Echocardiography Board Review: 500 Multiple Choice Questions With Discussion

Chapter 16

Questions

1.  301. The parasternal long-axis image of the mitral valve apparatus shows:c16f001

1.  A. Mitral annular calcification

2.  B. Rheumatic mitral stenosis

3.  C. Systolic anterior motion

4.  D. Annuloplasty ring

2.  302. The continuous wave signal with a peak velocity of 3.2 m/s shown here is indicative of:c16f002

1.  A. Moderate aortic stenosis

2.  B. Moderate pulmonary hypertension

3.  C. Acute severe mitral regurgitation due to papillary muscle rupture

4.  D. None of the above

3.  303. Assuming a right atrial (RA) pressure of 10 mmHg, the pulmonary regurgitation signal, with an end diastolic velocity of 2.2 m/s shown here is indicative of:c16f003

1.  A. Normal pulmonary artery (PA) pressure

2.  B. Moderate elevation of PA pressure

3.  C. Systemic level of PA pressure

4.  D. None of the above

4.  304. The abnormalities shown in this image include:c16f004

1.  A. Pericardial effusion

2.  B. Left pleural effusion

3.  C. Left pleural effusion and pericardial effusion

4.  D. Abnormally thick pericardium

5.  305. The pattern of aortic valve opening in this patient is likely to be due to:c16f005

1.  A. Hypertrophic obstructive cardiomyopathy (HOCM)

2.  B. Pulsus alternans

3.  C. Intra-aortic balloon pump (IABP) with 1:3 support

4.  D. Left ventricular assist device (LVAD) with 1:3 support

6.  306. This is an apical four-chamber view of the left ventricle (LV). The structure indicated by the arrow in the LV apex is likely to be:c16f006

1.  A. LV thrombus

2.  B. Rib artifact

3.  C. Cannula of LVAD

4.  D. False tendon in the LV apex

7.  307. The structure indicated by the arrow is:c16f007

1.  A. Descending thoracic aorta

2.  B. Coronary sinus

3.  C. Left lower pulmonary vein

4.  D. Left PA

8.  308. The transthoracic image shown here is indicative of:c16f008

1.  A. LV apical thrombus

2.  B. Moderator band

3.  C. Rib artifact

4.  D. Ventricular noncompaction

9.  309. The patient shown here is likely to have:c16f009

1.  A. Heart failure

2.  B. Intravascular volume depletion with hypotension

3.  C. Right atrial tumor

4.  D. None of the above

10. 310. The continuous wave Doppler signal shown here is suggestive of:c16f010

1.  A. Mixed mitral valve disease with significant mitral stenosis (MS) and mitral regurgitation (MR)

2.  B. Mixed aortic valve disease with significant aortic stenosis (AS) and aortic regurgitation (AR)

3.  C. Combination of AR and MR

4.  D. Ventricular septal defect (VSD) with bidirectional flow

11. 311. This patient is likely to have (BP 130/65 mmHg):c16f011

1.  A. High left ventricular end diastolic pressure (LVEDP)

2.  B. Diastolic MR

3.  C. Premature mitral valve closure

4.  D. All of the above

12. 312. The following statements are true of the Doppler signal shown here:c16f012

1.  A. The patient may have severe valvular aortic stenosis

2.  B. The patient may have severe systolic anterior motion (SAM)

3.  C. Patient may have severe MR

4.  D. None of the above

13. 313. The pulmonary vein flow pattern is indicative of:c16f013

1.  A. Volume depletion

2.  B. Atrial fibrillation

3.  C. Elevated LVEDP with normal left atrial (LA) pressure

4.  D. Elevated LVEDP with high LA pressure

14. 314. This patient has:c16f014

1.  A. Tricuspid atresia

2.  B. Right atrial myxoma

3.  C. Hydatid cyst of the heart

4.  D. Hypoplastic left heart syndrome

15. 315. The flow shown here is consistent with:c16f015

1.  A. Superior vena cava (SVC) flow

2.  B. Pulmonary vein flow

3.  C. Atrial septal defect (ASD) flow

4.  D. None of the above

16. 316. This patient had secundum ASD fairly circular with a diameter of 2 cm. The heart rate was 61/min. The approximate shunt flow would be:c16f016

1.  A. 5 L/min

2.  B. 7.4 L/min

3.  C. 13 L/min

4.  D. 20 L/min

17. 317. The abnormality shown in this image could be associated with:c16f017

1.  A. Accessory pathway

2.  B. Atrial septal defect

3.  C. Tricuspid regurgitation

4.  D. All of the above

18. 318. The patient shown here has:c16f018

1.  A. Prosthetic mitral valve

2.  B. Tricuspid atresia

3.  C. Left SVC

4.  D. Biventricular pacemaker

19. 319. The cause of the abnormality shown here could be due to:c16f019

1.  A. Persistent left SVC

2.  B. Congestive heart failure

3.  C. Unroofed coronary sinus

4.  D. All of the above

20. 320. The patient shown here has:c16f020

1.  A. Severe mitral annular calcification

2.  B. Mitral annuloplasty ring

3.  C. Rheumatic mitral valve disease

4.  D. None of the above

Answers for chapter 16

1.  301. Answer: D.

Posterior mitral annuloplasty ring in crosssection. This is circular in crosssection and on the atrial side of the base of the posterior mitral leaflet. Mitral annular calcification on the contrary will bury the leaflet base inside the calcification and generally starts from the base of the annulus and extends to the leaflets, and the shape is not circular in crosssection. There is no restriction of the leaflet tips to suggest rheumatic involvement and SAM is evaluated in systole. This is a diastolic frame.

2.  302. Answer: B.

This is a signal originating from A–V valve regurgitation as it starts with the QRS without any isovolumic contraction. Accompanying forward flow velocity is less than ½ m/s suggesting tricuspid origin. Mitral inflow velocity tends to be higher. The velocity of this signal is 3.2 m/s resulting in a transvalvular gradient of about 40 mmHg. Assuming an RA pressure of 10 mmHg, the RV systolic pressure would be 50 mmHg. Aortic signal is of shorter duration and starts later after the isovolumic contraction period and if mitral inflow is visible the isovolumic relaxation time could be discerned, that is, the aortic velocity curve will not be continuous with the mitral inflow velocity curve. In acute severe MR, the gradient could be low due to hypotension and high LA pressure. In such a situation, a large V-wave would result in rapid deceleration of the signal soon after finishing acceleration. This is so-called V-wave “cutoff” sign.

3.  303. Answer: B.

End diastolic pulmonary regurgitation velocity is 2 m/s, consistent with a PA to right ventricular (RV) end diastolic gradient of 16 mmHg (4 × 22) and assuming that the RV end diastolic pressure is close to the mean RA pressure, the PA diastolic pressure will be 26 mmHg.

4.  304. Answer: C.

Number 1 indicates pericardial effusion, 2 indicates pleural effusion, and 3 is the descending aorta. Pericardial effusion is always anterior to the aorta and pleural effusion extends posteriorly. The structure separating the two is combined parietal pericardium and pleura. The combined thickness is <3 mm, which is normal.

5.  305. Answer: D.

There is reduced aortic valve opening with every third beat. This is due to reduced transaortic flow with every third beat, which is assisted by the LVAD, and the bulk of the cardiac output is delivered through the assist device. During the intervening two beats, all the stroke volume is delivered through the aortic valve. With 1:3 IABP support the increase in stroke volume during the IABP deflation occurs through the aortic valve, hence there is increased opening. In pulsus alternans, strong and weak beats alternate in a 1:2 fashion. In HOCM, midsystolic closure occurs with every beat.

6.  306. Answer: C.

Echodense walls and echoluscent lumen of the cannula are seen. This LVAD cannula serves to deliver blood to the assist device. In these patients it is important to make sure that there is no obstruction to the inlet cannula by surrounding structures, including the ventricular septum, and no apical thrombi. Thrombus does not have a central luscency. False tendons are echodense and linear and rib artifacts are lighter and generally go through the anatomic boundaries.

7.  307. Answer: A.

This vessel is posterior to the left atrium, indicative of descending thoracic aorta. Coronary sinus is in the posterior A–V groove and is intrapericardial. The left PA and the left lower pulmonary vein are far away from this location.

8.  308. Answer: A.

An LV apical thrombus. There is a distinctly demarcated thrombus in the apex. When there is a question, this can be confirmed by obtaining additional views of the apex, such as two-chamber and short-axis views with color flow imaging at a low Nyquist limit or using transpulmonary contrast agents such as Definity, thrombus will be seen as a filling defect. The LV apex is a common place for a false tendon and may be mistaken for a thrombus. Rib artifact is less dense, goes beyond the endocardium, and does not move with the heart.

9.  309. Answer: A.

Heart failure. Dilated inferior vena cava (IVC) is suggestive of high RA pressure if it does not collapse with inspiration. Occasionally, in normal young individuals one may see a dilated IVC, which readily collapses with inspiration. A general guideline is that IVC > 2 cm and <10% collapse indicates RA pressure > 20 mmHg, >2 cm and 50% collapse indicates RA pressure of 15 mmHg, 1.5–2 cm and >50% collapse indicates RA pressure of 10 mmHg, and <1 cm and >50% collapse indicates RA pressure of 5 mmHg. However, new ASE guidelines are as follows: IVC size of ≤2.1 cm and >50% collapse with a sniff is suggestive of normal RA pressure of 3 mmHg (range, 0–5 mmHg). If IVC size is ≥2.1 cm and <50% collapse is suggestive of high RA pressure, 15 mmHg (range, 10–20 mm hg). In indeterminate cases, here, the size of IVC and collapse do not fit this paradigm, an intermediate value of 8 mmHg (range, 5–10 mm hg) may be used. Alternately, secondary indices of high RA pressure should be integrated such as tricuspid E/E′ >6, diastolic flow predominance in the hepatic veins. In indeterminate cases, if secondary indices of elevated RA pressure are not present, RA pressure can be downgraded to 3 mmHg. If there is minimal IVC collapse with a sniff (<35%) and secondary indices of high RA pressure are present, then RA pressure can be upgraded to 15 mmHg. If uncertain, leave RA pressure at 8 mmHg. In patients who are unable to perform a sniff, an IVC that collapses <20% with quiet respiration suggests high RA pressure. IVC collapse does not accurately reflect RA pressure in ventilator-dependent patients.(J Am Soc Echocardiogr 2010;23:685–713).

10. 310. Answer: B.

Mixed aortic valve disease with significant AS and AR. Diastolic signal is diagnostic of AR with a 4 m/s early diastolic velocity, which does not occur with MS. The velocity curve of AR is continuous with the systolic signal, indicating signal origin at the same valve. The MR signal would have a longer signal and overlap both the initial and terminal portions of the AR signal, as MR would occur with both isovolumic contraction and relaxation phases. Typical VSD signal will have a systolic component and a presystolic associated with left atrial contraction directed into the RV. If the patient has Eisenmenger's syndrome, the flow velocity would be very low.

11. 311. Answer: D.

All of the above. The AR signal decelerates rapidly with a pressure half-time of 185 ms (less than 250 ms indicates very rapid deceleration). The end diastolic velocity is about 2 ms, indicating an end diastolic gradient between the aorta and LV of 16 mmHg, assuming alignment of the ultrasound beam parallel to flow. As the patient's diastolic pressure is 65 mmHg, the LVEDP is 49 mmHg (65 − 16). Severe AR, generally acute, or significant AR in the presence of stiff LV may occur with severe AS or hypertension; high LVEDP resulting from this may cause diastolic MR and also presystolic closure of the mitral valve.

12. 312. Answer: A.

Severe valvular AS. The timing of the onset slightly after the onset of the QRS complex, suggestive of onset after the LV isovolumic contraction period, is suggestive of aortic origin. Although the aortic valve area is the best indicator of AS severity, a mean gradient of >50 mmHg is generally consistent with severe AS. In addition, the signal is mid to late peaking, which has the same significance as the mid to late peaking of the AS murmur. SAM would cause a dagger-shaped, late-peaking signal because of the dynamic nature of the obstruction.

13. 313. Answer: D.

Elevated LVEDP with high LA pressure. The D-wave velocity, which is higher than the S-wave velocity with a rapid deceleration (time < 170 ms), is indicative of high LA pressure in an adult. Small S and large D could be normal in children because of very efficient LV relaxation. In the example shown here, the AR wave duration is markedly increased. Normally, AR wave duration is less than mitral A-wave duration and is less than 110–120 ms. Although A-wave duration is not shown here, the AR wave duration is grossly abnormal at 200 ms, indicating high LVEDP, causing an increase in the duration of atrial systole because of increased atrial afterload. In a volume-depleted patient the S-wave will be prominent and the AR wave would be diminutive; in atrial fibrillation, the AR wave is lost.

14. 314. Answer: A.

Tricuspid atresia. The image shows an absent tricuspid valve, a right atrial mass that is consistent and likely to be a thrombus due to stasis and a ventricular septal defect. This patient had cavopulmonary anastomosis with SVC–RPA and RA–LPA shunt such that IVC blood drained into the LPA through the RA, causing thrombus formation. The PA was completely banded to facilitate cavopulmonary flow. This patient has a well-developed left heart and hence does not have hypoplastic left heart syndrome. Right atrial myxoma is a possibility, but thrombus is much more likely in this situation.

15. 315. Answer: C.

ASD flow. The flow shown is typical of ASD flow with systolic–diastolic wave and a second wave associated with atrial contraction, all left to right in the same direction. Both SVC and pulmonary vein flows are triphasic with S, D, and AR waves, with the AR wave being in an opposite direction to S- and D-waves.

16. 316. Answer: B.

7.4 L/min. The shunt flow per heart beat is the time velocity integral (TVI) across the defect × cross sectional area, that is, 39 × 3.14 × 1 × 1 = 122 cc (TVI of signal is 39 cm). Shunt flow per minute = shunt volume per beat × heart rate = 122 × 61 = 7.4 L/min.

17. 317. Answer: D.

The image is diagnostic of Ebstein's anomaly of the tricuspid valve. This is diagnosed when the attachment of the septal leaflet of the tricuspid valve is apically displaced in relation to the anterior leaflet by >8 mm/M2. In this disorder, the septal leaflet is large, sail like, and could be plastered to the RV wall through the chordae tendinae. The associations include severe tricuspid regurgitation, atrial septal defect, and right sided accessory pathway causing PSVT.

18. 318. Answer: D.

Biventricular pacemaker. A coronary sinus lead is clearly seen in this image. This is imaged from the apical four-chamber view with a posterior transducer tilt to obtain a tomographic plane through the coronary sinus. Because of this the mitral valve is not seen. The coronary sinus is not enlarged to support the diagnosis of left SVC.

19. 319. Answer: D.

All of the above. The coronary sinus is dilated, which could be due to increased flow or pressure, and any of the conditions listed can potentially result in a dilated coronary sinus. Note that the coronary sinus is in the A–V groove and intrapericardial versus descending aorta, which is in the posterior mediastinum and is extrapericardial.

20. 320. Answer: B.

Mitral annuloplasty ring. Echocardiographically, this is distinguished from mitral annular calcification by its rounded shape in crosssection and projection into the left atrium at the base of the posterior leaflet. On the contrary, mitral annular calcification would incorporate the base of the posterior mitral leaflet into itself.