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M mode echo

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The lost art......revisited.

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M mode echo

  1. 1. Dr. Amit Kumar Senior Resident, Department of Cardiology R.N.T Medical College Udaipur , India
  2. 2.  For many years, this type of examination was only available echocardiographic technique. They used to form backbone of clinical echocardiography.  Today also M-mode importance couldn’t be underestimated even in presence of 2D ,3D, real time 3D, or doppler echocardiography.
  3. 3. M-Mode Physics  The transducer emits an ultrasound beam, which reflects at each anatomic interface.  The reflected wavefronts can be represented as dots (B- mode) or spikes (A-mode). Brightness of dot or magnitude of spike vary with the amplitude of the reflected wave.  If the B-mode scan is swept from left to right with time, an M-mode image is produced
  4. 4. M-Mode Physics….  M-mode has got better temporal resolution and thus subtle abnormalities in motion and timing is better appreciated. For eg. systolic anterior motion of mitral valve in HCM & RV diastolic collapse in tamponade.  Because of its high sampling frequency( upto 1000 pulses per second), M-mode has excellent axial resolution and is useful in identifying the relative location of structures and measuring range of motion.
  5. 5.  M-mode echocardiography is use to evaluate the morphology of structures ; movement and velocity of cardiac valves and walls; and timing of cardiac events.
  6. 6. M-mode Evaluation  Amplitude  Velocity  Time intervals  Morphology
  7. 7. Amplitude = Y2 –Y1 Y1 Y2 Amplitude Measurement Distance Time
  8. 8. Time interval = T2 – T1 T2T1 Time Measurement Distance Time
  9. 9. dy = Y2 –Y1 Y1 Y2 Slope Measurement T1 T2 dt = T2 – T1 Slope = dy/dt = velocity
  10. 10. M-mode at the Mitral Valve  The mitral valve has 2 leaflets – anterior and posterior.
  11. 11. Mitral stenosis: M-mode features  Decrease EF slope.  Paradoxical anterior diastolic motion of PML.  Seperation between leaflets is decreased.  Thickening of leaflets.  Early diastolic dip of IVS.  Reduced mitral valve leaflet excursion( D-E excursion)  Earlier pliability for BMV used to be decided on basis of D- E amplitude. A MV with D-E amplitude of 20mm or more is usually considered pliable.
  12. 12. Mitral Stenosis
  13. 13. Mitral regurgitation: m-mode features  Indirect evidences- LA enlargement, LV enlargement  Exaggerated septal motion (1cm)  LAE with systolic expansion of the posterior left atrial wall.
  14. 14. Mitral valve prolapse : m- mode features  Thick redundant mitral valve leaflets.  Mid to late systolic sagging back of the anterior, posterior or both MV leaflet >2mm from C-D point of MV.  Holosystolic sagging back of the anterior, posterior, or both MV leaflet >3mm from the C-D point of MV.
  15. 15. Flail mitral leaflet : m-mode features  Coarse diastolic fluttering of mitral leaflets.  Flail mitral leaflet may appear within LA
  16. 16. Infective endocarditis: m- mode features  Valve leaflet appear thickened, “smudged”, “shaggy”.  Vegetation on a valve leaflet usually doesn’t restrict valve motion.
  17. 17. Mitral Valve Endocarditis
  18. 18. LA myxoma: m-mode features  Blunted E point of the mitral valve.  Decrease E-F slope.  Heavy band of echoes behind the anterior mitral leaflet in diastole.  Echo free space at anterior mitral leaflet at onset of diastole prior to dense echoes from tumor
  19. 19. Premature closure of Mitral valve: m-mode features  When C-point of the mitral valve occurs before the onset of the QRS complex.
  20. 20. Fluttering of AML in aortic regurgitation
  21. 21. “B” bump due to elevated EDP B-bump or notch
  22. 22. Hypertrophic Cardiomyopathy Systolic anterior motion of mitral valve s/o dynamic LVOT obstruction
  23. 23. M-mode at the Aortic Valve  The aortic valve has 3 cusps – right coronary, left coronary and non-coronary cusps.  The cusps imaged in the PLAX view are the right coronary and the non-coronary cusps.  Leaflet may show fine systolic fluttering in healthy individuals.
  24. 24. M-mode at the Aortic Valve Coronary cusp Non-coronary cusp Anterior aortic root Posterior aortic root Left Atrium
  25. 25. M-mode at the Aortic Valve LA dimension Cusp Separation (1.5-2.5cms in adult) Aortic root
  26. 26. M-mode at the Aortic Valve LA dimension Measurements are made from leading edge to leading edge.
  27. 27. Aortic stenosis: m-mode features  Thickening valve leaflets.  Decreased excursion of valve leaflet.  Absence of systolic flutter of aortic valve leaflet.
  28. 28. Critical Aortic Stenosis
  29. 29. M-mode at the Aortic Valve Bicuspid Valve Eccentric closure line Seen when there is a Bicuspid aortic valve
  30. 30. Aortic regurgitation: m-mode features  Diastolic fluttering of AML.  Diastolic fluttering of aortic valve.  Premature closure of mitral valve.  Premature opening of aortic valve.  Dilated LV.
  31. 31. Fluttering of AML in aortic regurgitation
  32. 32. Premature opening of Aortic valve in AR
  33. 33. Diastolic fluttering of aortic valve in AR
  34. 34. coarse fluttering of aortic valve cusp- SUBAORTIC MEMBRANE
  35. 35. Early closure of AV due to Severe LV dysfun M-mode in a pt with LV dysfunction- showing rounded closure of AV,indicating decrease forward flow at end of systole
  36. 36. Systolic notching of AV in HCM
  37. 37. a- downward motion, concides with A-wave of MV; b- represents onset of ventricular systole; c- max downward position ; d- closure begins; e- closure is completed
  38. 38.  In adults it is unusual to record more than posterior leaflet of the pulmonary valve.  In children or in pt with unusually large pulmonary arteries, one may also record anterior leaflet.  In reality one can rarely record the entire excursion of the pulmonar valve throughout cardiac cycle in adults.
  39. 39. M-mode at Pulmonary valve
  40. 40. Pulmonary stenosis m-mode feature- increase depth of pulmonary valve “a” wave (increased a-dip)
  41. 41. Pulmonary HTN with “Flying W sign” Pulmonary hypertension m-mode feature- loss of A-dip of pulmonary valve
  42. 42. M-mode at tricuspid valve
  43. 43. M-mode at Left Ventricle RVWT
  44. 44. M-mode at Left Ventricle RVIDd
  45. 45. M-mode at Left Ventricle IVSd
  46. 46. M-mode at Left Ventricle LVIDd
  47. 47. M-mode at Left Ventricle LVPWd
  48. 48. M-mode at Left Ventricle IVS excursion
  49. 49. M-mode at Left Ventricle IVSs
  50. 50. M-mode at Left Ventricle LVIDs
  51. 51. M-mode at Left Ventricle LVPWs
  52. 52. M-mode at Left Ventricle LVPW excursion
  53. 53. • FS • EF • LV mass M-mode LV Calculation
  54. 54. M-mode LV Calculation FS = LVIDd – LVIDs LVIDd
  55. 55. M-mode LV Calculation EF = LVIDd3 – LVIDs3 LVIDd3
  56. 56. M-mode LV Calculation LV Mass = 1.04 {(LVIDd + IVSd + LVPWd)3 – (LVIDd)3} x 0.8 + 0.6g
  57. 57. LV M-mode parameters range  Ventricular end-diastolic dimension- 37 to 56mm  Ventricular end-systolic dimension- 26 to 36mm  LV diastolic IVS thickness- 7to 11mm  IVS excursion – 6 to 11mm  IVS % thickening- 27 to 70%  LV posterior diastolic wall thickness- 7 to 11mm  LVPW excursion- 9 to 14mm  LVPW % thickening- 25 to 80%  %FS- 28-41%  EF- 48-78%
  58. 58. LV parameters….  Stroke volume- 75 to 100cc  Cardiac output- 4 to 8L/min  Cardiac index- 2.4 to 4.2L/min/m2  LV mass- male< 294gm; female<198gm  Mitral valve EF slope- 50 to 150mm/sec  DE Excursion- 15 to 25 mm  Mitral valve E-point septal seperation- <7mm
  59. 59. Increase LVW thickness
  60. 60. Ischemia
  61. 61. Ischemia  Normal Wall thickness  No systolic thickening  Reduced Motion
  62. 62. Post Infarct
  63. 63. Post Infarct  Thin echogenic wall  No systolic thickening  Reduced Motion
  64. 64. Dilated Cardiomyopathy
  65. 65. Paradoxic Septal Motion
  66. 66. Normal E point to septal separation is < 6 mm With reduced lvef, EPSS may be increased.
  67. 67. help in differentiating pleural effusion from pericardial effusion  If the ultrasonic beam is directed towards the left atrium : 1)Gradual decrease in the echo free space– pericardial effusion 2)Sudden cessation of echo free space- pleural effusion
  68. 68. Quantitation of pericardial fluid can be done by m-mode echo, but 2D-echocardiography gives a better idea esp. in c/o large or loculated effusion
  69. 69. Cardiac tamponade- m mode features  Compressed RV (RVID<7mm)  Increase in RV dimension with inspiration and simultaneously decrease in LV dimension during inspiration.  Decrease mitral valve EF-slope with inspiration.  Decrease mitral valve DE-amplitude with inspiration.  RV diastolic collapse.(specific)  RA diastolic collapse.(sensitive)  Dilated IVC with blunted respiratory changes.
  70. 70. Cardiac tamponade- RV early diastolic collapse
  71. 71. Constrictive pericarditis: m- mode features  Pericardial thickening  Paradoxical septal motion  Septal bounce( abrupt displacement of the IVS during early diastole)  Flattening of mid & late diastolic motion of the posterior LV wall.  Rapid early diastolic, or E-F, slope of the mitral valve.  Rapid downward motion of the posterior aortic wall in early diastole.  Premature opening of pulmonary valve  Dilated IVC with blunted respiratory changes.
  72. 72. Constrictive pericarditis- septal bounce
  73. 73. Motion of the posterior aortic wall reflects the filling and emptying patterns of the left atrium.
  74. 74.  With impaired LA emptying, the aortic wall motion is reduced during the rapid emptying phase, or the first third of diastole.  LA emptying index-  If the first third of diastole does not represent at least 40% of the total amplitude of the aortic wall motion during diastole, then restriction to ventricular filling is suspected.
  75. 75. LA emptying index: Decreased in c/o mitral stenosis Increased in c/o mitral regurgitation
  76. 76. Color doppler m-mode imaging  Used to determine velocity of propagation (Vp) of LV inflow.  Determination of width of AR jet.  Duration of MR.
  77. 77. Velocity of propagation
  78. 78. TAPSE (tricuspid annular plane systolic excursion)
  79. 79. TAPSE – a measure for assessing RV function  TAPSE reference range 15 to 20mm  Mildly abnormal- 13 to 15mm  Moderately abnormal- 10 to 12mm  Severely abnormal- <10mm
  80. 80. TAPSE

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