45mm (26mmm2)
Mitral stenosis - quantification
Severity MVA (cm2) LAP (mm Hg) CO
Mild gt20 lt10-12 NL
Moderate 11-20 ~10-17 NL
Severe lt10 gt18
Very Severe lt08 gt20-25
Part OneA 35-year-old woman has increasing breathlessness on exertion Her cardiac silhouette is slightly enlarged on a chest X-ray and an ECG demonstrates sinus rhythm The continuous wave Doppler flow signal through the mitral inflow tract (shown above) is most consistent with which one of the following A Severe pulmonary hypertension (cor pulmonale) B Aortic stenosis C Mitral regurgitation D Mitral stenosis E Aortic regurgitation
Part OneA 28-year-old woman who emigrated from Cambodia 10 years ago presents to the emergency department with a three-week history of increasing shortness of breath orthopnoea nocturnal dyspnoea and ankle oedema She is 25 weeks pregnant and has no significant past medical history The presence of pulmonary oedema is confirmed clinically and radiologically She responds well to intravenous frusemide but remains tachypnoeic with a heart rate of 120minute in sinus rhythm Her blood pressure is 12585 mmHg Echocardiography demonstrates mitral stenosis with an estimated valve area of 13 cm2 and a left atrial diameter of 50 mm [lt40 mm] There are no other abnormalities What is the most appropriate next step in management A Balloon valvotomy B Surgical valvotomy C Digoxin therapy D Beta-blocker therapy E Angiotensin converting enzyme (ACE) inhibitor therapy
Part OneA 55-year-old man presents with acute pulmonary oedema Five years earlier he has undergone a mitral valve replacement with a bileaflet tilting disk valve (St Jude) for mixed mitral valve disease He has been well with normal exercise tolerance prior to the day of admission Examination on admission reveals tachypnoea sinus tachycardia of 110minute blood pressure of 10560 mmHg elevated jugular venous pressure (+ 5 cm) and bilateral crepitations throughout the lung fields His prothrombin timeminusinternational normalised ratio (PT-INR) is 19 [desired therapeutic range 20-35] Serum urea creatinine and electrolytes are normal The cardiothoracic ratio on chest X-ray is normal but the presence of pulmonary oedema is confirmed Echocardiography reveals that one of the prosthetic valve leaflets is not moving and there is an increased flow rate in diastole across the valve orifice (2 metressecond) What is the most appropriate course of action A Administration of intravenous streptokinase B Administration of intravenous heparin C Administration of intravenous antibiotics D Addition of an antiplatelet agent E Immediate mitral valve replacement
Aortic stenosis - quantification
Aortic stenosis - quantification Mean gradient
(mmHg) Peak Ao velocity
AVA (cm2)
Normal 10-20 gt25
Mild lt20 25-29 gt17
Moderate 20-40 30-40 10-17
Severe gt40 gt40 lt10
Right ventricle - size amp function
Estimation of Pulmonary PressurePA systolic pressure
bull Tricuspid regurgitation jet velocity
Estimation of Pulmonary PressureRA pressure
bull IVC size
Part OneThe severity of pulmonary hypertension can be determined using continuous wave Doppler measurements of the velocity of tricuspid regurgitation This method uses the Bernoulli equation which states that 1048661P = 4v2 (where 1048661P = instantaneous pressure gradient and v = velocity across the valve) There is tricuspid regurgitation with a peak velocity of 4 metressecond and a mean velocity of 35 metressecond Assuming right atrial pressure is 5 mmHg the best estimate of the peak right ventricular systolic pressure (plusmn 2 mmHg) is
A 50 mmHg B 55 mmHg C 60 mmHg D 65 mmHg E 70 mmHg
Cardiac Tamponade
Cardiac Tamponade
Cardiac Tamponade
Part OneA 65-year-old woman presents with a one-week history of progressive dyspnoea On admission there are signs of shock a systolic murmur and an elevated jugular venous pressure The ECG shows sinus tachycardia but no other abnormality An antero-posterior chest X-ray shows cardiomegaly The serum troponin I level is 05 mgL [lt01] A computed tomography (CT) scan is shown below
What is the most likely diagnosis A Pulmonary embolism B Right ventricular infarction C Pericardial tamponade D Myocarditis E Acute mitral regurgitation
Endocarditis
Positive echocardiogram for IE Discrete echogenic oscillating intracardiac mass located at a site of endocardial injury (eg on a valve or supporting structure in pathway of regurgitant jet or site of implanted material) or Periannular abscess or
New dehiscence of a prosthetic valve
Cardiac Resynchronisation
Cardiac Resynchronisation
bullSevere heart failure treatment to restore co-ordination to LV contraction
bullNYHA 3-4bullEF lt 35bullQRS duration gt 120 msec
Echocardiography
bullUseful non-invasive tool
bullReports objective and subjective
bullLimitations
Left ventricle - wall thickness
IVS and PW
06 -11cm
Left ventricle - systolic function
Fractional Shortening (FS)
FS = EDD-ESD EDD
Left ventricle - systolic function
Fractional Shortening (FS)
FS = EDD-ESD EDD
Left ventricle - systolic function
Left ventricle - systolic function
Ejection fraction ()
Normal gt55
Mild 40-50
Moderate 30-40
Moderate-severe 20-30
Severe lt20
Part OneA 67-year-old woman with congestive cardiac failure remains breathless on moderate exertion despite treatment with 40 mg frusemide and 20 mg enalapril daily On examination she has a pulse rate of 80minute blood pressure of 12570 mmHg and a jugular venous pressure (JVP) of +1 cm She has a soft systolic murmur with no added sounds her chest is clear and she has no oedema An ECG shows sinus rhythm A chest X-ray shows cardiomegaly with a cardiothoracic ratio of 15528 but no pulmonary congestion Echocardiography demonstrates systolic dysfunction with fractional shortening of 18 and mild mitral regurgitation Her serum creatinine level is normal
Which of the following is the most appropriate next step in treatment A Increase the frusemide dose B Add digoxin C Add an aldosterone antagonist D Add an angiotensin II receptor antagonist E Add a beta blocker
Left ventricle - diastolic function
Mitral inflow Pulmonary veins
Mitral TVI
LV diastolic function - mitral inflow
EA gt 1 EA lt 1 EA gtgt1
LV diastolic function - mitral TVI
EA gt 1 EA lt 1 EA gtgt1
Left ventricle - RWMAs
Left ventricle - RWMAs
Left ventricle - RWMAs
Left ventricle - thrombus
Left atrium - size
Diameter
Normal 20-40cm
Mild 40-50cm
Moderate 50-60cm
Severe gt60cm
Left atrium - size
Area
Normal lt20cm2
Mild 20-30cm2
Moderate 30-40cm2
Severe gt40cm2
Left atrium - thrombus
Cardiac Valves
Morphology
Valve dysfunction
aetiology
quantification
consequences
serial evaluation
Valve regurgitation - quantification
Colour - jet sizewidth
PISA
Spectral doppler
Consequences
AR - LV Response
bull Chronic AR - decompensated LV
bull LVEFlt55 LVESDgt55mm LVESV 60mlm2
Part OneA patient with aortic regurgitation has the following haemodynamic measurements cardiac output (CO) 75 Lminute heart rate (HR) 75minute left ventricular end-diastolic volume (LVEDV) 200 mL left ventricular end-systolic volume (LVESV) 50 mL The regurgitant fraction is defined as the ratio of the regurgitant volume to the total volume flowing through the valve with each beat
The regurgitant fraction in this patient is A 25 B 33 C 50 D 67 E 75
Part OneA 45-year-old asymptomatic man returns for follow-up He was diagnosed 10 years ago with aortic regurgitation due to a congenital bicuspid aortic valve He has never had endocarditis Which one of the following echocardiographic profiles most strongly indicates the need for aortic valve replacement
LVEDD (mm)[35-55] FS [030-040] LA size (mm) [lt40]
A 70 030 60
B 75 040 40
C 70 025 45
D 65 045 50
E 75 035 55
Key LVEDD Left ventricular end-diastolic diameter LVESD Left ventricular end-systolic diameter FS Fractional shortening = (LVEDD - LVESD) LVEDD LA Left atrial
MR- Quantification of LV contractility
LV systolic function - most important parameter
bullEjection fraction fractional shortening velocity of
circumferential fibre shortening - load dependent
bullMR allows supranormal values of EF etc
bullEarly systolic dysfunction if
bullEF lt 60 (severe MR)
bullES diameter lt 45mm (26mmm2)
Mitral stenosis - quantification
Severity MVA (cm2) LAP (mm Hg) CO
Mild gt20 lt10-12 NL
Moderate 11-20 ~10-17 NL
Severe lt10 gt18
Very Severe lt08 gt20-25
Part OneA 35-year-old woman has increasing breathlessness on exertion Her cardiac silhouette is slightly enlarged on a chest X-ray and an ECG demonstrates sinus rhythm The continuous wave Doppler flow signal through the mitral inflow tract (shown above) is most consistent with which one of the following A Severe pulmonary hypertension (cor pulmonale) B Aortic stenosis C Mitral regurgitation D Mitral stenosis E Aortic regurgitation
Part OneA 28-year-old woman who emigrated from Cambodia 10 years ago presents to the emergency department with a three-week history of increasing shortness of breath orthopnoea nocturnal dyspnoea and ankle oedema She is 25 weeks pregnant and has no significant past medical history The presence of pulmonary oedema is confirmed clinically and radiologically She responds well to intravenous frusemide but remains tachypnoeic with a heart rate of 120minute in sinus rhythm Her blood pressure is 12585 mmHg Echocardiography demonstrates mitral stenosis with an estimated valve area of 13 cm2 and a left atrial diameter of 50 mm [lt40 mm] There are no other abnormalities What is the most appropriate next step in management A Balloon valvotomy B Surgical valvotomy C Digoxin therapy D Beta-blocker therapy E Angiotensin converting enzyme (ACE) inhibitor therapy
Part OneA 55-year-old man presents with acute pulmonary oedema Five years earlier he has undergone a mitral valve replacement with a bileaflet tilting disk valve (St Jude) for mixed mitral valve disease He has been well with normal exercise tolerance prior to the day of admission Examination on admission reveals tachypnoea sinus tachycardia of 110minute blood pressure of 10560 mmHg elevated jugular venous pressure (+ 5 cm) and bilateral crepitations throughout the lung fields His prothrombin timeminusinternational normalised ratio (PT-INR) is 19 [desired therapeutic range 20-35] Serum urea creatinine and electrolytes are normal The cardiothoracic ratio on chest X-ray is normal but the presence of pulmonary oedema is confirmed Echocardiography reveals that one of the prosthetic valve leaflets is not moving and there is an increased flow rate in diastole across the valve orifice (2 metressecond) What is the most appropriate course of action A Administration of intravenous streptokinase B Administration of intravenous heparin C Administration of intravenous antibiotics D Addition of an antiplatelet agent E Immediate mitral valve replacement
Aortic stenosis - quantification
Aortic stenosis - quantification Mean gradient
(mmHg) Peak Ao velocity
AVA (cm2)
Normal 10-20 gt25
Mild lt20 25-29 gt17
Moderate 20-40 30-40 10-17
Severe gt40 gt40 lt10
Right ventricle - size amp function
Estimation of Pulmonary PressurePA systolic pressure
bull Tricuspid regurgitation jet velocity
Estimation of Pulmonary PressureRA pressure
bull IVC size
Part OneThe severity of pulmonary hypertension can be determined using continuous wave Doppler measurements of the velocity of tricuspid regurgitation This method uses the Bernoulli equation which states that 1048661P = 4v2 (where 1048661P = instantaneous pressure gradient and v = velocity across the valve) There is tricuspid regurgitation with a peak velocity of 4 metressecond and a mean velocity of 35 metressecond Assuming right atrial pressure is 5 mmHg the best estimate of the peak right ventricular systolic pressure (plusmn 2 mmHg) is
A 50 mmHg B 55 mmHg C 60 mmHg D 65 mmHg E 70 mmHg
Cardiac Tamponade
Cardiac Tamponade
Cardiac Tamponade
Part OneA 65-year-old woman presents with a one-week history of progressive dyspnoea On admission there are signs of shock a systolic murmur and an elevated jugular venous pressure The ECG shows sinus tachycardia but no other abnormality An antero-posterior chest X-ray shows cardiomegaly The serum troponin I level is 05 mgL [lt01] A computed tomography (CT) scan is shown below
What is the most likely diagnosis A Pulmonary embolism B Right ventricular infarction C Pericardial tamponade D Myocarditis E Acute mitral regurgitation
Endocarditis
Positive echocardiogram for IE Discrete echogenic oscillating intracardiac mass located at a site of endocardial injury (eg on a valve or supporting structure in pathway of regurgitant jet or site of implanted material) or Periannular abscess or
New dehiscence of a prosthetic valve
Cardiac Resynchronisation
Cardiac Resynchronisation
bullSevere heart failure treatment to restore co-ordination to LV contraction
bullNYHA 3-4bullEF lt 35bullQRS duration gt 120 msec
Echocardiography
bullUseful non-invasive tool
bullReports objective and subjective
bullLimitations
Left ventricle - systolic function
Fractional Shortening (FS)
FS = EDD-ESD EDD
Left ventricle - systolic function
Fractional Shortening (FS)
FS = EDD-ESD EDD
Left ventricle - systolic function
Left ventricle - systolic function
Ejection fraction ()
Normal gt55
Mild 40-50
Moderate 30-40
Moderate-severe 20-30
Severe lt20
Part OneA 67-year-old woman with congestive cardiac failure remains breathless on moderate exertion despite treatment with 40 mg frusemide and 20 mg enalapril daily On examination she has a pulse rate of 80minute blood pressure of 12570 mmHg and a jugular venous pressure (JVP) of +1 cm She has a soft systolic murmur with no added sounds her chest is clear and she has no oedema An ECG shows sinus rhythm A chest X-ray shows cardiomegaly with a cardiothoracic ratio of 15528 but no pulmonary congestion Echocardiography demonstrates systolic dysfunction with fractional shortening of 18 and mild mitral regurgitation Her serum creatinine level is normal
Which of the following is the most appropriate next step in treatment A Increase the frusemide dose B Add digoxin C Add an aldosterone antagonist D Add an angiotensin II receptor antagonist E Add a beta blocker
Left ventricle - diastolic function
Mitral inflow Pulmonary veins
Mitral TVI
LV diastolic function - mitral inflow
EA gt 1 EA lt 1 EA gtgt1
LV diastolic function - mitral TVI
EA gt 1 EA lt 1 EA gtgt1
Left ventricle - RWMAs
Left ventricle - RWMAs
Left ventricle - RWMAs
Left ventricle - thrombus
Left atrium - size
Diameter
Normal 20-40cm
Mild 40-50cm
Moderate 50-60cm
Severe gt60cm
Left atrium - size
Area
Normal lt20cm2
Mild 20-30cm2
Moderate 30-40cm2
Severe gt40cm2
Left atrium - thrombus
Cardiac Valves
Morphology
Valve dysfunction
aetiology
quantification
consequences
serial evaluation
Valve regurgitation - quantification
Colour - jet sizewidth
PISA
Spectral doppler
Consequences
AR - LV Response
bull Chronic AR - decompensated LV
bull LVEFlt55 LVESDgt55mm LVESV 60mlm2
Part OneA patient with aortic regurgitation has the following haemodynamic measurements cardiac output (CO) 75 Lminute heart rate (HR) 75minute left ventricular end-diastolic volume (LVEDV) 200 mL left ventricular end-systolic volume (LVESV) 50 mL The regurgitant fraction is defined as the ratio of the regurgitant volume to the total volume flowing through the valve with each beat
The regurgitant fraction in this patient is A 25 B 33 C 50 D 67 E 75
Part OneA 45-year-old asymptomatic man returns for follow-up He was diagnosed 10 years ago with aortic regurgitation due to a congenital bicuspid aortic valve He has never had endocarditis Which one of the following echocardiographic profiles most strongly indicates the need for aortic valve replacement
LVEDD (mm)[35-55] FS [030-040] LA size (mm) [lt40]
A 70 030 60
B 75 040 40
C 70 025 45
D 65 045 50
E 75 035 55
Key LVEDD Left ventricular end-diastolic diameter LVESD Left ventricular end-systolic diameter FS Fractional shortening = (LVEDD - LVESD) LVEDD LA Left atrial
MR- Quantification of LV contractility
LV systolic function - most important parameter
bullEjection fraction fractional shortening velocity of
circumferential fibre shortening - load dependent
bullMR allows supranormal values of EF etc
bullEarly systolic dysfunction if
bullEF lt 60 (severe MR)
bullES diameter lt 45mm (26mmm2)
Mitral stenosis - quantification
Severity MVA (cm2) LAP (mm Hg) CO
Mild gt20 lt10-12 NL
Moderate 11-20 ~10-17 NL
Severe lt10 gt18
Very Severe lt08 gt20-25
Part OneA 35-year-old woman has increasing breathlessness on exertion Her cardiac silhouette is slightly enlarged on a chest X-ray and an ECG demonstrates sinus rhythm The continuous wave Doppler flow signal through the mitral inflow tract (shown above) is most consistent with which one of the following A Severe pulmonary hypertension (cor pulmonale) B Aortic stenosis C Mitral regurgitation D Mitral stenosis E Aortic regurgitation
Part OneA 28-year-old woman who emigrated from Cambodia 10 years ago presents to the emergency department with a three-week history of increasing shortness of breath orthopnoea nocturnal dyspnoea and ankle oedema She is 25 weeks pregnant and has no significant past medical history The presence of pulmonary oedema is confirmed clinically and radiologically She responds well to intravenous frusemide but remains tachypnoeic with a heart rate of 120minute in sinus rhythm Her blood pressure is 12585 mmHg Echocardiography demonstrates mitral stenosis with an estimated valve area of 13 cm2 and a left atrial diameter of 50 mm [lt40 mm] There are no other abnormalities What is the most appropriate next step in management A Balloon valvotomy B Surgical valvotomy C Digoxin therapy D Beta-blocker therapy E Angiotensin converting enzyme (ACE) inhibitor therapy
Part OneA 55-year-old man presents with acute pulmonary oedema Five years earlier he has undergone a mitral valve replacement with a bileaflet tilting disk valve (St Jude) for mixed mitral valve disease He has been well with normal exercise tolerance prior to the day of admission Examination on admission reveals tachypnoea sinus tachycardia of 110minute blood pressure of 10560 mmHg elevated jugular venous pressure (+ 5 cm) and bilateral crepitations throughout the lung fields His prothrombin timeminusinternational normalised ratio (PT-INR) is 19 [desired therapeutic range 20-35] Serum urea creatinine and electrolytes are normal The cardiothoracic ratio on chest X-ray is normal but the presence of pulmonary oedema is confirmed Echocardiography reveals that one of the prosthetic valve leaflets is not moving and there is an increased flow rate in diastole across the valve orifice (2 metressecond) What is the most appropriate course of action A Administration of intravenous streptokinase B Administration of intravenous heparin C Administration of intravenous antibiotics D Addition of an antiplatelet agent E Immediate mitral valve replacement
Aortic stenosis - quantification
Aortic stenosis - quantification Mean gradient
(mmHg) Peak Ao velocity
AVA (cm2)
Normal 10-20 gt25
Mild lt20 25-29 gt17
Moderate 20-40 30-40 10-17
Severe gt40 gt40 lt10
Right ventricle - size amp function
Estimation of Pulmonary PressurePA systolic pressure
bull Tricuspid regurgitation jet velocity
Estimation of Pulmonary PressureRA pressure
bull IVC size
Part OneThe severity of pulmonary hypertension can be determined using continuous wave Doppler measurements of the velocity of tricuspid regurgitation This method uses the Bernoulli equation which states that 1048661P = 4v2 (where 1048661P = instantaneous pressure gradient and v = velocity across the valve) There is tricuspid regurgitation with a peak velocity of 4 metressecond and a mean velocity of 35 metressecond Assuming right atrial pressure is 5 mmHg the best estimate of the peak right ventricular systolic pressure (plusmn 2 mmHg) is
A 50 mmHg B 55 mmHg C 60 mmHg D 65 mmHg E 70 mmHg
Cardiac Tamponade
Cardiac Tamponade
Cardiac Tamponade
Part OneA 65-year-old woman presents with a one-week history of progressive dyspnoea On admission there are signs of shock a systolic murmur and an elevated jugular venous pressure The ECG shows sinus tachycardia but no other abnormality An antero-posterior chest X-ray shows cardiomegaly The serum troponin I level is 05 mgL [lt01] A computed tomography (CT) scan is shown below
What is the most likely diagnosis A Pulmonary embolism B Right ventricular infarction C Pericardial tamponade D Myocarditis E Acute mitral regurgitation
Endocarditis
Positive echocardiogram for IE Discrete echogenic oscillating intracardiac mass located at a site of endocardial injury (eg on a valve or supporting structure in pathway of regurgitant jet or site of implanted material) or Periannular abscess or
New dehiscence of a prosthetic valve
Cardiac Resynchronisation
Cardiac Resynchronisation
bullSevere heart failure treatment to restore co-ordination to LV contraction
bullNYHA 3-4bullEF lt 35bullQRS duration gt 120 msec
Echocardiography
bullUseful non-invasive tool
bullReports objective and subjective
bullLimitations
Left ventricle - systolic function
Fractional Shortening (FS)
FS = EDD-ESD EDD
Left ventricle - systolic function
Left ventricle - systolic function
Ejection fraction ()
Normal gt55
Mild 40-50
Moderate 30-40
Moderate-severe 20-30
Severe lt20
Part OneA 67-year-old woman with congestive cardiac failure remains breathless on moderate exertion despite treatment with 40 mg frusemide and 20 mg enalapril daily On examination she has a pulse rate of 80minute blood pressure of 12570 mmHg and a jugular venous pressure (JVP) of +1 cm She has a soft systolic murmur with no added sounds her chest is clear and she has no oedema An ECG shows sinus rhythm A chest X-ray shows cardiomegaly with a cardiothoracic ratio of 15528 but no pulmonary congestion Echocardiography demonstrates systolic dysfunction with fractional shortening of 18 and mild mitral regurgitation Her serum creatinine level is normal
Which of the following is the most appropriate next step in treatment A Increase the frusemide dose B Add digoxin C Add an aldosterone antagonist D Add an angiotensin II receptor antagonist E Add a beta blocker
Left ventricle - diastolic function
Mitral inflow Pulmonary veins
Mitral TVI
LV diastolic function - mitral inflow
EA gt 1 EA lt 1 EA gtgt1
LV diastolic function - mitral TVI
EA gt 1 EA lt 1 EA gtgt1
Left ventricle - RWMAs
Left ventricle - RWMAs
Left ventricle - RWMAs
Left ventricle - thrombus
Left atrium - size
Diameter
Normal 20-40cm
Mild 40-50cm
Moderate 50-60cm
Severe gt60cm
Left atrium - size
Area
Normal lt20cm2
Mild 20-30cm2
Moderate 30-40cm2
Severe gt40cm2
Left atrium - thrombus
Cardiac Valves
Morphology
Valve dysfunction
aetiology
quantification
consequences
serial evaluation
Valve regurgitation - quantification
Colour - jet sizewidth
PISA
Spectral doppler
Consequences
AR - LV Response
bull Chronic AR - decompensated LV
bull LVEFlt55 LVESDgt55mm LVESV 60mlm2
Part OneA patient with aortic regurgitation has the following haemodynamic measurements cardiac output (CO) 75 Lminute heart rate (HR) 75minute left ventricular end-diastolic volume (LVEDV) 200 mL left ventricular end-systolic volume (LVESV) 50 mL The regurgitant fraction is defined as the ratio of the regurgitant volume to the total volume flowing through the valve with each beat
The regurgitant fraction in this patient is A 25 B 33 C 50 D 67 E 75
Part OneA 45-year-old asymptomatic man returns for follow-up He was diagnosed 10 years ago with aortic regurgitation due to a congenital bicuspid aortic valve He has never had endocarditis Which one of the following echocardiographic profiles most strongly indicates the need for aortic valve replacement
LVEDD (mm)[35-55] FS [030-040] LA size (mm) [lt40]
A 70 030 60
B 75 040 40
C 70 025 45
D 65 045 50
E 75 035 55
Key LVEDD Left ventricular end-diastolic diameter LVESD Left ventricular end-systolic diameter FS Fractional shortening = (LVEDD - LVESD) LVEDD LA Left atrial
MR- Quantification of LV contractility
LV systolic function - most important parameter
bullEjection fraction fractional shortening velocity of
circumferential fibre shortening - load dependent
bullMR allows supranormal values of EF etc
bullEarly systolic dysfunction if
bullEF lt 60 (severe MR)
bullES diameter lt 45mm (26mmm2)
Mitral stenosis - quantification
Severity MVA (cm2) LAP (mm Hg) CO
Mild gt20 lt10-12 NL
Moderate 11-20 ~10-17 NL
Severe lt10 gt18
Very Severe lt08 gt20-25
Part OneA 35-year-old woman has increasing breathlessness on exertion Her cardiac silhouette is slightly enlarged on a chest X-ray and an ECG demonstrates sinus rhythm The continuous wave Doppler flow signal through the mitral inflow tract (shown above) is most consistent with which one of the following A Severe pulmonary hypertension (cor pulmonale) B Aortic stenosis C Mitral regurgitation D Mitral stenosis E Aortic regurgitation
Part OneA 28-year-old woman who emigrated from Cambodia 10 years ago presents to the emergency department with a three-week history of increasing shortness of breath orthopnoea nocturnal dyspnoea and ankle oedema She is 25 weeks pregnant and has no significant past medical history The presence of pulmonary oedema is confirmed clinically and radiologically She responds well to intravenous frusemide but remains tachypnoeic with a heart rate of 120minute in sinus rhythm Her blood pressure is 12585 mmHg Echocardiography demonstrates mitral stenosis with an estimated valve area of 13 cm2 and a left atrial diameter of 50 mm [lt40 mm] There are no other abnormalities What is the most appropriate next step in management A Balloon valvotomy B Surgical valvotomy C Digoxin therapy D Beta-blocker therapy E Angiotensin converting enzyme (ACE) inhibitor therapy
Part OneA 55-year-old man presents with acute pulmonary oedema Five years earlier he has undergone a mitral valve replacement with a bileaflet tilting disk valve (St Jude) for mixed mitral valve disease He has been well with normal exercise tolerance prior to the day of admission Examination on admission reveals tachypnoea sinus tachycardia of 110minute blood pressure of 10560 mmHg elevated jugular venous pressure (+ 5 cm) and bilateral crepitations throughout the lung fields His prothrombin timeminusinternational normalised ratio (PT-INR) is 19 [desired therapeutic range 20-35] Serum urea creatinine and electrolytes are normal The cardiothoracic ratio on chest X-ray is normal but the presence of pulmonary oedema is confirmed Echocardiography reveals that one of the prosthetic valve leaflets is not moving and there is an increased flow rate in diastole across the valve orifice (2 metressecond) What is the most appropriate course of action A Administration of intravenous streptokinase B Administration of intravenous heparin C Administration of intravenous antibiotics D Addition of an antiplatelet agent E Immediate mitral valve replacement
Aortic stenosis - quantification
Aortic stenosis - quantification Mean gradient
(mmHg) Peak Ao velocity
AVA (cm2)
Normal 10-20 gt25
Mild lt20 25-29 gt17
Moderate 20-40 30-40 10-17
Severe gt40 gt40 lt10
Right ventricle - size amp function
Estimation of Pulmonary PressurePA systolic pressure
bull Tricuspid regurgitation jet velocity
Estimation of Pulmonary PressureRA pressure
bull IVC size
Part OneThe severity of pulmonary hypertension can be determined using continuous wave Doppler measurements of the velocity of tricuspid regurgitation This method uses the Bernoulli equation which states that 1048661P = 4v2 (where 1048661P = instantaneous pressure gradient and v = velocity across the valve) There is tricuspid regurgitation with a peak velocity of 4 metressecond and a mean velocity of 35 metressecond Assuming right atrial pressure is 5 mmHg the best estimate of the peak right ventricular systolic pressure (plusmn 2 mmHg) is
A 50 mmHg B 55 mmHg C 60 mmHg D 65 mmHg E 70 mmHg
Cardiac Tamponade
Cardiac Tamponade
Cardiac Tamponade
Part OneA 65-year-old woman presents with a one-week history of progressive dyspnoea On admission there are signs of shock a systolic murmur and an elevated jugular venous pressure The ECG shows sinus tachycardia but no other abnormality An antero-posterior chest X-ray shows cardiomegaly The serum troponin I level is 05 mgL [lt01] A computed tomography (CT) scan is shown below
What is the most likely diagnosis A Pulmonary embolism B Right ventricular infarction C Pericardial tamponade D Myocarditis E Acute mitral regurgitation
Endocarditis
Positive echocardiogram for IE Discrete echogenic oscillating intracardiac mass located at a site of endocardial injury (eg on a valve or supporting structure in pathway of regurgitant jet or site of implanted material) or Periannular abscess or
New dehiscence of a prosthetic valve
Cardiac Resynchronisation
Cardiac Resynchronisation
bullSevere heart failure treatment to restore co-ordination to LV contraction
bullNYHA 3-4bullEF lt 35bullQRS duration gt 120 msec
Echocardiography
bullUseful non-invasive tool
bullReports objective and subjective
bullLimitations
Left ventricle - systolic function
Left ventricle - systolic function
Ejection fraction ()
Normal gt55
Mild 40-50
Moderate 30-40
Moderate-severe 20-30
Severe lt20
Part OneA 67-year-old woman with congestive cardiac failure remains breathless on moderate exertion despite treatment with 40 mg frusemide and 20 mg enalapril daily On examination she has a pulse rate of 80minute blood pressure of 12570 mmHg and a jugular venous pressure (JVP) of +1 cm She has a soft systolic murmur with no added sounds her chest is clear and she has no oedema An ECG shows sinus rhythm A chest X-ray shows cardiomegaly with a cardiothoracic ratio of 15528 but no pulmonary congestion Echocardiography demonstrates systolic dysfunction with fractional shortening of 18 and mild mitral regurgitation Her serum creatinine level is normal
Which of the following is the most appropriate next step in treatment A Increase the frusemide dose B Add digoxin C Add an aldosterone antagonist D Add an angiotensin II receptor antagonist E Add a beta blocker
Left ventricle - diastolic function
Mitral inflow Pulmonary veins
Mitral TVI
LV diastolic function - mitral inflow
EA gt 1 EA lt 1 EA gtgt1
LV diastolic function - mitral TVI
EA gt 1 EA lt 1 EA gtgt1
Left ventricle - RWMAs
Left ventricle - RWMAs
Left ventricle - RWMAs
Left ventricle - thrombus
Left atrium - size
Diameter
Normal 20-40cm
Mild 40-50cm
Moderate 50-60cm
Severe gt60cm
Left atrium - size
Area
Normal lt20cm2
Mild 20-30cm2
Moderate 30-40cm2
Severe gt40cm2
Left atrium - thrombus
Cardiac Valves
Morphology
Valve dysfunction
aetiology
quantification
consequences
serial evaluation
Valve regurgitation - quantification
Colour - jet sizewidth
PISA
Spectral doppler
Consequences
AR - LV Response
bull Chronic AR - decompensated LV
bull LVEFlt55 LVESDgt55mm LVESV 60mlm2
Part OneA patient with aortic regurgitation has the following haemodynamic measurements cardiac output (CO) 75 Lminute heart rate (HR) 75minute left ventricular end-diastolic volume (LVEDV) 200 mL left ventricular end-systolic volume (LVESV) 50 mL The regurgitant fraction is defined as the ratio of the regurgitant volume to the total volume flowing through the valve with each beat
The regurgitant fraction in this patient is A 25 B 33 C 50 D 67 E 75
Part OneA 45-year-old asymptomatic man returns for follow-up He was diagnosed 10 years ago with aortic regurgitation due to a congenital bicuspid aortic valve He has never had endocarditis Which one of the following echocardiographic profiles most strongly indicates the need for aortic valve replacement
LVEDD (mm)[35-55] FS [030-040] LA size (mm) [lt40]
A 70 030 60
B 75 040 40
C 70 025 45
D 65 045 50
E 75 035 55
Key LVEDD Left ventricular end-diastolic diameter LVESD Left ventricular end-systolic diameter FS Fractional shortening = (LVEDD - LVESD) LVEDD LA Left atrial
MR- Quantification of LV contractility
LV systolic function - most important parameter
bullEjection fraction fractional shortening velocity of
circumferential fibre shortening - load dependent
bullMR allows supranormal values of EF etc
bullEarly systolic dysfunction if
bullEF lt 60 (severe MR)
bullES diameter lt 45mm (26mmm2)
Mitral stenosis - quantification
Severity MVA (cm2) LAP (mm Hg) CO
Mild gt20 lt10-12 NL
Moderate 11-20 ~10-17 NL
Severe lt10 gt18
Very Severe lt08 gt20-25
Part OneA 35-year-old woman has increasing breathlessness on exertion Her cardiac silhouette is slightly enlarged on a chest X-ray and an ECG demonstrates sinus rhythm The continuous wave Doppler flow signal through the mitral inflow tract (shown above) is most consistent with which one of the following A Severe pulmonary hypertension (cor pulmonale) B Aortic stenosis C Mitral regurgitation D Mitral stenosis E Aortic regurgitation
Part OneA 28-year-old woman who emigrated from Cambodia 10 years ago presents to the emergency department with a three-week history of increasing shortness of breath orthopnoea nocturnal dyspnoea and ankle oedema She is 25 weeks pregnant and has no significant past medical history The presence of pulmonary oedema is confirmed clinically and radiologically She responds well to intravenous frusemide but remains tachypnoeic with a heart rate of 120minute in sinus rhythm Her blood pressure is 12585 mmHg Echocardiography demonstrates mitral stenosis with an estimated valve area of 13 cm2 and a left atrial diameter of 50 mm [lt40 mm] There are no other abnormalities What is the most appropriate next step in management A Balloon valvotomy B Surgical valvotomy C Digoxin therapy D Beta-blocker therapy E Angiotensin converting enzyme (ACE) inhibitor therapy
Part OneA 55-year-old man presents with acute pulmonary oedema Five years earlier he has undergone a mitral valve replacement with a bileaflet tilting disk valve (St Jude) for mixed mitral valve disease He has been well with normal exercise tolerance prior to the day of admission Examination on admission reveals tachypnoea sinus tachycardia of 110minute blood pressure of 10560 mmHg elevated jugular venous pressure (+ 5 cm) and bilateral crepitations throughout the lung fields His prothrombin timeminusinternational normalised ratio (PT-INR) is 19 [desired therapeutic range 20-35] Serum urea creatinine and electrolytes are normal The cardiothoracic ratio on chest X-ray is normal but the presence of pulmonary oedema is confirmed Echocardiography reveals that one of the prosthetic valve leaflets is not moving and there is an increased flow rate in diastole across the valve orifice (2 metressecond) What is the most appropriate course of action A Administration of intravenous streptokinase B Administration of intravenous heparin C Administration of intravenous antibiotics D Addition of an antiplatelet agent E Immediate mitral valve replacement
Aortic stenosis - quantification
Aortic stenosis - quantification Mean gradient
(mmHg) Peak Ao velocity
AVA (cm2)
Normal 10-20 gt25
Mild lt20 25-29 gt17
Moderate 20-40 30-40 10-17
Severe gt40 gt40 lt10
Right ventricle - size amp function
Estimation of Pulmonary PressurePA systolic pressure
bull Tricuspid regurgitation jet velocity
Estimation of Pulmonary PressureRA pressure
bull IVC size
Part OneThe severity of pulmonary hypertension can be determined using continuous wave Doppler measurements of the velocity of tricuspid regurgitation This method uses the Bernoulli equation which states that 1048661P = 4v2 (where 1048661P = instantaneous pressure gradient and v = velocity across the valve) There is tricuspid regurgitation with a peak velocity of 4 metressecond and a mean velocity of 35 metressecond Assuming right atrial pressure is 5 mmHg the best estimate of the peak right ventricular systolic pressure (plusmn 2 mmHg) is
A 50 mmHg B 55 mmHg C 60 mmHg D 65 mmHg E 70 mmHg
Cardiac Tamponade
Cardiac Tamponade
Cardiac Tamponade
Part OneA 65-year-old woman presents with a one-week history of progressive dyspnoea On admission there are signs of shock a systolic murmur and an elevated jugular venous pressure The ECG shows sinus tachycardia but no other abnormality An antero-posterior chest X-ray shows cardiomegaly The serum troponin I level is 05 mgL [lt01] A computed tomography (CT) scan is shown below
What is the most likely diagnosis A Pulmonary embolism B Right ventricular infarction C Pericardial tamponade D Myocarditis E Acute mitral regurgitation
Endocarditis
Positive echocardiogram for IE Discrete echogenic oscillating intracardiac mass located at a site of endocardial injury (eg on a valve or supporting structure in pathway of regurgitant jet or site of implanted material) or Periannular abscess or
New dehiscence of a prosthetic valve
Cardiac Resynchronisation
Cardiac Resynchronisation
bullSevere heart failure treatment to restore co-ordination to LV contraction
bullNYHA 3-4bullEF lt 35bullQRS duration gt 120 msec
Echocardiography
bullUseful non-invasive tool
bullReports objective and subjective
bullLimitations
Left ventricle - systolic function
Ejection fraction ()
Normal gt55
Mild 40-50
Moderate 30-40
Moderate-severe 20-30
Severe lt20
Part OneA 67-year-old woman with congestive cardiac failure remains breathless on moderate exertion despite treatment with 40 mg frusemide and 20 mg enalapril daily On examination she has a pulse rate of 80minute blood pressure of 12570 mmHg and a jugular venous pressure (JVP) of +1 cm She has a soft systolic murmur with no added sounds her chest is clear and she has no oedema An ECG shows sinus rhythm A chest X-ray shows cardiomegaly with a cardiothoracic ratio of 15528 but no pulmonary congestion Echocardiography demonstrates systolic dysfunction with fractional shortening of 18 and mild mitral regurgitation Her serum creatinine level is normal
Which of the following is the most appropriate next step in treatment A Increase the frusemide dose B Add digoxin C Add an aldosterone antagonist D Add an angiotensin II receptor antagonist E Add a beta blocker
Left ventricle - diastolic function
Mitral inflow Pulmonary veins
Mitral TVI
LV diastolic function - mitral inflow
EA gt 1 EA lt 1 EA gtgt1
LV diastolic function - mitral TVI
EA gt 1 EA lt 1 EA gtgt1
Left ventricle - RWMAs
Left ventricle - RWMAs
Left ventricle - RWMAs
Left ventricle - thrombus
Left atrium - size
Diameter
Normal 20-40cm
Mild 40-50cm
Moderate 50-60cm
Severe gt60cm
Left atrium - size
Area
Normal lt20cm2
Mild 20-30cm2
Moderate 30-40cm2
Severe gt40cm2
Left atrium - thrombus
Cardiac Valves
Morphology
Valve dysfunction
aetiology
quantification
consequences
serial evaluation
Valve regurgitation - quantification
Colour - jet sizewidth
PISA
Spectral doppler
Consequences
AR - LV Response
bull Chronic AR - decompensated LV
bull LVEFlt55 LVESDgt55mm LVESV 60mlm2
Part OneA patient with aortic regurgitation has the following haemodynamic measurements cardiac output (CO) 75 Lminute heart rate (HR) 75minute left ventricular end-diastolic volume (LVEDV) 200 mL left ventricular end-systolic volume (LVESV) 50 mL The regurgitant fraction is defined as the ratio of the regurgitant volume to the total volume flowing through the valve with each beat
The regurgitant fraction in this patient is A 25 B 33 C 50 D 67 E 75
Part OneA 45-year-old asymptomatic man returns for follow-up He was diagnosed 10 years ago with aortic regurgitation due to a congenital bicuspid aortic valve He has never had endocarditis Which one of the following echocardiographic profiles most strongly indicates the need for aortic valve replacement
LVEDD (mm)[35-55] FS [030-040] LA size (mm) [lt40]
A 70 030 60
B 75 040 40
C 70 025 45
D 65 045 50
E 75 035 55
Key LVEDD Left ventricular end-diastolic diameter LVESD Left ventricular end-systolic diameter FS Fractional shortening = (LVEDD - LVESD) LVEDD LA Left atrial
MR- Quantification of LV contractility
LV systolic function - most important parameter
bullEjection fraction fractional shortening velocity of
circumferential fibre shortening - load dependent
bullMR allows supranormal values of EF etc
bullEarly systolic dysfunction if
bullEF lt 60 (severe MR)
bullES diameter lt 45mm (26mmm2)
Mitral stenosis - quantification
Severity MVA (cm2) LAP (mm Hg) CO
Mild gt20 lt10-12 NL
Moderate 11-20 ~10-17 NL
Severe lt10 gt18
Very Severe lt08 gt20-25
Part OneA 35-year-old woman has increasing breathlessness on exertion Her cardiac silhouette is slightly enlarged on a chest X-ray and an ECG demonstrates sinus rhythm The continuous wave Doppler flow signal through the mitral inflow tract (shown above) is most consistent with which one of the following A Severe pulmonary hypertension (cor pulmonale) B Aortic stenosis C Mitral regurgitation D Mitral stenosis E Aortic regurgitation
Part OneA 28-year-old woman who emigrated from Cambodia 10 years ago presents to the emergency department with a three-week history of increasing shortness of breath orthopnoea nocturnal dyspnoea and ankle oedema She is 25 weeks pregnant and has no significant past medical history The presence of pulmonary oedema is confirmed clinically and radiologically She responds well to intravenous frusemide but remains tachypnoeic with a heart rate of 120minute in sinus rhythm Her blood pressure is 12585 mmHg Echocardiography demonstrates mitral stenosis with an estimated valve area of 13 cm2 and a left atrial diameter of 50 mm [lt40 mm] There are no other abnormalities What is the most appropriate next step in management A Balloon valvotomy B Surgical valvotomy C Digoxin therapy D Beta-blocker therapy E Angiotensin converting enzyme (ACE) inhibitor therapy
Part OneA 55-year-old man presents with acute pulmonary oedema Five years earlier he has undergone a mitral valve replacement with a bileaflet tilting disk valve (St Jude) for mixed mitral valve disease He has been well with normal exercise tolerance prior to the day of admission Examination on admission reveals tachypnoea sinus tachycardia of 110minute blood pressure of 10560 mmHg elevated jugular venous pressure (+ 5 cm) and bilateral crepitations throughout the lung fields His prothrombin timeminusinternational normalised ratio (PT-INR) is 19 [desired therapeutic range 20-35] Serum urea creatinine and electrolytes are normal The cardiothoracic ratio on chest X-ray is normal but the presence of pulmonary oedema is confirmed Echocardiography reveals that one of the prosthetic valve leaflets is not moving and there is an increased flow rate in diastole across the valve orifice (2 metressecond) What is the most appropriate course of action A Administration of intravenous streptokinase B Administration of intravenous heparin C Administration of intravenous antibiotics D Addition of an antiplatelet agent E Immediate mitral valve replacement
Aortic stenosis - quantification
Aortic stenosis - quantification Mean gradient
(mmHg) Peak Ao velocity
AVA (cm2)
Normal 10-20 gt25
Mild lt20 25-29 gt17
Moderate 20-40 30-40 10-17
Severe gt40 gt40 lt10
Right ventricle - size amp function
Estimation of Pulmonary PressurePA systolic pressure
bull Tricuspid regurgitation jet velocity
Estimation of Pulmonary PressureRA pressure
bull IVC size
Part OneThe severity of pulmonary hypertension can be determined using continuous wave Doppler measurements of the velocity of tricuspid regurgitation This method uses the Bernoulli equation which states that 1048661P = 4v2 (where 1048661P = instantaneous pressure gradient and v = velocity across the valve) There is tricuspid regurgitation with a peak velocity of 4 metressecond and a mean velocity of 35 metressecond Assuming right atrial pressure is 5 mmHg the best estimate of the peak right ventricular systolic pressure (plusmn 2 mmHg) is
A 50 mmHg B 55 mmHg C 60 mmHg D 65 mmHg E 70 mmHg
Cardiac Tamponade
Cardiac Tamponade
Cardiac Tamponade
Part OneA 65-year-old woman presents with a one-week history of progressive dyspnoea On admission there are signs of shock a systolic murmur and an elevated jugular venous pressure The ECG shows sinus tachycardia but no other abnormality An antero-posterior chest X-ray shows cardiomegaly The serum troponin I level is 05 mgL [lt01] A computed tomography (CT) scan is shown below
What is the most likely diagnosis A Pulmonary embolism B Right ventricular infarction C Pericardial tamponade D Myocarditis E Acute mitral regurgitation
Endocarditis
Positive echocardiogram for IE Discrete echogenic oscillating intracardiac mass located at a site of endocardial injury (eg on a valve or supporting structure in pathway of regurgitant jet or site of implanted material) or Periannular abscess or
New dehiscence of a prosthetic valve
Cardiac Resynchronisation
Cardiac Resynchronisation
bullSevere heart failure treatment to restore co-ordination to LV contraction
bullNYHA 3-4bullEF lt 35bullQRS duration gt 120 msec
Echocardiography
bullUseful non-invasive tool
bullReports objective and subjective
bullLimitations
Part OneA 67-year-old woman with congestive cardiac failure remains breathless on moderate exertion despite treatment with 40 mg frusemide and 20 mg enalapril daily On examination she has a pulse rate of 80minute blood pressure of 12570 mmHg and a jugular venous pressure (JVP) of +1 cm She has a soft systolic murmur with no added sounds her chest is clear and she has no oedema An ECG shows sinus rhythm A chest X-ray shows cardiomegaly with a cardiothoracic ratio of 15528 but no pulmonary congestion Echocardiography demonstrates systolic dysfunction with fractional shortening of 18 and mild mitral regurgitation Her serum creatinine level is normal
Which of the following is the most appropriate next step in treatment A Increase the frusemide dose B Add digoxin C Add an aldosterone antagonist D Add an angiotensin II receptor antagonist E Add a beta blocker
Left ventricle - diastolic function
Mitral inflow Pulmonary veins
Mitral TVI
LV diastolic function - mitral inflow
EA gt 1 EA lt 1 EA gtgt1
LV diastolic function - mitral TVI
EA gt 1 EA lt 1 EA gtgt1
Left ventricle - RWMAs
Left ventricle - RWMAs
Left ventricle - RWMAs
Left ventricle - thrombus
Left atrium - size
Diameter
Normal 20-40cm
Mild 40-50cm
Moderate 50-60cm
Severe gt60cm
Left atrium - size
Area
Normal lt20cm2
Mild 20-30cm2
Moderate 30-40cm2
Severe gt40cm2
Left atrium - thrombus
Cardiac Valves
Morphology
Valve dysfunction
aetiology
quantification
consequences
serial evaluation
Valve regurgitation - quantification
Colour - jet sizewidth
PISA
Spectral doppler
Consequences
AR - LV Response
bull Chronic AR - decompensated LV
bull LVEFlt55 LVESDgt55mm LVESV 60mlm2
Part OneA patient with aortic regurgitation has the following haemodynamic measurements cardiac output (CO) 75 Lminute heart rate (HR) 75minute left ventricular end-diastolic volume (LVEDV) 200 mL left ventricular end-systolic volume (LVESV) 50 mL The regurgitant fraction is defined as the ratio of the regurgitant volume to the total volume flowing through the valve with each beat
The regurgitant fraction in this patient is A 25 B 33 C 50 D 67 E 75
Part OneA 45-year-old asymptomatic man returns for follow-up He was diagnosed 10 years ago with aortic regurgitation due to a congenital bicuspid aortic valve He has never had endocarditis Which one of the following echocardiographic profiles most strongly indicates the need for aortic valve replacement
LVEDD (mm)[35-55] FS [030-040] LA size (mm) [lt40]
A 70 030 60
B 75 040 40
C 70 025 45
D 65 045 50
E 75 035 55
Key LVEDD Left ventricular end-diastolic diameter LVESD Left ventricular end-systolic diameter FS Fractional shortening = (LVEDD - LVESD) LVEDD LA Left atrial
MR- Quantification of LV contractility
LV systolic function - most important parameter
bullEjection fraction fractional shortening velocity of
circumferential fibre shortening - load dependent
bullMR allows supranormal values of EF etc
bullEarly systolic dysfunction if
bullEF lt 60 (severe MR)
bullES diameter lt 45mm (26mmm2)
Mitral stenosis - quantification
Severity MVA (cm2) LAP (mm Hg) CO
Mild gt20 lt10-12 NL
Moderate 11-20 ~10-17 NL
Severe lt10 gt18
Very Severe lt08 gt20-25
Part OneA 35-year-old woman has increasing breathlessness on exertion Her cardiac silhouette is slightly enlarged on a chest X-ray and an ECG demonstrates sinus rhythm The continuous wave Doppler flow signal through the mitral inflow tract (shown above) is most consistent with which one of the following A Severe pulmonary hypertension (cor pulmonale) B Aortic stenosis C Mitral regurgitation D Mitral stenosis E Aortic regurgitation
Part OneA 28-year-old woman who emigrated from Cambodia 10 years ago presents to the emergency department with a three-week history of increasing shortness of breath orthopnoea nocturnal dyspnoea and ankle oedema She is 25 weeks pregnant and has no significant past medical history The presence of pulmonary oedema is confirmed clinically and radiologically She responds well to intravenous frusemide but remains tachypnoeic with a heart rate of 120minute in sinus rhythm Her blood pressure is 12585 mmHg Echocardiography demonstrates mitral stenosis with an estimated valve area of 13 cm2 and a left atrial diameter of 50 mm [lt40 mm] There are no other abnormalities What is the most appropriate next step in management A Balloon valvotomy B Surgical valvotomy C Digoxin therapy D Beta-blocker therapy E Angiotensin converting enzyme (ACE) inhibitor therapy
Part OneA 55-year-old man presents with acute pulmonary oedema Five years earlier he has undergone a mitral valve replacement with a bileaflet tilting disk valve (St Jude) for mixed mitral valve disease He has been well with normal exercise tolerance prior to the day of admission Examination on admission reveals tachypnoea sinus tachycardia of 110minute blood pressure of 10560 mmHg elevated jugular venous pressure (+ 5 cm) and bilateral crepitations throughout the lung fields His prothrombin timeminusinternational normalised ratio (PT-INR) is 19 [desired therapeutic range 20-35] Serum urea creatinine and electrolytes are normal The cardiothoracic ratio on chest X-ray is normal but the presence of pulmonary oedema is confirmed Echocardiography reveals that one of the prosthetic valve leaflets is not moving and there is an increased flow rate in diastole across the valve orifice (2 metressecond) What is the most appropriate course of action A Administration of intravenous streptokinase B Administration of intravenous heparin C Administration of intravenous antibiotics D Addition of an antiplatelet agent E Immediate mitral valve replacement
Aortic stenosis - quantification
Aortic stenosis - quantification Mean gradient
(mmHg) Peak Ao velocity
AVA (cm2)
Normal 10-20 gt25
Mild lt20 25-29 gt17
Moderate 20-40 30-40 10-17
Severe gt40 gt40 lt10
Right ventricle - size amp function
Estimation of Pulmonary PressurePA systolic pressure
bull Tricuspid regurgitation jet velocity
Estimation of Pulmonary PressureRA pressure
bull IVC size
Part OneThe severity of pulmonary hypertension can be determined using continuous wave Doppler measurements of the velocity of tricuspid regurgitation This method uses the Bernoulli equation which states that 1048661P = 4v2 (where 1048661P = instantaneous pressure gradient and v = velocity across the valve) There is tricuspid regurgitation with a peak velocity of 4 metressecond and a mean velocity of 35 metressecond Assuming right atrial pressure is 5 mmHg the best estimate of the peak right ventricular systolic pressure (plusmn 2 mmHg) is
A 50 mmHg B 55 mmHg C 60 mmHg D 65 mmHg E 70 mmHg
Cardiac Tamponade
Cardiac Tamponade
Cardiac Tamponade
Part OneA 65-year-old woman presents with a one-week history of progressive dyspnoea On admission there are signs of shock a systolic murmur and an elevated jugular venous pressure The ECG shows sinus tachycardia but no other abnormality An antero-posterior chest X-ray shows cardiomegaly The serum troponin I level is 05 mgL [lt01] A computed tomography (CT) scan is shown below
What is the most likely diagnosis A Pulmonary embolism B Right ventricular infarction C Pericardial tamponade D Myocarditis E Acute mitral regurgitation
Endocarditis
Positive echocardiogram for IE Discrete echogenic oscillating intracardiac mass located at a site of endocardial injury (eg on a valve or supporting structure in pathway of regurgitant jet or site of implanted material) or Periannular abscess or
New dehiscence of a prosthetic valve
Cardiac Resynchronisation
Cardiac Resynchronisation
bullSevere heart failure treatment to restore co-ordination to LV contraction
bullNYHA 3-4bullEF lt 35bullQRS duration gt 120 msec
Echocardiography
bullUseful non-invasive tool
bullReports objective and subjective
bullLimitations
Left ventricle - diastolic function
Mitral inflow Pulmonary veins
Mitral TVI
LV diastolic function - mitral inflow
EA gt 1 EA lt 1 EA gtgt1
LV diastolic function - mitral TVI
EA gt 1 EA lt 1 EA gtgt1
Left ventricle - RWMAs
Left ventricle - RWMAs
Left ventricle - RWMAs
Left ventricle - thrombus
Left atrium - size
Diameter
Normal 20-40cm
Mild 40-50cm
Moderate 50-60cm
Severe gt60cm
Left atrium - size
Area
Normal lt20cm2
Mild 20-30cm2
Moderate 30-40cm2
Severe gt40cm2
Left atrium - thrombus
Cardiac Valves
Morphology
Valve dysfunction
aetiology
quantification
consequences
serial evaluation
Valve regurgitation - quantification
Colour - jet sizewidth
PISA
Spectral doppler
Consequences
AR - LV Response
bull Chronic AR - decompensated LV
bull LVEFlt55 LVESDgt55mm LVESV 60mlm2
Part OneA patient with aortic regurgitation has the following haemodynamic measurements cardiac output (CO) 75 Lminute heart rate (HR) 75minute left ventricular end-diastolic volume (LVEDV) 200 mL left ventricular end-systolic volume (LVESV) 50 mL The regurgitant fraction is defined as the ratio of the regurgitant volume to the total volume flowing through the valve with each beat
The regurgitant fraction in this patient is A 25 B 33 C 50 D 67 E 75
Part OneA 45-year-old asymptomatic man returns for follow-up He was diagnosed 10 years ago with aortic regurgitation due to a congenital bicuspid aortic valve He has never had endocarditis Which one of the following echocardiographic profiles most strongly indicates the need for aortic valve replacement
LVEDD (mm)[35-55] FS [030-040] LA size (mm) [lt40]
A 70 030 60
B 75 040 40
C 70 025 45
D 65 045 50
E 75 035 55
Key LVEDD Left ventricular end-diastolic diameter LVESD Left ventricular end-systolic diameter FS Fractional shortening = (LVEDD - LVESD) LVEDD LA Left atrial
MR- Quantification of LV contractility
LV systolic function - most important parameter
bullEjection fraction fractional shortening velocity of
circumferential fibre shortening - load dependent
bullMR allows supranormal values of EF etc
bullEarly systolic dysfunction if
bullEF lt 60 (severe MR)
bullES diameter lt 45mm (26mmm2)
Mitral stenosis - quantification
Severity MVA (cm2) LAP (mm Hg) CO
Mild gt20 lt10-12 NL
Moderate 11-20 ~10-17 NL
Severe lt10 gt18
Very Severe lt08 gt20-25
Part OneA 35-year-old woman has increasing breathlessness on exertion Her cardiac silhouette is slightly enlarged on a chest X-ray and an ECG demonstrates sinus rhythm The continuous wave Doppler flow signal through the mitral inflow tract (shown above) is most consistent with which one of the following A Severe pulmonary hypertension (cor pulmonale) B Aortic stenosis C Mitral regurgitation D Mitral stenosis E Aortic regurgitation
Part OneA 28-year-old woman who emigrated from Cambodia 10 years ago presents to the emergency department with a three-week history of increasing shortness of breath orthopnoea nocturnal dyspnoea and ankle oedema She is 25 weeks pregnant and has no significant past medical history The presence of pulmonary oedema is confirmed clinically and radiologically She responds well to intravenous frusemide but remains tachypnoeic with a heart rate of 120minute in sinus rhythm Her blood pressure is 12585 mmHg Echocardiography demonstrates mitral stenosis with an estimated valve area of 13 cm2 and a left atrial diameter of 50 mm [lt40 mm] There are no other abnormalities What is the most appropriate next step in management A Balloon valvotomy B Surgical valvotomy C Digoxin therapy D Beta-blocker therapy E Angiotensin converting enzyme (ACE) inhibitor therapy
Part OneA 55-year-old man presents with acute pulmonary oedema Five years earlier he has undergone a mitral valve replacement with a bileaflet tilting disk valve (St Jude) for mixed mitral valve disease He has been well with normal exercise tolerance prior to the day of admission Examination on admission reveals tachypnoea sinus tachycardia of 110minute blood pressure of 10560 mmHg elevated jugular venous pressure (+ 5 cm) and bilateral crepitations throughout the lung fields His prothrombin timeminusinternational normalised ratio (PT-INR) is 19 [desired therapeutic range 20-35] Serum urea creatinine and electrolytes are normal The cardiothoracic ratio on chest X-ray is normal but the presence of pulmonary oedema is confirmed Echocardiography reveals that one of the prosthetic valve leaflets is not moving and there is an increased flow rate in diastole across the valve orifice (2 metressecond) What is the most appropriate course of action A Administration of intravenous streptokinase B Administration of intravenous heparin C Administration of intravenous antibiotics D Addition of an antiplatelet agent E Immediate mitral valve replacement
Aortic stenosis - quantification
Aortic stenosis - quantification Mean gradient
(mmHg) Peak Ao velocity
AVA (cm2)
Normal 10-20 gt25
Mild lt20 25-29 gt17
Moderate 20-40 30-40 10-17
Severe gt40 gt40 lt10
Right ventricle - size amp function
Estimation of Pulmonary PressurePA systolic pressure
bull Tricuspid regurgitation jet velocity
Estimation of Pulmonary PressureRA pressure
bull IVC size
Part OneThe severity of pulmonary hypertension can be determined using continuous wave Doppler measurements of the velocity of tricuspid regurgitation This method uses the Bernoulli equation which states that 1048661P = 4v2 (where 1048661P = instantaneous pressure gradient and v = velocity across the valve) There is tricuspid regurgitation with a peak velocity of 4 metressecond and a mean velocity of 35 metressecond Assuming right atrial pressure is 5 mmHg the best estimate of the peak right ventricular systolic pressure (plusmn 2 mmHg) is
A 50 mmHg B 55 mmHg C 60 mmHg D 65 mmHg E 70 mmHg
Cardiac Tamponade
Cardiac Tamponade
Cardiac Tamponade
Part OneA 65-year-old woman presents with a one-week history of progressive dyspnoea On admission there are signs of shock a systolic murmur and an elevated jugular venous pressure The ECG shows sinus tachycardia but no other abnormality An antero-posterior chest X-ray shows cardiomegaly The serum troponin I level is 05 mgL [lt01] A computed tomography (CT) scan is shown below
What is the most likely diagnosis A Pulmonary embolism B Right ventricular infarction C Pericardial tamponade D Myocarditis E Acute mitral regurgitation
Endocarditis
Positive echocardiogram for IE Discrete echogenic oscillating intracardiac mass located at a site of endocardial injury (eg on a valve or supporting structure in pathway of regurgitant jet or site of implanted material) or Periannular abscess or
New dehiscence of a prosthetic valve
Cardiac Resynchronisation
Cardiac Resynchronisation
bullSevere heart failure treatment to restore co-ordination to LV contraction
bullNYHA 3-4bullEF lt 35bullQRS duration gt 120 msec
Echocardiography
bullUseful non-invasive tool
bullReports objective and subjective
bullLimitations
LV diastolic function - mitral inflow
EA gt 1 EA lt 1 EA gtgt1
LV diastolic function - mitral TVI
EA gt 1 EA lt 1 EA gtgt1
Left ventricle - RWMAs
Left ventricle - RWMAs
Left ventricle - RWMAs
Left ventricle - thrombus
Left atrium - size
Diameter
Normal 20-40cm
Mild 40-50cm
Moderate 50-60cm
Severe gt60cm
Left atrium - size
Area
Normal lt20cm2
Mild 20-30cm2
Moderate 30-40cm2
Severe gt40cm2
Left atrium - thrombus
Cardiac Valves
Morphology
Valve dysfunction
aetiology
quantification
consequences
serial evaluation
Valve regurgitation - quantification
Colour - jet sizewidth
PISA
Spectral doppler
Consequences
AR - LV Response
bull Chronic AR - decompensated LV
bull LVEFlt55 LVESDgt55mm LVESV 60mlm2
Part OneA patient with aortic regurgitation has the following haemodynamic measurements cardiac output (CO) 75 Lminute heart rate (HR) 75minute left ventricular end-diastolic volume (LVEDV) 200 mL left ventricular end-systolic volume (LVESV) 50 mL The regurgitant fraction is defined as the ratio of the regurgitant volume to the total volume flowing through the valve with each beat
The regurgitant fraction in this patient is A 25 B 33 C 50 D 67 E 75
Part OneA 45-year-old asymptomatic man returns for follow-up He was diagnosed 10 years ago with aortic regurgitation due to a congenital bicuspid aortic valve He has never had endocarditis Which one of the following echocardiographic profiles most strongly indicates the need for aortic valve replacement
LVEDD (mm)[35-55] FS [030-040] LA size (mm) [lt40]
A 70 030 60
B 75 040 40
C 70 025 45
D 65 045 50
E 75 035 55
Key LVEDD Left ventricular end-diastolic diameter LVESD Left ventricular end-systolic diameter FS Fractional shortening = (LVEDD - LVESD) LVEDD LA Left atrial
MR- Quantification of LV contractility
LV systolic function - most important parameter
bullEjection fraction fractional shortening velocity of
circumferential fibre shortening - load dependent
bullMR allows supranormal values of EF etc
bullEarly systolic dysfunction if
bullEF lt 60 (severe MR)
bullES diameter lt 45mm (26mmm2)
Mitral stenosis - quantification
Severity MVA (cm2) LAP (mm Hg) CO
Mild gt20 lt10-12 NL
Moderate 11-20 ~10-17 NL
Severe lt10 gt18
Very Severe lt08 gt20-25
Part OneA 35-year-old woman has increasing breathlessness on exertion Her cardiac silhouette is slightly enlarged on a chest X-ray and an ECG demonstrates sinus rhythm The continuous wave Doppler flow signal through the mitral inflow tract (shown above) is most consistent with which one of the following A Severe pulmonary hypertension (cor pulmonale) B Aortic stenosis C Mitral regurgitation D Mitral stenosis E Aortic regurgitation
Part OneA 28-year-old woman who emigrated from Cambodia 10 years ago presents to the emergency department with a three-week history of increasing shortness of breath orthopnoea nocturnal dyspnoea and ankle oedema She is 25 weeks pregnant and has no significant past medical history The presence of pulmonary oedema is confirmed clinically and radiologically She responds well to intravenous frusemide but remains tachypnoeic with a heart rate of 120minute in sinus rhythm Her blood pressure is 12585 mmHg Echocardiography demonstrates mitral stenosis with an estimated valve area of 13 cm2 and a left atrial diameter of 50 mm [lt40 mm] There are no other abnormalities What is the most appropriate next step in management A Balloon valvotomy B Surgical valvotomy C Digoxin therapy D Beta-blocker therapy E Angiotensin converting enzyme (ACE) inhibitor therapy
Part OneA 55-year-old man presents with acute pulmonary oedema Five years earlier he has undergone a mitral valve replacement with a bileaflet tilting disk valve (St Jude) for mixed mitral valve disease He has been well with normal exercise tolerance prior to the day of admission Examination on admission reveals tachypnoea sinus tachycardia of 110minute blood pressure of 10560 mmHg elevated jugular venous pressure (+ 5 cm) and bilateral crepitations throughout the lung fields His prothrombin timeminusinternational normalised ratio (PT-INR) is 19 [desired therapeutic range 20-35] Serum urea creatinine and electrolytes are normal The cardiothoracic ratio on chest X-ray is normal but the presence of pulmonary oedema is confirmed Echocardiography reveals that one of the prosthetic valve leaflets is not moving and there is an increased flow rate in diastole across the valve orifice (2 metressecond) What is the most appropriate course of action A Administration of intravenous streptokinase B Administration of intravenous heparin C Administration of intravenous antibiotics D Addition of an antiplatelet agent E Immediate mitral valve replacement
Aortic stenosis - quantification
Aortic stenosis - quantification Mean gradient
(mmHg) Peak Ao velocity
AVA (cm2)
Normal 10-20 gt25
Mild lt20 25-29 gt17
Moderate 20-40 30-40 10-17
Severe gt40 gt40 lt10
Right ventricle - size amp function
Estimation of Pulmonary PressurePA systolic pressure
bull Tricuspid regurgitation jet velocity
Estimation of Pulmonary PressureRA pressure
bull IVC size
Part OneThe severity of pulmonary hypertension can be determined using continuous wave Doppler measurements of the velocity of tricuspid regurgitation This method uses the Bernoulli equation which states that 1048661P = 4v2 (where 1048661P = instantaneous pressure gradient and v = velocity across the valve) There is tricuspid regurgitation with a peak velocity of 4 metressecond and a mean velocity of 35 metressecond Assuming right atrial pressure is 5 mmHg the best estimate of the peak right ventricular systolic pressure (plusmn 2 mmHg) is
A 50 mmHg B 55 mmHg C 60 mmHg D 65 mmHg E 70 mmHg
Cardiac Tamponade
Cardiac Tamponade
Cardiac Tamponade
Part OneA 65-year-old woman presents with a one-week history of progressive dyspnoea On admission there are signs of shock a systolic murmur and an elevated jugular venous pressure The ECG shows sinus tachycardia but no other abnormality An antero-posterior chest X-ray shows cardiomegaly The serum troponin I level is 05 mgL [lt01] A computed tomography (CT) scan is shown below
What is the most likely diagnosis A Pulmonary embolism B Right ventricular infarction C Pericardial tamponade D Myocarditis E Acute mitral regurgitation
Endocarditis
Positive echocardiogram for IE Discrete echogenic oscillating intracardiac mass located at a site of endocardial injury (eg on a valve or supporting structure in pathway of regurgitant jet or site of implanted material) or Periannular abscess or
New dehiscence of a prosthetic valve
Cardiac Resynchronisation
Cardiac Resynchronisation
bullSevere heart failure treatment to restore co-ordination to LV contraction
bullNYHA 3-4bullEF lt 35bullQRS duration gt 120 msec
Echocardiography
bullUseful non-invasive tool
bullReports objective and subjective
bullLimitations
LV diastolic function - mitral TVI
EA gt 1 EA lt 1 EA gtgt1
Left ventricle - RWMAs
Left ventricle - RWMAs
Left ventricle - RWMAs
Left ventricle - thrombus
Left atrium - size
Diameter
Normal 20-40cm
Mild 40-50cm
Moderate 50-60cm
Severe gt60cm
Left atrium - size
Area
Normal lt20cm2
Mild 20-30cm2
Moderate 30-40cm2
Severe gt40cm2
Left atrium - thrombus
Cardiac Valves
Morphology
Valve dysfunction
aetiology
quantification
consequences
serial evaluation
Valve regurgitation - quantification
Colour - jet sizewidth
PISA
Spectral doppler
Consequences
AR - LV Response
bull Chronic AR - decompensated LV
bull LVEFlt55 LVESDgt55mm LVESV 60mlm2
Part OneA patient with aortic regurgitation has the following haemodynamic measurements cardiac output (CO) 75 Lminute heart rate (HR) 75minute left ventricular end-diastolic volume (LVEDV) 200 mL left ventricular end-systolic volume (LVESV) 50 mL The regurgitant fraction is defined as the ratio of the regurgitant volume to the total volume flowing through the valve with each beat
The regurgitant fraction in this patient is A 25 B 33 C 50 D 67 E 75
Part OneA 45-year-old asymptomatic man returns for follow-up He was diagnosed 10 years ago with aortic regurgitation due to a congenital bicuspid aortic valve He has never had endocarditis Which one of the following echocardiographic profiles most strongly indicates the need for aortic valve replacement
LVEDD (mm)[35-55] FS [030-040] LA size (mm) [lt40]
A 70 030 60
B 75 040 40
C 70 025 45
D 65 045 50
E 75 035 55
Key LVEDD Left ventricular end-diastolic diameter LVESD Left ventricular end-systolic diameter FS Fractional shortening = (LVEDD - LVESD) LVEDD LA Left atrial
MR- Quantification of LV contractility
LV systolic function - most important parameter
bullEjection fraction fractional shortening velocity of
circumferential fibre shortening - load dependent
bullMR allows supranormal values of EF etc
bullEarly systolic dysfunction if
bullEF lt 60 (severe MR)
bullES diameter lt 45mm (26mmm2)
Mitral stenosis - quantification
Severity MVA (cm2) LAP (mm Hg) CO
Mild gt20 lt10-12 NL
Moderate 11-20 ~10-17 NL
Severe lt10 gt18
Very Severe lt08 gt20-25
Part OneA 35-year-old woman has increasing breathlessness on exertion Her cardiac silhouette is slightly enlarged on a chest X-ray and an ECG demonstrates sinus rhythm The continuous wave Doppler flow signal through the mitral inflow tract (shown above) is most consistent with which one of the following A Severe pulmonary hypertension (cor pulmonale) B Aortic stenosis C Mitral regurgitation D Mitral stenosis E Aortic regurgitation
Part OneA 28-year-old woman who emigrated from Cambodia 10 years ago presents to the emergency department with a three-week history of increasing shortness of breath orthopnoea nocturnal dyspnoea and ankle oedema She is 25 weeks pregnant and has no significant past medical history The presence of pulmonary oedema is confirmed clinically and radiologically She responds well to intravenous frusemide but remains tachypnoeic with a heart rate of 120minute in sinus rhythm Her blood pressure is 12585 mmHg Echocardiography demonstrates mitral stenosis with an estimated valve area of 13 cm2 and a left atrial diameter of 50 mm [lt40 mm] There are no other abnormalities What is the most appropriate next step in management A Balloon valvotomy B Surgical valvotomy C Digoxin therapy D Beta-blocker therapy E Angiotensin converting enzyme (ACE) inhibitor therapy
Part OneA 55-year-old man presents with acute pulmonary oedema Five years earlier he has undergone a mitral valve replacement with a bileaflet tilting disk valve (St Jude) for mixed mitral valve disease He has been well with normal exercise tolerance prior to the day of admission Examination on admission reveals tachypnoea sinus tachycardia of 110minute blood pressure of 10560 mmHg elevated jugular venous pressure (+ 5 cm) and bilateral crepitations throughout the lung fields His prothrombin timeminusinternational normalised ratio (PT-INR) is 19 [desired therapeutic range 20-35] Serum urea creatinine and electrolytes are normal The cardiothoracic ratio on chest X-ray is normal but the presence of pulmonary oedema is confirmed Echocardiography reveals that one of the prosthetic valve leaflets is not moving and there is an increased flow rate in diastole across the valve orifice (2 metressecond) What is the most appropriate course of action A Administration of intravenous streptokinase B Administration of intravenous heparin C Administration of intravenous antibiotics D Addition of an antiplatelet agent E Immediate mitral valve replacement
Aortic stenosis - quantification
Aortic stenosis - quantification Mean gradient
(mmHg) Peak Ao velocity
AVA (cm2)
Normal 10-20 gt25
Mild lt20 25-29 gt17
Moderate 20-40 30-40 10-17
Severe gt40 gt40 lt10
Right ventricle - size amp function
Estimation of Pulmonary PressurePA systolic pressure
bull Tricuspid regurgitation jet velocity
Estimation of Pulmonary PressureRA pressure
bull IVC size
Part OneThe severity of pulmonary hypertension can be determined using continuous wave Doppler measurements of the velocity of tricuspid regurgitation This method uses the Bernoulli equation which states that 1048661P = 4v2 (where 1048661P = instantaneous pressure gradient and v = velocity across the valve) There is tricuspid regurgitation with a peak velocity of 4 metressecond and a mean velocity of 35 metressecond Assuming right atrial pressure is 5 mmHg the best estimate of the peak right ventricular systolic pressure (plusmn 2 mmHg) is
A 50 mmHg B 55 mmHg C 60 mmHg D 65 mmHg E 70 mmHg
Cardiac Tamponade
Cardiac Tamponade
Cardiac Tamponade
Part OneA 65-year-old woman presents with a one-week history of progressive dyspnoea On admission there are signs of shock a systolic murmur and an elevated jugular venous pressure The ECG shows sinus tachycardia but no other abnormality An antero-posterior chest X-ray shows cardiomegaly The serum troponin I level is 05 mgL [lt01] A computed tomography (CT) scan is shown below
What is the most likely diagnosis A Pulmonary embolism B Right ventricular infarction C Pericardial tamponade D Myocarditis E Acute mitral regurgitation
Endocarditis
Positive echocardiogram for IE Discrete echogenic oscillating intracardiac mass located at a site of endocardial injury (eg on a valve or supporting structure in pathway of regurgitant jet or site of implanted material) or Periannular abscess or
New dehiscence of a prosthetic valve
Cardiac Resynchronisation
Cardiac Resynchronisation
bullSevere heart failure treatment to restore co-ordination to LV contraction
bullNYHA 3-4bullEF lt 35bullQRS duration gt 120 msec
Echocardiography
bullUseful non-invasive tool
bullReports objective and subjective
bullLimitations
Left ventricle - RWMAs
Left ventricle - RWMAs
Left ventricle - RWMAs
Left ventricle - thrombus
Left atrium - size
Diameter
Normal 20-40cm
Mild 40-50cm
Moderate 50-60cm
Severe gt60cm
Left atrium - size
Area
Normal lt20cm2
Mild 20-30cm2
Moderate 30-40cm2
Severe gt40cm2
Left atrium - thrombus
Cardiac Valves
Morphology
Valve dysfunction
aetiology
quantification
consequences
serial evaluation
Valve regurgitation - quantification
Colour - jet sizewidth
PISA
Spectral doppler
Consequences
AR - LV Response
bull Chronic AR - decompensated LV
bull LVEFlt55 LVESDgt55mm LVESV 60mlm2
Part OneA patient with aortic regurgitation has the following haemodynamic measurements cardiac output (CO) 75 Lminute heart rate (HR) 75minute left ventricular end-diastolic volume (LVEDV) 200 mL left ventricular end-systolic volume (LVESV) 50 mL The regurgitant fraction is defined as the ratio of the regurgitant volume to the total volume flowing through the valve with each beat
The regurgitant fraction in this patient is A 25 B 33 C 50 D 67 E 75
Part OneA 45-year-old asymptomatic man returns for follow-up He was diagnosed 10 years ago with aortic regurgitation due to a congenital bicuspid aortic valve He has never had endocarditis Which one of the following echocardiographic profiles most strongly indicates the need for aortic valve replacement
LVEDD (mm)[35-55] FS [030-040] LA size (mm) [lt40]
A 70 030 60
B 75 040 40
C 70 025 45
D 65 045 50
E 75 035 55
Key LVEDD Left ventricular end-diastolic diameter LVESD Left ventricular end-systolic diameter FS Fractional shortening = (LVEDD - LVESD) LVEDD LA Left atrial
MR- Quantification of LV contractility
LV systolic function - most important parameter
bullEjection fraction fractional shortening velocity of
circumferential fibre shortening - load dependent
bullMR allows supranormal values of EF etc
bullEarly systolic dysfunction if
bullEF lt 60 (severe MR)
bullES diameter lt 45mm (26mmm2)
Mitral stenosis - quantification
Severity MVA (cm2) LAP (mm Hg) CO
Mild gt20 lt10-12 NL
Moderate 11-20 ~10-17 NL
Severe lt10 gt18
Very Severe lt08 gt20-25
Part OneA 35-year-old woman has increasing breathlessness on exertion Her cardiac silhouette is slightly enlarged on a chest X-ray and an ECG demonstrates sinus rhythm The continuous wave Doppler flow signal through the mitral inflow tract (shown above) is most consistent with which one of the following A Severe pulmonary hypertension (cor pulmonale) B Aortic stenosis C Mitral regurgitation D Mitral stenosis E Aortic regurgitation
Part OneA 28-year-old woman who emigrated from Cambodia 10 years ago presents to the emergency department with a three-week history of increasing shortness of breath orthopnoea nocturnal dyspnoea and ankle oedema She is 25 weeks pregnant and has no significant past medical history The presence of pulmonary oedema is confirmed clinically and radiologically She responds well to intravenous frusemide but remains tachypnoeic with a heart rate of 120minute in sinus rhythm Her blood pressure is 12585 mmHg Echocardiography demonstrates mitral stenosis with an estimated valve area of 13 cm2 and a left atrial diameter of 50 mm [lt40 mm] There are no other abnormalities What is the most appropriate next step in management A Balloon valvotomy B Surgical valvotomy C Digoxin therapy D Beta-blocker therapy E Angiotensin converting enzyme (ACE) inhibitor therapy
Part OneA 55-year-old man presents with acute pulmonary oedema Five years earlier he has undergone a mitral valve replacement with a bileaflet tilting disk valve (St Jude) for mixed mitral valve disease He has been well with normal exercise tolerance prior to the day of admission Examination on admission reveals tachypnoea sinus tachycardia of 110minute blood pressure of 10560 mmHg elevated jugular venous pressure (+ 5 cm) and bilateral crepitations throughout the lung fields His prothrombin timeminusinternational normalised ratio (PT-INR) is 19 [desired therapeutic range 20-35] Serum urea creatinine and electrolytes are normal The cardiothoracic ratio on chest X-ray is normal but the presence of pulmonary oedema is confirmed Echocardiography reveals that one of the prosthetic valve leaflets is not moving and there is an increased flow rate in diastole across the valve orifice (2 metressecond) What is the most appropriate course of action A Administration of intravenous streptokinase B Administration of intravenous heparin C Administration of intravenous antibiotics D Addition of an antiplatelet agent E Immediate mitral valve replacement
Aortic stenosis - quantification
Aortic stenosis - quantification Mean gradient
(mmHg) Peak Ao velocity
AVA (cm2)
Normal 10-20 gt25
Mild lt20 25-29 gt17
Moderate 20-40 30-40 10-17
Severe gt40 gt40 lt10
Right ventricle - size amp function
Estimation of Pulmonary PressurePA systolic pressure
bull Tricuspid regurgitation jet velocity
Estimation of Pulmonary PressureRA pressure
bull IVC size
Part OneThe severity of pulmonary hypertension can be determined using continuous wave Doppler measurements of the velocity of tricuspid regurgitation This method uses the Bernoulli equation which states that 1048661P = 4v2 (where 1048661P = instantaneous pressure gradient and v = velocity across the valve) There is tricuspid regurgitation with a peak velocity of 4 metressecond and a mean velocity of 35 metressecond Assuming right atrial pressure is 5 mmHg the best estimate of the peak right ventricular systolic pressure (plusmn 2 mmHg) is
A 50 mmHg B 55 mmHg C 60 mmHg D 65 mmHg E 70 mmHg
Cardiac Tamponade
Cardiac Tamponade
Cardiac Tamponade
Part OneA 65-year-old woman presents with a one-week history of progressive dyspnoea On admission there are signs of shock a systolic murmur and an elevated jugular venous pressure The ECG shows sinus tachycardia but no other abnormality An antero-posterior chest X-ray shows cardiomegaly The serum troponin I level is 05 mgL [lt01] A computed tomography (CT) scan is shown below
What is the most likely diagnosis A Pulmonary embolism B Right ventricular infarction C Pericardial tamponade D Myocarditis E Acute mitral regurgitation
Endocarditis
Positive echocardiogram for IE Discrete echogenic oscillating intracardiac mass located at a site of endocardial injury (eg on a valve or supporting structure in pathway of regurgitant jet or site of implanted material) or Periannular abscess or
New dehiscence of a prosthetic valve
Cardiac Resynchronisation
Cardiac Resynchronisation
bullSevere heart failure treatment to restore co-ordination to LV contraction
bullNYHA 3-4bullEF lt 35bullQRS duration gt 120 msec
Echocardiography
bullUseful non-invasive tool
bullReports objective and subjective
bullLimitations
Left ventricle - RWMAs
Left ventricle - RWMAs
Left ventricle - thrombus
Left atrium - size
Diameter
Normal 20-40cm
Mild 40-50cm
Moderate 50-60cm
Severe gt60cm
Left atrium - size
Area
Normal lt20cm2
Mild 20-30cm2
Moderate 30-40cm2
Severe gt40cm2
Left atrium - thrombus
Cardiac Valves
Morphology
Valve dysfunction
aetiology
quantification
consequences
serial evaluation
Valve regurgitation - quantification
Colour - jet sizewidth
PISA
Spectral doppler
Consequences
AR - LV Response
bull Chronic AR - decompensated LV
bull LVEFlt55 LVESDgt55mm LVESV 60mlm2
Part OneA patient with aortic regurgitation has the following haemodynamic measurements cardiac output (CO) 75 Lminute heart rate (HR) 75minute left ventricular end-diastolic volume (LVEDV) 200 mL left ventricular end-systolic volume (LVESV) 50 mL The regurgitant fraction is defined as the ratio of the regurgitant volume to the total volume flowing through the valve with each beat
The regurgitant fraction in this patient is A 25 B 33 C 50 D 67 E 75
Part OneA 45-year-old asymptomatic man returns for follow-up He was diagnosed 10 years ago with aortic regurgitation due to a congenital bicuspid aortic valve He has never had endocarditis Which one of the following echocardiographic profiles most strongly indicates the need for aortic valve replacement
LVEDD (mm)[35-55] FS [030-040] LA size (mm) [lt40]
A 70 030 60
B 75 040 40
C 70 025 45
D 65 045 50
E 75 035 55
Key LVEDD Left ventricular end-diastolic diameter LVESD Left ventricular end-systolic diameter FS Fractional shortening = (LVEDD - LVESD) LVEDD LA Left atrial
MR- Quantification of LV contractility
LV systolic function - most important parameter
bullEjection fraction fractional shortening velocity of
circumferential fibre shortening - load dependent
bullMR allows supranormal values of EF etc
bullEarly systolic dysfunction if
bullEF lt 60 (severe MR)
bullES diameter lt 45mm (26mmm2)
Mitral stenosis - quantification
Severity MVA (cm2) LAP (mm Hg) CO
Mild gt20 lt10-12 NL
Moderate 11-20 ~10-17 NL
Severe lt10 gt18
Very Severe lt08 gt20-25
Part OneA 35-year-old woman has increasing breathlessness on exertion Her cardiac silhouette is slightly enlarged on a chest X-ray and an ECG demonstrates sinus rhythm The continuous wave Doppler flow signal through the mitral inflow tract (shown above) is most consistent with which one of the following A Severe pulmonary hypertension (cor pulmonale) B Aortic stenosis C Mitral regurgitation D Mitral stenosis E Aortic regurgitation
Part OneA 28-year-old woman who emigrated from Cambodia 10 years ago presents to the emergency department with a three-week history of increasing shortness of breath orthopnoea nocturnal dyspnoea and ankle oedema She is 25 weeks pregnant and has no significant past medical history The presence of pulmonary oedema is confirmed clinically and radiologically She responds well to intravenous frusemide but remains tachypnoeic with a heart rate of 120minute in sinus rhythm Her blood pressure is 12585 mmHg Echocardiography demonstrates mitral stenosis with an estimated valve area of 13 cm2 and a left atrial diameter of 50 mm [lt40 mm] There are no other abnormalities What is the most appropriate next step in management A Balloon valvotomy B Surgical valvotomy C Digoxin therapy D Beta-blocker therapy E Angiotensin converting enzyme (ACE) inhibitor therapy
Part OneA 55-year-old man presents with acute pulmonary oedema Five years earlier he has undergone a mitral valve replacement with a bileaflet tilting disk valve (St Jude) for mixed mitral valve disease He has been well with normal exercise tolerance prior to the day of admission Examination on admission reveals tachypnoea sinus tachycardia of 110minute blood pressure of 10560 mmHg elevated jugular venous pressure (+ 5 cm) and bilateral crepitations throughout the lung fields His prothrombin timeminusinternational normalised ratio (PT-INR) is 19 [desired therapeutic range 20-35] Serum urea creatinine and electrolytes are normal The cardiothoracic ratio on chest X-ray is normal but the presence of pulmonary oedema is confirmed Echocardiography reveals that one of the prosthetic valve leaflets is not moving and there is an increased flow rate in diastole across the valve orifice (2 metressecond) What is the most appropriate course of action A Administration of intravenous streptokinase B Administration of intravenous heparin C Administration of intravenous antibiotics D Addition of an antiplatelet agent E Immediate mitral valve replacement
Aortic stenosis - quantification
Aortic stenosis - quantification Mean gradient
(mmHg) Peak Ao velocity
AVA (cm2)
Normal 10-20 gt25
Mild lt20 25-29 gt17
Moderate 20-40 30-40 10-17
Severe gt40 gt40 lt10
Right ventricle - size amp function
Estimation of Pulmonary PressurePA systolic pressure
bull Tricuspid regurgitation jet velocity
Estimation of Pulmonary PressureRA pressure
bull IVC size
Part OneThe severity of pulmonary hypertension can be determined using continuous wave Doppler measurements of the velocity of tricuspid regurgitation This method uses the Bernoulli equation which states that 1048661P = 4v2 (where 1048661P = instantaneous pressure gradient and v = velocity across the valve) There is tricuspid regurgitation with a peak velocity of 4 metressecond and a mean velocity of 35 metressecond Assuming right atrial pressure is 5 mmHg the best estimate of the peak right ventricular systolic pressure (plusmn 2 mmHg) is
A 50 mmHg B 55 mmHg C 60 mmHg D 65 mmHg E 70 mmHg
Cardiac Tamponade
Cardiac Tamponade
Cardiac Tamponade
Part OneA 65-year-old woman presents with a one-week history of progressive dyspnoea On admission there are signs of shock a systolic murmur and an elevated jugular venous pressure The ECG shows sinus tachycardia but no other abnormality An antero-posterior chest X-ray shows cardiomegaly The serum troponin I level is 05 mgL [lt01] A computed tomography (CT) scan is shown below
What is the most likely diagnosis A Pulmonary embolism B Right ventricular infarction C Pericardial tamponade D Myocarditis E Acute mitral regurgitation
Endocarditis
Positive echocardiogram for IE Discrete echogenic oscillating intracardiac mass located at a site of endocardial injury (eg on a valve or supporting structure in pathway of regurgitant jet or site of implanted material) or Periannular abscess or
New dehiscence of a prosthetic valve
Cardiac Resynchronisation
Cardiac Resynchronisation
bullSevere heart failure treatment to restore co-ordination to LV contraction
bullNYHA 3-4bullEF lt 35bullQRS duration gt 120 msec
Echocardiography
bullUseful non-invasive tool
bullReports objective and subjective
bullLimitations
Left ventricle - RWMAs
Left ventricle - thrombus
Left atrium - size
Diameter
Normal 20-40cm
Mild 40-50cm
Moderate 50-60cm
Severe gt60cm
Left atrium - size
Area
Normal lt20cm2
Mild 20-30cm2
Moderate 30-40cm2
Severe gt40cm2
Left atrium - thrombus
Cardiac Valves
Morphology
Valve dysfunction
aetiology
quantification
consequences
serial evaluation
Valve regurgitation - quantification
Colour - jet sizewidth
PISA
Spectral doppler
Consequences
AR - LV Response
bull Chronic AR - decompensated LV
bull LVEFlt55 LVESDgt55mm LVESV 60mlm2
Part OneA patient with aortic regurgitation has the following haemodynamic measurements cardiac output (CO) 75 Lminute heart rate (HR) 75minute left ventricular end-diastolic volume (LVEDV) 200 mL left ventricular end-systolic volume (LVESV) 50 mL The regurgitant fraction is defined as the ratio of the regurgitant volume to the total volume flowing through the valve with each beat
The regurgitant fraction in this patient is A 25 B 33 C 50 D 67 E 75
Part OneA 45-year-old asymptomatic man returns for follow-up He was diagnosed 10 years ago with aortic regurgitation due to a congenital bicuspid aortic valve He has never had endocarditis Which one of the following echocardiographic profiles most strongly indicates the need for aortic valve replacement
LVEDD (mm)[35-55] FS [030-040] LA size (mm) [lt40]
A 70 030 60
B 75 040 40
C 70 025 45
D 65 045 50
E 75 035 55
Key LVEDD Left ventricular end-diastolic diameter LVESD Left ventricular end-systolic diameter FS Fractional shortening = (LVEDD - LVESD) LVEDD LA Left atrial
MR- Quantification of LV contractility
LV systolic function - most important parameter
bullEjection fraction fractional shortening velocity of
circumferential fibre shortening - load dependent
bullMR allows supranormal values of EF etc
bullEarly systolic dysfunction if
bullEF lt 60 (severe MR)
bullES diameter lt 45mm (26mmm2)
Mitral stenosis - quantification
Severity MVA (cm2) LAP (mm Hg) CO
Mild gt20 lt10-12 NL
Moderate 11-20 ~10-17 NL
Severe lt10 gt18
Very Severe lt08 gt20-25
Part OneA 35-year-old woman has increasing breathlessness on exertion Her cardiac silhouette is slightly enlarged on a chest X-ray and an ECG demonstrates sinus rhythm The continuous wave Doppler flow signal through the mitral inflow tract (shown above) is most consistent with which one of the following A Severe pulmonary hypertension (cor pulmonale) B Aortic stenosis C Mitral regurgitation D Mitral stenosis E Aortic regurgitation
Part OneA 28-year-old woman who emigrated from Cambodia 10 years ago presents to the emergency department with a three-week history of increasing shortness of breath orthopnoea nocturnal dyspnoea and ankle oedema She is 25 weeks pregnant and has no significant past medical history The presence of pulmonary oedema is confirmed clinically and radiologically She responds well to intravenous frusemide but remains tachypnoeic with a heart rate of 120minute in sinus rhythm Her blood pressure is 12585 mmHg Echocardiography demonstrates mitral stenosis with an estimated valve area of 13 cm2 and a left atrial diameter of 50 mm [lt40 mm] There are no other abnormalities What is the most appropriate next step in management A Balloon valvotomy B Surgical valvotomy C Digoxin therapy D Beta-blocker therapy E Angiotensin converting enzyme (ACE) inhibitor therapy
Part OneA 55-year-old man presents with acute pulmonary oedema Five years earlier he has undergone a mitral valve replacement with a bileaflet tilting disk valve (St Jude) for mixed mitral valve disease He has been well with normal exercise tolerance prior to the day of admission Examination on admission reveals tachypnoea sinus tachycardia of 110minute blood pressure of 10560 mmHg elevated jugular venous pressure (+ 5 cm) and bilateral crepitations throughout the lung fields His prothrombin timeminusinternational normalised ratio (PT-INR) is 19 [desired therapeutic range 20-35] Serum urea creatinine and electrolytes are normal The cardiothoracic ratio on chest X-ray is normal but the presence of pulmonary oedema is confirmed Echocardiography reveals that one of the prosthetic valve leaflets is not moving and there is an increased flow rate in diastole across the valve orifice (2 metressecond) What is the most appropriate course of action A Administration of intravenous streptokinase B Administration of intravenous heparin C Administration of intravenous antibiotics D Addition of an antiplatelet agent E Immediate mitral valve replacement
Aortic stenosis - quantification
Aortic stenosis - quantification Mean gradient
(mmHg) Peak Ao velocity
AVA (cm2)
Normal 10-20 gt25
Mild lt20 25-29 gt17
Moderate 20-40 30-40 10-17
Severe gt40 gt40 lt10
Right ventricle - size amp function
Estimation of Pulmonary PressurePA systolic pressure
bull Tricuspid regurgitation jet velocity
Estimation of Pulmonary PressureRA pressure
bull IVC size
Part OneThe severity of pulmonary hypertension can be determined using continuous wave Doppler measurements of the velocity of tricuspid regurgitation This method uses the Bernoulli equation which states that 1048661P = 4v2 (where 1048661P = instantaneous pressure gradient and v = velocity across the valve) There is tricuspid regurgitation with a peak velocity of 4 metressecond and a mean velocity of 35 metressecond Assuming right atrial pressure is 5 mmHg the best estimate of the peak right ventricular systolic pressure (plusmn 2 mmHg) is
A 50 mmHg B 55 mmHg C 60 mmHg D 65 mmHg E 70 mmHg
Cardiac Tamponade
Cardiac Tamponade
Cardiac Tamponade
Part OneA 65-year-old woman presents with a one-week history of progressive dyspnoea On admission there are signs of shock a systolic murmur and an elevated jugular venous pressure The ECG shows sinus tachycardia but no other abnormality An antero-posterior chest X-ray shows cardiomegaly The serum troponin I level is 05 mgL [lt01] A computed tomography (CT) scan is shown below
What is the most likely diagnosis A Pulmonary embolism B Right ventricular infarction C Pericardial tamponade D Myocarditis E Acute mitral regurgitation
Endocarditis
Positive echocardiogram for IE Discrete echogenic oscillating intracardiac mass located at a site of endocardial injury (eg on a valve or supporting structure in pathway of regurgitant jet or site of implanted material) or Periannular abscess or
New dehiscence of a prosthetic valve
Cardiac Resynchronisation
Cardiac Resynchronisation
bullSevere heart failure treatment to restore co-ordination to LV contraction
bullNYHA 3-4bullEF lt 35bullQRS duration gt 120 msec
Echocardiography
bullUseful non-invasive tool
bullReports objective and subjective
bullLimitations
Left ventricle - thrombus
Left atrium - size
Diameter
Normal 20-40cm
Mild 40-50cm
Moderate 50-60cm
Severe gt60cm
Left atrium - size
Area
Normal lt20cm2
Mild 20-30cm2
Moderate 30-40cm2
Severe gt40cm2
Left atrium - thrombus
Cardiac Valves
Morphology
Valve dysfunction
aetiology
quantification
consequences
serial evaluation
Valve regurgitation - quantification
Colour - jet sizewidth
PISA
Spectral doppler
Consequences
AR - LV Response
bull Chronic AR - decompensated LV
bull LVEFlt55 LVESDgt55mm LVESV 60mlm2
Part OneA patient with aortic regurgitation has the following haemodynamic measurements cardiac output (CO) 75 Lminute heart rate (HR) 75minute left ventricular end-diastolic volume (LVEDV) 200 mL left ventricular end-systolic volume (LVESV) 50 mL The regurgitant fraction is defined as the ratio of the regurgitant volume to the total volume flowing through the valve with each beat
The regurgitant fraction in this patient is A 25 B 33 C 50 D 67 E 75
Part OneA 45-year-old asymptomatic man returns for follow-up He was diagnosed 10 years ago with aortic regurgitation due to a congenital bicuspid aortic valve He has never had endocarditis Which one of the following echocardiographic profiles most strongly indicates the need for aortic valve replacement
LVEDD (mm)[35-55] FS [030-040] LA size (mm) [lt40]
A 70 030 60
B 75 040 40
C 70 025 45
D 65 045 50
E 75 035 55
Key LVEDD Left ventricular end-diastolic diameter LVESD Left ventricular end-systolic diameter FS Fractional shortening = (LVEDD - LVESD) LVEDD LA Left atrial
MR- Quantification of LV contractility
LV systolic function - most important parameter
bullEjection fraction fractional shortening velocity of
circumferential fibre shortening - load dependent
bullMR allows supranormal values of EF etc
bullEarly systolic dysfunction if
bullEF lt 60 (severe MR)
bullES diameter lt 45mm (26mmm2)
Mitral stenosis - quantification
Severity MVA (cm2) LAP (mm Hg) CO
Mild gt20 lt10-12 NL
Moderate 11-20 ~10-17 NL
Severe lt10 gt18
Very Severe lt08 gt20-25
Part OneA 35-year-old woman has increasing breathlessness on exertion Her cardiac silhouette is slightly enlarged on a chest X-ray and an ECG demonstrates sinus rhythm The continuous wave Doppler flow signal through the mitral inflow tract (shown above) is most consistent with which one of the following A Severe pulmonary hypertension (cor pulmonale) B Aortic stenosis C Mitral regurgitation D Mitral stenosis E Aortic regurgitation
Part OneA 28-year-old woman who emigrated from Cambodia 10 years ago presents to the emergency department with a three-week history of increasing shortness of breath orthopnoea nocturnal dyspnoea and ankle oedema She is 25 weeks pregnant and has no significant past medical history The presence of pulmonary oedema is confirmed clinically and radiologically She responds well to intravenous frusemide but remains tachypnoeic with a heart rate of 120minute in sinus rhythm Her blood pressure is 12585 mmHg Echocardiography demonstrates mitral stenosis with an estimated valve area of 13 cm2 and a left atrial diameter of 50 mm [lt40 mm] There are no other abnormalities What is the most appropriate next step in management A Balloon valvotomy B Surgical valvotomy C Digoxin therapy D Beta-blocker therapy E Angiotensin converting enzyme (ACE) inhibitor therapy
Part OneA 55-year-old man presents with acute pulmonary oedema Five years earlier he has undergone a mitral valve replacement with a bileaflet tilting disk valve (St Jude) for mixed mitral valve disease He has been well with normal exercise tolerance prior to the day of admission Examination on admission reveals tachypnoea sinus tachycardia of 110minute blood pressure of 10560 mmHg elevated jugular venous pressure (+ 5 cm) and bilateral crepitations throughout the lung fields His prothrombin timeminusinternational normalised ratio (PT-INR) is 19 [desired therapeutic range 20-35] Serum urea creatinine and electrolytes are normal The cardiothoracic ratio on chest X-ray is normal but the presence of pulmonary oedema is confirmed Echocardiography reveals that one of the prosthetic valve leaflets is not moving and there is an increased flow rate in diastole across the valve orifice (2 metressecond) What is the most appropriate course of action A Administration of intravenous streptokinase B Administration of intravenous heparin C Administration of intravenous antibiotics D Addition of an antiplatelet agent E Immediate mitral valve replacement
Aortic stenosis - quantification
Aortic stenosis - quantification Mean gradient
(mmHg) Peak Ao velocity
AVA (cm2)
Normal 10-20 gt25
Mild lt20 25-29 gt17
Moderate 20-40 30-40 10-17
Severe gt40 gt40 lt10
Right ventricle - size amp function
Estimation of Pulmonary PressurePA systolic pressure
bull Tricuspid regurgitation jet velocity
Estimation of Pulmonary PressureRA pressure
bull IVC size
Part OneThe severity of pulmonary hypertension can be determined using continuous wave Doppler measurements of the velocity of tricuspid regurgitation This method uses the Bernoulli equation which states that 1048661P = 4v2 (where 1048661P = instantaneous pressure gradient and v = velocity across the valve) There is tricuspid regurgitation with a peak velocity of 4 metressecond and a mean velocity of 35 metressecond Assuming right atrial pressure is 5 mmHg the best estimate of the peak right ventricular systolic pressure (plusmn 2 mmHg) is
A 50 mmHg B 55 mmHg C 60 mmHg D 65 mmHg E 70 mmHg
Cardiac Tamponade
Cardiac Tamponade
Cardiac Tamponade
Part OneA 65-year-old woman presents with a one-week history of progressive dyspnoea On admission there are signs of shock a systolic murmur and an elevated jugular venous pressure The ECG shows sinus tachycardia but no other abnormality An antero-posterior chest X-ray shows cardiomegaly The serum troponin I level is 05 mgL [lt01] A computed tomography (CT) scan is shown below
What is the most likely diagnosis A Pulmonary embolism B Right ventricular infarction C Pericardial tamponade D Myocarditis E Acute mitral regurgitation
Endocarditis
Positive echocardiogram for IE Discrete echogenic oscillating intracardiac mass located at a site of endocardial injury (eg on a valve or supporting structure in pathway of regurgitant jet or site of implanted material) or Periannular abscess or
New dehiscence of a prosthetic valve
Cardiac Resynchronisation
Cardiac Resynchronisation
bullSevere heart failure treatment to restore co-ordination to LV contraction
bullNYHA 3-4bullEF lt 35bullQRS duration gt 120 msec
Echocardiography
bullUseful non-invasive tool
bullReports objective and subjective
bullLimitations
Left atrium - size
Diameter
Normal 20-40cm
Mild 40-50cm
Moderate 50-60cm
Severe gt60cm
Left atrium - size
Area
Normal lt20cm2
Mild 20-30cm2
Moderate 30-40cm2
Severe gt40cm2
Left atrium - thrombus
Cardiac Valves
Morphology
Valve dysfunction
aetiology
quantification
consequences
serial evaluation
Valve regurgitation - quantification
Colour - jet sizewidth
PISA
Spectral doppler
Consequences
AR - LV Response
bull Chronic AR - decompensated LV
bull LVEFlt55 LVESDgt55mm LVESV 60mlm2
Part OneA patient with aortic regurgitation has the following haemodynamic measurements cardiac output (CO) 75 Lminute heart rate (HR) 75minute left ventricular end-diastolic volume (LVEDV) 200 mL left ventricular end-systolic volume (LVESV) 50 mL The regurgitant fraction is defined as the ratio of the regurgitant volume to the total volume flowing through the valve with each beat
The regurgitant fraction in this patient is A 25 B 33 C 50 D 67 E 75
Part OneA 45-year-old asymptomatic man returns for follow-up He was diagnosed 10 years ago with aortic regurgitation due to a congenital bicuspid aortic valve He has never had endocarditis Which one of the following echocardiographic profiles most strongly indicates the need for aortic valve replacement
LVEDD (mm)[35-55] FS [030-040] LA size (mm) [lt40]
A 70 030 60
B 75 040 40
C 70 025 45
D 65 045 50
E 75 035 55
Key LVEDD Left ventricular end-diastolic diameter LVESD Left ventricular end-systolic diameter FS Fractional shortening = (LVEDD - LVESD) LVEDD LA Left atrial
MR- Quantification of LV contractility
LV systolic function - most important parameter
bullEjection fraction fractional shortening velocity of
circumferential fibre shortening - load dependent
bullMR allows supranormal values of EF etc
bullEarly systolic dysfunction if
bullEF lt 60 (severe MR)
bullES diameter lt 45mm (26mmm2)
Mitral stenosis - quantification
Severity MVA (cm2) LAP (mm Hg) CO
Mild gt20 lt10-12 NL
Moderate 11-20 ~10-17 NL
Severe lt10 gt18
Very Severe lt08 gt20-25
Part OneA 35-year-old woman has increasing breathlessness on exertion Her cardiac silhouette is slightly enlarged on a chest X-ray and an ECG demonstrates sinus rhythm The continuous wave Doppler flow signal through the mitral inflow tract (shown above) is most consistent with which one of the following A Severe pulmonary hypertension (cor pulmonale) B Aortic stenosis C Mitral regurgitation D Mitral stenosis E Aortic regurgitation
Part OneA 28-year-old woman who emigrated from Cambodia 10 years ago presents to the emergency department with a three-week history of increasing shortness of breath orthopnoea nocturnal dyspnoea and ankle oedema She is 25 weeks pregnant and has no significant past medical history The presence of pulmonary oedema is confirmed clinically and radiologically She responds well to intravenous frusemide but remains tachypnoeic with a heart rate of 120minute in sinus rhythm Her blood pressure is 12585 mmHg Echocardiography demonstrates mitral stenosis with an estimated valve area of 13 cm2 and a left atrial diameter of 50 mm [lt40 mm] There are no other abnormalities What is the most appropriate next step in management A Balloon valvotomy B Surgical valvotomy C Digoxin therapy D Beta-blocker therapy E Angiotensin converting enzyme (ACE) inhibitor therapy
Part OneA 55-year-old man presents with acute pulmonary oedema Five years earlier he has undergone a mitral valve replacement with a bileaflet tilting disk valve (St Jude) for mixed mitral valve disease He has been well with normal exercise tolerance prior to the day of admission Examination on admission reveals tachypnoea sinus tachycardia of 110minute blood pressure of 10560 mmHg elevated jugular venous pressure (+ 5 cm) and bilateral crepitations throughout the lung fields His prothrombin timeminusinternational normalised ratio (PT-INR) is 19 [desired therapeutic range 20-35] Serum urea creatinine and electrolytes are normal The cardiothoracic ratio on chest X-ray is normal but the presence of pulmonary oedema is confirmed Echocardiography reveals that one of the prosthetic valve leaflets is not moving and there is an increased flow rate in diastole across the valve orifice (2 metressecond) What is the most appropriate course of action A Administration of intravenous streptokinase B Administration of intravenous heparin C Administration of intravenous antibiotics D Addition of an antiplatelet agent E Immediate mitral valve replacement
Aortic stenosis - quantification
Aortic stenosis - quantification Mean gradient
(mmHg) Peak Ao velocity
AVA (cm2)
Normal 10-20 gt25
Mild lt20 25-29 gt17
Moderate 20-40 30-40 10-17
Severe gt40 gt40 lt10
Right ventricle - size amp function
Estimation of Pulmonary PressurePA systolic pressure
bull Tricuspid regurgitation jet velocity
Estimation of Pulmonary PressureRA pressure
bull IVC size
Part OneThe severity of pulmonary hypertension can be determined using continuous wave Doppler measurements of the velocity of tricuspid regurgitation This method uses the Bernoulli equation which states that 1048661P = 4v2 (where 1048661P = instantaneous pressure gradient and v = velocity across the valve) There is tricuspid regurgitation with a peak velocity of 4 metressecond and a mean velocity of 35 metressecond Assuming right atrial pressure is 5 mmHg the best estimate of the peak right ventricular systolic pressure (plusmn 2 mmHg) is
A 50 mmHg B 55 mmHg C 60 mmHg D 65 mmHg E 70 mmHg
Cardiac Tamponade
Cardiac Tamponade
Cardiac Tamponade
Part OneA 65-year-old woman presents with a one-week history of progressive dyspnoea On admission there are signs of shock a systolic murmur and an elevated jugular venous pressure The ECG shows sinus tachycardia but no other abnormality An antero-posterior chest X-ray shows cardiomegaly The serum troponin I level is 05 mgL [lt01] A computed tomography (CT) scan is shown below
What is the most likely diagnosis A Pulmonary embolism B Right ventricular infarction C Pericardial tamponade D Myocarditis E Acute mitral regurgitation
Endocarditis
Positive echocardiogram for IE Discrete echogenic oscillating intracardiac mass located at a site of endocardial injury (eg on a valve or supporting structure in pathway of regurgitant jet or site of implanted material) or Periannular abscess or
New dehiscence of a prosthetic valve
Cardiac Resynchronisation
Cardiac Resynchronisation
bullSevere heart failure treatment to restore co-ordination to LV contraction
bullNYHA 3-4bullEF lt 35bullQRS duration gt 120 msec
Echocardiography
bullUseful non-invasive tool
bullReports objective and subjective
bullLimitations
Left atrium - size
Area
Normal lt20cm2
Mild 20-30cm2
Moderate 30-40cm2
Severe gt40cm2
Left atrium - thrombus
Cardiac Valves
Morphology
Valve dysfunction
aetiology
quantification
consequences
serial evaluation
Valve regurgitation - quantification
Colour - jet sizewidth
PISA
Spectral doppler
Consequences
AR - LV Response
bull Chronic AR - decompensated LV
bull LVEFlt55 LVESDgt55mm LVESV 60mlm2
Part OneA patient with aortic regurgitation has the following haemodynamic measurements cardiac output (CO) 75 Lminute heart rate (HR) 75minute left ventricular end-diastolic volume (LVEDV) 200 mL left ventricular end-systolic volume (LVESV) 50 mL The regurgitant fraction is defined as the ratio of the regurgitant volume to the total volume flowing through the valve with each beat
The regurgitant fraction in this patient is A 25 B 33 C 50 D 67 E 75
Part OneA 45-year-old asymptomatic man returns for follow-up He was diagnosed 10 years ago with aortic regurgitation due to a congenital bicuspid aortic valve He has never had endocarditis Which one of the following echocardiographic profiles most strongly indicates the need for aortic valve replacement
LVEDD (mm)[35-55] FS [030-040] LA size (mm) [lt40]
A 70 030 60
B 75 040 40
C 70 025 45
D 65 045 50
E 75 035 55
Key LVEDD Left ventricular end-diastolic diameter LVESD Left ventricular end-systolic diameter FS Fractional shortening = (LVEDD - LVESD) LVEDD LA Left atrial
MR- Quantification of LV contractility
LV systolic function - most important parameter
bullEjection fraction fractional shortening velocity of
circumferential fibre shortening - load dependent
bullMR allows supranormal values of EF etc
bullEarly systolic dysfunction if
bullEF lt 60 (severe MR)
bullES diameter lt 45mm (26mmm2)
Mitral stenosis - quantification
Severity MVA (cm2) LAP (mm Hg) CO
Mild gt20 lt10-12 NL
Moderate 11-20 ~10-17 NL
Severe lt10 gt18
Very Severe lt08 gt20-25
Part OneA 35-year-old woman has increasing breathlessness on exertion Her cardiac silhouette is slightly enlarged on a chest X-ray and an ECG demonstrates sinus rhythm The continuous wave Doppler flow signal through the mitral inflow tract (shown above) is most consistent with which one of the following A Severe pulmonary hypertension (cor pulmonale) B Aortic stenosis C Mitral regurgitation D Mitral stenosis E Aortic regurgitation
Part OneA 28-year-old woman who emigrated from Cambodia 10 years ago presents to the emergency department with a three-week history of increasing shortness of breath orthopnoea nocturnal dyspnoea and ankle oedema She is 25 weeks pregnant and has no significant past medical history The presence of pulmonary oedema is confirmed clinically and radiologically She responds well to intravenous frusemide but remains tachypnoeic with a heart rate of 120minute in sinus rhythm Her blood pressure is 12585 mmHg Echocardiography demonstrates mitral stenosis with an estimated valve area of 13 cm2 and a left atrial diameter of 50 mm [lt40 mm] There are no other abnormalities What is the most appropriate next step in management A Balloon valvotomy B Surgical valvotomy C Digoxin therapy D Beta-blocker therapy E Angiotensin converting enzyme (ACE) inhibitor therapy
Part OneA 55-year-old man presents with acute pulmonary oedema Five years earlier he has undergone a mitral valve replacement with a bileaflet tilting disk valve (St Jude) for mixed mitral valve disease He has been well with normal exercise tolerance prior to the day of admission Examination on admission reveals tachypnoea sinus tachycardia of 110minute blood pressure of 10560 mmHg elevated jugular venous pressure (+ 5 cm) and bilateral crepitations throughout the lung fields His prothrombin timeminusinternational normalised ratio (PT-INR) is 19 [desired therapeutic range 20-35] Serum urea creatinine and electrolytes are normal The cardiothoracic ratio on chest X-ray is normal but the presence of pulmonary oedema is confirmed Echocardiography reveals that one of the prosthetic valve leaflets is not moving and there is an increased flow rate in diastole across the valve orifice (2 metressecond) What is the most appropriate course of action A Administration of intravenous streptokinase B Administration of intravenous heparin C Administration of intravenous antibiotics D Addition of an antiplatelet agent E Immediate mitral valve replacement
Aortic stenosis - quantification
Aortic stenosis - quantification Mean gradient
(mmHg) Peak Ao velocity
AVA (cm2)
Normal 10-20 gt25
Mild lt20 25-29 gt17
Moderate 20-40 30-40 10-17
Severe gt40 gt40 lt10
Right ventricle - size amp function
Estimation of Pulmonary PressurePA systolic pressure
bull Tricuspid regurgitation jet velocity
Estimation of Pulmonary PressureRA pressure
bull IVC size
Part OneThe severity of pulmonary hypertension can be determined using continuous wave Doppler measurements of the velocity of tricuspid regurgitation This method uses the Bernoulli equation which states that 1048661P = 4v2 (where 1048661P = instantaneous pressure gradient and v = velocity across the valve) There is tricuspid regurgitation with a peak velocity of 4 metressecond and a mean velocity of 35 metressecond Assuming right atrial pressure is 5 mmHg the best estimate of the peak right ventricular systolic pressure (plusmn 2 mmHg) is
A 50 mmHg B 55 mmHg C 60 mmHg D 65 mmHg E 70 mmHg
Cardiac Tamponade
Cardiac Tamponade
Cardiac Tamponade
Part OneA 65-year-old woman presents with a one-week history of progressive dyspnoea On admission there are signs of shock a systolic murmur and an elevated jugular venous pressure The ECG shows sinus tachycardia but no other abnormality An antero-posterior chest X-ray shows cardiomegaly The serum troponin I level is 05 mgL [lt01] A computed tomography (CT) scan is shown below
What is the most likely diagnosis A Pulmonary embolism B Right ventricular infarction C Pericardial tamponade D Myocarditis E Acute mitral regurgitation
Endocarditis
Positive echocardiogram for IE Discrete echogenic oscillating intracardiac mass located at a site of endocardial injury (eg on a valve or supporting structure in pathway of regurgitant jet or site of implanted material) or Periannular abscess or
New dehiscence of a prosthetic valve
Cardiac Resynchronisation
Cardiac Resynchronisation
bullSevere heart failure treatment to restore co-ordination to LV contraction
bullNYHA 3-4bullEF lt 35bullQRS duration gt 120 msec
Echocardiography
bullUseful non-invasive tool
bullReports objective and subjective
bullLimitations
Left atrium - thrombus
Cardiac Valves
Morphology
Valve dysfunction
aetiology
quantification
consequences
serial evaluation
Valve regurgitation - quantification
Colour - jet sizewidth
PISA
Spectral doppler
Consequences
AR - LV Response
bull Chronic AR - decompensated LV
bull LVEFlt55 LVESDgt55mm LVESV 60mlm2
Part OneA patient with aortic regurgitation has the following haemodynamic measurements cardiac output (CO) 75 Lminute heart rate (HR) 75minute left ventricular end-diastolic volume (LVEDV) 200 mL left ventricular end-systolic volume (LVESV) 50 mL The regurgitant fraction is defined as the ratio of the regurgitant volume to the total volume flowing through the valve with each beat
The regurgitant fraction in this patient is A 25 B 33 C 50 D 67 E 75
Part OneA 45-year-old asymptomatic man returns for follow-up He was diagnosed 10 years ago with aortic regurgitation due to a congenital bicuspid aortic valve He has never had endocarditis Which one of the following echocardiographic profiles most strongly indicates the need for aortic valve replacement
LVEDD (mm)[35-55] FS [030-040] LA size (mm) [lt40]
A 70 030 60
B 75 040 40
C 70 025 45
D 65 045 50
E 75 035 55
Key LVEDD Left ventricular end-diastolic diameter LVESD Left ventricular end-systolic diameter FS Fractional shortening = (LVEDD - LVESD) LVEDD LA Left atrial
MR- Quantification of LV contractility
LV systolic function - most important parameter
bullEjection fraction fractional shortening velocity of
circumferential fibre shortening - load dependent
bullMR allows supranormal values of EF etc
bullEarly systolic dysfunction if
bullEF lt 60 (severe MR)
bullES diameter lt 45mm (26mmm2)
Mitral stenosis - quantification
Severity MVA (cm2) LAP (mm Hg) CO
Mild gt20 lt10-12 NL
Moderate 11-20 ~10-17 NL
Severe lt10 gt18
Very Severe lt08 gt20-25
Part OneA 35-year-old woman has increasing breathlessness on exertion Her cardiac silhouette is slightly enlarged on a chest X-ray and an ECG demonstrates sinus rhythm The continuous wave Doppler flow signal through the mitral inflow tract (shown above) is most consistent with which one of the following A Severe pulmonary hypertension (cor pulmonale) B Aortic stenosis C Mitral regurgitation D Mitral stenosis E Aortic regurgitation
Part OneA 28-year-old woman who emigrated from Cambodia 10 years ago presents to the emergency department with a three-week history of increasing shortness of breath orthopnoea nocturnal dyspnoea and ankle oedema She is 25 weeks pregnant and has no significant past medical history The presence of pulmonary oedema is confirmed clinically and radiologically She responds well to intravenous frusemide but remains tachypnoeic with a heart rate of 120minute in sinus rhythm Her blood pressure is 12585 mmHg Echocardiography demonstrates mitral stenosis with an estimated valve area of 13 cm2 and a left atrial diameter of 50 mm [lt40 mm] There are no other abnormalities What is the most appropriate next step in management A Balloon valvotomy B Surgical valvotomy C Digoxin therapy D Beta-blocker therapy E Angiotensin converting enzyme (ACE) inhibitor therapy
Part OneA 55-year-old man presents with acute pulmonary oedema Five years earlier he has undergone a mitral valve replacement with a bileaflet tilting disk valve (St Jude) for mixed mitral valve disease He has been well with normal exercise tolerance prior to the day of admission Examination on admission reveals tachypnoea sinus tachycardia of 110minute blood pressure of 10560 mmHg elevated jugular venous pressure (+ 5 cm) and bilateral crepitations throughout the lung fields His prothrombin timeminusinternational normalised ratio (PT-INR) is 19 [desired therapeutic range 20-35] Serum urea creatinine and electrolytes are normal The cardiothoracic ratio on chest X-ray is normal but the presence of pulmonary oedema is confirmed Echocardiography reveals that one of the prosthetic valve leaflets is not moving and there is an increased flow rate in diastole across the valve orifice (2 metressecond) What is the most appropriate course of action A Administration of intravenous streptokinase B Administration of intravenous heparin C Administration of intravenous antibiotics D Addition of an antiplatelet agent E Immediate mitral valve replacement
Aortic stenosis - quantification
Aortic stenosis - quantification Mean gradient
(mmHg) Peak Ao velocity
AVA (cm2)
Normal 10-20 gt25
Mild lt20 25-29 gt17
Moderate 20-40 30-40 10-17
Severe gt40 gt40 lt10
Right ventricle - size amp function
Estimation of Pulmonary PressurePA systolic pressure
bull Tricuspid regurgitation jet velocity
Estimation of Pulmonary PressureRA pressure
bull IVC size
Part OneThe severity of pulmonary hypertension can be determined using continuous wave Doppler measurements of the velocity of tricuspid regurgitation This method uses the Bernoulli equation which states that 1048661P = 4v2 (where 1048661P = instantaneous pressure gradient and v = velocity across the valve) There is tricuspid regurgitation with a peak velocity of 4 metressecond and a mean velocity of 35 metressecond Assuming right atrial pressure is 5 mmHg the best estimate of the peak right ventricular systolic pressure (plusmn 2 mmHg) is
A 50 mmHg B 55 mmHg C 60 mmHg D 65 mmHg E 70 mmHg
Cardiac Tamponade
Cardiac Tamponade
Cardiac Tamponade
Part OneA 65-year-old woman presents with a one-week history of progressive dyspnoea On admission there are signs of shock a systolic murmur and an elevated jugular venous pressure The ECG shows sinus tachycardia but no other abnormality An antero-posterior chest X-ray shows cardiomegaly The serum troponin I level is 05 mgL [lt01] A computed tomography (CT) scan is shown below
What is the most likely diagnosis A Pulmonary embolism B Right ventricular infarction C Pericardial tamponade D Myocarditis E Acute mitral regurgitation
Endocarditis
Positive echocardiogram for IE Discrete echogenic oscillating intracardiac mass located at a site of endocardial injury (eg on a valve or supporting structure in pathway of regurgitant jet or site of implanted material) or Periannular abscess or
New dehiscence of a prosthetic valve
Cardiac Resynchronisation
Cardiac Resynchronisation
bullSevere heart failure treatment to restore co-ordination to LV contraction
bullNYHA 3-4bullEF lt 35bullQRS duration gt 120 msec
Echocardiography
bullUseful non-invasive tool
bullReports objective and subjective
bullLimitations
Cardiac Valves
Morphology
Valve dysfunction
aetiology
quantification
consequences
serial evaluation
Valve regurgitation - quantification
Colour - jet sizewidth
PISA
Spectral doppler
Consequences
AR - LV Response
bull Chronic AR - decompensated LV
bull LVEFlt55 LVESDgt55mm LVESV 60mlm2
Part OneA patient with aortic regurgitation has the following haemodynamic measurements cardiac output (CO) 75 Lminute heart rate (HR) 75minute left ventricular end-diastolic volume (LVEDV) 200 mL left ventricular end-systolic volume (LVESV) 50 mL The regurgitant fraction is defined as the ratio of the regurgitant volume to the total volume flowing through the valve with each beat
The regurgitant fraction in this patient is A 25 B 33 C 50 D 67 E 75
Part OneA 45-year-old asymptomatic man returns for follow-up He was diagnosed 10 years ago with aortic regurgitation due to a congenital bicuspid aortic valve He has never had endocarditis Which one of the following echocardiographic profiles most strongly indicates the need for aortic valve replacement
LVEDD (mm)[35-55] FS [030-040] LA size (mm) [lt40]
A 70 030 60
B 75 040 40
C 70 025 45
D 65 045 50
E 75 035 55
Key LVEDD Left ventricular end-diastolic diameter LVESD Left ventricular end-systolic diameter FS Fractional shortening = (LVEDD - LVESD) LVEDD LA Left atrial
MR- Quantification of LV contractility
LV systolic function - most important parameter
bullEjection fraction fractional shortening velocity of
circumferential fibre shortening - load dependent
bullMR allows supranormal values of EF etc
bullEarly systolic dysfunction if
bullEF lt 60 (severe MR)
bullES diameter lt 45mm (26mmm2)
Mitral stenosis - quantification
Severity MVA (cm2) LAP (mm Hg) CO
Mild gt20 lt10-12 NL
Moderate 11-20 ~10-17 NL
Severe lt10 gt18
Very Severe lt08 gt20-25
Part OneA 35-year-old woman has increasing breathlessness on exertion Her cardiac silhouette is slightly enlarged on a chest X-ray and an ECG demonstrates sinus rhythm The continuous wave Doppler flow signal through the mitral inflow tract (shown above) is most consistent with which one of the following A Severe pulmonary hypertension (cor pulmonale) B Aortic stenosis C Mitral regurgitation D Mitral stenosis E Aortic regurgitation
Part OneA 28-year-old woman who emigrated from Cambodia 10 years ago presents to the emergency department with a three-week history of increasing shortness of breath orthopnoea nocturnal dyspnoea and ankle oedema She is 25 weeks pregnant and has no significant past medical history The presence of pulmonary oedema is confirmed clinically and radiologically She responds well to intravenous frusemide but remains tachypnoeic with a heart rate of 120minute in sinus rhythm Her blood pressure is 12585 mmHg Echocardiography demonstrates mitral stenosis with an estimated valve area of 13 cm2 and a left atrial diameter of 50 mm [lt40 mm] There are no other abnormalities What is the most appropriate next step in management A Balloon valvotomy B Surgical valvotomy C Digoxin therapy D Beta-blocker therapy E Angiotensin converting enzyme (ACE) inhibitor therapy
Part OneA 55-year-old man presents with acute pulmonary oedema Five years earlier he has undergone a mitral valve replacement with a bileaflet tilting disk valve (St Jude) for mixed mitral valve disease He has been well with normal exercise tolerance prior to the day of admission Examination on admission reveals tachypnoea sinus tachycardia of 110minute blood pressure of 10560 mmHg elevated jugular venous pressure (+ 5 cm) and bilateral crepitations throughout the lung fields His prothrombin timeminusinternational normalised ratio (PT-INR) is 19 [desired therapeutic range 20-35] Serum urea creatinine and electrolytes are normal The cardiothoracic ratio on chest X-ray is normal but the presence of pulmonary oedema is confirmed Echocardiography reveals that one of the prosthetic valve leaflets is not moving and there is an increased flow rate in diastole across the valve orifice (2 metressecond) What is the most appropriate course of action A Administration of intravenous streptokinase B Administration of intravenous heparin C Administration of intravenous antibiotics D Addition of an antiplatelet agent E Immediate mitral valve replacement
Aortic stenosis - quantification
Aortic stenosis - quantification Mean gradient
(mmHg) Peak Ao velocity
AVA (cm2)
Normal 10-20 gt25
Mild lt20 25-29 gt17
Moderate 20-40 30-40 10-17
Severe gt40 gt40 lt10
Right ventricle - size amp function
Estimation of Pulmonary PressurePA systolic pressure
bull Tricuspid regurgitation jet velocity
Estimation of Pulmonary PressureRA pressure
bull IVC size
Part OneThe severity of pulmonary hypertension can be determined using continuous wave Doppler measurements of the velocity of tricuspid regurgitation This method uses the Bernoulli equation which states that 1048661P = 4v2 (where 1048661P = instantaneous pressure gradient and v = velocity across the valve) There is tricuspid regurgitation with a peak velocity of 4 metressecond and a mean velocity of 35 metressecond Assuming right atrial pressure is 5 mmHg the best estimate of the peak right ventricular systolic pressure (plusmn 2 mmHg) is
A 50 mmHg B 55 mmHg C 60 mmHg D 65 mmHg E 70 mmHg
Cardiac Tamponade
Cardiac Tamponade
Cardiac Tamponade
Part OneA 65-year-old woman presents with a one-week history of progressive dyspnoea On admission there are signs of shock a systolic murmur and an elevated jugular venous pressure The ECG shows sinus tachycardia but no other abnormality An antero-posterior chest X-ray shows cardiomegaly The serum troponin I level is 05 mgL [lt01] A computed tomography (CT) scan is shown below
What is the most likely diagnosis A Pulmonary embolism B Right ventricular infarction C Pericardial tamponade D Myocarditis E Acute mitral regurgitation
Endocarditis
Positive echocardiogram for IE Discrete echogenic oscillating intracardiac mass located at a site of endocardial injury (eg on a valve or supporting structure in pathway of regurgitant jet or site of implanted material) or Periannular abscess or
New dehiscence of a prosthetic valve
Cardiac Resynchronisation
Cardiac Resynchronisation
bullSevere heart failure treatment to restore co-ordination to LV contraction
bullNYHA 3-4bullEF lt 35bullQRS duration gt 120 msec
Echocardiography
bullUseful non-invasive tool
bullReports objective and subjective
bullLimitations
Valve regurgitation - quantification
Colour - jet sizewidth
PISA
Spectral doppler
Consequences
AR - LV Response
bull Chronic AR - decompensated LV
bull LVEFlt55 LVESDgt55mm LVESV 60mlm2
Part OneA patient with aortic regurgitation has the following haemodynamic measurements cardiac output (CO) 75 Lminute heart rate (HR) 75minute left ventricular end-diastolic volume (LVEDV) 200 mL left ventricular end-systolic volume (LVESV) 50 mL The regurgitant fraction is defined as the ratio of the regurgitant volume to the total volume flowing through the valve with each beat
The regurgitant fraction in this patient is A 25 B 33 C 50 D 67 E 75
Part OneA 45-year-old asymptomatic man returns for follow-up He was diagnosed 10 years ago with aortic regurgitation due to a congenital bicuspid aortic valve He has never had endocarditis Which one of the following echocardiographic profiles most strongly indicates the need for aortic valve replacement
LVEDD (mm)[35-55] FS [030-040] LA size (mm) [lt40]
A 70 030 60
B 75 040 40
C 70 025 45
D 65 045 50
E 75 035 55
Key LVEDD Left ventricular end-diastolic diameter LVESD Left ventricular end-systolic diameter FS Fractional shortening = (LVEDD - LVESD) LVEDD LA Left atrial
MR- Quantification of LV contractility
LV systolic function - most important parameter
bullEjection fraction fractional shortening velocity of
circumferential fibre shortening - load dependent
bullMR allows supranormal values of EF etc
bullEarly systolic dysfunction if
bullEF lt 60 (severe MR)
bullES diameter lt 45mm (26mmm2)
Mitral stenosis - quantification
Severity MVA (cm2) LAP (mm Hg) CO
Mild gt20 lt10-12 NL
Moderate 11-20 ~10-17 NL
Severe lt10 gt18
Very Severe lt08 gt20-25
Part OneA 35-year-old woman has increasing breathlessness on exertion Her cardiac silhouette is slightly enlarged on a chest X-ray and an ECG demonstrates sinus rhythm The continuous wave Doppler flow signal through the mitral inflow tract (shown above) is most consistent with which one of the following A Severe pulmonary hypertension (cor pulmonale) B Aortic stenosis C Mitral regurgitation D Mitral stenosis E Aortic regurgitation
Part OneA 28-year-old woman who emigrated from Cambodia 10 years ago presents to the emergency department with a three-week history of increasing shortness of breath orthopnoea nocturnal dyspnoea and ankle oedema She is 25 weeks pregnant and has no significant past medical history The presence of pulmonary oedema is confirmed clinically and radiologically She responds well to intravenous frusemide but remains tachypnoeic with a heart rate of 120minute in sinus rhythm Her blood pressure is 12585 mmHg Echocardiography demonstrates mitral stenosis with an estimated valve area of 13 cm2 and a left atrial diameter of 50 mm [lt40 mm] There are no other abnormalities What is the most appropriate next step in management A Balloon valvotomy B Surgical valvotomy C Digoxin therapy D Beta-blocker therapy E Angiotensin converting enzyme (ACE) inhibitor therapy
Part OneA 55-year-old man presents with acute pulmonary oedema Five years earlier he has undergone a mitral valve replacement with a bileaflet tilting disk valve (St Jude) for mixed mitral valve disease He has been well with normal exercise tolerance prior to the day of admission Examination on admission reveals tachypnoea sinus tachycardia of 110minute blood pressure of 10560 mmHg elevated jugular venous pressure (+ 5 cm) and bilateral crepitations throughout the lung fields His prothrombin timeminusinternational normalised ratio (PT-INR) is 19 [desired therapeutic range 20-35] Serum urea creatinine and electrolytes are normal The cardiothoracic ratio on chest X-ray is normal but the presence of pulmonary oedema is confirmed Echocardiography reveals that one of the prosthetic valve leaflets is not moving and there is an increased flow rate in diastole across the valve orifice (2 metressecond) What is the most appropriate course of action A Administration of intravenous streptokinase B Administration of intravenous heparin C Administration of intravenous antibiotics D Addition of an antiplatelet agent E Immediate mitral valve replacement
Aortic stenosis - quantification
Aortic stenosis - quantification Mean gradient
(mmHg) Peak Ao velocity
AVA (cm2)
Normal 10-20 gt25
Mild lt20 25-29 gt17
Moderate 20-40 30-40 10-17
Severe gt40 gt40 lt10
Right ventricle - size amp function
Estimation of Pulmonary PressurePA systolic pressure
bull Tricuspid regurgitation jet velocity
Estimation of Pulmonary PressureRA pressure
bull IVC size
Part OneThe severity of pulmonary hypertension can be determined using continuous wave Doppler measurements of the velocity of tricuspid regurgitation This method uses the Bernoulli equation which states that 1048661P = 4v2 (where 1048661P = instantaneous pressure gradient and v = velocity across the valve) There is tricuspid regurgitation with a peak velocity of 4 metressecond and a mean velocity of 35 metressecond Assuming right atrial pressure is 5 mmHg the best estimate of the peak right ventricular systolic pressure (plusmn 2 mmHg) is
A 50 mmHg B 55 mmHg C 60 mmHg D 65 mmHg E 70 mmHg
Cardiac Tamponade
Cardiac Tamponade
Cardiac Tamponade
Part OneA 65-year-old woman presents with a one-week history of progressive dyspnoea On admission there are signs of shock a systolic murmur and an elevated jugular venous pressure The ECG shows sinus tachycardia but no other abnormality An antero-posterior chest X-ray shows cardiomegaly The serum troponin I level is 05 mgL [lt01] A computed tomography (CT) scan is shown below
What is the most likely diagnosis A Pulmonary embolism B Right ventricular infarction C Pericardial tamponade D Myocarditis E Acute mitral regurgitation
Endocarditis
Positive echocardiogram for IE Discrete echogenic oscillating intracardiac mass located at a site of endocardial injury (eg on a valve or supporting structure in pathway of regurgitant jet or site of implanted material) or Periannular abscess or
New dehiscence of a prosthetic valve
Cardiac Resynchronisation
Cardiac Resynchronisation
bullSevere heart failure treatment to restore co-ordination to LV contraction
bullNYHA 3-4bullEF lt 35bullQRS duration gt 120 msec
Echocardiography
bullUseful non-invasive tool
bullReports objective and subjective
bullLimitations
AR - LV Response
bull Chronic AR - decompensated LV
bull LVEFlt55 LVESDgt55mm LVESV 60mlm2
Part OneA patient with aortic regurgitation has the following haemodynamic measurements cardiac output (CO) 75 Lminute heart rate (HR) 75minute left ventricular end-diastolic volume (LVEDV) 200 mL left ventricular end-systolic volume (LVESV) 50 mL The regurgitant fraction is defined as the ratio of the regurgitant volume to the total volume flowing through the valve with each beat
The regurgitant fraction in this patient is A 25 B 33 C 50 D 67 E 75
Part OneA 45-year-old asymptomatic man returns for follow-up He was diagnosed 10 years ago with aortic regurgitation due to a congenital bicuspid aortic valve He has never had endocarditis Which one of the following echocardiographic profiles most strongly indicates the need for aortic valve replacement
LVEDD (mm)[35-55] FS [030-040] LA size (mm) [lt40]
A 70 030 60
B 75 040 40
C 70 025 45
D 65 045 50
E 75 035 55
Key LVEDD Left ventricular end-diastolic diameter LVESD Left ventricular end-systolic diameter FS Fractional shortening = (LVEDD - LVESD) LVEDD LA Left atrial
MR- Quantification of LV contractility
LV systolic function - most important parameter
bullEjection fraction fractional shortening velocity of
circumferential fibre shortening - load dependent
bullMR allows supranormal values of EF etc
bullEarly systolic dysfunction if
bullEF lt 60 (severe MR)
bullES diameter lt 45mm (26mmm2)
Mitral stenosis - quantification
Severity MVA (cm2) LAP (mm Hg) CO
Mild gt20 lt10-12 NL
Moderate 11-20 ~10-17 NL
Severe lt10 gt18
Very Severe lt08 gt20-25
Part OneA 35-year-old woman has increasing breathlessness on exertion Her cardiac silhouette is slightly enlarged on a chest X-ray and an ECG demonstrates sinus rhythm The continuous wave Doppler flow signal through the mitral inflow tract (shown above) is most consistent with which one of the following A Severe pulmonary hypertension (cor pulmonale) B Aortic stenosis C Mitral regurgitation D Mitral stenosis E Aortic regurgitation
Part OneA 28-year-old woman who emigrated from Cambodia 10 years ago presents to the emergency department with a three-week history of increasing shortness of breath orthopnoea nocturnal dyspnoea and ankle oedema She is 25 weeks pregnant and has no significant past medical history The presence of pulmonary oedema is confirmed clinically and radiologically She responds well to intravenous frusemide but remains tachypnoeic with a heart rate of 120minute in sinus rhythm Her blood pressure is 12585 mmHg Echocardiography demonstrates mitral stenosis with an estimated valve area of 13 cm2 and a left atrial diameter of 50 mm [lt40 mm] There are no other abnormalities What is the most appropriate next step in management A Balloon valvotomy B Surgical valvotomy C Digoxin therapy D Beta-blocker therapy E Angiotensin converting enzyme (ACE) inhibitor therapy
Part OneA 55-year-old man presents with acute pulmonary oedema Five years earlier he has undergone a mitral valve replacement with a bileaflet tilting disk valve (St Jude) for mixed mitral valve disease He has been well with normal exercise tolerance prior to the day of admission Examination on admission reveals tachypnoea sinus tachycardia of 110minute blood pressure of 10560 mmHg elevated jugular venous pressure (+ 5 cm) and bilateral crepitations throughout the lung fields His prothrombin timeminusinternational normalised ratio (PT-INR) is 19 [desired therapeutic range 20-35] Serum urea creatinine and electrolytes are normal The cardiothoracic ratio on chest X-ray is normal but the presence of pulmonary oedema is confirmed Echocardiography reveals that one of the prosthetic valve leaflets is not moving and there is an increased flow rate in diastole across the valve orifice (2 metressecond) What is the most appropriate course of action A Administration of intravenous streptokinase B Administration of intravenous heparin C Administration of intravenous antibiotics D Addition of an antiplatelet agent E Immediate mitral valve replacement
Aortic stenosis - quantification
Aortic stenosis - quantification Mean gradient
(mmHg) Peak Ao velocity
AVA (cm2)
Normal 10-20 gt25
Mild lt20 25-29 gt17
Moderate 20-40 30-40 10-17
Severe gt40 gt40 lt10
Right ventricle - size amp function
Estimation of Pulmonary PressurePA systolic pressure
bull Tricuspid regurgitation jet velocity
Estimation of Pulmonary PressureRA pressure
bull IVC size
Part OneThe severity of pulmonary hypertension can be determined using continuous wave Doppler measurements of the velocity of tricuspid regurgitation This method uses the Bernoulli equation which states that 1048661P = 4v2 (where 1048661P = instantaneous pressure gradient and v = velocity across the valve) There is tricuspid regurgitation with a peak velocity of 4 metressecond and a mean velocity of 35 metressecond Assuming right atrial pressure is 5 mmHg the best estimate of the peak right ventricular systolic pressure (plusmn 2 mmHg) is
A 50 mmHg B 55 mmHg C 60 mmHg D 65 mmHg E 70 mmHg
Cardiac Tamponade
Cardiac Tamponade
Cardiac Tamponade
Part OneA 65-year-old woman presents with a one-week history of progressive dyspnoea On admission there are signs of shock a systolic murmur and an elevated jugular venous pressure The ECG shows sinus tachycardia but no other abnormality An antero-posterior chest X-ray shows cardiomegaly The serum troponin I level is 05 mgL [lt01] A computed tomography (CT) scan is shown below
What is the most likely diagnosis A Pulmonary embolism B Right ventricular infarction C Pericardial tamponade D Myocarditis E Acute mitral regurgitation
Endocarditis
Positive echocardiogram for IE Discrete echogenic oscillating intracardiac mass located at a site of endocardial injury (eg on a valve or supporting structure in pathway of regurgitant jet or site of implanted material) or Periannular abscess or
New dehiscence of a prosthetic valve
Cardiac Resynchronisation
Cardiac Resynchronisation
bullSevere heart failure treatment to restore co-ordination to LV contraction
bullNYHA 3-4bullEF lt 35bullQRS duration gt 120 msec
Echocardiography
bullUseful non-invasive tool
bullReports objective and subjective
bullLimitations
Part OneA patient with aortic regurgitation has the following haemodynamic measurements cardiac output (CO) 75 Lminute heart rate (HR) 75minute left ventricular end-diastolic volume (LVEDV) 200 mL left ventricular end-systolic volume (LVESV) 50 mL The regurgitant fraction is defined as the ratio of the regurgitant volume to the total volume flowing through the valve with each beat
The regurgitant fraction in this patient is A 25 B 33 C 50 D 67 E 75
Part OneA 45-year-old asymptomatic man returns for follow-up He was diagnosed 10 years ago with aortic regurgitation due to a congenital bicuspid aortic valve He has never had endocarditis Which one of the following echocardiographic profiles most strongly indicates the need for aortic valve replacement
LVEDD (mm)[35-55] FS [030-040] LA size (mm) [lt40]
A 70 030 60
B 75 040 40
C 70 025 45
D 65 045 50
E 75 035 55
Key LVEDD Left ventricular end-diastolic diameter LVESD Left ventricular end-systolic diameter FS Fractional shortening = (LVEDD - LVESD) LVEDD LA Left atrial
MR- Quantification of LV contractility
LV systolic function - most important parameter
bullEjection fraction fractional shortening velocity of
circumferential fibre shortening - load dependent
bullMR allows supranormal values of EF etc
bullEarly systolic dysfunction if
bullEF lt 60 (severe MR)
bullES diameter lt 45mm (26mmm2)
Mitral stenosis - quantification
Severity MVA (cm2) LAP (mm Hg) CO
Mild gt20 lt10-12 NL
Moderate 11-20 ~10-17 NL
Severe lt10 gt18
Very Severe lt08 gt20-25
Part OneA 35-year-old woman has increasing breathlessness on exertion Her cardiac silhouette is slightly enlarged on a chest X-ray and an ECG demonstrates sinus rhythm The continuous wave Doppler flow signal through the mitral inflow tract (shown above) is most consistent with which one of the following A Severe pulmonary hypertension (cor pulmonale) B Aortic stenosis C Mitral regurgitation D Mitral stenosis E Aortic regurgitation
Part OneA 28-year-old woman who emigrated from Cambodia 10 years ago presents to the emergency department with a three-week history of increasing shortness of breath orthopnoea nocturnal dyspnoea and ankle oedema She is 25 weeks pregnant and has no significant past medical history The presence of pulmonary oedema is confirmed clinically and radiologically She responds well to intravenous frusemide but remains tachypnoeic with a heart rate of 120minute in sinus rhythm Her blood pressure is 12585 mmHg Echocardiography demonstrates mitral stenosis with an estimated valve area of 13 cm2 and a left atrial diameter of 50 mm [lt40 mm] There are no other abnormalities What is the most appropriate next step in management A Balloon valvotomy B Surgical valvotomy C Digoxin therapy D Beta-blocker therapy E Angiotensin converting enzyme (ACE) inhibitor therapy
Part OneA 55-year-old man presents with acute pulmonary oedema Five years earlier he has undergone a mitral valve replacement with a bileaflet tilting disk valve (St Jude) for mixed mitral valve disease He has been well with normal exercise tolerance prior to the day of admission Examination on admission reveals tachypnoea sinus tachycardia of 110minute blood pressure of 10560 mmHg elevated jugular venous pressure (+ 5 cm) and bilateral crepitations throughout the lung fields His prothrombin timeminusinternational normalised ratio (PT-INR) is 19 [desired therapeutic range 20-35] Serum urea creatinine and electrolytes are normal The cardiothoracic ratio on chest X-ray is normal but the presence of pulmonary oedema is confirmed Echocardiography reveals that one of the prosthetic valve leaflets is not moving and there is an increased flow rate in diastole across the valve orifice (2 metressecond) What is the most appropriate course of action A Administration of intravenous streptokinase B Administration of intravenous heparin C Administration of intravenous antibiotics D Addition of an antiplatelet agent E Immediate mitral valve replacement
Aortic stenosis - quantification
Aortic stenosis - quantification Mean gradient
(mmHg) Peak Ao velocity
AVA (cm2)
Normal 10-20 gt25
Mild lt20 25-29 gt17
Moderate 20-40 30-40 10-17
Severe gt40 gt40 lt10
Right ventricle - size amp function
Estimation of Pulmonary PressurePA systolic pressure
bull Tricuspid regurgitation jet velocity
Estimation of Pulmonary PressureRA pressure
bull IVC size
Part OneThe severity of pulmonary hypertension can be determined using continuous wave Doppler measurements of the velocity of tricuspid regurgitation This method uses the Bernoulli equation which states that 1048661P = 4v2 (where 1048661P = instantaneous pressure gradient and v = velocity across the valve) There is tricuspid regurgitation with a peak velocity of 4 metressecond and a mean velocity of 35 metressecond Assuming right atrial pressure is 5 mmHg the best estimate of the peak right ventricular systolic pressure (plusmn 2 mmHg) is
A 50 mmHg B 55 mmHg C 60 mmHg D 65 mmHg E 70 mmHg
Cardiac Tamponade
Cardiac Tamponade
Cardiac Tamponade
Part OneA 65-year-old woman presents with a one-week history of progressive dyspnoea On admission there are signs of shock a systolic murmur and an elevated jugular venous pressure The ECG shows sinus tachycardia but no other abnormality An antero-posterior chest X-ray shows cardiomegaly The serum troponin I level is 05 mgL [lt01] A computed tomography (CT) scan is shown below
What is the most likely diagnosis A Pulmonary embolism B Right ventricular infarction C Pericardial tamponade D Myocarditis E Acute mitral regurgitation
Endocarditis
Positive echocardiogram for IE Discrete echogenic oscillating intracardiac mass located at a site of endocardial injury (eg on a valve or supporting structure in pathway of regurgitant jet or site of implanted material) or Periannular abscess or
New dehiscence of a prosthetic valve
Cardiac Resynchronisation
Cardiac Resynchronisation
bullSevere heart failure treatment to restore co-ordination to LV contraction
bullNYHA 3-4bullEF lt 35bullQRS duration gt 120 msec
Echocardiography
bullUseful non-invasive tool
bullReports objective and subjective
bullLimitations
Part OneA 45-year-old asymptomatic man returns for follow-up He was diagnosed 10 years ago with aortic regurgitation due to a congenital bicuspid aortic valve He has never had endocarditis Which one of the following echocardiographic profiles most strongly indicates the need for aortic valve replacement
LVEDD (mm)[35-55] FS [030-040] LA size (mm) [lt40]
A 70 030 60
B 75 040 40
C 70 025 45
D 65 045 50
E 75 035 55
Key LVEDD Left ventricular end-diastolic diameter LVESD Left ventricular end-systolic diameter FS Fractional shortening = (LVEDD - LVESD) LVEDD LA Left atrial
MR- Quantification of LV contractility
LV systolic function - most important parameter
bullEjection fraction fractional shortening velocity of
circumferential fibre shortening - load dependent
bullMR allows supranormal values of EF etc
bullEarly systolic dysfunction if
bullEF lt 60 (severe MR)
bullES diameter lt 45mm (26mmm2)
Mitral stenosis - quantification
Severity MVA (cm2) LAP (mm Hg) CO
Mild gt20 lt10-12 NL
Moderate 11-20 ~10-17 NL
Severe lt10 gt18
Very Severe lt08 gt20-25
Part OneA 35-year-old woman has increasing breathlessness on exertion Her cardiac silhouette is slightly enlarged on a chest X-ray and an ECG demonstrates sinus rhythm The continuous wave Doppler flow signal through the mitral inflow tract (shown above) is most consistent with which one of the following A Severe pulmonary hypertension (cor pulmonale) B Aortic stenosis C Mitral regurgitation D Mitral stenosis E Aortic regurgitation
Part OneA 28-year-old woman who emigrated from Cambodia 10 years ago presents to the emergency department with a three-week history of increasing shortness of breath orthopnoea nocturnal dyspnoea and ankle oedema She is 25 weeks pregnant and has no significant past medical history The presence of pulmonary oedema is confirmed clinically and radiologically She responds well to intravenous frusemide but remains tachypnoeic with a heart rate of 120minute in sinus rhythm Her blood pressure is 12585 mmHg Echocardiography demonstrates mitral stenosis with an estimated valve area of 13 cm2 and a left atrial diameter of 50 mm [lt40 mm] There are no other abnormalities What is the most appropriate next step in management A Balloon valvotomy B Surgical valvotomy C Digoxin therapy D Beta-blocker therapy E Angiotensin converting enzyme (ACE) inhibitor therapy
Part OneA 55-year-old man presents with acute pulmonary oedema Five years earlier he has undergone a mitral valve replacement with a bileaflet tilting disk valve (St Jude) for mixed mitral valve disease He has been well with normal exercise tolerance prior to the day of admission Examination on admission reveals tachypnoea sinus tachycardia of 110minute blood pressure of 10560 mmHg elevated jugular venous pressure (+ 5 cm) and bilateral crepitations throughout the lung fields His prothrombin timeminusinternational normalised ratio (PT-INR) is 19 [desired therapeutic range 20-35] Serum urea creatinine and electrolytes are normal The cardiothoracic ratio on chest X-ray is normal but the presence of pulmonary oedema is confirmed Echocardiography reveals that one of the prosthetic valve leaflets is not moving and there is an increased flow rate in diastole across the valve orifice (2 metressecond) What is the most appropriate course of action A Administration of intravenous streptokinase B Administration of intravenous heparin C Administration of intravenous antibiotics D Addition of an antiplatelet agent E Immediate mitral valve replacement
Aortic stenosis - quantification
Aortic stenosis - quantification Mean gradient
(mmHg) Peak Ao velocity
AVA (cm2)
Normal 10-20 gt25
Mild lt20 25-29 gt17
Moderate 20-40 30-40 10-17
Severe gt40 gt40 lt10
Right ventricle - size amp function
Estimation of Pulmonary PressurePA systolic pressure
bull Tricuspid regurgitation jet velocity
Estimation of Pulmonary PressureRA pressure
bull IVC size
Part OneThe severity of pulmonary hypertension can be determined using continuous wave Doppler measurements of the velocity of tricuspid regurgitation This method uses the Bernoulli equation which states that 1048661P = 4v2 (where 1048661P = instantaneous pressure gradient and v = velocity across the valve) There is tricuspid regurgitation with a peak velocity of 4 metressecond and a mean velocity of 35 metressecond Assuming right atrial pressure is 5 mmHg the best estimate of the peak right ventricular systolic pressure (plusmn 2 mmHg) is
A 50 mmHg B 55 mmHg C 60 mmHg D 65 mmHg E 70 mmHg
Cardiac Tamponade
Cardiac Tamponade
Cardiac Tamponade
Part OneA 65-year-old woman presents with a one-week history of progressive dyspnoea On admission there are signs of shock a systolic murmur and an elevated jugular venous pressure The ECG shows sinus tachycardia but no other abnormality An antero-posterior chest X-ray shows cardiomegaly The serum troponin I level is 05 mgL [lt01] A computed tomography (CT) scan is shown below
What is the most likely diagnosis A Pulmonary embolism B Right ventricular infarction C Pericardial tamponade D Myocarditis E Acute mitral regurgitation
Endocarditis
Positive echocardiogram for IE Discrete echogenic oscillating intracardiac mass located at a site of endocardial injury (eg on a valve or supporting structure in pathway of regurgitant jet or site of implanted material) or Periannular abscess or
New dehiscence of a prosthetic valve
Cardiac Resynchronisation
Cardiac Resynchronisation
bullSevere heart failure treatment to restore co-ordination to LV contraction
bullNYHA 3-4bullEF lt 35bullQRS duration gt 120 msec
Echocardiography
bullUseful non-invasive tool
bullReports objective and subjective
bullLimitations
MR- Quantification of LV contractility
LV systolic function - most important parameter
bullEjection fraction fractional shortening velocity of
circumferential fibre shortening - load dependent
bullMR allows supranormal values of EF etc
bullEarly systolic dysfunction if
bullEF lt 60 (severe MR)
bullES diameter lt 45mm (26mmm2)
Mitral stenosis - quantification
Severity MVA (cm2) LAP (mm Hg) CO
Mild gt20 lt10-12 NL
Moderate 11-20 ~10-17 NL
Severe lt10 gt18
Very Severe lt08 gt20-25
Part OneA 35-year-old woman has increasing breathlessness on exertion Her cardiac silhouette is slightly enlarged on a chest X-ray and an ECG demonstrates sinus rhythm The continuous wave Doppler flow signal through the mitral inflow tract (shown above) is most consistent with which one of the following A Severe pulmonary hypertension (cor pulmonale) B Aortic stenosis C Mitral regurgitation D Mitral stenosis E Aortic regurgitation
Part OneA 28-year-old woman who emigrated from Cambodia 10 years ago presents to the emergency department with a three-week history of increasing shortness of breath orthopnoea nocturnal dyspnoea and ankle oedema She is 25 weeks pregnant and has no significant past medical history The presence of pulmonary oedema is confirmed clinically and radiologically She responds well to intravenous frusemide but remains tachypnoeic with a heart rate of 120minute in sinus rhythm Her blood pressure is 12585 mmHg Echocardiography demonstrates mitral stenosis with an estimated valve area of 13 cm2 and a left atrial diameter of 50 mm [lt40 mm] There are no other abnormalities What is the most appropriate next step in management A Balloon valvotomy B Surgical valvotomy C Digoxin therapy D Beta-blocker therapy E Angiotensin converting enzyme (ACE) inhibitor therapy
Part OneA 55-year-old man presents with acute pulmonary oedema Five years earlier he has undergone a mitral valve replacement with a bileaflet tilting disk valve (St Jude) for mixed mitral valve disease He has been well with normal exercise tolerance prior to the day of admission Examination on admission reveals tachypnoea sinus tachycardia of 110minute blood pressure of 10560 mmHg elevated jugular venous pressure (+ 5 cm) and bilateral crepitations throughout the lung fields His prothrombin timeminusinternational normalised ratio (PT-INR) is 19 [desired therapeutic range 20-35] Serum urea creatinine and electrolytes are normal The cardiothoracic ratio on chest X-ray is normal but the presence of pulmonary oedema is confirmed Echocardiography reveals that one of the prosthetic valve leaflets is not moving and there is an increased flow rate in diastole across the valve orifice (2 metressecond) What is the most appropriate course of action A Administration of intravenous streptokinase B Administration of intravenous heparin C Administration of intravenous antibiotics D Addition of an antiplatelet agent E Immediate mitral valve replacement
Aortic stenosis - quantification
Aortic stenosis - quantification Mean gradient
(mmHg) Peak Ao velocity
AVA (cm2)
Normal 10-20 gt25
Mild lt20 25-29 gt17
Moderate 20-40 30-40 10-17
Severe gt40 gt40 lt10
Right ventricle - size amp function
Estimation of Pulmonary PressurePA systolic pressure
bull Tricuspid regurgitation jet velocity
Estimation of Pulmonary PressureRA pressure
bull IVC size
Part OneThe severity of pulmonary hypertension can be determined using continuous wave Doppler measurements of the velocity of tricuspid regurgitation This method uses the Bernoulli equation which states that 1048661P = 4v2 (where 1048661P = instantaneous pressure gradient and v = velocity across the valve) There is tricuspid regurgitation with a peak velocity of 4 metressecond and a mean velocity of 35 metressecond Assuming right atrial pressure is 5 mmHg the best estimate of the peak right ventricular systolic pressure (plusmn 2 mmHg) is
A 50 mmHg B 55 mmHg C 60 mmHg D 65 mmHg E 70 mmHg
Cardiac Tamponade
Cardiac Tamponade
Cardiac Tamponade
Part OneA 65-year-old woman presents with a one-week history of progressive dyspnoea On admission there are signs of shock a systolic murmur and an elevated jugular venous pressure The ECG shows sinus tachycardia but no other abnormality An antero-posterior chest X-ray shows cardiomegaly The serum troponin I level is 05 mgL [lt01] A computed tomography (CT) scan is shown below
What is the most likely diagnosis A Pulmonary embolism B Right ventricular infarction C Pericardial tamponade D Myocarditis E Acute mitral regurgitation
Endocarditis
Positive echocardiogram for IE Discrete echogenic oscillating intracardiac mass located at a site of endocardial injury (eg on a valve or supporting structure in pathway of regurgitant jet or site of implanted material) or Periannular abscess or
New dehiscence of a prosthetic valve
Cardiac Resynchronisation
Cardiac Resynchronisation
bullSevere heart failure treatment to restore co-ordination to LV contraction
bullNYHA 3-4bullEF lt 35bullQRS duration gt 120 msec
Echocardiography
bullUseful non-invasive tool
bullReports objective and subjective
bullLimitations
Mitral stenosis - quantification
Severity MVA (cm2) LAP (mm Hg) CO
Mild gt20 lt10-12 NL
Moderate 11-20 ~10-17 NL
Severe lt10 gt18
Very Severe lt08 gt20-25
Part OneA 35-year-old woman has increasing breathlessness on exertion Her cardiac silhouette is slightly enlarged on a chest X-ray and an ECG demonstrates sinus rhythm The continuous wave Doppler flow signal through the mitral inflow tract (shown above) is most consistent with which one of the following A Severe pulmonary hypertension (cor pulmonale) B Aortic stenosis C Mitral regurgitation D Mitral stenosis E Aortic regurgitation
Part OneA 28-year-old woman who emigrated from Cambodia 10 years ago presents to the emergency department with a three-week history of increasing shortness of breath orthopnoea nocturnal dyspnoea and ankle oedema She is 25 weeks pregnant and has no significant past medical history The presence of pulmonary oedema is confirmed clinically and radiologically She responds well to intravenous frusemide but remains tachypnoeic with a heart rate of 120minute in sinus rhythm Her blood pressure is 12585 mmHg Echocardiography demonstrates mitral stenosis with an estimated valve area of 13 cm2 and a left atrial diameter of 50 mm [lt40 mm] There are no other abnormalities What is the most appropriate next step in management A Balloon valvotomy B Surgical valvotomy C Digoxin therapy D Beta-blocker therapy E Angiotensin converting enzyme (ACE) inhibitor therapy
Part OneA 55-year-old man presents with acute pulmonary oedema Five years earlier he has undergone a mitral valve replacement with a bileaflet tilting disk valve (St Jude) for mixed mitral valve disease He has been well with normal exercise tolerance prior to the day of admission Examination on admission reveals tachypnoea sinus tachycardia of 110minute blood pressure of 10560 mmHg elevated jugular venous pressure (+ 5 cm) and bilateral crepitations throughout the lung fields His prothrombin timeminusinternational normalised ratio (PT-INR) is 19 [desired therapeutic range 20-35] Serum urea creatinine and electrolytes are normal The cardiothoracic ratio on chest X-ray is normal but the presence of pulmonary oedema is confirmed Echocardiography reveals that one of the prosthetic valve leaflets is not moving and there is an increased flow rate in diastole across the valve orifice (2 metressecond) What is the most appropriate course of action A Administration of intravenous streptokinase B Administration of intravenous heparin C Administration of intravenous antibiotics D Addition of an antiplatelet agent E Immediate mitral valve replacement
Aortic stenosis - quantification
Aortic stenosis - quantification Mean gradient
(mmHg) Peak Ao velocity
AVA (cm2)
Normal 10-20 gt25
Mild lt20 25-29 gt17
Moderate 20-40 30-40 10-17
Severe gt40 gt40 lt10
Right ventricle - size amp function
Estimation of Pulmonary PressurePA systolic pressure
bull Tricuspid regurgitation jet velocity
Estimation of Pulmonary PressureRA pressure
bull IVC size
Part OneThe severity of pulmonary hypertension can be determined using continuous wave Doppler measurements of the velocity of tricuspid regurgitation This method uses the Bernoulli equation which states that 1048661P = 4v2 (where 1048661P = instantaneous pressure gradient and v = velocity across the valve) There is tricuspid regurgitation with a peak velocity of 4 metressecond and a mean velocity of 35 metressecond Assuming right atrial pressure is 5 mmHg the best estimate of the peak right ventricular systolic pressure (plusmn 2 mmHg) is
A 50 mmHg B 55 mmHg C 60 mmHg D 65 mmHg E 70 mmHg
Cardiac Tamponade
Cardiac Tamponade
Cardiac Tamponade
Part OneA 65-year-old woman presents with a one-week history of progressive dyspnoea On admission there are signs of shock a systolic murmur and an elevated jugular venous pressure The ECG shows sinus tachycardia but no other abnormality An antero-posterior chest X-ray shows cardiomegaly The serum troponin I level is 05 mgL [lt01] A computed tomography (CT) scan is shown below
What is the most likely diagnosis A Pulmonary embolism B Right ventricular infarction C Pericardial tamponade D Myocarditis E Acute mitral regurgitation
Endocarditis
Positive echocardiogram for IE Discrete echogenic oscillating intracardiac mass located at a site of endocardial injury (eg on a valve or supporting structure in pathway of regurgitant jet or site of implanted material) or Periannular abscess or
New dehiscence of a prosthetic valve
Cardiac Resynchronisation
Cardiac Resynchronisation
bullSevere heart failure treatment to restore co-ordination to LV contraction
bullNYHA 3-4bullEF lt 35bullQRS duration gt 120 msec
Echocardiography
bullUseful non-invasive tool
bullReports objective and subjective
bullLimitations
Part OneA 35-year-old woman has increasing breathlessness on exertion Her cardiac silhouette is slightly enlarged on a chest X-ray and an ECG demonstrates sinus rhythm The continuous wave Doppler flow signal through the mitral inflow tract (shown above) is most consistent with which one of the following A Severe pulmonary hypertension (cor pulmonale) B Aortic stenosis C Mitral regurgitation D Mitral stenosis E Aortic regurgitation
Part OneA 28-year-old woman who emigrated from Cambodia 10 years ago presents to the emergency department with a three-week history of increasing shortness of breath orthopnoea nocturnal dyspnoea and ankle oedema She is 25 weeks pregnant and has no significant past medical history The presence of pulmonary oedema is confirmed clinically and radiologically She responds well to intravenous frusemide but remains tachypnoeic with a heart rate of 120minute in sinus rhythm Her blood pressure is 12585 mmHg Echocardiography demonstrates mitral stenosis with an estimated valve area of 13 cm2 and a left atrial diameter of 50 mm [lt40 mm] There are no other abnormalities What is the most appropriate next step in management A Balloon valvotomy B Surgical valvotomy C Digoxin therapy D Beta-blocker therapy E Angiotensin converting enzyme (ACE) inhibitor therapy
Part OneA 55-year-old man presents with acute pulmonary oedema Five years earlier he has undergone a mitral valve replacement with a bileaflet tilting disk valve (St Jude) for mixed mitral valve disease He has been well with normal exercise tolerance prior to the day of admission Examination on admission reveals tachypnoea sinus tachycardia of 110minute blood pressure of 10560 mmHg elevated jugular venous pressure (+ 5 cm) and bilateral crepitations throughout the lung fields His prothrombin timeminusinternational normalised ratio (PT-INR) is 19 [desired therapeutic range 20-35] Serum urea creatinine and electrolytes are normal The cardiothoracic ratio on chest X-ray is normal but the presence of pulmonary oedema is confirmed Echocardiography reveals that one of the prosthetic valve leaflets is not moving and there is an increased flow rate in diastole across the valve orifice (2 metressecond) What is the most appropriate course of action A Administration of intravenous streptokinase B Administration of intravenous heparin C Administration of intravenous antibiotics D Addition of an antiplatelet agent E Immediate mitral valve replacement
Aortic stenosis - quantification
Aortic stenosis - quantification Mean gradient
(mmHg) Peak Ao velocity
AVA (cm2)
Normal 10-20 gt25
Mild lt20 25-29 gt17
Moderate 20-40 30-40 10-17
Severe gt40 gt40 lt10
Right ventricle - size amp function
Estimation of Pulmonary PressurePA systolic pressure
bull Tricuspid regurgitation jet velocity
Estimation of Pulmonary PressureRA pressure
bull IVC size
Part OneThe severity of pulmonary hypertension can be determined using continuous wave Doppler measurements of the velocity of tricuspid regurgitation This method uses the Bernoulli equation which states that 1048661P = 4v2 (where 1048661P = instantaneous pressure gradient and v = velocity across the valve) There is tricuspid regurgitation with a peak velocity of 4 metressecond and a mean velocity of 35 metressecond Assuming right atrial pressure is 5 mmHg the best estimate of the peak right ventricular systolic pressure (plusmn 2 mmHg) is
A 50 mmHg B 55 mmHg C 60 mmHg D 65 mmHg E 70 mmHg
Cardiac Tamponade
Cardiac Tamponade
Cardiac Tamponade
Part OneA 65-year-old woman presents with a one-week history of progressive dyspnoea On admission there are signs of shock a systolic murmur and an elevated jugular venous pressure The ECG shows sinus tachycardia but no other abnormality An antero-posterior chest X-ray shows cardiomegaly The serum troponin I level is 05 mgL [lt01] A computed tomography (CT) scan is shown below
What is the most likely diagnosis A Pulmonary embolism B Right ventricular infarction C Pericardial tamponade D Myocarditis E Acute mitral regurgitation
Endocarditis
Positive echocardiogram for IE Discrete echogenic oscillating intracardiac mass located at a site of endocardial injury (eg on a valve or supporting structure in pathway of regurgitant jet or site of implanted material) or Periannular abscess or
New dehiscence of a prosthetic valve
Cardiac Resynchronisation
Cardiac Resynchronisation
bullSevere heart failure treatment to restore co-ordination to LV contraction
bullNYHA 3-4bullEF lt 35bullQRS duration gt 120 msec
Echocardiography
bullUseful non-invasive tool
bullReports objective and subjective
bullLimitations
Part OneA 28-year-old woman who emigrated from Cambodia 10 years ago presents to the emergency department with a three-week history of increasing shortness of breath orthopnoea nocturnal dyspnoea and ankle oedema She is 25 weeks pregnant and has no significant past medical history The presence of pulmonary oedema is confirmed clinically and radiologically She responds well to intravenous frusemide but remains tachypnoeic with a heart rate of 120minute in sinus rhythm Her blood pressure is 12585 mmHg Echocardiography demonstrates mitral stenosis with an estimated valve area of 13 cm2 and a left atrial diameter of 50 mm [lt40 mm] There are no other abnormalities What is the most appropriate next step in management A Balloon valvotomy B Surgical valvotomy C Digoxin therapy D Beta-blocker therapy E Angiotensin converting enzyme (ACE) inhibitor therapy
Part OneA 55-year-old man presents with acute pulmonary oedema Five years earlier he has undergone a mitral valve replacement with a bileaflet tilting disk valve (St Jude) for mixed mitral valve disease He has been well with normal exercise tolerance prior to the day of admission Examination on admission reveals tachypnoea sinus tachycardia of 110minute blood pressure of 10560 mmHg elevated jugular venous pressure (+ 5 cm) and bilateral crepitations throughout the lung fields His prothrombin timeminusinternational normalised ratio (PT-INR) is 19 [desired therapeutic range 20-35] Serum urea creatinine and electrolytes are normal The cardiothoracic ratio on chest X-ray is normal but the presence of pulmonary oedema is confirmed Echocardiography reveals that one of the prosthetic valve leaflets is not moving and there is an increased flow rate in diastole across the valve orifice (2 metressecond) What is the most appropriate course of action A Administration of intravenous streptokinase B Administration of intravenous heparin C Administration of intravenous antibiotics D Addition of an antiplatelet agent E Immediate mitral valve replacement
Aortic stenosis - quantification
Aortic stenosis - quantification Mean gradient
(mmHg) Peak Ao velocity
AVA (cm2)
Normal 10-20 gt25
Mild lt20 25-29 gt17
Moderate 20-40 30-40 10-17
Severe gt40 gt40 lt10
Right ventricle - size amp function
Estimation of Pulmonary PressurePA systolic pressure
bull Tricuspid regurgitation jet velocity
Estimation of Pulmonary PressureRA pressure
bull IVC size
Part OneThe severity of pulmonary hypertension can be determined using continuous wave Doppler measurements of the velocity of tricuspid regurgitation This method uses the Bernoulli equation which states that 1048661P = 4v2 (where 1048661P = instantaneous pressure gradient and v = velocity across the valve) There is tricuspid regurgitation with a peak velocity of 4 metressecond and a mean velocity of 35 metressecond Assuming right atrial pressure is 5 mmHg the best estimate of the peak right ventricular systolic pressure (plusmn 2 mmHg) is
A 50 mmHg B 55 mmHg C 60 mmHg D 65 mmHg E 70 mmHg
Cardiac Tamponade
Cardiac Tamponade
Cardiac Tamponade
Part OneA 65-year-old woman presents with a one-week history of progressive dyspnoea On admission there are signs of shock a systolic murmur and an elevated jugular venous pressure The ECG shows sinus tachycardia but no other abnormality An antero-posterior chest X-ray shows cardiomegaly The serum troponin I level is 05 mgL [lt01] A computed tomography (CT) scan is shown below
What is the most likely diagnosis A Pulmonary embolism B Right ventricular infarction C Pericardial tamponade D Myocarditis E Acute mitral regurgitation
Endocarditis
Positive echocardiogram for IE Discrete echogenic oscillating intracardiac mass located at a site of endocardial injury (eg on a valve or supporting structure in pathway of regurgitant jet or site of implanted material) or Periannular abscess or
New dehiscence of a prosthetic valve
Cardiac Resynchronisation
Cardiac Resynchronisation
bullSevere heart failure treatment to restore co-ordination to LV contraction
bullNYHA 3-4bullEF lt 35bullQRS duration gt 120 msec
Echocardiography
bullUseful non-invasive tool
bullReports objective and subjective
bullLimitations
Part OneA 55-year-old man presents with acute pulmonary oedema Five years earlier he has undergone a mitral valve replacement with a bileaflet tilting disk valve (St Jude) for mixed mitral valve disease He has been well with normal exercise tolerance prior to the day of admission Examination on admission reveals tachypnoea sinus tachycardia of 110minute blood pressure of 10560 mmHg elevated jugular venous pressure (+ 5 cm) and bilateral crepitations throughout the lung fields His prothrombin timeminusinternational normalised ratio (PT-INR) is 19 [desired therapeutic range 20-35] Serum urea creatinine and electrolytes are normal The cardiothoracic ratio on chest X-ray is normal but the presence of pulmonary oedema is confirmed Echocardiography reveals that one of the prosthetic valve leaflets is not moving and there is an increased flow rate in diastole across the valve orifice (2 metressecond) What is the most appropriate course of action A Administration of intravenous streptokinase B Administration of intravenous heparin C Administration of intravenous antibiotics D Addition of an antiplatelet agent E Immediate mitral valve replacement
Aortic stenosis - quantification
Aortic stenosis - quantification Mean gradient
(mmHg) Peak Ao velocity
AVA (cm2)
Normal 10-20 gt25
Mild lt20 25-29 gt17
Moderate 20-40 30-40 10-17
Severe gt40 gt40 lt10
Right ventricle - size amp function
Estimation of Pulmonary PressurePA systolic pressure
bull Tricuspid regurgitation jet velocity
Estimation of Pulmonary PressureRA pressure
bull IVC size
Part OneThe severity of pulmonary hypertension can be determined using continuous wave Doppler measurements of the velocity of tricuspid regurgitation This method uses the Bernoulli equation which states that 1048661P = 4v2 (where 1048661P = instantaneous pressure gradient and v = velocity across the valve) There is tricuspid regurgitation with a peak velocity of 4 metressecond and a mean velocity of 35 metressecond Assuming right atrial pressure is 5 mmHg the best estimate of the peak right ventricular systolic pressure (plusmn 2 mmHg) is
A 50 mmHg B 55 mmHg C 60 mmHg D 65 mmHg E 70 mmHg
Cardiac Tamponade
Cardiac Tamponade
Cardiac Tamponade
Part OneA 65-year-old woman presents with a one-week history of progressive dyspnoea On admission there are signs of shock a systolic murmur and an elevated jugular venous pressure The ECG shows sinus tachycardia but no other abnormality An antero-posterior chest X-ray shows cardiomegaly The serum troponin I level is 05 mgL [lt01] A computed tomography (CT) scan is shown below
What is the most likely diagnosis A Pulmonary embolism B Right ventricular infarction C Pericardial tamponade D Myocarditis E Acute mitral regurgitation
Endocarditis
Positive echocardiogram for IE Discrete echogenic oscillating intracardiac mass located at a site of endocardial injury (eg on a valve or supporting structure in pathway of regurgitant jet or site of implanted material) or Periannular abscess or
New dehiscence of a prosthetic valve
Cardiac Resynchronisation
Cardiac Resynchronisation
bullSevere heart failure treatment to restore co-ordination to LV contraction
bullNYHA 3-4bullEF lt 35bullQRS duration gt 120 msec
Echocardiography
bullUseful non-invasive tool
bullReports objective and subjective
bullLimitations
Aortic stenosis - quantification
Aortic stenosis - quantification Mean gradient
(mmHg) Peak Ao velocity
AVA (cm2)
Normal 10-20 gt25
Mild lt20 25-29 gt17
Moderate 20-40 30-40 10-17
Severe gt40 gt40 lt10
Right ventricle - size amp function
Estimation of Pulmonary PressurePA systolic pressure
bull Tricuspid regurgitation jet velocity
Estimation of Pulmonary PressureRA pressure
bull IVC size
Part OneThe severity of pulmonary hypertension can be determined using continuous wave Doppler measurements of the velocity of tricuspid regurgitation This method uses the Bernoulli equation which states that 1048661P = 4v2 (where 1048661P = instantaneous pressure gradient and v = velocity across the valve) There is tricuspid regurgitation with a peak velocity of 4 metressecond and a mean velocity of 35 metressecond Assuming right atrial pressure is 5 mmHg the best estimate of the peak right ventricular systolic pressure (plusmn 2 mmHg) is
A 50 mmHg B 55 mmHg C 60 mmHg D 65 mmHg E 70 mmHg
Cardiac Tamponade
Cardiac Tamponade
Cardiac Tamponade
Part OneA 65-year-old woman presents with a one-week history of progressive dyspnoea On admission there are signs of shock a systolic murmur and an elevated jugular venous pressure The ECG shows sinus tachycardia but no other abnormality An antero-posterior chest X-ray shows cardiomegaly The serum troponin I level is 05 mgL [lt01] A computed tomography (CT) scan is shown below
What is the most likely diagnosis A Pulmonary embolism B Right ventricular infarction C Pericardial tamponade D Myocarditis E Acute mitral regurgitation
Endocarditis
Positive echocardiogram for IE Discrete echogenic oscillating intracardiac mass located at a site of endocardial injury (eg on a valve or supporting structure in pathway of regurgitant jet or site of implanted material) or Periannular abscess or
New dehiscence of a prosthetic valve
Cardiac Resynchronisation
Cardiac Resynchronisation
bullSevere heart failure treatment to restore co-ordination to LV contraction
bullNYHA 3-4bullEF lt 35bullQRS duration gt 120 msec
Echocardiography
bullUseful non-invasive tool
bullReports objective and subjective
bullLimitations
Aortic stenosis - quantification Mean gradient
(mmHg) Peak Ao velocity
AVA (cm2)
Normal 10-20 gt25
Mild lt20 25-29 gt17
Moderate 20-40 30-40 10-17
Severe gt40 gt40 lt10
Right ventricle - size amp function
Estimation of Pulmonary PressurePA systolic pressure
bull Tricuspid regurgitation jet velocity
Estimation of Pulmonary PressureRA pressure
bull IVC size
Part OneThe severity of pulmonary hypertension can be determined using continuous wave Doppler measurements of the velocity of tricuspid regurgitation This method uses the Bernoulli equation which states that 1048661P = 4v2 (where 1048661P = instantaneous pressure gradient and v = velocity across the valve) There is tricuspid regurgitation with a peak velocity of 4 metressecond and a mean velocity of 35 metressecond Assuming right atrial pressure is 5 mmHg the best estimate of the peak right ventricular systolic pressure (plusmn 2 mmHg) is
A 50 mmHg B 55 mmHg C 60 mmHg D 65 mmHg E 70 mmHg
Cardiac Tamponade
Cardiac Tamponade
Cardiac Tamponade
Part OneA 65-year-old woman presents with a one-week history of progressive dyspnoea On admission there are signs of shock a systolic murmur and an elevated jugular venous pressure The ECG shows sinus tachycardia but no other abnormality An antero-posterior chest X-ray shows cardiomegaly The serum troponin I level is 05 mgL [lt01] A computed tomography (CT) scan is shown below
What is the most likely diagnosis A Pulmonary embolism B Right ventricular infarction C Pericardial tamponade D Myocarditis E Acute mitral regurgitation
Endocarditis
Positive echocardiogram for IE Discrete echogenic oscillating intracardiac mass located at a site of endocardial injury (eg on a valve or supporting structure in pathway of regurgitant jet or site of implanted material) or Periannular abscess or
New dehiscence of a prosthetic valve
Cardiac Resynchronisation
Cardiac Resynchronisation
bullSevere heart failure treatment to restore co-ordination to LV contraction
bullNYHA 3-4bullEF lt 35bullQRS duration gt 120 msec
Echocardiography
bullUseful non-invasive tool
bullReports objective and subjective
bullLimitations
Right ventricle - size amp function
Estimation of Pulmonary PressurePA systolic pressure
bull Tricuspid regurgitation jet velocity
Estimation of Pulmonary PressureRA pressure
bull IVC size
Part OneThe severity of pulmonary hypertension can be determined using continuous wave Doppler measurements of the velocity of tricuspid regurgitation This method uses the Bernoulli equation which states that 1048661P = 4v2 (where 1048661P = instantaneous pressure gradient and v = velocity across the valve) There is tricuspid regurgitation with a peak velocity of 4 metressecond and a mean velocity of 35 metressecond Assuming right atrial pressure is 5 mmHg the best estimate of the peak right ventricular systolic pressure (plusmn 2 mmHg) is
A 50 mmHg B 55 mmHg C 60 mmHg D 65 mmHg E 70 mmHg
Cardiac Tamponade
Cardiac Tamponade
Cardiac Tamponade
Part OneA 65-year-old woman presents with a one-week history of progressive dyspnoea On admission there are signs of shock a systolic murmur and an elevated jugular venous pressure The ECG shows sinus tachycardia but no other abnormality An antero-posterior chest X-ray shows cardiomegaly The serum troponin I level is 05 mgL [lt01] A computed tomography (CT) scan is shown below
What is the most likely diagnosis A Pulmonary embolism B Right ventricular infarction C Pericardial tamponade D Myocarditis E Acute mitral regurgitation
Endocarditis
Positive echocardiogram for IE Discrete echogenic oscillating intracardiac mass located at a site of endocardial injury (eg on a valve or supporting structure in pathway of regurgitant jet or site of implanted material) or Periannular abscess or
New dehiscence of a prosthetic valve
Cardiac Resynchronisation
Cardiac Resynchronisation
bullSevere heart failure treatment to restore co-ordination to LV contraction
bullNYHA 3-4bullEF lt 35bullQRS duration gt 120 msec
Echocardiography
bullUseful non-invasive tool
bullReports objective and subjective
bullLimitations
Estimation of Pulmonary PressurePA systolic pressure
bull Tricuspid regurgitation jet velocity
Estimation of Pulmonary PressureRA pressure
bull IVC size
Part OneThe severity of pulmonary hypertension can be determined using continuous wave Doppler measurements of the velocity of tricuspid regurgitation This method uses the Bernoulli equation which states that 1048661P = 4v2 (where 1048661P = instantaneous pressure gradient and v = velocity across the valve) There is tricuspid regurgitation with a peak velocity of 4 metressecond and a mean velocity of 35 metressecond Assuming right atrial pressure is 5 mmHg the best estimate of the peak right ventricular systolic pressure (plusmn 2 mmHg) is
A 50 mmHg B 55 mmHg C 60 mmHg D 65 mmHg E 70 mmHg
Cardiac Tamponade
Cardiac Tamponade
Cardiac Tamponade
Part OneA 65-year-old woman presents with a one-week history of progressive dyspnoea On admission there are signs of shock a systolic murmur and an elevated jugular venous pressure The ECG shows sinus tachycardia but no other abnormality An antero-posterior chest X-ray shows cardiomegaly The serum troponin I level is 05 mgL [lt01] A computed tomography (CT) scan is shown below
What is the most likely diagnosis A Pulmonary embolism B Right ventricular infarction C Pericardial tamponade D Myocarditis E Acute mitral regurgitation
Endocarditis
Positive echocardiogram for IE Discrete echogenic oscillating intracardiac mass located at a site of endocardial injury (eg on a valve or supporting structure in pathway of regurgitant jet or site of implanted material) or Periannular abscess or
New dehiscence of a prosthetic valve
Cardiac Resynchronisation
Cardiac Resynchronisation
bullSevere heart failure treatment to restore co-ordination to LV contraction
bullNYHA 3-4bullEF lt 35bullQRS duration gt 120 msec
Echocardiography
bullUseful non-invasive tool
bullReports objective and subjective
bullLimitations
Estimation of Pulmonary PressureRA pressure
bull IVC size
Part OneThe severity of pulmonary hypertension can be determined using continuous wave Doppler measurements of the velocity of tricuspid regurgitation This method uses the Bernoulli equation which states that 1048661P = 4v2 (where 1048661P = instantaneous pressure gradient and v = velocity across the valve) There is tricuspid regurgitation with a peak velocity of 4 metressecond and a mean velocity of 35 metressecond Assuming right atrial pressure is 5 mmHg the best estimate of the peak right ventricular systolic pressure (plusmn 2 mmHg) is
A 50 mmHg B 55 mmHg C 60 mmHg D 65 mmHg E 70 mmHg
Cardiac Tamponade
Cardiac Tamponade
Cardiac Tamponade
Part OneA 65-year-old woman presents with a one-week history of progressive dyspnoea On admission there are signs of shock a systolic murmur and an elevated jugular venous pressure The ECG shows sinus tachycardia but no other abnormality An antero-posterior chest X-ray shows cardiomegaly The serum troponin I level is 05 mgL [lt01] A computed tomography (CT) scan is shown below
What is the most likely diagnosis A Pulmonary embolism B Right ventricular infarction C Pericardial tamponade D Myocarditis E Acute mitral regurgitation
Endocarditis
Positive echocardiogram for IE Discrete echogenic oscillating intracardiac mass located at a site of endocardial injury (eg on a valve or supporting structure in pathway of regurgitant jet or site of implanted material) or Periannular abscess or
New dehiscence of a prosthetic valve
Cardiac Resynchronisation
Cardiac Resynchronisation
bullSevere heart failure treatment to restore co-ordination to LV contraction
bullNYHA 3-4bullEF lt 35bullQRS duration gt 120 msec
Echocardiography
bullUseful non-invasive tool
bullReports objective and subjective
bullLimitations
Part OneThe severity of pulmonary hypertension can be determined using continuous wave Doppler measurements of the velocity of tricuspid regurgitation This method uses the Bernoulli equation which states that 1048661P = 4v2 (where 1048661P = instantaneous pressure gradient and v = velocity across the valve) There is tricuspid regurgitation with a peak velocity of 4 metressecond and a mean velocity of 35 metressecond Assuming right atrial pressure is 5 mmHg the best estimate of the peak right ventricular systolic pressure (plusmn 2 mmHg) is
A 50 mmHg B 55 mmHg C 60 mmHg D 65 mmHg E 70 mmHg
Cardiac Tamponade
Cardiac Tamponade
Cardiac Tamponade
Part OneA 65-year-old woman presents with a one-week history of progressive dyspnoea On admission there are signs of shock a systolic murmur and an elevated jugular venous pressure The ECG shows sinus tachycardia but no other abnormality An antero-posterior chest X-ray shows cardiomegaly The serum troponin I level is 05 mgL [lt01] A computed tomography (CT) scan is shown below
What is the most likely diagnosis A Pulmonary embolism B Right ventricular infarction C Pericardial tamponade D Myocarditis E Acute mitral regurgitation
Endocarditis
Positive echocardiogram for IE Discrete echogenic oscillating intracardiac mass located at a site of endocardial injury (eg on a valve or supporting structure in pathway of regurgitant jet or site of implanted material) or Periannular abscess or
New dehiscence of a prosthetic valve
Cardiac Resynchronisation
Cardiac Resynchronisation
bullSevere heart failure treatment to restore co-ordination to LV contraction
bullNYHA 3-4bullEF lt 35bullQRS duration gt 120 msec
Echocardiography
bullUseful non-invasive tool
bullReports objective and subjective
bullLimitations
Cardiac Tamponade
Cardiac Tamponade
Cardiac Tamponade
Part OneA 65-year-old woman presents with a one-week history of progressive dyspnoea On admission there are signs of shock a systolic murmur and an elevated jugular venous pressure The ECG shows sinus tachycardia but no other abnormality An antero-posterior chest X-ray shows cardiomegaly The serum troponin I level is 05 mgL [lt01] A computed tomography (CT) scan is shown below
What is the most likely diagnosis A Pulmonary embolism B Right ventricular infarction C Pericardial tamponade D Myocarditis E Acute mitral regurgitation
Endocarditis
Positive echocardiogram for IE Discrete echogenic oscillating intracardiac mass located at a site of endocardial injury (eg on a valve or supporting structure in pathway of regurgitant jet or site of implanted material) or Periannular abscess or
New dehiscence of a prosthetic valve
Cardiac Resynchronisation
Cardiac Resynchronisation
bullSevere heart failure treatment to restore co-ordination to LV contraction
bullNYHA 3-4bullEF lt 35bullQRS duration gt 120 msec
Echocardiography
bullUseful non-invasive tool
bullReports objective and subjective
bullLimitations
Cardiac Tamponade
Cardiac Tamponade
Part OneA 65-year-old woman presents with a one-week history of progressive dyspnoea On admission there are signs of shock a systolic murmur and an elevated jugular venous pressure The ECG shows sinus tachycardia but no other abnormality An antero-posterior chest X-ray shows cardiomegaly The serum troponin I level is 05 mgL [lt01] A computed tomography (CT) scan is shown below
What is the most likely diagnosis A Pulmonary embolism B Right ventricular infarction C Pericardial tamponade D Myocarditis E Acute mitral regurgitation
Endocarditis
Positive echocardiogram for IE Discrete echogenic oscillating intracardiac mass located at a site of endocardial injury (eg on a valve or supporting structure in pathway of regurgitant jet or site of implanted material) or Periannular abscess or
New dehiscence of a prosthetic valve
Cardiac Resynchronisation
Cardiac Resynchronisation
bullSevere heart failure treatment to restore co-ordination to LV contraction
bullNYHA 3-4bullEF lt 35bullQRS duration gt 120 msec
Echocardiography
bullUseful non-invasive tool
bullReports objective and subjective
bullLimitations
Cardiac Tamponade
Part OneA 65-year-old woman presents with a one-week history of progressive dyspnoea On admission there are signs of shock a systolic murmur and an elevated jugular venous pressure The ECG shows sinus tachycardia but no other abnormality An antero-posterior chest X-ray shows cardiomegaly The serum troponin I level is 05 mgL [lt01] A computed tomography (CT) scan is shown below
What is the most likely diagnosis A Pulmonary embolism B Right ventricular infarction C Pericardial tamponade D Myocarditis E Acute mitral regurgitation
Endocarditis
Positive echocardiogram for IE Discrete echogenic oscillating intracardiac mass located at a site of endocardial injury (eg on a valve or supporting structure in pathway of regurgitant jet or site of implanted material) or Periannular abscess or
New dehiscence of a prosthetic valve
Cardiac Resynchronisation
Cardiac Resynchronisation
bullSevere heart failure treatment to restore co-ordination to LV contraction
bullNYHA 3-4bullEF lt 35bullQRS duration gt 120 msec
Echocardiography
bullUseful non-invasive tool
bullReports objective and subjective
bullLimitations
Part OneA 65-year-old woman presents with a one-week history of progressive dyspnoea On admission there are signs of shock a systolic murmur and an elevated jugular venous pressure The ECG shows sinus tachycardia but no other abnormality An antero-posterior chest X-ray shows cardiomegaly The serum troponin I level is 05 mgL [lt01] A computed tomography (CT) scan is shown below
What is the most likely diagnosis A Pulmonary embolism B Right ventricular infarction C Pericardial tamponade D Myocarditis E Acute mitral regurgitation
Endocarditis
Positive echocardiogram for IE Discrete echogenic oscillating intracardiac mass located at a site of endocardial injury (eg on a valve or supporting structure in pathway of regurgitant jet or site of implanted material) or Periannular abscess or
New dehiscence of a prosthetic valve
Cardiac Resynchronisation
Cardiac Resynchronisation
bullSevere heart failure treatment to restore co-ordination to LV contraction
bullNYHA 3-4bullEF lt 35bullQRS duration gt 120 msec
Echocardiography
bullUseful non-invasive tool
bullReports objective and subjective
bullLimitations
Endocarditis
Positive echocardiogram for IE Discrete echogenic oscillating intracardiac mass located at a site of endocardial injury (eg on a valve or supporting structure in pathway of regurgitant jet or site of implanted material) or Periannular abscess or
New dehiscence of a prosthetic valve
Cardiac Resynchronisation
Cardiac Resynchronisation
bullSevere heart failure treatment to restore co-ordination to LV contraction
bullNYHA 3-4bullEF lt 35bullQRS duration gt 120 msec
Echocardiography
bullUseful non-invasive tool
bullReports objective and subjective
bullLimitations
Cardiac Resynchronisation
Cardiac Resynchronisation
bullSevere heart failure treatment to restore co-ordination to LV contraction
bullNYHA 3-4bullEF lt 35bullQRS duration gt 120 msec
Echocardiography
bullUseful non-invasive tool
bullReports objective and subjective
bullLimitations
Cardiac Resynchronisation
bullSevere heart failure treatment to restore co-ordination to LV contraction
bullNYHA 3-4bullEF lt 35bullQRS duration gt 120 msec
Echocardiography
bullUseful non-invasive tool
bullReports objective and subjective
bullLimitations
Echocardiography
bullUseful non-invasive tool
bullReports objective and subjective
bullLimitations
![Quantification of systemic right ventricle by echocardiography · 2017-02-26 · of systemic right ventricle by echocardiography ... with dobutamine stress [17]. These data were confirmed](https://img.pdfslide.net/doc/110x75/5ecb2f51d4cb202a22168cb3/quantification-of-systemic-right-ventricle-by-echocardiography-2017-02-26-of-systemic.jpg)
