Lange Review Ultrasonography Examination, 4th Edition

Answers and Explanations

At the end of each explained answer, there is a number combination in parentheses. The first number identifies the reference source; the second number or set of numbers indicates the page or pages on which the relevant information can be found.

1. (B) Secundum. Sinus venosus is the rarest form, and the single atrium is not considered to be an atrial septal defect because there is complete absence of the atrial septum. (13:1391)

2. (C) In the subxiphoid position, the sound beam is perpendicular to the interatrial septum, thereby utilizing the axial resolution of the transducer. The atrial septum may also be visualized from the parasternal short-axis view, but it is more parallel to the sound beam and, therefore, may not be resolved optimally. In the apical position, the sound beam is parallel to the atrial septum, and the atrial septum is a great distance from the transducer, so echocardiographic dropout may be mistaken for an atrial communication. (26:144–147)

3. (C) Sinus venosus atrial septal defects are bordered posteriorly by the posterior atrial wall and superiorly by the entrance of the superior vena cava. Because of this, the upper right pulmonary vein may empty into the right atrium or superior vena cava. (6:175)

4. (C) Ventricular Septal Defect. Atrial septal defect and pulmonary stenosis are also common. Mitral stenosis is relatively uncommon in the pediatric population. (6:190)

5. (B) The “T” artifact is visualized on 2-D echocardiography as a prominence of echoes at the edges of the septal tissue. (32:415)

6. (E) Muscular ventricular septal defects may occur anywhere and be very small. Color-flow Doppler allows relatively rapid evaluation of the entire interventricular septum. Visualization of a jet of turbulent flow identifies a ventricular septal defect; pulsed-wave or continuous-wave Doppler interrogation can be tedious and may miss a small muscular defect in an unusual position. (30:544—548)

7. (A) When pulmonary pressures exceed systemic pressures, the flow through the patent ductus arteriosus will be right to left; therefore, there would be no reversal in the descending aorta. All of the other choices should cause a reversal of flow in the descending aorta. (12: 285–287)

8. (E) Although patent ductus arteriosus and Coarctation of the Aorta are more commonly associated with valvar aortic stenosis, ventricular septal defect and pulmonary stenosis may also be associated. (6:224)

9. (B) Although all of the listed malformations may be associated findings, bicuspid aortic valve has been reported to be an associated finding in as much as 85% of cases. (6:244)

10. (C) The aortic view is posterior and to the right of the pulmonic valve in the normally related heart. The aortic valve is located centrally in the base of the heart, whereas the pulmonic valve is anterior and left. (1:578–581)

11. (D) The Fontan procedure was originally developed to treat patients with tricuspid atresia. Although it is now used in a modified form to treat other forms of complex congenital heart disease, it is not commonly used to treat patients with transposition of the great arteries. (6:357–359, 402–417)

12. (C) The Jantene procedure. The Rashkind procedure is an interventional catheterization technique that also is known as a balloon atrial septostomy. The Mustard and Senning procedures also are known as atrial switches. (6:402–417)

13. (A) Normally related great vessels course perpendicular to each other. Demonstration of this relationship rules out transposition of the great vessels. (26:498)

14. (B) The purpose of an atrial septostomy is to mix deoxygenated systemic venous return with oxygenated pulmonary venous return. In truncus arteriosus and tetralogy of Fallot, this mixing occurs through a large ventricular septal defect. In Ebstein’s anomaly of the tricuspid valve, blood flow sequence is normal; therefore, mixing is not desirable. (6:399–400)

15. (B) There is about a 15–25% incidence of coronary artery aneurysm formation in children with untreated Kawasaki disease. (85:269)

16. (B) Kawasaki disease is a childhood disease. Infants seem to be more likely to develop aneurysms than other children. (85:273)

17. (E) All of the above that are available should be used. (7:223; 18:157–171)

18. (A) Greater. The right ventricular outflow obstruction of tetralogy of Fallot is a dynamic obstruction; therefore, it may increase when the patient is distressed. (6:278)

19. (E) Although the proximal portions are the most frequently involved, the coronary system should be evaluated from every available view because aneurysms may occur anywhere. (85:269–273)

20. (C) In Coarctation of the Aorta, the descending aortic flow pulsatility is blunted such that the Doppler signal shows a slow acceleration and deceleration. (7:217–221)

21. (D) Right atrial isomerism. In situs solitus, the aorta descends anterior and to the left of the spine and the inferior vena cava ascends to the right of the spine. In situs inversus, the opposite is true. In left atrial isomerism, the inferior vena cava is frequently interrupted. (2:35–56)

22. (B) Early closure and partial reopening. An asymmetric closure line is suggestive of a bicuspid aortic valve. Gradual closure is suggestive of depressed left ventricular contractility. Ejection time may be prolonged in severe valvular aortic stenosis. (32:380–386)

23. (E) Reversal of flow during diastole, as shown in Fig. 3–1, may be seen in any of the other conditions. The characteristic pulsed-wave Doppler pattern in the descending aorta is very different for Coarctation of the Aorta. (7:217–228; 12:279–295)

24. (B) From the ECG, we can see that this is an end-diastolic frame. The 2-D image shows closed aortic and pulmonary valves, confirming that this is an end-diastolic frame. Red color representing flow toward the transducer may be appreciated coming into the main pulmonary artery from the patent ductus arteriosus. (29:161, 162, 189, 190)

25. (C) The red jet seen traversing the interatrial septum represents flow coming toward the transducer, therefore, it is shunting from the left atrium to the right atrium. Portions of the superior and inferior interatrial septum may be seen in the 2-D image. (30:548–550)

26. (D) The mitral valve is open in Fig. 3–4A. A thick bank of tissue appears in place of a normal tricuspid valve. A ventricular septal defect may be appreciated at the top of the ventricular septum in this image. In Fig. 3–4B, flow through the ventricular septal defect into the right ventricle is demonstrated by color-flow Doppler during systole. (32:374–375)

27. (B) Flow through an inflow ventricular septal defect would be visualized at the level of the mitral annulus. Flow through a doubly committed subarterial ventricular septal defect would be visualized just proximal to the pulmonary valve in this view. Flow through a muscular ventricular septal defect would be visualized in the muscular portion of the ventricular septum. This portion of the ventricular septum is visible from the parasternal short axis at the level of the mitral valve and more apically. (32:155–161, 183–188)

28. (D) The mitral valve is always higher on the ventricular septum in the absence of an inflow ventricular septal defect. In this case, the atrioventricular valve of the right-sided ventricle inserts higher on the ventricular septum than the atrioventricular valve of the left-sided ventricle. (26:324, 325)

29. (C) Discrete membranous subaortic stenosis. The aortic valve is closed and does not appear thickened. There is an echogenic line that extends posteriorly from the ventricular septum just proximal to the aortic valve. This represents a discrete subaortic membrane. In idiopathic hypertrophic subaortic stenosis, the interventricular septum would be significantly thickened. (26:424–427)

30. (A) Valvular aortic stenosis would cause the velocity of flow to increase just distal to the valve. Supravalvular aortic stenosis would cause the velocity of flow to increase in the aortic root. Coarctation of the Aorta would cause the velocity of flow to increase past the level of the left subclavian artery. (32:382)

31. (C) The left coronary artery appears mildly dilated, and the large circle noted in the right atrium is the right coronary artery (with aneurysmal dilatation) as it courses within the right atrioventricular groove. (85:268–273)

32. (D) The entire right ventricular outflow tract is small in caliber. (26:434)

33. (E) The pulmonary artery branches may be imaged from all of these views. (66:767–782)

34. (B) The thickness of the right ventricular free wall may not be proportionate to the increase in pulmonary artery pressure. The end-diastolic and not peak gradient of pulmonary regurgitation may be used. Acceleration and ejection time should be measured from the right ventricular outflow tract. (18:157–171)

35. (D) The modified Blalock–Taussig shunt is a Gore-Tex tube that provides pulmonary blood flow with its takeoff from the innominate artery (the classic Blalock–Taussig shunt connected the subclavian artery to the pulmonary artery—rarely in use these days). In a central shunt, the pulmonary artery is connected to the aorta directly or via a conduit. In the Waterston shunt, the ascending aorta is connected to the right pulmonary artery, and in the Potts anastomosis, the descending aorta is connected to the pulmonary artery. Both the Waterston and the Potts shunts are rarely used today but occasionally can be found in adult congenital patients. (34:384, 385)

36. (A) Qp:Qs is a comparison of pulmonary flow to systemic flow used to estimate the amount of blood flow through a systemic to pulmonary shunt. Flow is calculated by multiplying area by velocity of flow. This calculation must be done for the systemic circulation and for the pulmonary circulation. When the shunt is at the level of the ventricles, pulmonary flow may be calculated using the pulmonary valve or the mitral valve (i.e., pulmonary venous return). The systemic flow may be calculated by using the aortic valve or tricuspid valve (i.e., systemic venous return). The calculation is done to determine how much more blood is going through the pulmonary vasculature than the systemic vasculature. (9:825–827; 11:339–344)

37. (B) Because the atrial septal defect is the only outlet for the blood in the right atrium, it is an obligatory right-to-left shunt. (32:375)

38. (A) Patients with Marfan syndrome are also at risk for aortic dissections, but only a limited amount of the aorta is visualized here. The other two abnormalities are not frequently associated with this syndrome. (6:792, 793)

39. (D) The echogenic line visualized in the left atrium in Fig. 3–11 is an interatrial baffle constructed to redirect blood flow in what is known as an “atrial switch.” (26:552–557)

40. (D) Because pulmonary venous flow returns directly to the right atrium, it will be dilated. (32:368–371)

41. (E) Color flow aids tremendously in demonstrating the anomalous channels and connections. (90:341–347)

42. True. Constriction of the ductus is physiologically delayed in this group. (6:209–218)

43. True. Prostaglandin E may be administered to keep the ductus arteriosus patent in infants with severe right ventricular outflow obstruction or atresia or great vessel malformations. (6:221, 222)

44. True. The membrane inserts proximal to the left atrial appendage in cor triatriatum and distal to it in supravalvar mitral ring. (6:599–602)

45. False. These children more commonly have the complete form of atrioventricular defect. (6:176)

46. False. Significant cyanosis during infancy occurs only when there is associated pulmonary stenosis. (6:507)

47. False. There is a spectrum of severity in this malformation, and mild forms may remain asymptomatic. (24:142)

48. False. It is very rare to have distal involvement in the absence of proximal aneurysm formation. (85:275)

49. True. In severe cases, it may be difficult to obtain a reliable Doppler signal because of decreased flow through the area of obstruction. The Doppler derived gradient may be somewhat higher than the systolic pressure differences measured from the arm and thigh because peak systolic pressure occurs at slightly different times in these two areas; therefore, the blood pressure method yields a peak-to-peak pressure difference, whereas the Doppler method yields an instantaneous pressure difference. (7:217–219)

50. True. Suprasternal coronal evaluation of the extracardiac vessel should be included in patients in whom this may be a concern for planning of surgical procedures, as the left superior vena cava may drain into the roof of the right atrium. (88:137)

51. True. This has traditionally been the most common position for evaluation of pulmonary valve stenosis. (66:765)

52. True. The sound beam is angled anteriorly, and the transducer is moved to just below the left nipple. (67:844–848)

53. True. The sound beam is angled anteriorly and slightly to the left. (66:765)

54. True. In a few cases, this may be the only position from which a diagnostic Doppler signal can be obtained. (67:844–848)

55. False. The area of the fossa ovalis appears to be intact. (6:173, 174)

56. True. The portion of atrial septum just above the level of the atrioventricular valves is absent. (50:309–314)

57. False. There is a common atrioventricular valve with chordal insertions onto the ventricular septum. (50:315-319)

58. True. The left ventricle is about one-third the size of the right ventricle. The interventricular septum may be seen bowing into the left ventricle. (50:319–330)

59. False. The diagnosis is an unbalanced complete atrioventricular septal defect. In Ebstein’s anomaly of the tricuspid valve, the tricuspid valve leaflets are adherent to the right ventricular walls. (26:293–305)

60. False. The systolic murmur is probably caused by atrioventricular valve insufficiency (6:181–187)

*Michael W. Yates wrote the previous edition version of this chapter.