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Jinyang Yu Profile picture
@dritsyk
Feb 11 • 10 tweets • 7 min read • Read on X
Scrolly
The RVOT or PA Doppler has a lot of underutilized potential for hemodynamic monitoring of the RV #ThePeoplesVentricle

🧵On the physiology of the RVOT/PA Doppler. Simplified understandings. Corrections are welcome!😃
#FOAMcc #EchoFirst #Cardiotwitter #FOAMed #Medtwitter #POCUS Image
VTI reflects stroke volume, but values are much lower than for LVOT. Lower cut-off for 60-79 year olds is actually around 10 cm.
Monitoring changes are likely more useful. doi.org/10.1016/j.jcmg…
Image
AcT and Vmax/AT both reflects RV afterload. Increased afterload reduces AT and Vmax/AT.
➡️AcT correlates with mPAP and PVR.
doi.org/10.1161/01.CIR…
Image
➡️Vmax/AcT detects increased RV afterload with lung inflation.
➡️Vmax/AcT does not change after fluid bolus in fluid responsive patients
➡️Vmax/AcT is improved when PEEP = optimal respiratory compliance doi.org/10.1152/jappl.…
doi.org/10.1097/000005…
doi.org/10.1097/000032…
Image
Notching in the Doppler waveform represents wave reflections from vascular stiffening and the "vascular source" of RV afterload.
➡️For details on waveforms & physiology➡️
➡️DT is a potential quantitative metric of wave reflections doi.org/10.1164/rccm.2…
doi.org/10.1016/j.jcmg…
Image
PET reflects the time the RV takes to overcome PA diastolic pressure.
➡️PET is increased in PHT, likely due to RV-PA uncoupling
➡️PET correlates well with RVFAC
➡️PET increases during mechanical inspiration doi.org/10.1161/01.CIR…
doi.org/10.1093/ejecho…
doi.org/10.1016/1053-0…
Image
ET reflects the ratio of displacement/velocity of fiber shortening - at least for the LV
➡️ET is decreased in PHT
➡️ET does not ⬆️after fluids, but decreases during inspiration in fluid responsive patients. doi.org/10.1161/01.CIR…
doi.org/10.1161/01.CIR…
doi.org/10.1097/000005…
Image
(PET+ET) reflects inotropic state (at least for the LV. )
➡️(PET+ET) is correlated with RVFAC; better than PET alone
➡️(PET+ET) is also increased for RV volume overloaded ASD patients doi.org/10.1161/01.CIR…
doi.org/10.1093/ejecho…
doi.org/10.1161/01.CIR…
Image
Lastly, PET/ET-ratio is also a robust marker for ventricular function (higher ratio is bad).
➡️PET/ET-ratio increases during increased RV afterload from inspiration doi.org/10.1016/1053-0…
Image
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More from @dritsyk

Jinyang Yu Profile picture
Jan 31
🚨Automatic measurement of LV function in #ICU is possible by automatic measurement of #MAPSE using TEE and AI #AutoMAPSE
🔓

1/🧵Still, many prefer EF for LV function. How does MAPSE compare to EF, and is MAPSE better?
#EchoFirst #POCUS #FOAMed rdcu.be/dxsEU
Image
2/ #MAPSE and EF are highly correlated. EF reflects SV/EDV, while MAPSE reflect SV/outer cross-sectional area.

Appreciate their relationship in this figure⬇️ doi.org/10.1152/ajphea…
Image
3/ In heart failure with⬇️EF, the LV dilates, and both EF and #MAPSE falls from increases EDV and outer cross-sectional area.

The figure shows that both EF and MAPSE falls during LV dilatation. #CardioTwitter Image
Read 10 tweets
Jinyang Yu Profile picture
Jan 28
🧵1/
Many try to monitor LV function using #POCUS or #EchoFirst, but echo does not work for monitoring.

Let's understand why #POCUS fails at monitoring LV function and how #AutoMAPSE can help.
#MAPSE

🔓

@JcmcSoMe #FOAMcc #FOAMed #CardioTwitter rdcu.be/dw7fT
Image
2/
 The goal of monitoring is
1⃣to detecting small and early changes
2⃣so that therapies can help patients.

For successful monitoring, the measurements must be precise and acquired rapidly and effortlessly. Neither #EchoFirst nor #POCUS fulfil these criteria.
3/
 Eyeballing is rapid, effortless, and OK for diagnosing LV dysfunction.

But eyeballing is NOT precise because it categorises LV function.

Changes in LVEF from 45 to 30% are important, yet still in the same category ➡️ undetectable by categorical assessment.
Read 12 tweets
Jinyang Yu Profile picture
Jan 13
1/
 Ventriculoarterial coupling (#VAC) determines the harms and benefits of hemodynamic therapies.

VAC describes cardiac efficiency, and offers a complementary perspective to CO, MAP and tissue perfusion.

Let’s try to understand it🧵
#FOAMcc #FOAMed #MedTwitter #CardioTwitter Image
2/
 VAC is the matching afterload (Ea) to contractility (Ees) and reflect the heart's energy efficiency.

VAC can be understood using the analogy of riding a bicycle.
3/
 The resistance in the pedals represent afterload (Ea). Your leg strength represent contractility (Ees).
With too⬆️resistance in the pedals, you spend a lot of energy without moving forward and eventually give up. This is analogous to poor VAC progressing into cardiac failure.
Read 13 tweets
Jinyang Yu Profile picture
Dec 5, 2023
1/
 #MAPSE: an unappreciated treasure for assessing LV function? #EchoFirst #WhyCMR

#MAPSE is easy and feasible in almost every patient, also in #ICU. It is highly prognostic, yet unpopular. The reasons are not rational.
🧵👇

#CardioTwitter #POCUS #FOAMed #MedTwitter Image
2/
 #MAPSE is easy to measure using #EchoFirst, and was described already in 1967:

However....doi.org/10.1093/cvr/1.…
3/
 ...during that era, physiologists were focused on cardiac pressure/volume relationships. LVEF emerged as a metric reflecting cardiac volumes, thus filling an unmet need.
doi.org/10.1161/01.cir…
Read 10 tweets
Jinyang Yu Profile picture
Oct 9, 2023
1/🧵Suppl. material for abstract @ESICM #LIVES2023
LV dysfunction in #ICU is bad, yet the LV is not monitored.

Can we use #TEE➕AI➕#MAPSE to monitor LV function in ICU? ✅Yes, #AutoMAPSE had excellent feasibility!

#FOAMcc #FOAMed #MedTwitter #CardioTwitter #EchoFirst #POCUS
2/  INTRODUCTION

As LV function is a crucial for effective hemodynamic management, one would expect it to be closely monitored in #ICU patients - but its not.

LV function is only assessed intermittently, and often assessed late and when LV dysfunction is severe and complicated.
3/
 Therefore, we have developed a method for continuous monitoring of LV function in #ICU.

Our method combines #TEE and AI to automatically estimate #MAPSE. We call it #AutoMAPSE.

1st📜 on #AutoMAPSE:

#EHJIMP #EchoFirst #CardioTwitter doi.org/10.1093/ehjimp…
Figure. Automatic measurement of mitral annular plane systolic excursion (autoMAPSE) on a hands-free image. Left: The mitral annulus is detected automatically using artificial intelligence (red and blue dots). Right: The longitudinal motion of the mitral annulus for 10 heartbeats. For each heartbeat (vertical lines), MAPSE is the distance between the highest and the lowest point. Brackets, demonstrating the MAPSE of one particular heartbeat; MAPSE, mitral annular plane systolic excursion
Read 15 tweets
Jinyang Yu Profile picture
Nov 7, 2022
MAPSE in #IntensiveCare (with examples)🧵#FOAMcc #FOAMed #MedTwitter #Hemodynamic #POCUS #EchoFirst #CriticalCare
Take homes:
1⃣ Redefining "the hyperdynamic heart" with #MAPSE
2⃣ MAPSE is better than EF in the #ICU
3⃣ Linking MAPSE with supply/demand-ischemia
1/n
1⃣ Can MAPSE redefine "the hyperdynamic heart?
The term "hyperdynamic LV" - EF > 55% - is misleading. It has no relation to a hyperdyanmic circulation; SV/CO. Someone bleeding to death has a hyperdynamic heart, but the circulation is life-threatening hypodynamic.
2/n
MAPSE is cardiac motion, and defining the hyperDYNAMIC heart as good cardiac motion makes perfect sense. Recent geometrical analysis of cardiac pumping shows that MAPSE is the main determinant of SV. Fig from @mugander: tinyurl.com/mxbfmcyk
Why?
3/n
Read 17 tweets

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