Lange Review Ultrasonography Examination, 4th Edition

Questions

GENERAL INSTRUCTIONS: For each question, select the best answer. Select only one answer for each question unless otherwise specified.

1. Which heart groove or sulci separates the atria from the ventricles?

(A) interventricular

(B) interatrial

(C) anterior interventricular

(D) coronary or atrioventricular

Identify the coronary arteries in Fig. 2–12.

Image

FIGURE 2–12. Anatomic drawing of the heart and vessels.

2. _______ left posterolateral branch

3. _______ left circumflex branch

4. _______ pulmonary trunk

5. _______ left marginal branch

6. _______ atrioventricular node branch

7. _______ left main coronary artery

8. _______ right coronary artery

9. _______ aortic arch

10. _______ left anterior descending branch

11. Which of the following is not an indication for stress echocardiography?

(A) screening of new patients for coronary artery disease

(B) assessing states before and after intervention

(C) determining prognosis after myocardial infarction

(D) unstable angina

12. Which of the following cardiology examination requires a physician to perform?

(A) echocardiography

(B) stress echocardiography

(C) transesophageal echocardiography

(D) color-flow Doppler

13. What is the purpose of the pericardium?

(A) allow the heart to move freely with each beat

(B) facilitating ejection and volume changes

(C) contain the heart within the mediastinum

(D) serve as a barrier to infection

(E) all of the above

14. What is the largest cardiac chamber?

(A) right atrium

(B) right ventricle

(C) left atrium

(D) left ventricle

15. The left atrium receives how many pulmonary veins?

(A) one

(B) two

(C) three

(D) four

16. What is crista terminalis?

(A) anterior portion of the right atrium

(B) posterior portion of the right atrium

(C) a ridge of muscle separating the right atrium

(D) a heart groove or sulci

17. Which valve is located between the left atrium and the left ventricle?

(A) tricuspid

(B) mitral

(C) aortic

(D) foramen ovale

18. Which of the following is not a right heart characteristic and/or function?

(A) supplies blood to the pulmonary circulation

(B) normal pressure in the ventricle is approximately 140 mm Hg

(C) blood returning to the right heart has a lower oxygen saturation

(D) contains the tricuspid valve

19. Mitral valve stenosis results primarily from which of the following?

(A) atherosclerosis

(B) endocarditis

(C) hypertension

(D) rheumatic disease

20. Vegetations are more commonly associated with which of the following?

(A) pulmonary hypertension

(B) aneurysms

(C) endocarditis

(D) mitral valve disease

21. Which of the following is not a type of bioprosthetic heart valve?

(A) xenograft

(B) heterograft

(C) homograft

(D) Bjork–Shiley valve

22. Which of the following would indicate pericardial effusion?

(A) 5–10 mL of fluid

(B) 10–15 mL of fluid

(C) 15–50 mL of fluid

(D) 75–100 mL of fluid

23. The term cardiomyopathy is used to describe which of the following?

(A) pericardial effusion

(B) variety of cardiac diseases that affect the pericardium

(C) variety of cardiac diseases that affect the myocardium

(D) variety of cardiac diseases that affect the endocardium

24. What is the most common type of benign tumor of the heart?

(A) myxoma

(B) rhabdomyoma

(C) lipoma

(D) fibroma

25. What is the most common malignant cardiac tumor?

(A) teratoma

(B) rhabdomyoma

(C) carcinoma

(D) angiosarcoma

26. Which type of aneurysm results from intimal tears of the aortic wall?

(A) saccular

(B) fusiform

(C) pseudo

(D) dissecting

27. What is the most common congenital heart disease?

(A) atrial septal defects

(B) ventricular septal defects

(C) muscular septal defects

(D) abnormalities of the left ventricular outflow tract

28. What is the primary congenital disease in adults that produces cyanosis?

(A) pulmonic stenosis

(B) Coarctation of the Aorta

(C) persistent ductus arteriosus

(D) tetralogy of Fallot

29. Which of the following is not a characteristic of cardiomyopathy?

(A) dilatation

(B) pericarditis

(C) restrictive

(D) hypertrophic

30–36. Identify the structures in Fig. 2–13.

Image

FIGURE 2–13. Events of the cardiac cycle.

30. aortic valve closure

31. _______ aortic valve opening

32. _______ aortic pressure

33. _______ left ventricular pressure

34. _______ mitral valve closure

35. _______ left atrial pressure

36. ________ mitral valve opening

37. In stenotic diseases of the tricuspid, which of the following is dilated?

(A) left atrium

(B) left ventricle

(C) right atrium

(D) right ventricle

38. In tricuspid valve disease, what is the primary cause of regurgitation?

(A) carcinoid heart disease

(B) prolapse of the valve

(C) rheumatic heart disease

(D) secondary to pulmonary hypertension

39. Which of the following is not a type of endocarditis?

(A) Ebstein’s anomaly

(B) bacterial

(C) mycotic

(D) Löffler’s

40. Which of the following is not a clinical symptom associated with aortic valve stenosis?

(A) chest pain

(B) dyspnea on exertion

(C) shortness of breath

(D) syncope

41. Which of the following is the bicuspid valve with two major leaflets?

(A) tricuspid valve

(B) aortic valve

(C) pulmonic valve

(D) mitral valve

42. What is a classic finding in mitral valve prolapse?

(A) systolic doming

(B) fluttering of the mitral valve

(C) pulmonary edema

(D) a systolic click

43. What is the most common cause of a flail leaflet?

(A) rupture of the chordal tendineae

(B) rupture of the papillary muscle

(C) annular calcification

(D) congenital defect

44. Which cardiac examination provides the highest resolution?

(A) transthoracic echocardiography

(B) contrast transthoracic echocardiography

(C) stress echocardiography

(D) transesophageal echocardiography

45. In which cardiac sinus is a thin fold of tissue guard called the the besian valve?

(A) sinus of Morgagni

(B) aortic sinus

(C) coronary sinus

(D) sinus of Valsalva

46. What is the average length of an adult heart?

(A) 12 cm

(B) 8–9 cm

(C) 6 cm

(D) 16 cm

47. The atrioventricular node is located in which trinagular region of the right atrium?

(A) posterior region

(B) anterior region

(C) triangular region

(D) triangle of Koch

48. Which vessel drains the head and parts of the upper extremities?

(A) aorta

(B) superior vena cava

(C) inferior vena cava

(D) portal venous system

49. Which of the following views would best demonstrate all four cardiac chambers simultaneously?

(A) left parasternal

(B) right parasternal

(C) subcostal

(D) suprasternal

50. Which of the following is used to denote the three orthogonal planes for two-dimensional echocardiographic imaging?

(A) long axis, short axis, and four chamber

(B) apical, subcostal, and parasternal

(C) suprasternal, right sternal border, and left sternal border

(D) anterior, posterior, and coronal

51. Which of the following abnormalities are usually best demonstrated with the subcostal four-chamber view?

(A) atrial septal defects and ventricular septal defects

(B) mitral regurgitation and tricuspid regurgitation

(C) mitral stenosis and tricuspid stenosis

(D) aortic insufficiency and pulmonic insufficiency

52. Which of the following terms is used to describe the control that suppresses near-field echoes and enhances the intensity of the far-field echoes?

(A) attenuation

(B) time-gain compensation

(C) reject

(D) compression

53. When does the tricuspid valve open?

(A) the right ventricular pressure drops below the right atrial pressure

(B) the papillary muscle contracts

(C) the velocity of blood flow in the right ventricle exceeds the velocity of flow in the right atrium

(D) the pulmonic valve opens

54. Which of the following is not a remnant of the fetal circulation?

(A) the eustachian valve

(B) the coronary ligament

(C) the foramen ovale

(D) the ligamentum arteriosus

55. Blood normally flows from the right ventricle to which of the following?

(A) pulmonary artery

(B) aorta

(C) right atrium

(D) pulmonary vein

56. A pulmonary vein is normally attached to which of the following?

(A) right ventricle

(B) left ventricle

(C) left atrium

(D) right atrium

57. Which of the following statements regarding cardiac anatomy is false?

(A) The heart tends to assume a more vertical position in tall thin people and a more horizontal position in short, heavy people.

(B) The ligamentum arteriosum runs from the left pulmonary artery to the descending aorta.

(C) The coronary arteries arise from the sinuses within the pockets of the left and right coronary cusps of the aortic valve.

(D) The left ventricle constitutes most of the ventral surface of the heart.

58. Left ventricular ejection time can be assessed from an M-mode echocardiogram by measuring the distance between which of the following?

(A) aortic valve opening and closing points

(B) mitral D and C points

(C) R wave and T wave

(D) mitral valve closure and aortic valve opening

59. Often, what is the best two-dimensional view for examining patients with chronic obstructive pulmonary disease?

(A) parasternal

(B) apical

(C) suprasternal

(D) subcostal

60. What are the two best transducer positions for Doppler investigation of systolic blood flow across the aortic valve?

(A) parasternal and suprasternal

(B) apical and right sternal border

(C) suprasternal and subcostal

(D) subcostal and apical

61. When should the size of the left atrium be measured on the M-mode?

(A) at end-systole

(B) at the peak of the R wave

(C) with the onset of aortic valve opening

(D) at the beginning of the P wave

62. Doming of any cardiac valve on two-dimensional echocardiography is consistent with which of the following?

(A) regurgitation

(B) decreased cardiac output

(C) stenosis

(D) congenital malformation

63. Two-dimensional images are best obtained when the ultrasound beam is directed ______ to the structure of interest. Doppler signals are best obtained when the ultrasound beam is directed ______ to the flow of blood.

(A) oblique; perpendicular

(B) parallel; perpendicular

(C) perpendicular; parallel

(D) perpendicular; oblique

64. Right ventricular systolic pressure overload can be caused by which of the following?

(A) pulmonary insufficiency

(B) an atrial septal defect

(C) aortic stenosis

(D) pulmonary hypertension

65. Left ventricular measurements should be obtained from the parasternal long-axis view at the level of which of the following?

(A) mitral valve annulus

(B) tips of the mitral leaflets

(C) chordae tendineae

(D) papillary muscle

66. Which of the following cannot cause paradoxical interventricular septal motion?

(A) left bundle branch block

(B) postpericardiotomy

(C) left ventricular volume overload

(D) severe tricuspid regurgitation

67. In a patient with volume overload of the right ventricle, the onset of ventricular systole is likely to show the interventricular septum moving

(A) toward the right ventricular free wall

(B) toward the left ventricular wall

(C) laterally

(D) not at all

68. A murmur that is associated with a thrill is likely to be which of the following?

(A) organic in origin

(B) insignificant

(C) functional

(D) the result of an atrial septal defect

69. The Valsalva maneuver and the inhalation of amyl nitrite are techniques that are sometimes used during an echocardiographic examination when checking for which of the following?

(A) mitral valve prolapse or systolic anterior motion of the mitral valve

(B) aortic stenosis or mitral stenosis

(C) aortic stenosis or aortic regurgitation

(D) a ventricular septal defect or pulmonic stenosis

70. Clubbing of the fingers and nail beds is a sign of which of the following?

(A) cyanotic heart disease

(B) Marfan syndrome

(C) Barlow syndrome

(D) increased cardiac output

71. Even though two-dimensional echocardiography has largely replaced M-mode echocardiography for cardiac diagnosis, M-mode still has the advantage of which of the following?

(A) defining spatial relationships of cardiac structures

(B) providing enhanced temporal resolution

(C) providing dynamic assessment of the velocity of blood flow

(D) providing superior lateral resolution

72. When attempting a parasternal short-axis view, if the left ventricle appears oval rather than circular, where should the echocardiographer move the transducer?

(A) medially

(B) laterally

(C) to a higher intercostal space

(D) to a lower intercostal space

73. A Doppler tracing of the mitral valve in which the A point is higher than the E point indicates which of the following?

(A) high cardiac output

(B) low cardiac output

(C) decreased left ventricular compliance

(D) high left ventricular end-diastolic pressures

74. Which of the following is usually not a secondary finding in patients with mitral stenosis?

(A) a dilated left atrium

(B) a dilated right atrium

(C) a left ventricular thrombus

(D) a left atrial thrombus

75. Which of the following is most likely to not be demonstrated on the Doppler signal obtained from the apex in a patient with mitral stenosis?

(A) an increased diastolic peak velocity

(B) spectral broadening

(C) a decreased E–F slope

(D) a peak gradient occurring in late diastole

76. Torn chordae tendineae will cause which of the following?

(A) aortic insufficiency

(B) myocardial infarction

(C) mitral insufficiency

(D) mitral stenosis

77. Which of the following cannot produce false-positive signs of mitral valve prolapse on an M-mode?

(A) pericardial effusion

(B) premature ventricular contractions

(C) improper placement of the transducer

(D) hypertrophic obstructive cardiomyopathy

78. Which of the following is a secondary echocardiographic finding in mitral regurgitation?

(A) a dilated left atrium

(B) left ventricular hypertrophy

(C) a hypokinetic left ventricle

(D) a dilated aortic root

79. The degree of mitral regurgitation is best estimated by measuring which of the following?

(A) width and length of the systolic jet by color Doppler

(B) peak velocity of the continuous-wave Doppler systolic mitral signal

(C) pressure half-time of the continuous-wave Doppler diastolic signal

(D) integral of the continuous-wave systolic curve

80. Which of the following is least likely to occur as a sequela of rheumatic fever?

(A) mitral stenosis

(B) mitral insufficiency

(C) aortic stenosis

(D) pulmonic stenosis

81. The two-dimensional echocardiogram of a patient with combined mitral and aortic stenosis is most likely to demonstrate which of the following?

(A) a dilated left atrium and left ventricular hypertrophy

(B) a dilated left atrium and a dilated left ventricle

(C) a small left atrium and a small left ventricle

(D) systolic anterior motion of the mitral valve and left ventricular hypertrophy

82. Why is the M-mode of the mitral valve in mitral stenosis often missing an A wave?

(A) high initial diastolic pressures in the left ventricle

(B) concurrent atrial fibrillation

(C) decreased compliance of the left ventricle

(D) a dilated left atrium

83. A Doppler tracing that demonstrates a late diastolic mitral inflow velocity (A point) that is higher than the initial diastolic velocity (E point) can be seen with which of the following pathologies?

(A) aortic insufficiency

(B) hypertrophic cardiomyopathy

(C) mitral regurgitation

(D) a ventricular septal defect

84. If the two-dimensional examination demonstrates a markedly dilated and hyperkinetic left ventricle and a left atrium of normal size, one should suspect the presence of which of the following?

(A) mitral regurgitation

(B) aortic regurgitation

(C) a ventricular septal defect

(D) aortic stenosis

85. Which group of echocardiographic findings would give a definitive diagnosis of mitral stenosis?

(A) a decreased E–F slope, a dilated left atrium, and a small left ventricle

(B) a thickened mitral valve, a dilated left atrium, and a small left ventricle

(C) a decreased E–F slope, a thickened mitral valve, and diastolic doming of the mitral valve

(D) a thickened mitral valve and a mitral diastolic velocity >1.5 m/s

86. A patient with mitral stenosis will usually not have which of the following?

(A) a diastolic rumble on auscultation

(B) an increased E–F slope on M-mode

(C) a history of rheumatic fever

(D) a dilated left atrium

87. To obtain the true circumference of the mitral valve, one should obtain a short-axis view at the level of which of the following?

(A) papillary muscle

(B) chordae tendineae

(C) tips of the mitral leaflets

(D) mitral annulus

88. Which of the following is not a secondary echocardiographic finding of mitral stenosis?

(A) a dilated left atrium

(B) a dilated right atrium

(C) a dilated left ventricle

(D) a left atrial thrombus

89. Which of the following is a successful mitral valve commissurotomy least likely to demonstrate?

(A) doming of the mitral valve

(B) mitral valve thickening

(C) an increase in pressure half-time

(D) a dilated left atrium

90. Which of the following can be suggested by left ventricular dilatation in a patient with mitral stenosis?

(A) severe mitral stenosis

(B) concomitant mitral regurgitation

(C) aortic stenosis

(D) hypertrophic cardiomyopathy

91. Early diastolic closure of the mitral valve is usually a sign of which of the following?

(A) severe acute aortic regurgitation

(B) a left bundle branch block

(C) poor function of the left ventricle

(D) first-degree A-V block

92. Which one of the following conditions cannot accelerate degenerative calcification of the mitral annulus?

(A) systemic hypertension

(B) aortic stenosis

(C) hypertrophic obstructive cardiomyopathy

(D) a ventricular septal defect

93. A mitral valve pressure half-time of 220 ms is consistent with which of the following mitral valve areas?

(A) 0.6 cm2

(B) 1 cm2

(C) 2.2 cm2

(D) 5 cm2

94. Echocardiographic findings of significant aortic stenosis do not include which of the following?

(A) reduced separation of the aortic valve cusp

(B) diastolic fluttering of the anterior mitral leaflet

(C) Doppler systolic velocities greater than 4 m/s

(D) thickened left ventricular walls

95. Which of the following causes the left ventricular walls to appear thick on an echocardiogram?

(A) mitral stenosis

(B) aortic insufficiency

(C) mitral regurgitation

(D) systemic hypertension

96. The presence of a systolic ejection murmur should alert one to look for which of the following?

(A) a ventricular septal defect

(B) mitral regurgitation

(C) aortic stenosis

(D) patent ductus arteriosus

97. Which of the following statements regarding a bicuspid aortic valve is false?

(A) The problem is a congenital one.

(B) It may be associated with aortic stenosis.

(C) It is often seen in conjunction with mitral stenosis.

(D) It may be associated with Coarctation of the Aorta.

98. The continuity equation is used to calculate the ______. It is most helpful in patients with______.

(A) mitral valve area; mitral stenosis

(B) aortic valve area; poor left ventricular function

(C) aortic valve velocity; systemic hypertension

(D) degree of shunting; a ventricular septal defect

99. In patients with combined aortic stenosis and aortic insufficiency, which of the following parameters is best for assessing the severity of aortic stenosis?

(A) the maximum pressure gradient

(B) the mean pressure gradient

(C) the high pulse-repetition frequency

(D) the analog waveform

100. Which of the following two-dimensional views will best illustrate a color Doppler jet of aortic insufficiency?

(A) the apical long-axis view

(B) the suprasternal view

(C) the subcostal fine-chamber view

(D) the short-axis view of the base

101. Which of the following is a secondary echocardiographic sign of aortic stenosis?

(A) a thickened aortic valve

(B) left ventricular hypertrophy

(C) a hyperdynamic left ventricle

(D) a dilated left ventricle

102. Which of the following is consistent with an M-mode finding of fine diastolic fluttering of the anterior mitral leaflet?

(A) aortic insufficiency

(B) mitral stenosis

(C) atrial fibrillation

(D) a prolonged heart rate

103. Diastolic velocity signals were detected in a patient’s left ventricular outflow tract using pulsed Doppler. They could be detected between the tip of the anterior mitral leaflet and the aortic valve from the parasternal position. Which of the following can be said about this finding?

(A) normal

(B) consistent with severe mitral regurgitation

(C) consistent with severe aortic regurgitation

(D) consistent with moderate aortic regurgitation

(E) consistent with moderate mitral regurgitation

104. The referring physician hears an Austin-Flint murmur. What is the M-mode echocardiogram of this patient most likely to demonstrate?

(A) a thickened mitral valve with a decreased E-F slope

(B) fine diastolic fluttering and possible flattening of the anterior mitral leaflet

(C) a thickened aortic valve with a decreased opening

(D) systolic posterior motion of the tricuspid valve

105. Which of the following is the best approach for obtaining the maximum aortic velocity in patients with aortic stenosis?

(A) left sternal border

(B) left supraclavicular region

(C) subcostal region

(D) right sternal border view

106. The best way to rule out an aortic dissection is with which of the following?

(A) M-mode echocardiography

(B) transthoracic two-dimensional imaging

(C) color Doppler

(D) transesophageal echocardiography

107. Which echocardiographic finding is not associated with tricuspid insufficiency?

(A) a dilated right atrium

(B) tricuspid prolapse

(C) a dilated right ventricle

(D) a thickened anterior right ventricle wall

108. A tricuspid regurgitant velocity of 4 m/s indicates the presence of which of the following?

(A) tricuspid stenosis

(B) severe tricuspid regurgitation

(C) a flail tricuspid leaflet

(D) pulmonary hypertension

109. Which of the following regarding tricuspid stenosis is not true?

(A) It occurs as a sequela to rheumatic fever.

(B) Doppler echocardiography demonstrates a decreased pressure half-time.

(C) Two-dimensional echocardiography shows diastolic doming, and M-mode reveals a decreased E–F slope.

(D) It is usually seen as part of the aging process.

110. A peripheral contrast injection into the arm of a patient with severe tricuspid regurgitation is likely to demonstrate which of the following?

(A) contrast in the pulmonary veins during diastole

(B) right-to-left shunting

(C) contrast in the inferior vena cava during ventricular systole

(D) left-to-right shunting

111. If the physician suspects carcinoid heart disease, the echocardiographer should pay special attention to which of the following?

(A) mitral valve

(B) tricuspid valve

(C) inferior vena cava

(D) interatrial septum

112. Which of the following can be calculated using the velocity of a tricuspid regurgitant jet?

(A) the severity of tricuspid regurgitation

(B) right ventricular systolic pressure

(C) the severity of pulmonic regurgitation

(D) left atrial pressure

113. Coarse systolic fluttering of the pulmonic valve with an extremely high systolic velocity in the right ventricular outflow tract is most likely to be found in a patient with which of the following?

(A) pulmonic regurgitation

(B) paradoxical interventricular septal motion

(C) infundibular pulmonic stenosis

(D) pulmonary hypertension

114. Which of the following is the most common window used to record peak pulmonic systolic velocity?

(A) suprasternal

(B) apical

(C) right parasternal

(D) left parasternal

115. The pulmonic valve is located where in relation to the aortic valve?

(A) cranial and lateral

(B) caudal and lateral

(C) cranial and medial

(D) caudal and medial

116. Which one of the following echocardiographic findings is not associated with pulmonic stenosis?

(A) right ventricular hypertrophy

(B) M-mode demonstration of a steep pulmonic A wave

(C) midsystolic notching noted on M-mode

(D) systolic pulmonic Doppler velocities >3 m/s

117. Valvular vegetations are best detected with which of the following?

(A) M-mode echocardiography

(B) two-dimensional echocardiography

(C) Doppler echocardiography

(D) contrast injection

118. A 30-year-old intravenous drug abuser presents with an embolus to the right leg. The presence of which of the following is the most likely cause of the embolic event?

(A) a left atrial myxoma

(B) mitral valve vegetation

(C) a right ventricular thrombus

(D) a myocardial abscess

119. Color Doppler assessment of prosthetic heart valves is especially helpful when checking for which of the following?

(A) presence of valve stenosis

(B) presence of paravalvular regurgitation

(C) presence of a clot

(D) valve area

120. Which of the following describes a normally functioning Starr–Edwards valve?

(A) may exhibit high Doppler velocities

(B) will echocardiographically resemble a bioprosthetic valve

(C) has a major and a minor orifice

(D) may exhibit mild to moderate regurgitation

121. Which of the following describes a Bjork–Shiley?

(A) an example of a mechanical heart valve

(B) an example of a bioprosthetic heart valve

(C) not noticeable on the two-dimensional image

(D) a surgical procedure used to correct for transposition of the great vessels

122. Which of the following echocardiographic examinations is best used for evaluating the function of a prosthetic valve?

(A) M-mode echocardiography

(B) high-pulse repetition-frequency Doppler echocardiography

(C) transesophageal echocardiography

(D) contrast echocardiography

123. Which one of the following is not an example of a mechanical prosthetic valve?

(A) St. Jude

(B) Bjork–Shiley

(C) Starr–Edwards

(D) Hancock

124. To check for prosthetic valve dehiscence, what should the echocardiographer look for?

(A) decreased valve excursion

(B) an abnormal mass of echoes on the valve

(C) abnormal rocking motion of the valve

(D) Doppler evidence of stenosis

125. A 26-year-old woman with significant mitral insufficiency is about to receive a mitral valve replacement. Why are the surgeons most likely to use a porcine valve?

(A) It tends to last longer.

(B) It preserves myocardium better.

(C) It often makes anticoagulation unnecessary.

(D) It obstructs flow less.

126. Why are prophylactic antibiotics often recommended for individuals with mitral valve prolapse who are undergoing dental or surgical procedures?

(A) These patients are at a higher risk for endocarditis.

(B) To prevent possible mitral regurgitation.

(C) To prevent pneumonia.

(D) Incisions on patients with mitral valve prolapse usually take longer to heal.

127. One can be reasonably certain that a large amount of pericardial effusion is present by noting which of the following?

(A) echocardiographic signs of cardiac tamponade

(B) a crescent-shaped pattern on the short-axis view

(C) a “swinging heart” on the two-dimensional examination

(D) a posterior echo-free space

128. Which of the following is true concerning constrictive pericarditis?

(A) It impairs diastolic filling.

(B) It is sometimes referred to as “Dressler’s syndrome.”

(C) It is detected by noting increased echogenicity of the pericardium.

(D) It is usually associated with a large pericardial effusion.

129. When is cardiac tamponade most likely to occur?

(A) Pressure in the pericardial cavity rises to equal or exceed the diastolic pressure in the heart.

(B) There is a small pericardial effusion.

(C) There is a large chronic pericardial effusion.

(D) The pericardium becomes a sheath of fibrous tissue that interferes with diastolic filling.

130. Which one of the following statements about pericardial effusion is false?

(A) Pericardial effusion may be confused with epicardial fat.

(B) An effusion may accumulate anteriorly without accumulating posteriorly.

(C) A pericardial effusion can consist of blood or clear fluid.

(D) In Dressler’s syndrome, a pericardial effusion develops as a result of renal disease.

131. A 38-year-old woman with a history of breast cancer is referred for an echocardiogram because she is experiencing shortness of breath. Which of the following is the echocardiogram most likely to reveal?

(A) metastasis to the left atrium

(B) metastasis to the right atrium

(C) a left atrial myxoma

(D) a pericardial effusion

132. Which one of the following cannot lead to a false-positive diagnosis of pericardial effusion on M-mode?

(A) the descending aorta

(B) a calcified mitral annulus

(C) ascites

(D) mitral valve prolapse

133. A false-negative sign of tamponade may occur in patients with which of the following?

(A) pulmonic stenosis

(B) a pleural effusion

(C) mitral regurgitation

(D) loculated effusions

134. Why does the pericardium appear as an extremely bright linear structure on the echocardiogram?

(A) It is a thick structure.

(B) It is a fibrous band.

(C) There is a large acoustic mismatch between lung tissue and pericardial tissue.

(D) It contains calcium.

135. Which two echocardiographic techniques are useful when evaluating for the presence of pericardial effusion?

(A) increasing reject and decreasing frame-rate

(B) decreasing time-gain control and increasing overall gain

(C) decreasing overall gain and increasing depth setting

(D) increasing reject and decreasing depth setting

136. Which structure often aids in differentiating a pericardial effusion from a pleural effusion on two-dimensional examination?

(A) liver

(B) inferior vena cava

(C) pleural sac

(D) descending aorta

137. Flat mid-diastolic motion of the posterior wall on an M-mode echocardiogram suggests which of the following?

(A) constrictive pericarditis

(B) left ventricular volume overload

(C) myocardial infarction

(D) dilated cardiomyopathy

138. What is the most striking echocardiographic feature of patients with an absent pericardium?

(A) excessive cardiac motion

(B) absence of bright linear pericardial echoes

(C) hypokinesis of the heart

(D) dyskinetic motion of the heart

139. What is the effect of systemic hypertension on the heart?

(A) thickening of the right ventricular free wall

(B) decreased systolic function of the left ventricle

(C) reduced compliance of the left ventricle

(D) right ventricular dilatation

140. Which of the following is not an echocardiographic sign of outflow tract obstruction in hypertrophic cardiomyopathy?

(A) midsystolic notching of the aortic valve

(B) left ventricular hypertrophy

(C) systolic anterior motion of the mitral valve

(D) high systolic velocity in the left ventricular outflow tract

141. A definitive diagnosis of amyloid heart disease is best made with which of the following?

(A) M-mode echocardiography

(B) transthoracic echocardiography

(C) transesophageal echocardiography

(D) endomyocardial biopsy

142. Which of the following cannot cause dilated (congestive) cardiomyopathy?

(A) coronary artery disease

(B) sarcoidosis

(C) viral myocarditis

(D) long-term alcohol abuse

143. Which of the following is not an echocardiographic finding seen in dilated cardiomyopathy?

(A) increased systolic velocity in the left ventricular outflow tract

(B) dilated chambers

(C) global hypokinesis

(D) an increased E point-to-septal separation

144. Which of the following is true concerning cardiac contusion?

(A) It is more likely to affect the right ventricle than the left ventricle.

(B) It is the same as a myocardial infarction.

(C) It occurs when there is underlying coronary artery disease.

(D) It leads to hypercontractility of the left ventricle.

145. A 64-year-old man presents with an acute myocardial infarction of the anterior wall and an embolus to the right leg. Before beginning the examination, the echocardiographer should suspect the possibility of which one of the following (choose the most likely diagnosis)?

(A) an apical aneurysm with a mural thrombus

(B) mitral stenosis and a left atrial clot

(C) a right ventricular infarct with a clot

(D) vegetation on the mitral or aortic valve

146. Which one of the following echocardiographic findings is not consistent with diastolic dysfunction of the left ventricle?

(A) M-mode demonstration of a mitral valve B notch

(B) M-mode demonstration of a high mitral A wave

(C) two-dimensional demonstration of an ejection fraction lower than 50%

(D) Doppler demonstration of a mitral valve E-to-A ratio >1.0

147. Akinesis of the anterior left ventricular wall is most likely to indicate obstruction of which of the following arteries?

(A) right coronary artery

(B) left circumflex artery

(C) left anterior descending artery

(D) posterior descending artery

148. Which of the following is true concerning pseudoaneurysms?

(A) They are usually hyperkinetic.

(B) They have a low risk of rupture.

(C) They have walls comprised of endocardium, myocardium, epicardium, and pericardium.

(D) They have a narrow neck.

149. An increased E point-to-septal separation is usually a good indicator of which of the following?

(A) high end-diastolic pressures in the left ventricle

(B) a reduced ejection fraction

(C) high initial diastolic pressures

(D) poor compliance of the left ventricle

150. Which of the following best describes a segment of the left ventricle that lacks systolic wall thickening and motion?

(A) hypokinetic

(B) akinetic

(C) dyskinetic

(D) aneurysmal

151. Aneurysms in the inferior wall of the left ventricle may be associated with all of the following except

(A) an increased E point-to-septal separation

(B) thrombus formation

(C) mitral regurgitation

(D) occlusion of the left anterior descending coronary artery

152. The echocardiogram of a patient with a ruptured papillary muscle will exhibit which of the following?

(A) mitral valve prolapse

(B) severe mitral regurgitation

(C) some degree of aortic insufficiency

(D) dyskinesis of the posterior left ventricular wall

153. Which of the following describes stress echocardiography?

(A) It is used instead of standard stress testing.

(B) It is used in the study of acoustic properties of the myocardium.

(C) It allows for visualization of myocardial perfusion.

(D) It is used in diagnosing ischemic heart disease.

154. Which of the following statements regarding left atrial myxomas is not true?

(A) They usually attach to the interatrial septum.

(B) They may be pedunculated.

(C) They do not recur once they are surgically removed.

(D) Clinically, they can mimic mitral stenosis.

155. The QP/QS ratio is used to evaluate the severity of which of the following?

(A) pulmonic stenosis

(B) ventricular septal defects

(C) aortic stenosis

(D) systemic hypertension

156. Which of the following would best describe the pulsed Doppler pattern of a patent ductus arteriosus if the sample volume were placed in the pulmonary artery from a short-axis view of the base of the heart?

(A) systolic flow below baseline

(B) continuous flow (systolic and diastolic) above baseline

(C) diastolic flow above baseline

(D) a biphasic systolic flow pattern below baseline

157. Which of the following is the best way to detect a small atrial septal defect?

(A) two-dimensional echocardiography

(B) contrast injection echocardiography

(C) M-mode echocardiography

(D) pulsed-wave Doppler echocardiography

158. What is the most common type of atrial septal defect?

(A) primurn

(B) secundum

(C) fenestrated

(D) sinus venosus

159. Which of the following is consistent with a ventricular septal defect with right-to-left shunting?

(A) Ebstein’s anomaly

(B) tetralogy of Fallot

(C) Eisenmenger’s syndrome

(D) a double-outlet right ventricle

160. Which of the following is not associated with Ebstein’s anomaly?

(A) an abnormally large tricuspid valve

(B) infundibular pulmonic stenosis

(C) “atrialization” of the right ventricle

(D) an atrial septal defect

161. The echocardiogram of a patient with an endocardial cushion defect might exhibit which of the following?

(A) a muscular ventricular septal defect and tricuspid valve vegetation

(B) a hypokinetic left ventricle and mitral valve vegetation

(C) overriding of the aorta and subpulmonic stenosis

(D) ostium primum atrial septal defect and an inlet ventricular septal defect

162. An echocardiographic diagnosis of Coarctation of the Aorta can be made by detecting a high-velocity Doppler jet in which of the following?

(A) left branch of the pulmonary artery

(B) aortic arch, proximal to the subclavian artery

(C) descending thoracic aorta

(D) abdominal aorta

163. Which of the following is not one of the four principal components of tetralogy of Fallot?

(A) a ventricular septal defect

(B) an override of the aorta

(C) an obstruction of pulmonary blood flow

(D) an atrial septal defect

164. Which of the following describes cor triatriatum?

(A) It is a fairly common congenital abnormality.

(B) It is a congenital malformation in which a fibrous membrane divides the left atrium into an upper and lower chamber.

(C) It results in mitral stenosis.

(D) It is a condition in which the pulmonary veins drain into the right atrium.

165. Which of the following echocardiographic findings is most commonly associated with left bundle branch block?

(A) left ventricular hypertrophy

(B) a hypercontractile interventricular septum

(C) paradoxical septal motion

(D) a dilated left ventricle

166. The echocardiographic pattern of the mitral valve in Fig. 2–14 is consistent with which of the following?

(A) mitral stenosis

(B) mitral valve vegetation

(C) a mechanical prosthetic valve

(D) a calcified mitral valve annulus

Image

FIGURE 2–14. Apical four-chamber view.

167. The M-mode pattern in Fig. 2–15 suggests which of the following about the ejection fraction of the left ventricle?

(A) normal

(B) mildly increased

(C) significantly increased

(D) significantly decreased

Image

FIGURE 2–15. M-mode echocardiogram at the level of the mitral valve.

168. What other hemodynamic information could be derived from the M-mode (Fig. 2–15)?

(A) cardiac output is increased

(B) left ventricular end-diastolic pressure is increased

(C) the systolic ejection period is prolonged

(D) atrial flutter is present

169. The Doppler tracing in Fig. 2–16 demonstrates which of the following?

(A) aortic stenosis and aortic insufficiency

(B) mitral stenosis and mitral regurgitation

(C) tricuspid stenosis and tricuspid regurgitation

(D) mitral stenosis and aortic stenosis

Image

FIGURE 2–16. Continuous-wave Doppler tracing obtained from the apical position.

170. The echocardiographic findings in Fig. 2–17 indicate that the patient probably has a history of which of the following?

(A) hypertension

(B) diabetes mellitus

(C) rheumatic fever

(D) coronary artery disease

Image

FIGURE 2–17. Split-screen display of a two-dimensional long-axis (left) and a correlating M-mode pattern (right). Note M-mode scan plane indicated by cursor (arrow).

171. What is the arrow in Fig. 2–17 pointing to?

(A) a side-lobe artifact

(B) papillary muscle

(C) chordae tendineae

(D) the anterior mitral leaflet

172Fig. 2–18 demonstrates echoes within the left ventricular cavity. These echoes are which of the following?

(A) artifactual

(B) caused by a mural thrombus

(C) caused by stagnant blood

(D) caused by a high near-gain setting

Image

FIGURE 2–18. Apical four-chamber view showing a dilated left ventricle.

Questions 173 through 179: Match the numbered structures in Fig. 2–19 with the correct term given in Column B.

Image

FIGURE 2–19. Parasternal long-axis view with an increased depth setting.

COLUMN A

173 ________

174 ________

175 ________

176 _______

177 ________

178 ________

179________

COLUMN B

left ventricle

coronary sinus

left atrium

right ventricle

pericardial effusion

descending aorta

pleural effusion aortic root right atrium

180. What is demonstrated in Fig. 2–20?

(A) a large pleural effusion

(B) pneumomediastinum

(C) ascites

(D) a large pericardial effusion

Image

FIGURE 2–20. Apical four-chamber view.

181. The echocardiographic examination of this patient should include analysis of the motion of which of the following?

(A) interventricular septum

(B) right ventricular wall

(C) left ventricular wall

182. Color Doppler interrogation of the aortic valve shown in Fig. 2–21 is most likely to demonstrate which of the following?

(A) a narrow diastolic jet directed at the anterior mitral leaflet

(B) a diastolic jet filling the left ventricular outflow tract and extending deep into the left ventricle

(C) a normal pattern of blood flow

(D) a narrow systolic jet directed at the anterior mitral leaflet

Image

FIGURE 2–21. Narrow sector parasternal long-axis view.

183. The arrow in Fig. 2–22 is pointing to which of the following?

(A) a fistula between the aorta and right ventricle

(B) the coronary sinus

(C) the left main coronary artery

(D) the origin of the right coronary artery

Image

FIGURE 2–22. Short-axis view of the base of the heart.

184. The right ventricular outflow tract is located medial to the arrow in Fig. 2–22.

(A) true

(B) false

185. The contrast study in Fig. 2–23 shows which of the following?

(A) left-to-right shunting at the atrial level

(B) no shunting of blood

(C) right-to-left shunting at the atrial level

(D) right-to-left shunting at the ventricular level

Image

FIGURE 2–23. Subcostal four-chamber view with contrast injection.

186. A secondary finding noted on Fig. 2–23 is a moderate-sized pericardial effusion.

(A) true

(B) false

187. The arrow in Fig. 2–23 is pointing to which of the following?

(A) lung tissue

(B) liver parenchyma

(C) a mediastinal tumor

(D) the spleen

188. The absence of an A wave and midsystolic notching of the pulmonic valve on the M-mode in Fig. 2–24 is consistent with which of the following?

(A) pulmonic stenosis

(B) tricuspid stenosis

(C) mitral stenosis

(D) pulmonary hypertension

Image

FIGURE 2–24. M-mode of the pulmonic valve.

189. What other abnormality should be ruled out in the presence of the abnormality noted on the M-mode of the tricuspid valve in Fig. 2–25?

(A) tricuspid stenosis

(B) pulmonary hypertension

(C) mitral valve prolapse

(D) atrial septal defect

Image

FIGURE 2–25. M-mode of the tricuspid valve.

190. An 85-year-old woman with a long history of chest pain is sent for an echocardiogram. The M-mode of the mitral valve is shown in Fig. 2–26. The M-mode of the aortic valve would be likely to demonstrate which of the following?

(A) diastolic fluttering

(B) delayed opening

(C) midsystolic notching

(D) systolic fluttering

Image

FIGURE 2–26. M-mode echocardiogram at the level of the mitral valve.

191. An extremely tall, slender young man was referred for an echocardiogram because he has a murmur. Echocardiographic findings in Fig. 2–27 include which of the following?

(A) a bicuspid aortic valve

(B) a cleft mitral valve

(C) a dilated aortic root

(D) left ventricular hypertrophy

Image

FIGURE 2–27. Parasternal long-axis view.

192. Which echocardiographic view would be best for further evaluation of this abnormality?

(A) the long-axis suprasternal view

(B) the short-axis view of the base of the heart

(C) the apical four-chamber view

(D) the subcostal four-chamber view

193. The left ventricle in Fig. 2–28 demonstrates which of the following?

(A) hypertrophic cardiomyopathy

(B) an infiltrative tumor

(C) a large apical thrombus

(D) a myxoma

Image

FIGURE 2–28. Apical four-chamber view.

194. Which of the following is true about the mitral valve shown in Fig. 2–29?

(A) it is normal

(B) it is flail

(C) it is stenotic

(D) it is prolapsing

Image

FIGURE 2–29. Parasternal long-axis view.

195. What is the arrow in Fig. 2–30 pointing to?

(A) left subclavian artery

(B) right pulmonary artery

(C) superior vena cava

(D) left pulmonary vein

Image

FIGURE 2–30. Suprasternal notch long-axis view of the aorta and transverse arch.

196. Posterior to this structure is an echo-free space, which represents which of the following?

(A) the left atrium

(B) a pleural effusion

(C) pericardial effusion

(D) the superior vena cava

197. The curved arrow in Fig. 2–31 is directed at which of the following?

(A) a pacemaker wire

(B) the Chiari network

(C) false chordae tendineae

(D) the moderator band

Image

FIGURE 2–31. Apical four-chamber view.

198. The straight arrow in Fig. 2–31 is pointing to a structure that most likely represents which of the following?

(A) a right atrial myxoma

(B) a left atrial thrombus

(C) the left pulmonary vein

(D) the eustachian valve

199. The echocardiographic findings in the long-axis view presented in Fig. 2–32 include which of the following?

(A) a dilated left atrium, mitral stenosis, and a pericardial effusion

(B) aortic stenosis, a calcified mitral annulus, and basal septal hypertrophy

(C) a dilated coronary sinus, left ventricular hypertrophy, and mitral valve vegetation

(D) a dilated aortic root, a dilated left ventricle, and a thickened mitral valve

Image

FIGURE 2–32. Parasternal long-axis view with slightly increased depth setting.

200. What are these findings most consistent with?

(A) rheumatic heart disease

(B) congenital heart disease

(C) subacute bacterial endocarditis

(D) an aged heart

201. The mitral valve diastolic waveforms in Fig. 2–33C are not uniform. Which of the following causes this?

(A) high end-diastolic pressure of the left ventricle

(B) faulty technique

(C) inspiration

(D) atrial fibrillation

Image

Image

Image

FIGURE 2–33. (A) Parasternal long-axis view; (B) apical four-chamber view; (C) continuous-wave Doppler tracing of mitral inflow from the apical position.

The following study is of a 58-year-old woman who vaguely remembers a childhood illness that included pain in her joints. She presented with a transischemic attack and atrial fibrillation. For questions 202 through 204, refer to Fig. 2–33A, B, and C.

202. What does the mitral valve demonstrate?

(A) systolic prolapse

(B) diastolic doming

(C) myxomatous degeneration

(D) hyperkinesis

203. Which chamber is significantly dilated?

(A) the left atrium

(B) the left ventricle

(C) the right atrium

(D) the right ventricle

204. What is most likely to be revealed by auscultation of this patient?

(A) a midsystolic click

(B) a systolic ejection murmur

(C) a systolic rumble

(D) an opening snap

205. What is the arrow in Fig. 2–33B pointing to?

(A) coronary sinus

(B) inferior vena cava

(C) descending aorta

(D) left pulmonary vein

206. The pressure half-time derived from the Doppler tracing of the mitral valve in Fig. 2–33C can be used to estimate which of the following?

(A) the mitral valve area

(B) the mitral valve gradient

(C) the severity of aortic insufficiency

(D) the ejection fraction

A 52-year-old woman presents with chronic dyspnea. Chest x-ray reveals cardiomegaly. For questions 207 through 210, refer to Fig. 2–34A and B.

Image

Image

FIGURE 2–34. (A) Parasternal long-axis view; (B) apical four-chamber view.

207. What is the most striking feature of this echocardiogram?

(A) left atrial compression

(B) mitral valve doming

(C) left ventricular hypertrophy

(D) right ventricular dilatation

208. Which of the following are additional findings on this echocardiogram?

(A) a dilated aortic root, mitral valve prolapse, and a dilated coronary sinus

(B) a thickened mitral valve, a prominent inter-atrial septum, a small left ventricle, and pericardial effusion

(C) a calcified mitral annulus, an extracardiac mass, and pleural effusion

(D) left atrial dilatation, systolic anterior motion of the mitral valve, and a thickened aortic valve

209. Given all the above information, what is the most likely diagnosis?

(A) hypertrophic obstructive cardiomyopathy

(B) Marfan syndrome

(C) endomyocardial fibrosis

(D) amyloid cardiomyopathy

210. The best way to substantiate this diagnosis is by obtaining which of the following?

(A) a computed tomographic scan

(B) an endomyocardial biopsy

(C) a cardiac catheterization

(D) an electrocardiogram

A 64-year-old man sustained a myocardial infarction 1 week before this echocardiogram. He developed congestive heart failure and became hypotensive. A new murmur was detected on auscultation. For questions 211 through 215, refer to Fig. 2–35A and B.

Image

Image

FIGURE 2–35. (A) Parasternal short-axis view at the level of the papillary muscles; (B) modified apical four-chamber view: The transducer is angled posteriorly and the depth setting is decreased.

211. What does the echocardiogram reveal?

(A) dilated cardiomyopathy

(B) ventricular septal defect

(C) cleft mitral valve

(D) pseudoaneurysm

212. Which of the following would be most helpful in confirming the diagnosis?

(A) color-flow Doppler imaging

(B) M-mode echocardiography

(C) continuous-wave Doppler imaging

(D) pulsed-wave Doppler imaging

213. The arrow in Fig. 2–35B is pointing to a linear structure called which of the following?

(A) coronary sinus

(B) left anterior descending coronary artery

(C) left pulmonary vein

(D) left circumflex coronary artery

214. What does this linear structure contain?

(A) serous fluid

(B) deoxygenated blood

(C) oxygenated blood

(D) air

215. In Fig. 2–35B, in what direction would the transducer need to be directed to visualize the left ventricular outflow tract?

(A) anteriorly

(B) medially

(C) laterally

(D) inferiorly

A 34-year-old woman is extremely nervous at the time of the examination. She states that she often experiences chest pain and palpitations. Auscultation reveals a systolic murmur. For questions 216 through 219, refer to Fig. 2–36A and B.

Image

Image

FIGURE 2–36. (A) Narrow sector parasternal long-axis view; (B) apical four-chamber view.

216. What does the mitral valve demonstrate?

(A) diastolic doming

(B) prolapse of the anterior leaflet

(C) prolapse of the posterior leaflet

(D) systolic anterior motion

217. Continuous-wave Doppler evaluation of the mitral valve from the apical position would most likely demonstrate which of the following?

(A) a systolic curve below baseline >3 m/s

(B) a diastolic signal above baseline with a decreased pressure half-time

(C) a systolic curve above baseline <3 m/s

(D) a diastolic curve below baseline >3 m/s

218. The arrow in Fig. 2–36B is pointing to the posterior wall of the left ventricle.

(A) true

(B) false

219. The dropout of echoes in the interatrial septum in Fig. 2–36B is most likely which of the following?

(A) a primum atrial septal defect

(B) a secundum atrial septal defect

(C) artifactual

(D) the result of interatrial septal prolapse

A 23-year-old man was referred for an echocardiogram because a systolic ejection murmur was heard on auscultation. For questions 220 through 223, refer to Fig. 2–37A and B.

Image

Image

FIGURE 2–37. (A) M-mode tracing at the aortic valve level; (B) Continuous-wave Doppler tracing of aortic flow from the right sternal border (calibration marks are 1 m/s).

220. What does the M-mode of the aortic valve in Fig. 2–37A demonstrate?

(A) slight thickening of the valve with a normal opening

(B) the absence of aortic valve echoes

(C) systolic fluttering of the aortic valve

(D) a thickened aortic valve with a markedly decreased opening

221. According to the Doppler tracing in Fig. 2–37B, what is the approximate peak aortic gradient using the simplified Bernoulli formula?

(A) 4 mm Hg

(B) 16 mm Hg

(C) 36 mm Hg

(D) 100 mm Hg

222. Which of the following is the most likely diagnosis for this patient?

(A) aortic valve vegetation

(B) congenital aortic stenosis

(C) moderate aortic insufficiency

(D) rheumatic heart disease

223. Two-dimensional examination of the aortic valve is most likely to demonstrate which of the following?

(A) systolic doming

(B) a mass of echoes in the left ventricular outflow tract

(C) diastolic doming

(D) four aortic cusps

A 38-year-old woman, who recently had extensive dental work performed, presented with fever, chills, and a transischemic attack. Auscultation revealed a grade 2/6 systolic murmur. For questions 224 through 229, refer to Fig. 2–38A, B, and C.

224. Which of the following best describes the mitral valve?

(A) normal

(B) doming

(C) exhibiting shaggy irregular echoes

(D) flail

Image

Image

Image

FIGURE 2–38. (A) Parasternal long-axis view; (B) parasternal short-axis view at the papillary muscle level; (C) apical four-chamber view.

225. What is the most likely diagnosis for this patient?

(A) rheumatic heart disease

(B) subacute bacterial endocarditis

(C) ruptured papillary muscle

(D) mitral valve prolapse

226. Which of the following best describes the mitral valve excursion?

(A) reduced

(B) increased

(C) normal

(D) absent

227. Which of the following is most likely to be demonstrated on apical continuous-wave Doppler examination of the mitral valve?

(A) systolic waveform below baseline

(B) diastolic waveform below baseline

(C) diastolic waveform above baseline >3 m/s

(D) systolic waveform above baseline

228. By referring to all three echocardiographic views presented in this case, one could suggest which of the following about the mass of echoes on the mitral valve?

(A) it is stationary

(B) it prolapses into the left atrium

(C) it prolapses into the left ventricle

(D) it prolapses into the left atrium and left ventricle

229. What does the arrow in Fig. 2–38B point to?

(A) a mural thrombus

(B) the posteromedial papillary muscle

(C) vegetation

(D) a cleft mitral valve