# HEMODYNAMIC PROBLEMS IN ECHOCARDIOGRAPHY

Daniel W Mason MD FACC FASE

CW, PW, and Color Flow
1. This is all doppler, you are all familiar with this, with a frequency shift of reflected ultrasound waves proportional to the speed of the reflecting medium. ΛF = 2f0v/c x cosΘ 2. Increasing or decreasing frequency is related to direction of flow.

CW vs PW
1. The magnitude of frequency shift we can measure depends on the frequency with which we can sample. 2. CW requires 2 transducers, one is continually sending, the other is continually receiving. Therefore, sampling frequency is rapid so high shifts can be measured. However, there is no ranging.

CW vs PW
2. PW sends out very brief pulses, and then just listens with the one transducer. Since we know the speed of sound in tissue, we can range. This allows us to localize in space where the shift occurs, but dramatically reduces the frequency shifts we can measure before aliasing occurs.

So the doppler shift will look like a sine wave, but we only get a brief look at each wave with each pulse (sampling)

So as long as we sample ≥ than 2 x the doppler shift frequency, we can determine it’s frequency and direction. Otherwise, if sampling is less, then we get velocity and direction ambiguity. The Nyquist Limit is the place where aliasing begins, and that is why it is = ½ PRF.

Color Flow
Color flow is an extension of PW into a 2 dimensional image just as 2D is to M mode echo. Ranging allows us to see the location, and frequency shift is represented by arbitrary colors. I will not get into resolution issues today.

Calculations
Getting comfortable with the formulas Doing our best to understand what a TVI or VTI really is (Time Velocity Integral) Solving problems

FORMULAS
πR 2 = area of circle πR 2 = π(1/2D)2 = 1/4πD2 = 0.785D2 Area of circle = 0.785D2

FORMULAS
Area x Length = Volume

L

FORMULAS
If flow through a cylinder were constant, we can easily measure volume if we know velocity, time, and diameter.

FORMULAS
L=VxT V

T

FORMULAS
Then, if we know diameter, we can calculate area of the cylinder. Multiply this by the length and we get a volume V = area x length. In this case, L would be the length of the cylinder described by flow over that time (T), and could be referred to as stroke distance, the distance the fluid traveled over that period of time.

FORMULAS
But flow is not constant, it’s velocity is constantly changing, so how can we measure volume. What would Sir Isaac Newton have done? Calculus? Integrate?

VTI
V a

T

VTI
The intergral of the curve in essence is taking the average velocity during that time, and multiplying it by the time of the systolic period, giving us stroke distance. If this were the LVOT, and the aorta had the same diameter, it would tell us how far the blood traveled, stroke distance. Since the aorta is larger, the distance will be smaller. However, multiplying the VTI x area will still give stroke volume.

Area x length = volume Area x TVI = volume TVI = length There is nothing in the physical world that is measured by the distance given by VTI, but the mathematical model gives a number that is proportional to the stroke volume.

TVI or time velocity integral

MORE FORMULAS
Flow = Velocity x Area (cm3/sec) = (cm/sec x cm2) Therefore Area = Flow/Velocity Don’t confuse flow used in PISA continuity with stroke volumes used with AVA by continuity. P = 4V2 Simplified Bernoulli Equation

MORE FORMULAS
AVA x TVIav = Arealvot x TVIlvot AVA = (Arealvot x TVIlvot)/ TVIav Using Maximal velocities of the aortic valve and lvot gives a reasonable approximation of the area. Ratio’s of TVI’s or maximal velocities are most helpful when it is difficult to measure a diameter (calcium or prosthesis)

PRESSURE HALF TIMES
By definition, this is the time it takes for the pressure to decrease by ½. But pressure and vel oci ty are not linear, so it is not the time it takes the velocity to decrease by ½. P = 4V2

PRESSURE HALF TIMES
P

V

PRESSURE HALF TIMES
P1 = 4V12 1/2P1 = 4VX2 ½(4V12) = 4Vx2 1/2V12 = Vx2 Vx = V1/sqrt 2 =V1/1.4 The time it takes to go from V1 to Vx is the pressure half time

PRESSURE HALF TIMES
Vmax Vt1/2 = Vmax/1.4 PHT

PRESSURE HALF TIMES
DT is deceleration time, from peak to zero. PHT = .29 x DT MVA = 220/PHT This was empirically derived Anything above 220 suggest severe MS. Less than 200 for AI suggest it may be severe

Pitfalls of Pressure ½ Time
Diastolic dysfunction (severe) with high filling pressures or acute severe aortic insufficiency will shorten the ½ time, making the MVA to high. An ASD drops LA pressures quickly, giving the same result.

PISA
Proximal Isovelocity Surface Area

r

PISA
Area of a sphere= 4 πr2 Area of a hemisphere= 2 πr2 Flow = Velocitya x Area Flow = Velocitya x 6.28r2 ERO (area) = Flow/Velocityp Regurg. Volume = ERO x TVImr

PISA
MVA = (6.28r2 x Va)/MSVp x α°/180°

Qp/Qs
.785D2rvot x TVIrvot = SVrv = Qp .785D2lvot x TVIlvot = SVlv = Qs Qp/Qs = Pul. Flow/Sys. Flow

Pulmonary Vascular Resistance
R = Pressure / CO Peak TR Velocity ~ RVSP ~ Pressure TVIrvot ~ CO therefore

R ~ Peak TR Velocity / TVIrvot

If TVIrvot is in cm and TRpeak V is in M/sec R(Woods) = TRpeak V / TVIrvot x 10 +.16 Down and dirty a TRpeak V / TVIrvot ratio of < 0.2 suggest low R

Problem 1
58yom with previous MI and mitral regurgitation Dlvot = 2.0cm TVIlvot = 0.19m Dma = 3.4cm TVIma = 0.176m What is the regurgitant volume? What is the regurgitant fraction?

Answer 1
SVlvot = .785 x 22 x19 = 59.96 SVma = .785 x 3.42 x 17.6 = 159.7 Regurg. Volume = 160 – 60 = 100 Regurg. Fraction = 100/160 = .625 = 63%

Problem 2
On TEE, the following was found pisa r = 0.9cm aliasing velocity = 40cm/sec MV Regurg. Velocity = 4.5m/sec TVImvr = 227cm What is the ERO and Regurg. Fraction?

Answer 2
ERO = (6.28 x (.9)2 x 40)/ 450 = .45cm2 = 45mm2 Regurg. Volume = .45 x 227 = 102cc

Problem 3
72 yof with a murmur and syncope Heart Rate 60 TVIlvot = .21M/sec LVOTd =2.2cm TVIav = 1.15M/sec What is the AV area? What is the cardiac output?

Answer 3
AVA = Arealvot x TVIlvot/TVIav = .785 x (2.2)2 x 21/115 = .69 CO = .785 x (2.2)2 x 21 x 60 = 4.79L/min

Problem 4
65yom with AI LVOTd = 2.6cm TVIlvot =16cm MVannulus = 3.5cm TVImv = 6.0cm AR peak velocity = 5.14M/sec TVIavr = 2.77M What is the regurgitant volume? What is the regurgitant fraction? What is the effective regurg. orifice area?

Answer 4
LVOTsv = .785 x (2.6)2 x 16 = 85cc MVsv = .785 x (3.5)2 x 6 = 58cc Regurgitant Volume = 85-58 = 27cc Regurgitant Fraction = 27/85 = 32% ERO = 27/277 = 0.1 cm2

PROBLEM 5
What is the PA end diastolic pressure in a patient whose PR endiastolic velocity is 1.5m/sec? What is the LA pressure when the velocity over a PFO is 1.5m/sec? What view would we get that velocity with a TTE?

Answer 5
 (1.5

x 1.5 x 4) + 10 = 19mmHg  (1.5 x 1.5 x 4) + 10 = 19mmHg  subcostal

PROLBLEM 6
If the CW tracing of an aortic insufficiency jet shows a maximum velocity of 3.0m/sec, what is the velocity at the pressure half time? If that velocity occurs 240 msec latter, what is the DT? If the end-diastolic velocity of this jet is 2.7m/sec and the BP is 136/60, what is the LVEDP?

ANSWER 6
3/1.4 = 2.14m/sec 240/.29 = 828msec 60 – (4 x (2.7)2) = 31mmHg

PROBLEM 7
An ASD measured 1 cm in diameter on TTE. HR 70bpm. TVI of flow / beat was 0.6M. LVOTTVI was 0.25 M, LVOTD was 2 cm. The shunt was L to R. What is the flow / minute through the ASD? What is the Qp/Qs.

Answer 7
Qshunt = .785 x 12 x 60 x70 / 1000 = 3.3L/min QS = .785 x 22 x 25 x 70 / 1000 QP = QS + Qshunt = 5.5 + 3.3 QP/ QS = 8.8 / 5.5 = 1.6 = 5.5L/min = 8.8L/min

The End

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