This document discusses hemodynamic assessment using echocardiography. It describes how Doppler shift is used to calculate blood flow velocities and pressure gradients. Methods for quantifying stroke volume at the LV outflow tract and mitral annulus are covered. The use of pulmonary to systemic blood flow ratio and calculation of pressure gradients across valves are explained. Pitfalls related to alignment and imaging quality are addressed. Pressure half-time for assessing mitral stenosis severity is summarized. The document also discusses indicators of increased left ventricular end-diastolic pressure.

1. HEMODYNAMIC ASSESSMENT BY ECHOCARDIOGRAPHY
DR NISHANT TYAGI
DR NISHANT TYAGI
MODERATOR : DR R R KASLIWAL
Escorts Heart Institute And Research CentreEscorts Heart Institute And Research Centre

3. In acute AR

4. B BUMP IN LV DYSFUNCTION

5. Genesis of B bump

6. E POINT SEPTAL SEPRATION IN LV DYSFUNCTION

7. EARLY DIASTOLIC RV COLLAPSE IN PERICARDIAL TAMPONADE

8. EARLY CLOSURE OF AV IN LOW EF

9. EARLY SYSTOLIC DOWNWARD MOVEMENT OF IVS IN LBBB

10. DOPPLER SHIFT
• Christian Doppler in 1842 described the Doppler effect that sound frequency
increases as a sound source moves towards the observer and decreases as
the source moves away, the change in frequency is called Doppler shift
• Doppler shift depends on transmitted frequency, velocity of target and the
angle between the ultrasound beam and the direction of moving target
• Based on Doppler shift blood flow velocities are calculated
• Blood flow velocities can be then be converted to pressure gradients in
mmHg by Bernoulli equation

15. QUANTIFYING BLOOD FLOW

16. CO = SV x HR
CI = CO
BSA

18. STROKE VOLUME AT LVOT

19. PITFALL

20. STROKE VOLUME AT MITRAL ANNULUS

21. CORRECT METHOD

23. PULMONARY TO SYSTEMIC BLOOD FLOW

27. CALCULATION OF PG ACROSS AV

29. Pitfalls
• Technical
• Improper alignment of US beam
• Poor image quality leading to incomplete envelop
• Improper gain settings
• MR
• Increased proximal velocity(v1)
In case of LV dysfunction

30. Improper alignment of US beam

31. Apical 5 chamber view Right parasternal view
POOR IMAGING

32. Use in mitral stenosis

33. In MS with AF multiple 5-10 tracings are taken

34. TR jet is the reflection of peak pressure difference between RV and RA
in systole and RA pressure is equal to JVP

35. The acceleration of blood through VSD in systole is reflection of pressure
difference between LVSP and RVSP and LVSP is equal to SBP
RESTRICTIVE VSD NON RESTRICTIVE VSD

36. In PR, the end diastolic PR velocity gives the pressure gradient between
P artery and the RV at the end of diastole and RV EDP = RAP = JVP
So PADP= 18 + 10
= 28 mm Hg

37. Similarly on the left side the end diastolic AR velocity gives the pressure gradient
between aorta and the LV at the end of diastole
So Aortic EDP = LVEDP + PGAR
The problem here is to measure aortic DP non-invasively, as it is not acceptable
to substitute DBP for this value

38. Final application of Bernoulli eq is the use of MR to find the rate of LV pressure
increase during early systole i.e. during isovolumic contraction
It is a index of LV contractility
Normal dP/dT > 1000 mm Hg/sec i.e. dT should be < 32 msec
It is useful in predicting postop LV function in patients with severe MR

40. PRESSURE HALF TIME
MVA(cm2
)= 220
PHT (msec)

41. The advantage of PHT is that it is less dependent on HR than other measures
of severity like PG for e.g. in AF

42. PITFALLS
• Presence of AR
• Presence of LVH
• For 48 - 72 hours after BMV

43. IN AR
Rate of decrease in the Velocity is reflection of increase in
LVDP and fall in aortic pressure.
So severe the AR the steeper will be the slope and lesser the PHT
PHT < 250 msec indicates severe AR
Pitfall
In chronic AR, LV becomes dilated and complaint
and so LVDP rises slowly leading to falsely prolonged PHT

46. INDICATERS OF INCREASED LVEDP
IF dt < 130 msec ,
IF Pva(t) – MIPa (t) > 50 msec IT INDICATES LVEDP >20 mm Hg

47. Gorlin formula (Continuity equation)
• Based on Newton's second law of thermodynamics, involving
conservation of mass
• The volumetric flow rate through the CVS is constant, assuming that
the blood is noncompressible and the conduct is inelastic
• So flow across a stenotic or regurgitant orifice is same as a proximal
flow across a known area and velocity
• A1 x TVI1 = A2 x TVI2
• Used to find AVA even in the presence of AR or LVD

49. THANKS