Loading ...
Sorry, an error occurred while loading the content.

Re: [echocardiography] Is this patient's left atrial pressure elevated?

Expand Messages
  • Michael Koblic
    Ha! All of this helps little if at all. FWIW, his A/E reversed by more than 0.5 which is said to be significant. What did his CXR show? What was his BNP?
    Message 1 of 21 , Oct 31, 2005
    • 0 Attachment
      Ha! All of this helps little if at all.

      FWIW, his A/E reversed by more than 0.5 which is said to be significant.

      What did his CXR show? What was his BNP?

      Michael Koblic,
      Campbell River, B. C.

      ----- Original Message -----
      From: "Mark Harry" <mharry@...>
      To: <echocardiography@yahoogroups.com>
      Sent: Friday, October 28, 2005 11:46 AM
      Subject: Re: [echocardiography] Is this patient's left atrial pressure
      elevated?


      > Here are the patient's demographic information, history and an m-mode
      > image showing LV wall thickness and LV function.
      >
      > 50 years old - 5'11" - 176lbs - BP 112/64 - pulse 64
      > 2004 - anterior MI, EF 45%, 90% LAD, LAD bypass surgery
      > Risk Factors - dyslipidemia, hypertension and tobacco abuse
      > Symptoms - none
      >
      > Summary of echo findings. The LV anterior wall and septum appeared
      > mildly hypo-kinetic with the posterior wall somewhat hyper-kinetic.
      > LV end diastolic dimension was mildly increased. Estimated EF was
      > 65%. The left atrium was upper limits normal to mildly dilated.
      > Mild mitral, tricuspid and pulmonary regurgitation were present. TR
      > gradient was 25 mmHg and the IVC was dilated and reactive.
      >
      >
      >
      >
      >
      > Yahoo! Groups Links
      >
      >
      >
      >
      >


      ----------------------------------------------------------------------------
      ----


      >
      > Mark
      >
      >
      >
      >
      >
      > On Oct 27, 2005, at 9:37 PM, Alan Ross MD wrote:
      >
      >
      > > Is this not a pseudonormal pattern (type II) ?
      > >
      > >
      > >
      > > At 10:24 AM 10/27/2005, you wrote:
      > >
      > >
      > >> See attached image.
      > >>
      > >> Mark J. Harry RDCS
      > >>
      > >>
      > >>
      > >>
      > >> Yahoo! Groups Links
      > >>
      > >>
      > >>
      > >>
      > >>
      > >>
      > >>
      > >
      > >
      > >
      > >
      > >
      > > Yahoo! Groups Links
      > >
      > >
      > >
      > >
      > >
      > >
      > >
      > >
      >
      >
      >
    • Mark Harry
      This patient was seen last week in the office for one year follow- up. The echo was ordered to check the status of his EF. No other testing was performed. My
      Message 2 of 21 , Nov 1, 2005
      • 0 Attachment
        This patient was seen last week in the office for one year follow-
        up. The echo was ordered to check the status of his EF. No other
        testing was performed.

        My main concern regarding this study is why is there such a
        discrepancy between the diastolic filling Doppler findings. Patients
        of this age with a history of CAD and hypertension typically have a
        grade 1 filling pattern if their LA pressure is normal to upper
        limits normal. This patient's filling pattern and response to
        valsalva indicate that his LA pressure and LVEDP is elevated. So why
        does the tissue Doppler E/E' indicate normal LA pressure? The
        patient had bypass surgery a year ago. This type of finding would be
        consistent with post operative constriction. Because this was a
        digital study ( 2 cardiac cycle capture ) it was not possible to look
        for evidence of respiratory variation in the mitral inflow and
        remember the patient is not symptomatic. I have seen these types of
        discrepancy on many occasions where constriction was not a concern
        but maybe this should be considered.

        Here are some of the questions that I have regarding tissue Doppler.
        Dose the E'/A' ratio have any clinical significance and has anyone
        studied this? Why is the E'/A' ratio less than 1 at the septal
        annulus and greater than 1 at the lateral annulus in this patient?
        Does it have to do with the subtle wall motion abnormalities ( septum
        appeared to be hypokinetic )? If tissue Doppler is a load
        independent measure of Tau, does this mean the rate of relaxation of
        the septum is slower than the lateral wall? Last but not least, when
        there is a discrepancy such as this, which is the more reliable
        indication of the state of the LA pressures, E/E' or the combination
        of mitral inflow and pulmonary venous measurements? My own personal
        bias is the later.

        Mark




        On Oct 31, 2005, at 5:32 PM, Michael Koblic wrote:

        > Ha! All of this helps little if at all.
        >
        > FWIW, his A/E reversed by more than 0.5 which is said to be
        > significant.
        >
        > What did his CXR show? What was his BNP?
        >
        > Michael Koblic,
        > Campbell River, B. C.
        >
        > ----- Original Message -----
        > From: "Mark Harry" <mharry@...>
        > To: <echocardiography@yahoogroups.com>
        > Sent: Friday, October 28, 2005 11:46 AM
        > Subject: Re: [echocardiography] Is this patient's left atrial pressure
        > elevated?
        >
        >
        >
        >> Here are the patient's demographic information, history and an m-mode
        >> image showing LV wall thickness and LV function.
        >>
        >> 50 years old - 5'11" - 176lbs - BP 112/64 - pulse 64
        >> 2004 - anterior MI, EF 45%, 90% LAD, LAD bypass surgery
        >> Risk Factors - dyslipidemia, hypertension and tobacco abuse
        >> Symptoms - none
        >>
        >> Summary of echo findings. The LV anterior wall and septum appeared
        >> mildly hypo-kinetic with the posterior wall somewhat hyper-kinetic.
        >> LV end diastolic dimension was mildly increased. Estimated EF was
        >> 65%. The left atrium was upper limits normal to mildly dilated.
        >> Mild mitral, tricuspid and pulmonary regurgitation were present. TR
        >> gradient was 25 mmHg and the IVC was dilated and reactive.
        >>
        >>
        >>
        >>
        >>
        >> Yahoo! Groups Links
        >>
        >>
        >>
        >>
        >>
        >>
        >
        >
        > ----------------------------------------------------------------------
        > ------
        > ----
        >
        >
        >
        >>
        >> Mark
        >>
        >>
        >>
        >>
        >>
        >> On Oct 27, 2005, at 9:37 PM, Alan Ross MD wrote:
        >>
        >>
        >>
        >>> Is this not a pseudonormal pattern (type II) ?
        >>>
        >>>
        >>>
        >>> At 10:24 AM 10/27/2005, you wrote:
        >>>
        >>>
        >>>
        >>>> See attached image.
        >>>>
        >>>> Mark J. Harry RDCS
        >>>>
        >>>>
        >>>>
        >>>>
        >>>> Yahoo! Groups Links
        >>>>
        >>>>
        >>>>
        >>>>
        >>>>
        >>>>
        >>>>
        >>>>
        >>>
        >>>
        >>>
        >>>
        >>>
        >>> Yahoo! Groups Links
        >>>
        >>>
        >>>
        >>>
        >>>
        >>>
        >>>
        >>>
        >>>
        >>
        >>
        >>
        >>
        >
        >
        >
        >
        >
        > Yahoo! Groups Links
        >
        >
        >
        >
        >
        >
        >
      • Amy Johnson
        Mark- The question that I have for you is what are you setting your gate size at when your are doing in flows as well as when you are doing tissue doppler?
        Message 3 of 21 , Nov 1, 2005
        • 0 Attachment
          Mark-
          The question that I have for you is what are you
          setting your gate size at when your are doing in flows
          as well as when you are doing tissue doppler? This is
          very important to know. My other question is did you
          valsalva this patient again? It seens to me off your
          clips that the sample moved slightly toward the LA and
          was not at the leaflet tips, this will throw you off.
          The other thing is are you doing a LA volume
          measurement?
          And yes, the E/A measurement does have a function in
          all this data, Mayo Clinic has comprehensive
          guidelines for the analysis of diastology grades vary
          from 1, 1a, 2, 3 and 4..varying factors effect all and
          all measurements have a play in the diagnosis. I
          advice you to research any article by DR. Jay OH,
          Tajik or Seward from the Mayo clinic

          Amy

          --- Mark Harry <mharry@...> wrote:

          > This patient was seen last week in the office for
          > one year follow-
          > up. The echo was ordered to check the status of his
          > EF. No other
          > testing was performed.
          >
          > My main concern regarding this study is why is there
          > such a
          > discrepancy between the diastolic filling Doppler
          > findings. Patients
          > of this age with a history of CAD and hypertension
          > typically have a
          > grade 1 filling pattern if their LA pressure is
          > normal to upper
          > limits normal. This patient's filling pattern and
          > response to
          > valsalva indicate that his LA pressure and LVEDP is
          > elevated. So why
          > does the tissue Doppler E/E' indicate normal LA
          > pressure? The
          > patient had bypass surgery a year ago. This type of
          > finding would be
          > consistent with post operative constriction.
          > Because this was a
          > digital study ( 2 cardiac cycle capture ) it was not
          > possible to look
          > for evidence of respiratory variation in the mitral
          > inflow and
          > remember the patient is not symptomatic. I have
          > seen these types of
          > discrepancy on many occasions where constriction was
          > not a concern
          > but maybe this should be considered.
          >
          > Here are some of the questions that I have regarding
          > tissue Doppler.
          > Dose the E'/A' ratio have any clinical significance
          > and has anyone
          > studied this? Why is the E'/A' ratio less than 1 at
          > the septal
          > annulus and greater than 1 at the lateral annulus in
          > this patient?
          > Does it have to do with the subtle wall motion
          > abnormalities ( septum
          > appeared to be hypokinetic )? If tissue Doppler is
          > a load
          > independent measure of Tau, does this mean the rate
          > of relaxation of
          > the septum is slower than the lateral wall? Last
          > but not least, when
          > there is a discrepancy such as this, which is the
          > more reliable
          > indication of the state of the LA pressures, E/E' or
          > the combination
          > of mitral inflow and pulmonary venous measurements?
          > My own personal
          > bias is the later.
          >
          > Mark
          >
          >
          >
          >
          > On Oct 31, 2005, at 5:32 PM, Michael Koblic wrote:
          >
          > > Ha! All of this helps little if at all.
          > >
          > > FWIW, his A/E reversed by more than 0.5 which is
          > said to be
          > > significant.
          > >
          > > What did his CXR show? What was his BNP?
          > >
          > > Michael Koblic,
          > > Campbell River, B. C.
          > >
          > > ----- Original Message -----
          > > From: "Mark Harry" <mharry@...>
          > > To: <echocardiography@yahoogroups.com>
          > > Sent: Friday, October 28, 2005 11:46 AM
          > > Subject: Re: [echocardiography] Is this patient's
          > left atrial pressure
          > > elevated?
          > >
          > >
          > >
          > >> Here are the patient's demographic information,
          > history and an m-mode
          > >> image showing LV wall thickness and LV function.
          > >>
          > >> 50 years old - 5'11" - 176lbs - BP 112/64 - pulse
          > 64
          > >> 2004 - anterior MI, EF 45%, 90% LAD, LAD bypass
          > surgery
          > >> Risk Factors - dyslipidemia, hypertension and
          > tobacco abuse
          > >> Symptoms - none
          > >>
          > >> Summary of echo findings. The LV anterior wall
          > and septum appeared
          > >> mildly hypo-kinetic with the posterior wall
          > somewhat hyper-kinetic.
          > >> LV end diastolic dimension was mildly increased.
          > Estimated EF was
          > >> 65%. The left atrium was upper limits normal to
          > mildly dilated.
          > >> Mild mitral, tricuspid and pulmonary
          > regurgitation were present. TR
          > >> gradient was 25 mmHg and the IVC was dilated and
          > reactive.
          > >>
          > >>
          > >>
          > >>
          > >>
          > >> Yahoo! Groups Links
          > >>
          > >>
          > >>
          > >>
          > >>
          > >>
          > >
          > >
          > >
          >
          ----------------------------------------------------------------------
          >
          > > ------
          > > ----
          > >
          > >
          > >
          > >>
          > >> Mark
          > >>
          > >>
          > >>
          > >>
          > >>
          > >> On Oct 27, 2005, at 9:37 PM, Alan Ross MD wrote:
          > >>
          > >>
          > >>
          > >>> Is this not a pseudonormal pattern (type II) ?
          > >>>
          > >>>
          > >>>
          > >>> At 10:24 AM 10/27/2005, you wrote:
          > >>>
          > >>>
          > >>>
          > >>>> See attached image.
          > >>>>
          > >>>> Mark J. Harry RDCS
          > >>>>
          > >>>>
          > >>>>
          > >>>>
          > >>>> Yahoo! Groups Links
          > >>>>
          > >>>>
          > >>>>
          > >>>>
          > >>>>
          > >>>>
          > >>>>
          > >>>>
          > >>>
          > >>>
          > >>>
          > >>>
          > >>>
          > >>> Yahoo! Groups Links
          > >>>
          > >>>
          > >>>
          > >>>
          > >>>
          > >>>
          > >>>
          > >>>
          > >>>
          > >>
          > >>
          > >>
          > >>
          > >
          > >
          > >
          > >
          > >
          > > Yahoo! Groups Links
          > >
          > >
          > >
          > >
          > >
          > >
          > >
          >
          >
          >
          === message truncated ===





          __________________________________
          Yahoo! Mail - PC Magazine Editors' Choice 2005
          http://mail.yahoo.com
        • Mark Harry
          I believe the gate size is 3 to 5 mm. I can t say for sure just looking at the images. I can check into that and get back to you. Attached is an image with
          Message 4 of 21 , Nov 2, 2005
          • 0 Attachment
            I believe the gate size is 3 to 5 mm. I can't say for sure just
            looking at the images. I can check into that and get back to you.
            Attached is an image with the second valsalva and LA measurements.

            There may be some confusion. The E/A measurement I am interested in
            is the tissue Doppler E'/A' ratio not the mitral inflow E/A ratio. I
            could be wrong but I don't remember this measurement being mentioned
            or investigated in any of the Mayo papers or any other papers for
            that matter. If you know of such a paper could you send me the
            references. I would greatly appreciate it.

            Thanks for you feedback
            Mark
          • Justin Adams
            After reading the article (I quoted in my previous post) fully (!), I am now swayed towards a raised LA pressure. However, I remain a little confused on the
            Message 5 of 21 , Nov 2, 2005
            • 0 Attachment
              After reading the article (I quoted in my previous post) fully (!), I am now swayed towards a raised LA pressure.  However, I remain a little confused on the pulmonary vein flows - other postings have talked about the pulmonary vein flow being abnormal as the PVs is less than the PVd.  The paper by S R Ommen, R A Nishimura of the Mayo Clinic shows a normal pulm vein flow to be a PVs slightly less than PVd - is this correct??? 
               
              In Mark's case study the PVa duration exceeds the A wave duration significantly which (according to S R Ommen, R A Nishimura) is highly specific for raised LVEDP.  I have not previously used this.
               
              The post Valsalva trans-mitral Doppler did show a large drop in the E wave velocity and an absolute reduction in the E:A ratio of 0.6, but I thought that the A wave velocity should increase in a true response - the A velocity seems to have reduced slightly here.  Am I wrong with this?
               
              As for the TDI, I have read Dr Thomas' article, but I'm not sure I understand TDI in great enough depth to conclude whether he has a valid point or not.  Surely TDI cannot be used so widely and yet be of dubious validity can it??????
               
              Thanks
               
              Justin

              Mark Harry <mharry@...> wrote:
              Here are the patient's demographic information, history and an m-mode
              image showing LV wall thickness and LV function.

              50 years old - 5'11" - 176lbs - BP 112/64 - pulse 64
              2004 - anterior MI, EF 45%, 90% LAD, LAD bypass surgery
              Risk Factors - dyslipidemia, hypertension and tobacco abuse
              Symptoms - none

              Summary of echo findings. The LV anterior wall and septum appeared
              mildly hypo-kinetic with the posterior wall somewhat hyper-kinetic.
              LV end diastolic dimension was mildly increased. Estimated EF was
              65%. The left atrium was upper limits normal to mildly dilated.
              Mild mitral, tricuspid and pulmonary regurgitation were present. TR
              gradient was 25 mmHg and the IVC was dilated and reactive.





              Yahoo! Groups Links

              <*> To visit your group on the web, go to:
              http://groups.yahoo.com/group/echocardiography/

              <*> To unsubscribe from this group, send an email to:
              echocardiography-unsubscribe@yahoogroups.com

              <*> Your use of Yahoo! Groups is subject to:
              http://docs.yahoo.com/info/terms/


              Mark





              On Oct 27, 2005, at 9:37 PM, Alan Ross MD wrote:


              > Is this not a pseudonormal pattern (type II) ?
              >
              >
              >
              > At 10:24 AM 10/27/2005, you wrote:
              >
              >
              >> See attached image.
              >>
              >> Mark J. Harry RDCS
              >>
              >>
              >>
              >>
              >> Yahoo! Groups Links
              >>
              >>
              >>
              >>
              >>
              >>
              >>
              >
              >
              >
              >
              >
              > Yahoo! Groups Links
              >
              >
              >
              >
              >
              >
              >
              >



              Yahoo! Messenger NEW - crystal clear PC to PC calling worldwide with voicemail

            Your message has been successfully submitted and would be delivered to recipients shortly.