Echocardiography

A Case-Based
Review
Case 2
SYNCOPE
Diastolic

Syncopal Episode
Ms NE is a 19 y/o woman who is referred for TTE after a Syncopal episode
She was at college basketball practice and felt briefly light-headed and then
passed out, striking her head and sustaining a scalp laceration
She has no known cardiac history and is on no medications
On physical examination, her blood pressure is 100/62, HR is 50 bpm
with a regular rhythm
Carotid pulses and jugular venous pulse were normal. Precordial
examination was normal, apart from a 1/6 systolic ejection murmur.
Video 1 Link; and Figure 2-1 and figure 2-2 :
PLAX view with LV measurements:
LVIDd 50 mm
LVIDs was: 35 mm
Blood pressure is:
126/82 mmHg.

 Question 1:
Concerning measurement of the LV dimensions (Video 2-1 and figs. 2-1
and 2-2), which of the following statements is correct?
A. LVIDd and LVIDs dimensions are measured at the level of the MV
tips.
B. The timing of the LVIDd measurement is at the time of the largest
dimension, typically at the onset of the QRS complex.
C. Using the apical contractility correction factor (assuming it is
normal), the calculated LV EF is 58%.
D. All of the choices
My Answer: D) All the choices

EF
=
EF =
Apical Correction factor: (%
apical contractility
5% is the apical factor if hypokinetic apex
0% if akinetic apex
- 5% if dyskinetic apex
- 10% if apical aneurysm
FORMULA:

= 58%

 Question 1:
(Continuation).

 Question 1:
(Continuation).

 Question 1: Normal reference values

 Question 1: Normal reference ranges for men and women

Normal

Mild

Moderate

Severe

IVSd (cm)

0.6 1.2

1.3 1.5

1.6 1.9

2.0

LVIDd (cm)

4.2 5.9

6.0 6.3

6.4 6.8

6.9

LVIDd/BSA )

2.2 3.1

3.2 3.4

3.5 -3.6

3.7

LVPWd (cm)

0.6 1.2

1.3 1.5

1.6- 1.9

2.0

IVSd (cm)

0.6 1.2

1.3 1.5

1.6 1.9

2.0

LVIDd (cm)

3.9 5.3

5.4 5.7

5.8 6.1

6.2

LVIDd/BSA )

2.4 3.2

3.3 3.4

3.5 3.7

3.8

LVPWd (cm)

0.6 1.2

1.3 1.5

1.6 1.9

2.0

MEN

WOMEN

Answer to Question1:

 Question 2:
The estimated PA systolic pressure (PASP) and diastolic pressures (PADP)
(see VIDEO 2 and figs. 2-3 and 2.4) are:
A. 18/3 mmHg
B. 23/14 mmHg
C. 23/8 mmHg
D. 23/11 mmHg
E. 18/8 mmHg
My Answer:

?) ???

PASP

calculation
Since: PASP = RVSP
And:
RVSP = 4 ( + RAP

PADP
calculationwe need the
peak end-diastolic PR velocity:
PADP = 4 (
And:
RVSP = 4 ( + RAP

Fig. 2-3
Fig. 2-4

TR = 2.1 m/s

 Question 2:

Fig. 2-3

Given
the pt.'s IVC is normal in size and
changes with inspiratory collapse, and
that the IVC pressure is equal to the RA
pressure , a RA pressure of 5 mmHg is
assumed.
PASP calculation
Since: PASP = RVSP
RVSP = 4 ( + 5
And:
RVSP = 4 ( + 5 = 22.6 mmHg

PADP
calculationwe need the
peak end-diastolic PR velocity:
PADP = 4 (
- Since RVDP equals RAP, then:
PADP = 4 ( + RAP
PADP = 4 ( = 7.56 mm

My Answer:

C) 23/8

Fig. 2-4

uation of PA Systolic Pressure (P

SYSTOLIC PULMONARY ARTERY PRESSURE: 15 25 mmHg

(mean: 9 18 mmHg)
PULMONARY ARTERY END-DIASTOLIC

2 10

mmHg

In the absence of pulmonic stenosis, the pressure gradient

between the RV and the PA can be ignored and it can be
assumed that the PASP equal the RV systolic pressure
Therefore, the PASP equals the tricuspid regurgitation (TR)
gradient plus the right atrial pressure (RAP)

In the presence of pulmonic stenosis (PS), the flow velocity

across the stenotic pulmonic valve can be evaluated and the
pulmonic stenosis gradient can be calculated
In these patients, the PASP equals the right ventricular
systolic pressure (RVSP) minus the pulmonic stenosis
gradient

PA End-Diastolic Pressure (PADP)

SYSTOLIC PULMONARY ARTERY PRESSURE: 15 25 mmHg

(mean: 9 18 mmHg)
PULMONARY ARTERY END-DIASTOLIC

2 10

mmHg

The majority of patients have some degree (trace to mild) of

pulmonic regurgitation (PR)
The velocity of PR is defined by the diastolic pressure gradient
between the PA and the RVTHUS, the Pulmonary Artery
Diastolic Pressure (PADP) equals the PR gradient plus the RVDP
Since the right atrial pressure (RAP),in the absence of
tricuspid stenosis, is approximately equal to the RVDP,
pulmonary artery diastolic pressure (PADP) equals the PR
gradient plus right atrial pressure (RAP):

Since PR gradient = 4 (PR end diastolic velocity),

then:

CW Doppler of Pulmonic Valve

The ability to measure PR velocity may

be helpful in the evaluation of the PA

pressure in patients who do not have
tricuspid regurgitation (TR)
The figure shows a CW Doppler
tracing of pulmonic valve in a
patient evaluated for significant
pulmonary hypertension who did
not have TR
The velocity of the pulmonic
regurgitant (PR) flow is 2.5 m/s at
end diastole, which indicates an
end-diastolic gradient of 25 mmHg
across the pulmonic valve:
The diastolic pulmonary artery pressure is therefore at least 25

PR Gradient
25 mmHg
mmHga
markedly=elevated
value!
Then, if we apply the previous slide formula for PADP, where we
add the RAP, we even arrive to the higher value, confirming the
diagnosis of Pulmonary Hypertension
=

25 mmHg + 10 mmHg = 35 mm HG

Evaluation of PAP in the Absence of

Tricuspid or Pulmonic Regurgitation

Rough, indirect estimation of PA pressure can be obtained by Mmode of the PV. Characteristic M-mode pattern of the PV in patients
with severe pulmonary HTN (> 70 mmHg) includes the absence of
the a wave during atrial contraction, a flying W appearance
of the systolic opening, and lack of backward motion of the diastolic
closure
A slightline
posterior movement of the leaflet, related to atrial contraction, called a

wave is just after the ECG P wave (or just before the QRS)
The a wave is increased in PS and is decreased in PHT (Pulmonary
Hypertension)
A transient mid-systolic closure or notching of the PV is another marker
for PHT: this is called the flying W sign
The point b is the leaflet position at the beginning of systole, and the point
c marks the maximal posterior motion in systole. The point d is the mark at
the end of systole and the closure point of the valve is the point eDuring
diastole and just before the atrial a contraction, the leaflet moves slightly

Answer to Question2:

Question 3:
The grade of diastolic dysfunction, if any, is:
(VIDEO 3 and Figs 2-5, 2-6, 2-7)
A. Normal diastolic function
B. Grade 1 (impaired)
C. Grade 2 (delayed relaxation)
D. Grade 3 (restrictive)
My Answer: A) Normal Diastolic Function

Normal Diastolic Filling Pattern

In the young, LV elastic recoil is vigorous
and myocardial relaxation is swiftthus,
more filling is completed in early diastole,
with only a small contribution at atrial
contraction
Therefore: E/A ratio is usually 1.5 of
higher
DT 130 to 230 ms
E 10 cm/s or more
E/E less than 8

Question 3 Explanation/ExpansionAPPROACH

STEP 1: Measuring LV Inflow Velocities

At the level of the mitral leaflet tips and at the
mitral annulus
Measurements: PW Doppler E velocity, DT, A
velocity and duration
Recordings at leaflet tips used to measure
E and A velocity and DT and to perform a
Valsalva maneuverRecordings at the
annulus are used to measure A duration.
E/A ratio is 1.5 or higher and DT is 160 to
230 ms.
Normal Pattern is: E higher than A, which may
be reversed with impaired early diastolic
relaxation. With more severe diastolic
Note: the transmitral E/A ratio decreases with age, reversing at 50
dysfunction, the pattern may be
pseudonormalized.
Low wall filter settings allow accurate
measurements that require identification
An example of LV inflow recorded at the
annulus with the wall filters set at a low level
( wall filters set at 1) to allow accurate
measurements of the A wave duration (top)

Question 3 Explanation/ExpansionAPPROACH

STEP 2: Measuring Left Atrial Inflowthe

Pulmonary Veins PV
Measure the PVs inflow at the right superior
pulmonary vein from the 4-CH view
Measurements: Peak systolic (S) velocity,
peak diastolic (D) velocity, and the atrial
reverse (Adur) duration and velocity
Normal Pattern is: PVs is equal or greater
than D and Adur should be less than 0.35
ms. The duration of the atrial reversal Adur
is normally less than the A wave duration
measured at the mitral valve tips level.
An Adur greater than 0.35 ms and an
Adur 20 ms longer than transmitral A
duration indicate
an elevated
Example
of Left Atrial
Inflow: enddiastolicwith
pressure
(elevated
recorded
PW Doppler
with filling
the
pressures)...
sample
volume at the level of the
right superior pulmonary vein
(RSPV) from the 4-CH approach,
with low wall filter settings
With atrial contraction, there is a
small atrial reversal velocity (a),
with a normal pattern of systolic (S)
predominance and diastolic (D)

Note: the PV diastolic

Flow declines with age
So that the S/D ratio in
creases with age.

Question 3 Explanation/ExpansionAPPROACH

STEP 3: Measuring Tissue Doppler (TDI) at

the MV annulus
TDI velocities are recorded at the mitral
annulus from a 4-CH viewusing a small
sample volume, with a reduced scale (in the
picture, the velocity range is only 0.2 m/s),
the wall filters at a low level (setting is 1),
and a reduced gain (gain in the picture is -17
dB)
Measurements: standard measurements are
the early myocardial velocity E and atrial
myocardial velocity A
Normal Pattern is: An E/A ratio more than
1.0 is normal, with a reduced ratio indicating
impaired early diastolic relaxation.
The ratio of the transmitral E velocity to TDI
E velocity
ratio greater
than 15
TDI
patterns (E/E)
from normal
to restrictive
physiology:
predicts an LVEDP greater than 15
In
a normal pattern E is greater than A
mmHg.

In all other patterns E is smaller than A

Relaxation abnormality: E and A
parallel E and A mitral velocities
Pseudonormalization: when filling
pressure is increased with restrictive
physiology, after Valsalva, E mitral
increases but E remains decreased.

Question 3 Explanation/ExpansionAPPROACH

STEP 4: Measuring the IVRT

PW Doppler is used to show the time interval
between the AoV closure and the MV opening or
IVRT
The IVRT (normal is 50-100 ms) is prolonged
with impaired relaxation (Note: DT is also
prolonged) but it is shortened with severe
diastolic dysfunction and impaired
compliance.
As shown in the picture (R), the scale and wall
filters have been adjusted to optimize
identification of the onset and end of flow, at
their intersection with the baseline. In this
patient, the IVRT is normal at 88 ms.
How to measure IVRT: in an anteriorly angulated
4-CH to include the AoV, a 2-3 mm sample
volume is placed midway between the AoV and
MV
The sample is placed so that it is on the LV
side of the anterior MV leaflet in systole (to
record LV outflow) and on the atrial side in
diastole (to record LV inflow)
This way, the Doppler will show both LV

Question 3 Explanation/ExpansionAPPROACH

STEP 5: Measuring of LA size (diameter and/or

indexed volume)
Measurement of LA size is key in the assessment of
diastolic dysfunction. A normal LA volume can
exclude clinically important diastolic
dysfunction. The LA is a good parameter of the
chronicity of filling pressures in the LV, so that, if the
LA is normal in size, then the heart has not had a
long term elevated filling pressures, because the LA
will enlarge in the face of elevated filling pressures.
A normal-appearing MV inflow pattern usually
represents a pseudonormalized pattern if LA
volume is increased.
Chronically elevated LV filling pressure leads to
increased LA chamber sizeand is predictive of CV
events such as Afib, heart failure, stroke and
death.
There are four ways to measure the LA: 1) Prolate
ellipse method, 2) Biplane area-length method, 3)
Biplane Simpsons and 4) 3D echocardiography

Prolate Ellipse (A): the LA volume is

calculate as:
LA =
The Biplane Area-Length (B): requires
mal:measuring
LA diameter
(cm)from
3.0 two
to 4.0
Volume: 18-58 ml
LA Area
orthogonal
men:apical
LA diameter
2.7
3.8
Volume: 22 - 52
views (A1
and
A2) and the LA length
(L)

Question 3 Explanation/ExpansionAPPROACH

LEFT ATRIAL PRESSURE ESTIMATES

An exact measurement is not possible, but
there are several parameters that suggest an
elevation of LA pressures...
PVa reversal velocity: if more than 0.35 m/s
And PVa duration (adur) more than 20 ms
longer than transmitral A duration
recorded at the mitral annulus.
Ratio of mitral E velocity to myocardial tissue
E velocity more than 15
Pulmonary venous diastolic flow deceleration
time less than 175 ms.
E velocity DT less than 140 ms
E/A ratio more than 2
With MV stenosis or regurgitation, evaluation
of LV diastolic dysfunction and LA pressure are
difficult because transmitral filling reflects MV
hemodynamics,
ratherwith
than
LV and
diastolic
Top
picture: PV in a patient
HCMP
severefx.
diastolic

dysfunction: the diastolic flow is reduced compared with

systolic flow. Atrial reversal is prolonged with an increased
velocity 0.47 m/s. These findings suggest markedly elevated
LV filling pressures.
Middle and bottom: another marker of elevated filling
pressures is the ratio of the mitral E velocity to the E velocity
of myocardial tissue Doppler of more than 15
In this example, the ratio is 1.15 : 0.15 = 7.7
Suggesting normal filling pressures.

 Question 3: Integrating the Data

Based on integration of data from LA size, LV filling pressures, LA filling
velocities, TDI, and IVRT, a diastolic dysfunction can be detected and
graded

When LV size, wall thickness, and EF are normal, further evaluation

of diastolic function is needed only if there is LA enlargement of an
abnormal E/A ratio for age.
If LVH or dilation is present, with a normal EF, diastolic function
should be fully evaluated, especially if there is concern that diastolic
dysfunction may account for symptoms
When EF is reduced, the first step is to evaluate for elevated filling
pressures. If simple criteria for elevated filling pressures are not

Question 3 Explanation/ExpansionAPPROACH

Normal Diastolic Function

Normal LA size
E/A velocity ration between 1 and 2
The E DT is 150 200 ms
The tissue Doppler E/A ratio is 1 to 2 and E/E
less than 8
The PV systolic to diastolic flow ratio is 1 or
more
The PV a-velocity is less than 0.35 m/s and
duration is less than 20 ms longer than
transmitral A duration
Normal IVRT

Question 3 Explanation/ExpansionAPPROACH

MILD Diastolic Function

Increased LA diameter and
volume
Impaired relaxation is typical of
mild diastolic dysfunction due to
hypertension, CAD or infiltrative
cardiomyopathy
The decreased rate of early
diastolic filling (the E wave) is
associated with reduced E
velocity (reduced E/A ratio),
reduced E and a reduced
E/A ratio, reduced PV
diastolic flow (D), and a
prolonged IVRT
Mild diastolic dysfunction with
LV filling pressure may be normal
impaired early diastolic relaxation is
with mild diastolic dysfunction, so
characterized by
PVa velocity and duration are
A)
An E/A ratio less than 1 on the
normal
LV inflow curve
B) TDI with a mirror image of the
LV inflow curve, showing
decreased E waveand:
C) PV flow curve with a reduced
diastolic flow curve but still a

Question 3 Explanation/ExpansionAPPROACH

Moderate Diastolic Function

LV relaxation is impaired and LV filling pressures

are already elevated with moderate diastolic
dysfunction secondary to i.e.: DCMP,
hypertrophy or RCMP.
In addition to the findings of mild diastolic
dysfunction, now there is evidence for elevated
filling pressures, including a higher peak (more
than 0.35 ms) and duration of the PVa reversal;
an increased E/E ratio (greater than 15); and a
shortened E velocity DT.
The mitral filling wave shows an apparently
normal E/A ratio of 1 to 2this is
pseudonormal. It is distinguished from a true
normal by the TDI showing an E/A less than 1
and a shortened E velocity DT.
The change in the mitral flow pattern with
Moderate
diastolic
dysfunction
Valsalva also
can be used
to identifyis
a
characterized
by: A)patternThe
A normal looking
pseudonormal mitral
E velocity
will decrease
Pseudonormalization.
mitral
inflow with
curve,
with normal E/A

ratio, but with a steep, short DT

B) TDI E/A ratio is less than 1, the E
wave is shortened and E/E ratio is
increased.
C) Typically, the PV signal shows
greater systolic than diastolic flow and
a prolonged duration and increased
velocity of the PVa reversal
In this case, the PVa reversal looks

Question 3 Explanation/ExpansionAPPROACH

Severe Diastolic Function

Is characterized by decreased compliance, in addition to an impaired

relaxation, an enlarged LA and an elevated filling pressure.
Decreased compliance means there is greater increase in LV pressure for
a given increase in volume, compared with a normal LV. The ventricle is
usually hypertrophic.
Although the E/A ratio is more than 2 and the E/A ratio is normal
looking more than 1, severe diastolic dysfunction is differentiated from
normal by the higher E/A ratio (more than 2), decreased DT (less than 150
ms), shorter IVRT, and the E/E ratio is greater than 15
The PV signal shows a blunted PV systolic flow, and increased PVa
reversal wave velocity and duration.
SEVERE
diastolic
dysfunction
is characterized
by: diastolic
The E velocity
is very
low (less than
5 cm/s) with severe
dysfunction.
A) MV inflow curve with an E/A ratio greater than 2 and

short DT
B) TDI E/A ratio is more that 1
C) Short IVRT
D) Reduced PV systolic flow with diastolic predominance
with a PVa reversal that is prolonged (more than 20 msec
longer than mitral A duration and increased in velocity
(greater than 0.35 m/s)

nswer from the book to Question 3:

Question 4:
This PW flow pattern taken in the
abdominal aorta would be
compatible with:
A. Coarctation of the descending
aorta
B. What is seen in the majority of
patients with a bicuspid aortic
valve
C. PDA
D. Severe congenital stenosis
My Answer: D) PDA

Normal Diastolic Filling

Patternxxxxxxxx
In the young, LV elastic recoil is vigorous
and myocardial relaxation is swiftthus,
more filling is completed in early diastole,
with only a small contribution at atrial
contraction
Therefore: E/A ratio is usually 1.5 of
higher
DT 130 to 230 ms
E 10 cm/s or more
E/E less than 8

Question 5:
TTE can exclude the following potential causes for
syncope in a young woman, except:
A. Critical congenital aortic stenosis
B. DCMP with reduced EF
C. Pulmonary arterial hypertension
D. Hypertrophic cardiomyopathy
My Answer: D) Normal Diastolic Function

Normal Diastolic Filling Pattern

In the young, LV elastic recoil is vigorous
and myocardial relaxation is swiftthus,
more filling is completed in early diastole,
with only a small contribution at atrial
contraction
Therefore: E/A ratio is usually 1.5 of
higher
DT 130 to 230 ms
E 10 cm/s or more
E/E less than 8