Specialty exams and cath info
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| 4 TEE probes: | • Omniplane/Multiplane
• Biplane (obsolete)
• Single plane (obsolete)
• Pediatric
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| 4 Transducer Positions – TEE: | • Transgastric 40-45cm
• Mid-esophageal 30-40cm
• Upper esophageal 20-25cm
• Descending thoracic aorta
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| 8 TEE Indications: | 1. Thrombus, CSOE (cardiac source of emboli)
2. Infective endocarditis
3. Prosthetic heart valve dysfunction
4. Diseases of the Ao
5. Pre-cardioversion
6. Intracardiac masses
7. Congenital heart disease
8. Complications with an MI
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| 5 Contraindications – TEE: | 1. Uncooperative/unwilling patient
2. Known esophageal pathology
3. Upper GI bleeding
4. Unstable respiratory status
5. Trachea may obstruct view
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| TEE Supplies – 8 items: | 1. BP cuff/device
2. EKG monitor
3. Pulse ox
4. Crash cart
5. Drugs – Versed, sterile saline
6. Emesis basin
7. Topical Lidocaine, Surgilube, gauze, bite guard
8. Cidex to disinfect probe afterward
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| 3 Complications – TEE: | 1. Esophageal perforation (rare)
2. Transient vocal cord paralysis (rare)
3. Sore throat (most common complaint)
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| New contrast agents were developed to improve LV ___________________________ | endocardial border resolution
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| Agitated saline can be used as a contrast agent to look for _______ _______ during a TEE/TTE | interatrial shunts
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| 3 common contrast agents Smaller than a RBC are: | • Imigent
• Optison
• Definity
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| 3 Indications – Contrast: | 1. Better LV endocardial resolution for poor echocardiographic images
2. Improved assessment of LV function
3. Assessment for thrombus, atypical deformities
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| 2 Contraindications – Contrast agents: | • Pregnancy
• Known liver disease
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| 5 techniques for optimum image using contrast agents: | 1. Use harmonic setting
2. Low mechanical index (.3-.5)
3. Focus mid screen
4. 12-15cm depth (minimal visual of LA)
5. Low frequency
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| 6 Indications, Stress Echo: | 1. Chest pain of unknown origin
2. SOB
3. Abnormal EKG
4. Exercise related dysrhythmias
5. Previous non-diagnostic stress EKG
6. Increased risk factors (age, smoking, HTN, obesity)
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| 3 Types – Stress Echo: | 1. Treadmill Stress Echocardiogram
2. Supine Bicycle Stress Echocardiogram
3. Pharmacological (Dobutamine) Stress Echocardiogram
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| 4 Images obtained at rest and post in a stress echo: | 1. AP4
2. AP2
3. PLAX
4. PSAX
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| When are images obtained in a Pharmacological Stress Echocardiogram? | rest, low dose, peak dose, post infusion
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| 5 Stress Echocardiogram Advantages: | 1. Office or hospital based
2. Easy addition to routine treadmill EKG
3. Immediate diagnostic testing
4. Low cost (½ to ¾ less than nuclear)
5. No radiation
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| 5 Stress Echocardiogram Disadvantages: | 1. Poor endocardial tissue definition
2. Obesity
3. COPD
4. Barrel chest
5. Breathing obstructing views post exercise!
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| 2 Complications – Stress Echocardiogram: | 1. Could cause acute MI
2. Sudden death
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| Four 3D Advantages with full acquisition: | 1. Able to acquire and image full 3D image of heart
2. Can cut/slice areas and look inside (crop box)
3. Image can be rotated to see all structures
4. Can image trabeculations vs. thrombus
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| Three 3D Disadvantages: | 1. EKG must be decent or will not acquire correctly
2. Artifact – respirations can cover image
3. Poor 2D image = poor 3D image
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| Gold Standard utilization for coronary artery stenosis: | Cardiac Catheterization
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| 2 cardiac catheterization incision sites: | 1. Most commonly femoral junction
2. Can utilize upper extremity arteries
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| Cardiac Catheterization Technique – 5 steps: | 1. Femoral incision is made
2. Guide wire inserted to the level of the aorta
3. Catheter is inserted over guide wire
4. Dye injected into coronary arteries
5. Simultaneously, X-rays are taken (fluoroscope) to look for filling defects
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| Cardiac Cath lab can be utilized to determine _______ ________and _________ of valves | pressure curves, gradients
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| Cath Technique, L side: 1.Insertion same as ____ ____ 2.Aortic valve: Catheter is placed into the ___ and pulled back into ____to record pressure differences 3.MV: Catheter is placed into __ and pulled back into __ to record MV pressure gradients | 1.coronary cath
2. LV, aorta
3. LA, LV
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| Cath Technique, Right side: 1. _____ _____ used to obtain pressure gradients in right side of heart 2. PV: catheter is placed into __ and drawn back for pressure gradients 3. TV: catheter is placed into __/__for pressure gradient | 1. Femoral vein
2. PA
3. RV/RA
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| Gold Standard for AoV area: | Peak-to-peak gradient
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| Cath lab uses ____________ pressure gradients: | Peak-to-peak
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| Peak-to-peak gradients – 4 characteristics: | 1. Difference between peak LV and peak aortic pressures
2. Do not occur simultaneously
3. Will generally be lower than echo
4. GOLD STANDARD for AoV area
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| Echo lab pressure gradient: | Peak instantaneous gradient
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| Peak instantaneous gradient – 3 characteristics: | 1. Method used by echo lab with CW Doppler
2. Converting max Doppler velocity by Bernoulli’s equation
3. Usually exceeds peak to peak method
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| Cath averages _____________________ and ____________ to calculate mean gradient | maximum instantaneous pressure, peak to peak gradient
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| From cath lab, _____________ is used to determine AoV area | Gorlin formula
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| From Echo lab, ______________ is used to determine AoV area | continuity equation
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| _____ Doppler and _____ catheterization gradients correlate the best! | Mean, mean
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| Cath Assessment in Mitral Stenosis determines _______ _______ gradient across MV (Hallmark finding) | transvalvular diastolic
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| Cath Assessment: AS 1. _________ pressure gradient 2. _________________ pressure gradient 3. AVA determined by the ___________ 4. Pressure waveforms show ________ gradients between the ventricle and great vessels between __-__mmHg | 1. Peak to peak
2. Mean transvalvular
3. Gorlin formula
4. systolic, 10-100mmHg
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| Mitral Regurgitation determined by _________ _________ *Radiopaque dye (contrast) injected into LV and amount of reflux into LA is graded (1+ – 4+) Pressure waveforms show elevation in _______ _______ into LA | left ventriculography, systolic pressures
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| Cath Assessment: AI Regurgitant volume determined by _____ _____ *Contrast injected above the AoV to evaluate for reversal of flow into LV during _____ |
supravalvular aortography, diastole
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| Cath Assessment: AI Pressure waveforms show _____ in end diastolic LV pressures and _____ end diastolic pressures of the AoV | elevation, decreased
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| Cath Assessment: TS 1. TVA determined by __________ 2. Increased mean ______ PG between the RA & RV (increases with inspiration) 3. Pressure waveforms show elevated _____ pressures above _____ pressures during diastolic filling | 1. Gorlin formula
2. diastolic
3. atrial, ventricular
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| Cath Assessment: TI 1. Regurgitant volume determined by __________ 2. Increased right atrial pressure and right ventricular _______ pressure 3. Pressure waveforms will show elevation in ______ pressures in the LA or RA | 1. right ventriculography
2. diastolic
3. systolic
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| Cath Assessment: PI 1. Regurgitant volume determined by _______ ________ 2. *Shows reflux into the RV during ________ 3. Pressure waveforms show ______ in end diastolic RV pressures and ______ end diastolic pressures of the pulmonic valve | 1. pulmonary angiography
2. diastole
3. elevation, decreased
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| Four methods of determining cardiac output: | 1. Thermodilution – injection of chilled saline into RA.
2. Indicator Dilution –Rarely used today.
3. Fick method
4. Angiography
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| Cath Assessment of Left global & systolic function is done by: | left ventriculography
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