Study for Examination of Special Competence in Critical Care Echocardiography, (CCEeXAM®)
What phase of the cardiac cycle follows isovolumic contraction?
- After isovolumic contraction, the next phase is systolic ejection.
- This is when the left ventricle ejects blood through the aortic valve into the aorta.
- In Doppler of transmitral inflow:
- E wave = early filling
- A wave = atrial contraction
- Isovolumic contraction comes after A wave
- Systolic ejection is the flow phase after this
What does isovolumic contraction mean?
- The left ventricle is contracting, but no valves are open yet.
- Both mitral and aortic valves are closed.
- Pressure builds in the ventricle until it exceeds aortic pressure.
- Corresponds with the QRS complex on ECG.
Where should we measure the left ventricular end-diastolic diameter?
- Use the parasternal long-axis view.
- Measure perpendicular to the long axis of the ventricle.
- Position calipers at or just below the mitral valve leaflet tips.
- M-mode gives better resolution but may misalign with the long axis.
- EPSS (E-point septal separation) is also measured here:
- EPSS > 7 mm → likely EF < 50%
- Not reliable in AR, MS, or inferior wall abnormalities
How do you diagnose concentric hypertrophy?
- Wall thickness is increased, especially posterior wall.
- Normal thickness = 0.6 to 0.9 cm
- Use Relative Wall Thickness (RWT):
- Formula: (2 × posterior wall thickness) ÷ end-diastolic diameter
- RWT > 0.42 = concentric hypertrophy
How do you diagnose eccentric hypertrophy?
- LV mass is elevated, and chamber is dilated.
- RWT ≤ 0.42 indicates eccentric hypertrophy.
- Seen when the wall is thick, but the cavity is also enlarged.
How do you determine if systolic function is reduced using fractional shortening?
- Use this formula:
(LVEDD − LVESD) / LVEDD
- Values:
- ≥25% = normal
- <25% = reduced
- Best when:
- No wall motion issues
- No conduction delays
- Normal LV geometry
- Example: FS of 12.7% = reduced function
What is an advantage of 2D echo over M-mode in LV assessment?
- 2D ensures measurements are aligned with the LV axis.
- M-mode may cut obliquely, leading to errors.
- M-mode has better resolution but may miss axis alignment.
Why can a single apical four-chamber view overestimate LV function?
- This view shows only anterolateral and inferoseptal walls.
- Infarcts in anterior or inferior walls may be missed.
- Can falsely suggest preserved function in MI.
Which papillary muscle is most vulnerable to rupture in MI?
- Posteromedial papillary muscle.
- Supplied by RCA only → vulnerable to ischemia.
- Anterolateral muscle has dual supply (LAD + LCx) → more protected.
Which view allows you to see the mid-anterior wall?
- Apical two-chamber view.
- Also shows the inferior wall.
- Doesn’t include the right ventricle.
What coronary artery supplies the mid-inferior wall?
- Right coronary artery (RCA).
- This region is visible in the apical two-chamber view.
What percent thickening defines hypokinesis?
- <30% thickening during systole.
- Normal thickening = >30%
- Akinesis = no thickening
- Dyskinesis = bulging out
What’s the recommended method to quantify LV ejection fraction?
- Biplane method of disks (Simpson’s method).
- Most accurate for 2D echo.
- Avoids geometric assumptions.
- Preferred over FS or fractional area change, especially with regional wall issues.
Why is the biplane method better than linear methods?
- Linear methods assume LV is bullet-shaped.
- Biplane method:
- Measures actual endocardial borders
- Incorporates aneurysms into volume
- Can still be limited by:
- Foreshortened apex
- Endocardial dropout
- Missed out-of-plane wall motion issues
Which views are used in the biplane method of disks?
- Apical four-chamber
- Apical two-chamber
- Not used: apical long-axis (3-chamber view)
Do normal EF values differ between men and women?
- Yes, for normal EF:
- Men: 52%–72%
- Women: 54%–74%
- For moderate or severe dysfunction, cutoff is the same:
- Moderate: 30%–40%
- Severe: <30%
What measurements are used in Doppler cardiac output calculation?
- LVOT diameter → calculate cross-sectional area
- Velocity-time integral (VTI) at LVOT
- Heart rate
- These give stroke volume, then cardiac output
When is fractional shortening most accurate?
- In patients with:
- No wall motion abnormalities
- No conduction delays
- Normal LV shape
- Example: hyperdynamic states like sepsis
How do you identify end-diastole using biplane disks?
- Use the frame when the LV volume is largest.
- This is just after mitral valve closure.
- Often correlates with the R wave on ECG.
- Do not use the T wave or aortic valve opening.
How do you interpret EF in severe mitral regurgitation?
- EF may look normal (e.g. 56%) but be misleading.
- MR lowers afterload, making EF seem better than it is.
- Pre-op EF should be ≥60% for favorable post-op outcomes.
- <60% pre-op = higher risk of LV dysfunction after surgery
How do you measure EF in atrial fibrillation?
- EF is variable due to inconsistent filling.
- Average 5 beats for accuracy.
- Use a beat that doesn’t look like an outlier.
- In sinus rhythm, average at least 3 beats.
What global longitudinal strain indicates normal systolic function?
- <−20% is considered normal.
- Strain is negative because the ventricle shortens during systole.
- −30% = very good function
- 0 or positive = abnormal
What non-ischemic conditions cause regional wall motion abnormalities?
- Left bundle branch block (LBBB)
- Ventricular pacing
- Subarachnoid hemorrhage or stroke
- All cause abnormal LV contraction patterns
How do you score wall motion abnormalities?
- Use the 17-segment model.
- Each segment gets a score:
- Normal/hyperkinetic = 1
- Hypokinetic = 2
- Akinetic = 3
- Dyskinetic = 4
- Wall motion score index = average of all segment scores
- Akinetic area (like in anterior MI) = score of 3