Echocardiography Board Review: 500 Multiple Choice Questions With Discussion

Chapter 24

Questions

1.  461. A two-chamber view (systolic frame) of the patient is shown in question 460. The arrow points to a defect in:c24f001

1.  A. P1 scallop

2.  B. P2, A2 scallops

3.  C. P3 scallops

4.  D. A3 scallop

2.  462. The TEE image of the patient in 461 shows:c24f002

1.  A. Severe MR

2.  B. 2+ MR

3.  C. Severe TR

4.  D. None of the above

3.  463. This pulse Doppler signal from a TEE image from the patient in question 461 is suggestive of:c24f003

1.  A. Normal pattern of pulmonary vein pattern

2.  B. Systolic flow reversal in the pulmonary vein suggestive of severe MR

3.  C. Systolic flow reversal in the SVC suggestive of severe TR

4.  D. None of the above

4.  464. This is a TEE image from the midesophageal position from patient in question 461. The arrow points to:c24f004

1.  A. Mild TR

2.  B. Moderate TR

3.  C. Severe TR

4.  D. None of the above

5.  465. The CW pattern from the same patient is suggestive of: RA pressure was 20 mm hgc24f005

1.  A. Severe pulmonary hypertension

2.  B. Moderate pulmonary hypertension

3.  C. Mild pulmonary hypertension

4.  D. Cannot be determined

6.  466. This is a TEE image of a four-chamber view from a 32-year-old male patient. What is the abnormality noted.c24f006

1.  A. D-TGA

2.  B. L-TGA

3.  C. Dextrocardia

4.  D. Normal heart

7.  467. The numbers 1 and 2 depict which structures?c24f007

1.  A. Morphological left ventricle and aorta

2.  B. Morphological left ventricle and pulmonary artery

3.  C. Morphological right ventricle and pulmonary artery

4.  D. Morphological right ventricle and aorta

8.  468. The numbers 1 and 2 denote:c24f008

1.  A. Morphological left ventricle and aorta

2.  B. Morphological left ventricle and pulmonary artery

3.  C. Morphological right ventricle and pulmonary artery

4.  D. Morphological right ventricle and aorta

9.  469. The numbers 1 and 2 denote which structures:c24f009

1.  A. Aortic valve, pulmonary valve

2.  B. Short axis of mitral, tricuspid valves

3.  C. Pulmonary valve, aortic valve

4.  D. None of the above

10. 470. The diastolic and systolic frame of the pulmonary valve flow is suggestive of:c24f010

1.  A. Mild PR only

2.  B. Mild PR, moderate-to-severe PS

3.  C. Normal flow pattern

4.  D. Cannot be determined

11. 471. This is a parasternal long-axis view from a 28-year-old female with c/o shortness of breath. She gives a history of “heart surgery” as a child. The image is suggestive of:c24f011

1.  A. Normal chamber orientation

2.  B. D-transposition

3.  C. L-TGA

4.  D. Cannot determine

12. 472. This is a still frame of an apical view. The arrow points to:c24f012

1.  A. pulmonary vein

2.  B. SVC

3.  C. IVC

4.  D. Pulmonary vein baffle into RA

13. 473. This is a still frame of an apical view. The arrow depicts:c24f013

1.  A. IVC

2.  B. Pulmonary veins

3.  C. Pulmonary artery

4.  D. Systemic venous baffle into the LA

14. 474. This is an echo image from a 23-year-old female with c/o shortness of breath. She has a h/o D-TGA s/p Mustard procedure. Saline contrast was injected from the arm. The image is suggestive of:c24f014

1.  A. Normal saline contrast image

2.  B. Baffle leak

3.  C. Baffle obstruction

4.  D. Need more information

15. 475. This is a parasternal long-axis view form a patient with d-TGA s/p Mustard. The arrow points to:c24f015

1.  A. False tendon

2.  B. Papillary muscle

3.  C. Pacemaker lead

4.  D. Artifact

16. 476. A 40-year-old male, previously an athlete, was referred for an echocardiogram for complaints of severe shortness of breath. On the basis of the parasternal long-axis image of the heart and ECG, you suspect:c24f016

1.  A. Normal left ventricle

2.  B. Hypertrophic cardiomyopathy

3.  C. Amyloidosis

4.  D. Pericarditis

17. 477. A 70-year-old female with a history of Hodgkin's lymphoma and a history of radiation therapy had an echocardiogram for complaints of shortness of breath. The parasternal long- and short-axis images are suggestive of:c24f017

1.  A. Normal valves

2.  B. Radiation-induced aortic valve calcification

3.  C. Endocarditis of the aortic valve

4.  D. Rheumatic changes of the aortic valve

18. 478. A 30-year-old female with a history of SLE was admitted with complaints of fever, malaise, chills, and shortness of breath. The still frame of parasternal long-axis image is suggestive of:c24f018

1.  A. Libman-Sach's endocarditis of the mitral valve

2.  B. Normal mitral valve

3.  C. Endocarditis of the aortic valve

4.  D. Cannot be determined

19. 479. A 58-year-old female with a history of cardiomyopathy and a h/o ventricular tachycardia had this echocardiogram. Accompanying MRI image is shown. Images are suggestive of:c24f019

1.  A. Coronary artery disease

2.  B. Sarcoidosis

3.  C. Myocarditis

4.  D. None of the above

20. 480. A 44-year-old male with lupus nephritis had complaints of fatigue, malaise, and fever. The patient was on hemodialysis through a temporary subclavian line. The still frame of a long-axis view of the heart from a TEE is suggestive of:c24f020

1.  A. Calcified aortic and mitral valves

2.  B. An abscess involving mitral-aortic intervalvular fibrosa

3.  C. Normal valves

4.  D. Bioprosthetic valves

Answers for chapter 24

1.  461. Answer. B.

This is a TEE image of a commissural view. There is a defect in the mitral valve in the middle, where P2 or A2 scallops would be. These scallops were probably inflamed leading to destruction.

2.  462. Answer: A.

The TEE image (long axis) shows color filling the entire left atrium. The origin of the jet is at P2/A2 scallops, where the valve leaflets have been destroyed. The PISA is large, which is suggestive of large volume of regurgitation.

3.  463. Answer. B.

The pulse wave Doppler pattern was obtained from the right upper pulmonary vein. The PW Doppler shows systolic flow reversal. This is indicative of severe mitral regurgitation. This is another sign that can be coupled with color flow imaging to evaluate for severity of MR.

4.  464. Answer: C.

The TEE image is obtained by clockwise rotation from the mid esophagus. This helps in visualization of the tricuspid valve. The color flow imaging shows tricuspid regurgitation jet with a vena contracta diameter of 8 mm suggestive of severe TR.

5.  465. Answer: A.

This patient's TR velocity was measured at 4.5 m/s. This yields an RA–RV gradient of 81 mm hg. With a RA pressure of 20, her RVSP was 100 mm hg, which is suggestive of severe pulmonary hypertension.

6.  466. Answer: B.

The left-sided ventricle that is in continuity with LA has an atrio-ventricular valve that is closer to the apex, suggestive of morphologic right ventricle. The right-sided ventricle is the morphologic left ventricle with mitral valve. The right atrium is connected to the left ventricle and the left atrium is connected to the right ventricle. There is ventriculo-atrial discordance.

7.  467. Answer: D.

This TEE image shows the morphologic right ventricle connected to the transposed aorta, which lies to the left of the pulmonary artery. There is heavy trabeculation (arrow) which also helps is identifying this chamber as the morphologic right ventricle, which also goes with the tricuspid valve.

8.  468. Answer: B.

This image shows the morphologic left ventricle connected to the pulmonary artery. The chamber is smoother with less trabeculations suggestive of morphologic left ventricle. In this image, the left-sided aorta is also seen. The right atrium is connected to the left ventricle. Thus, there is atrio-ventricular and ventriculo-arterial discordance, two wrongs making it “right.” This is suggestive of congenitally corrected transposition or L-TGA.

9.  469. Answer: C.

This is a TEE short-axis image at the basal level. Both the great vessels are seen in short axis as opposed to the normal depiction of one great vessel (usually the aorta in short axis) and the pulmonary artery in long axis. Both the valves are seen in short-axis orientation, which is pathognomonic for transposition. The pulmonary valve is also thickened. This should be recognized as transposition of great vessels.

10. 470. Answer B.

These images show color flow images of the pulmonary valve – diastolic frame revealing mild pulmonary regurgitation (panel A) and systolic frame showing aliasing and turbulence suggestive of pulmonary stenosis (panel B).

11. 471. Answer: B.

D-transposition. This is a transthoracic image from parasternal long-axis view of the heart. Most noticeable feature is depiction of both great arteries in parallel. This is very characteristic of transposition of great arteries. Normally, only the aorta is visible in parasternal long-axis view. In parasternal short-axis view, both arteries are visible, aorta in short axis and pulmonary artery in long axis. In DTGA, the aorta is anterior and is connected to the trabeculated right ventricle. The pulmonary artery is connected to the left ventricle. Here, the left ventricle is connected to a posteriorly situated great vessel, the pulmonary artery.

12. 472. Answer: D.

This is an apical four-chamber view of the heart. Because the patient had undergone surgical correction with the Mustard procedure, the pulmonary veins are baffled into the right atrium and the systemic veins are baffled into the left atrium. The white arrow points to the pulmonary venous baffle.

13. 473. Answer D.

This is an apical four-chamber view of the heart. The white arrow points to the systemic venous baffle.

14. 474. Answer: B.

Saline contrast echocardiogram performed from the arm showed dense opacification of the systemic RV suggesting a massive baffle leak from right to left causing hypoxemia. Also note the moderator band in the RV.

15. 475. Answer: C.

This is a parasternal long-axis view showing a pacer lead in the LV, which is the subpulmonic ventricle or the venous ventricle.

16. 476. Answer: C.

This figure shows a parasternal long-axis view of the heart. There is left ventricular hypertrophy. There is a sparkling appearance to the myocardium. The figure also shows a 12 lead ECG of the patient. There is low voltage in all the limb leads. The combination of LVH on echo and low voltage on ECG is suggestive of an infiltrative disease such as amyloid.

17. 477. Answer: B.

The still frame is a parasternal long-axis view of the heart. The valve is severely calcified and is not opening well (systolic frame of the short-axis image). The aortic valve is severely stenosed, which is an effect of prior radiation therapy. Radiation-induced carditis can be associated with pericardial thickening leading to constrictive pericarditis. Associated calcific stenosis of the aortic and mitral valve is commonly seen. Some patients can also have calcific stenosis of the coronary arteries.

18. 478. Answer. A.

This is a still frame of a parasternal long-axis image. There is a small mass attached to the posterior mitral leaflet suggestive of Libman-Sach's, which is a common finding in SLE.

19. 479. Answer. B.

This is a still frame of her two-chamber view. There is a localized aneurysm in the midanterior wall. The patient was worked up for sarcoidosis. The accompanying CMR image shows transmural scar in the midanterior wall (bright area denotes scar). The scar distribution in sarcoidosis is typically in the lateral wall and is mostly epicardial. There can also be a midmyocardial scar and a scar in the right ventricle.

20. 480. Answer B.

This is a long-axis view (TEE) from a midesophageal level from the patient described above. The aortic valve is thickened. There is an echo-free space (arrow) adjacent to the aortic valve suggestive of an abscess of the fibrous continuity of the aortic and mitral valves (mitral intervalvular fibrosa). This patient had lupus nephritis. His aortic valve probably started out with endocarditis, which in due course progressed to an abscess.