Pulmonary Hypertension and Heart Conditions

Cardiac Axis (Normal)

• A diagram shows the relationship between the electrical axis of the heart and the leads.
• AVR, AVL, AVF, Lead I, Lead II, Lead III are labeled.
• The vectors are displayed graphically.

Pulmonic Stenosis

• Definition: Narrowing/thickening/obstruction of the pulmonary valve (PV) impeding systolic flow from the right ventricle (RV) to the pulmonary artery (PA).
• Classification:
  • Subvalvular PS
  • Valvular PS
  • Supravalvular PS
• Congenital: Usually a congenital condition.
• Murmur: Harsh systolic ejection murmur, heard at the left upper sternal border.

Pulmonic Stenosis 2D & M-Mode

• 2D Echo: Thickened cusps, systolic doming, RV hypertrophy, IVS flattening, D-shaped left ventricle (LV), right heart failure (RHF) in later stages, post stenotic PA dilation.
• M-Mode: Right posterior PV cusp, evaluate "a" wave dip. A wave depth of ≥ 8 mm indicates severe pulmonic stenosis.

Doppler

• PVA Calculation: PVA = (VT_RVOT) (CSA_RVOT) / (VT_PV)
• RVOT: Acquire RVOT proximal diameter (normal 21-35 mm).
• CWD Focus: Acquire peak V_PV and V_TPV.
• PWD Gate: Acquire peak V_RVOT and V_TRVOT.
• Severity Scale: The table shows the relationship between peak PG (mmHg) and velocity (m/s), classifying severity as mild, moderate and severe.

Pulmonic Regurgitation

• Definition: Incompetent pulmonary valve (PV) permitting backward diastolic flow from the pulmonary artery (PA) to the RV.
• Murmur: Low-pitched diastolic murmur that may increase with inspiration; and when pulmonary hypertension (PH) is present, a high-pitched blowing diastolic murmur may be heard (Graham-Steele Murmur).
• Causes: Incomplete pulmonary valve closure, infective endocarditis (IE)/vegetations, rheumatic heart disease (RHD), congenital anomalies, carcinoid heart disease.
• Complications: Usually well-tolerated for years; however possible increased risk of infective endocarditis (IE); dyspnea, and possible right heart failure.

2D Echo (Pulmonic Regurgitation)

• 2D Echo: Trivial/mild pulmonic regurgitation is common. Anatomic basis/defect, right ventricular outflow tract (RVOT) and tricuspid valve (TV) diastolic flutter are features.
• CFD: Turbulent diastolic flow from the pulmonary artery (PA) to the RV, backward. Evaluate the regurgitation from all views.

CW (Pulmonic regurgitation)

• CW: Measure pressure half-time (PHT)

Pulmonary Hypertension

• Definition: Pulmonary hypertension (PHTN) initiates with narrowing, blockage or destruction of tiny pulmonary arteries and capillaries in the lungs.
• Classification: Pulmonary arterial hypertension (PAH), left-sided heart disease, lung disease, chronic blood clots, other health conditions.

Echocardiography (RV function)

• Main findings: Right ventricular enlargement (RVE), right ventricular hypertrophy (RVH), right atrial enlargement (RAE).
• Functional tricuspid regurgitation (TR) with high velocity regurgitant jet by Doppler; mid-systolic notch in pulmonary artery (PA) flow tracing.
• Interventricular septum: Shifted towards the left ventricular cavity.

Pulmonary Artery Pressures

• Normal PA pressure: 15-25 mmHg.
• Systolic Pulmonary Artery Pressure (SPAP):
  • 18-25 mmHg / Normal
  • 30-40 mmHg / Mild
  • 40-70 mmHg / Moderate

  • 70 mmHg / Severe.

• Pulmonary Artery Acceleration time:

  • 120 msec - Normal

  • 80-100 msec - Mild pulmonary hypertension
  • 60-80 msec - Moderate pulmonary hypertension
  • <60 msec - Severe pulmonary hypertension

Right Ventricular Function

• Visual assessment of the right ventricle requires multiple views
• RV anterior wall, all thickness (1-)
• PSLAX, SAX, AORTA, APICAL 4CH, SUBCOSTAL 4CH

Right Ventricle Diameter

• Measured in the SAX Aorta view
• Measure Proximal and Distal RVOT during End-diastole
• End-diastolic RVOT proximal diameter (21-35 mm)
• End-diastolic RVOT distal diameter (17-27 mm)

Right Atrial Measurements

• Trace/Acquire RA area: During end systole, normal range <18 cm².
• Obtain RA length: During end systole, normal range <5.3 cm. .
• Acquire RA dimension: During end systole, normal range < 4.4 cm.

TAPSE

• Place M-mode cursor between the RV free wall and the lateral annulus of the TV. Measure the peak systolic longitudinal motion of the Tricuspid valve annular motion from end systole.
• A TAPSE value <17 mm indicates decreased RV function.

Tissue Doppler Imaging (TDI)

• Pulsed TDI can calculate tissue Doppler velocities of the tricuspid annulus.
• The S' prime wave represents the systolic velocity, assessing right ventricular longitudinal function and measures the TV annulus moving towards the apex during systole.
• Place sample volume at the base of the RV free wall.

2D Fractional Area Change (FAC)

• Fractional area change (FAC) estimates global RV systolic function.
• Right ventricular fractional area change (RVFAC) expresses the percentage change in RV area between end-diastole and end-systole.
• Measured from a four-chamber view (RVEDA, RVESA)

Estimation of Right Atrial Pressure

• Evaluate the inferior vena cava (IVC) with respiratory variation.

Diastolic Dysfunction

• Diastolic dysfunction is the inability of the heart muscle to relax normally after each heartbeat. This phase is called diastole and ventricles fill with blood in preparation for the next heartbeat.
• Diastolic dysfunction can impair cardiac filling, restrict the amount of blood the heart can pump with each beat.

LV Mass and LV Mass Index

• Left ventricular mass and left ventricular mass indexed to body surface area, estimated by LV cavity dimension and wall thickness at end-diastole.
• Measurement: LVED, IVSd and PWd
• Left ventricular mass = 0.8{1.04[[LVEDD + IVSd +PWd] 3}]} + 0.6 = L V Mass g
• Left ventricular mass index = LVM/BSA (g/m²)

MV Inflow

• **Method: ** Includes steps such as lateral swing with posterior tilt, PWD at mitral valve leaflet tips, and increasing sweep speed.
• Protocol includes: E-wave peak velocity, A-wave peak velocity, E/A ratio (1.0 – 1.5), E-DT (160-240 ms), and A-Wave duration.

TDI of Mitral Annular Motion

• **Method: ** 4C and TDI; gate at the mitral annulus, lateral wall and septal wall.
• Protocol involves: e' wave peak velocity; and E/e' ratio (0.15–10).
• An E'/e' ratio <8 shows Normal LV filling pressure.
• An E'/e' >14 indicates Increased LV filling pressure.

Left Atrium Volume Index (LAVI)

• LAVI is LAV/BSA (left atrium volume index/body surface area)
• Increased LAVI: Predicts outcome, reflects increased LAP in absence of MV disease, significant signs of diastolic dysfunction and of LAP severity.
• ASE Guidelines: Normal: ≤ 34 mL/m²; Mild 35-41 mL/m², Moderate 42-48 mL/m², Severe: > 48 mL/m²

Pulmonary Venous Flow

• Method: Dependent on pressure difference between pulmonary veins and left atrium (LA), 4C/5C, PWD, and CFD.
• Increase sweep speed: 1-2cm into pulmonary vein.
• Protocol involves: S-wave peak velocity, D-wave peak velocity, AR wave duration (150 ms), and S/D ratio (0.7–1.2).

Impaired Relaxation (Diastolic Dysfunction)

• Impaired early filling of the ventricle.
• The magnitude of the E wave decreases.
• Atrial contraction ejects more blood into the left ventricle.
• The A wave will be larger than normal and typically larger than the E wave.
• Grade I: Impaired.

Pseudonormal Filling Pattern Diastolic Dysfunction)

• Left atrial pressure rises, increasing pressure gradient between left atrium and left ventricles.
• Increased E/A ratio.
• Reduced E/e ratio and decreased deceleration time.

Restrictive Diastolic Dysfunction (Grade 3)

• Restrictive Cardiomyopathy. Myocardium impairs diastolic filling.
• Marked biatrial enlargement
• Presents with a large E-wave and small A-wave.

Restrictive Filling Pattern (Grade 3 or 4)

• E/A ratio >2
• DT <160msec
• Decreased e' velocity
• E/e' ratio >14
• Increased LAP.
• Grade III (reversible): Left atrial pressures elevated significantly.
• Grade IV (fixed): Poor prognosis and very elevated left atrial pressures.

Echocardiographic Classification of Diastolic Dysfunction (Table)

• Table showing different stages of diastolic dysfunction (Normal, Impaired Relaxation, Pseudonormal, Reversible Restrictive, Fixed Restrictive)

12 Lead Electrode Placement (Diagram)

• Diagram illustrating the placement of 12 lead electrodes on the chest.

Limb Leads

• Einthoven Triangle Formation
  • RA (Right Arm) , LA (Left Arm) , LL (Left Leg) and their positive/negative relationships
  • Leads I, II, III (Bipolar leads)
• RA - White
• LA-Black
• RL - Green
• LL - Red

Precordial Leads (Diagram)

• Diagram illustrating the placement of precordial leads (V1-V6), including V1 (right sternal border, 4th intercostal space), V2 (left sternal border, 4th intercostal space), V3 (midway between V2 and V4, 4th intercostal space), V4 (left midclavicular line, 5th intercostal space), V5 (anterior axillary line, horizontally aligned with V4), V6 (mid-axillary line horizontally aligned with V4 and V5).

Augmented Leads

• Augmented Voltage leads (aVR, aVL, aVF).
• Unipolar leads measure current flow toward one electrode, located at the right arm (aVR), left arm (aVL), and left leg (aVF);
• aVR, aVL, aVF are low voltage.

EKG Machines

• Multichannel recorder monitors all 12 leads simultaneously; automatic switching between leads is done
• Signal processing and recording are happening within the machine.
  • Output is a computerized display.
  • Measuring paper speed (e.g., 25 mm/sec).
• Gain controls the output waveform height (i.e., normal setting 10 mm/mV)."

Troubleshooting EKG

• Somatic and muscle tremors are possible sources of erratic spikes; positioning patient's arms under buttocks and slowing breathing may help reduce tremors
• Electrode repositioning, cleaning, and removing tension on wires may fix wandering baselines.

EKG Graph Paper

• Vertical lines: Voltage (mV).
• Horizontal lines: Time (mm).
• Small box: 0.04 seconds.
• Heavy line: 0.2 seconds

Electrical Conduction Review (Diagram)

• P wave: Atrial depolarization.
• QRS complex: Ventricular depolarization .
• T wave: Ventricular repolarization.
• Shows the process in sequential timing.

Determining Rate Method 1

• R-R Method
• Count large boxes between two R waves.
• Divide by 300 to get the rate per minute.

Determining Rate Method 2

• 1500 Method.
• Count small squares between two R waves.
• Divide by 1500 to get the rate per minute. Only useful for regular rhythms.

Determining Rate Method 3

• 6-Second Method.
• Count QRS complexes within a six-second segment, then multiply by 10 to get the rate.

Overview of Normal Values

• Describes normal duration of various EKG components (P wave, PR interval, QRS complex, ST segment, T wave, QT interval).

Normal Sinus Rhythm

• Heart Rate: 60-100 BPM.
  • Regular rhythm
  • Intervals between P and R waves are equally spaced.
  • P wave precedes QRS Complex.
  • PR and QRS intervals have normal durations

Bradycardia (Rhythm)

• Heart Rate <60 BPM.
• Regular rhythm
• Intervals between P and R waves are equally spaced.

Tachycardia (Rhythm)

• Heart Rate >100 BPM.
• Regular rhythm
• Intervals between P and R waves are equally spaced.

Sinus Dysrhythmia (Rhythm)

• Heart Rate 60–100 BPM.
• Irregular rhythm; variations in P-P and R-R interval lengths occur.

Additional Notes

• Study all 2D anatomy and use class 14 powerpoint.

Test your knowledge on conditions related to pulmonary hypertension, including risk factors for right heart failure and complications of pulmonary stenosis. This quiz covers key concepts and clinical assessments important for understanding these cardiovascular issues.