Case 1: 

• • TR has a velocity of 4m/s. There is also a pulmonary valvular stenosis with a gradient of 2 m/s

    • What is the RV systolic pressure 

    • What is the PA systolic pressure

  • If the Aortic pressure is 98 mmHg, what would be the directionality and  the expected peak velocity through the ductus

Case 2: 

• Blood pressure is 100/55 mmHg in Aorta

• VSD gradient restrictive is left to right and 45 mmHg of gradient.

• There is an Aortic Valvular Gradient because of aortic valve stenosis of 65 mmHg. 

• What is the RV systolic pressure. What is the PA systolic pressure.

Case 3:

• The Aortic blood pressure is 110/60

• The LVOT gradient through aortic stenosis is 60 mmHg

• What is the LV systolic pressure?

• If you assume a LA pressure of around 10 mmHg. What would be the MR velocity gradient?

Case 4:

• A PDA is left to right with a gradient of 80 mmHg

• The Aortic pressure (systolic) is 100 mmHg

• The TRJ gives a RV systolic pressure of 130 mmHg of RV-RA gradient.

• What is the PA systolic pressure?

• What is the RV systolic pressure? 

• What is the gradient via the RVOT? 

Case 5: 

• • If Ao saturation=100%, Mixed venous saturation=70%, Pulmonary Venous saturation=100%, and Pulmonary arterial saturation=85% (indicating oxygen enrichment from the shunt), then Qp/Qs is ?

Case 6: Large left to right VSD:

• Aortic pressure is 90/60 (mean 70)

• The LA pressure is 15 mmHg. RA pressure is 5 mmHg.

• mPAP is 30 mmHg

• There is no hepatomegaly (low IVC pressure).

• The LV is dilated on echocardiography (LV end-diastolic diameter with a Z-score 3.5) due to the high pulmonary blood flow by the left to right shunt. 

• Qp >> Qs because the LA and LV are dilated. 

• If Qp/Qs = 3, what is the pulmonary vascular resistance to systemic vascular resistance ratio?

Case 7: Large VSD on echocardiography 

• • The patient has an aortic blood pressure of 110/60 (85 mean). By cath, the PA saturation is 70%. The pulmonary venous saturation is 100%. The Aortic saturation is 100%. The RA saturation is 70%. Mean PAP is 45 mmhg, Mean LA pressure is 10 mmHg, Mean Aortic pressure is 70 and Mean RA pressure is 5. 

  • What is the Rp/Rs?

  • What is the Qp/Qs?

Case 8 - Large right to left VSD

• Is the Rp/Rs ratio less or more than 1?

• Ao saturation is 85%, SVC saturation is 55 (AV difference of 30%). PA saturation is 55%. There is no VQ mismatch. What is the Qp/Qs?

• The patient has an aortic blood pressure of 110/60 (85 mean). PA pressure is: 110/38 (mean 70). RA pressure is 5, LA pressure is 10.

• What is the Rp/Rs Ratio?

Case 9

• Central venous line reads a pressure of 10 mmHg

• The PFO gradient is restrictive and estimating a peak gradient of 15 mmHg

• There is a prolonged retrograde flow in the pulmonary vein.

• What would be the LA pressure?

• What could explain this rise in LA pressure?

Case 10

• At baseline, the patient is evaluated in room air with iNO at 10 ppm. 

  • RA pressure is 5 mmHg with a RA saturation of 69% (SVC saturation 72%, IVC satuation 67%). The saturation at the LPA is also 69%. 

  • Is there a left to right shunt at a VSD or PDA level? 

  • The RV pressures are 44/4 compared to LV pressures of 82/8. Is the RV pressure infra, supra, or isosystemic?

  • The MPA pressure is 45/17 (mean of 30). Is this pulmonary hypertension?

  • The RPA and LPA pressure are similar (46/19; mean 30 for the RPA; 48/19; mean 30 for LPA). Is there obstruction of the RPA or LPA, could it be a sadle emboli? 

  • The wedge pressure on both side is similar (9 and 10 mmHg). Is there pulmonary venous hypertension? 

Case 11

• Blood pressure is 29/10 and saturation post-ductal is 65%

• Pre-ductal saturation is 85%

• There is minimal V/Q mismatch on the chest radiography with nice aeration of the lungs

• On ECHO the TRJ gives RV-RA of 25 mmHg

• The PDA is large and strictly right to left

• There is retrograde flow in the Ascending Arch.

• The PFO is shunting strictly left to right. 

• What would be your management of this patient? What is the phenotype of the patient?

• What is the expected saturation in the left atrium?

• What would be the expected saturation in the LV?

• What would be the expected saturation in the RA?

• What would be the expected saturation in the RV? What is the expected blood presure in the RV?

• What is the expected sPAP and diastolic PAP?

Case 12

• Blood pressure is 29/10 and saturation post-ductal is 75%

• Pre-ductal saturation is 75%

• There is minimal V/Q mismatch on the chest radiography with nice aeration of the lungs

• The PDA is large and strictly left to right

• The PFO is shunting strictly right to left. The patient has significant hepatomegaly.

• There is no congenital heart defect (outside of the inter-atrial shunt and PDA presence). 

• What would be your management of this patient? What is the phenotype of the patient?

• What is the expected saturation in the left atrium?

• What would be the expected saturation in the LV?

• What would be the expected saturation in the RA?

• What would be the expected saturation in the RV? 

• What is the expected sPAP and diastolic PAP?

Case 13

• If Qp/Qs is 3 with a arterio-venous difference (O2 consumption) of 30%, what will be the pulmonary artery saturation in:

  • Large ASD

  • Truncus Arteriosus

  • Sinus Venosus ASD

  • Ventricular Septal Defect

Case 14

• A patient has pulmonary atresia with a large VSD and a large PDA. The aortic saturation is 85%. The patient has good cardiac function and is well perfused. You assume the AV-difference of 30%. There is no signs of V-Q mismatch or parenchymal lung disease. What is the Qp/Qs in this patient?

Case 15

• You are called at bedside for a TnECHO. There is a large non-restrictive left to right PDA bigger than the size of the LPA. The Aortic Pressure is 85/65. 

• If you would do a cath, what would likely be the blood pressure in the pulmonary artery. 

• If you obtain a saturation in the LPA, what would it be if the Qp:Qs is 4/1, knowing that the saturation in the Aorta is 100%. 

• What will be the septal curve on TnECHO?

Case 16

• A patient has a large VSD that shunts left to right at low-velocity.

• The Aortic pressure is 85/65. What would be the systolic RV pressure?

• If there is a pulmonary stenosis with a gradient of 20 mmHg at peak systole, what would be the systolic PA pressure.

• What would be the septal curve position at peak of systole? 

Case 17

• A patient has a large unrestrictive VSD that shunts right to left at low-velocity.

• The Aortic pressure is 85/65. What would be the systolic RV pressure?

• If there is a pulmonary stenosis with a gradient of 75 mmHg at peak systole, what would be the systolic PA pressure.

• What would be the septal curve position at peak of systole? 

• If there is no V/Q mismatch and the Qp:Qs is 1/2, what would be the saturation in the Aorta, Pulmonary Artery, Right Atrium and Left Atrium. 

Case 18

• You are seeing a patient with TnECHO, the septal curvature is flat. 

• There is a large PDA that is left to right. What is higher, PVR or SVR? What is higher sPAP or sBP? Why is the septal curve flat and not bowing to RV? If PDA was very small, left to right, and restrictive, what would be the septal position?

• There is a large PDA that is right to left. What is higher, PVR or SVR? What is higher sPAP or sBP? Why is the septal curve flat and not bowing to LV? If PDA was very small, right to left, and restrictive, what would be the septal position?

Case 19

• You are assessing a patient by TNE

• The mitral insufficiency jet gives a LV-LA gradient of 60 mmHg

• The LA-RA gradient by PW-Doppler is 7 mmHg

• The gradient via the LVOT is 14 mmHg

• What is the Aortic systolic blood pressure, if the RA is 5 mmHg

Case 20

• You are assessing a patient with Tricuspid Atresia, normally related great vessels and a VSD. There is no PDA.

• The aortic saturation is 75%. The pulmonary venous saturation is 100%.

• Explained how this patient could have a Qp/Qs of 0.5:1, a Qp/Qs of 1:1 or a Qp/Qs of 2:1?

Case 21

• You are doing a TnECHO on a preterm infant at 36 weeks. The PDA is left to right and unristrictive, pulsatile in pattern. There is a low velocity gradient accross the duct that is completely left to right. There is retrograde holodiastolic flow in the descending aorta, celiac, SMA, ACA and MCA. The LA and the LV are dilated. There is mitral insufficiency. The Systolic BP at the time of the ECHO is 76 mmHg, diastolic is 50 mmHg. There is no RVOT or LVOT obstruction. There is no VSD. The PFO is stretched, restrictive and left to right with a peak gradient of about 10 mmHg. 

• The septum is flat. The TRJ gives a RV-RA of 70 mmHg

• Is the PA pressure infra-systemic, iso-systemic or supra-systemic? 

• What is the expected diastolic BP in the pulmonary artery.

• If you put CW-Doppler accross the MR, what would be your gradient by Bernouilli?

Case 22

A newborn presents with refractory cyanosis and oxygen saturations around 90% (regardless of oxygen supplementation) in both pre- and post-ductal sites. Chest radiography shows cardiomegaly with oligemic (“black”) lung fields. What is your differential diagnosis?

If it is a PAIVS - What is the Qp/Qs?

The patient undergoes a radiofrequency perforation of the RV outflow atretic pulmonary valve. The saturation is now 85% on PGE. How come? What is the Qp:Qs?

PGE are weaned off and the saturation drops to 70%. How come? What is the Qp:Qs? Which treatment can improve the saturation?

At 6 months, the saturation is 85%. What is the Qp:Qs? How would you describe the pressure-volume loop?

If you do a partial cavo-pulmonary shunt (BTT shunt) from SVC to the PA, what would be the expected estimated saturation after the surgery? Assuming that the SVC and IVC contribution to the overall venous return is equivalent (50% - 50%). 

Case 23

3 months old baby with a VSD. BP 90/50 mmHg and you are told the Qp/Qs is 3. The VSD is described as somewhat restrictive. The cardiologist is quite reassured because the cardiology team estimates the PA pressure is less than 1/3 systemic. They will follow only in 1 month. What would be the saturation in the Pulmonary Artery? What is the Max Velocity via the VSD? How is the Pressure-Volume loop?

For a left-to-right shunt producing Qp:Qs = 3:1, describe and compare the total left-ventricular output in a ventricular septal defect (VSD) and a patent ductus arteriosus (PDA). Include in your answer which chambers handle the excess volume and why the LV ejection differs (generated LV stroke volume differs from the VSD vs the PDA)?

Case 24

Baby with a Truncus Arteriosus and is saturating at 90%. The Blood pressure is 120/40 (mean 80). What is the Qp/Qs? What is the PVR/SVR ratio? After surgery, if PVR and SVR are unchanged, what is the mPAP if the systemic BP is 125/60 - mean 80?

Case 26

In aortic stenosis or pulmonary stenosis, what is the instantaneous pressure gradient? What is the peak-to-peak pressure gradient? What do you measure by Doppler echocardiography? What do you measure by cath? Which one tends to be higher?