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

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.
 TVI or time velocity
integral
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.
 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 = 5.5L/min

QP = QS + Qshunt = 5.5 + 3.3 = 8.8L/min

QP/ QS = 8.8 / 5.5 = 1.6

The End