1. 361. The image shows:
1. A. Normal native tricuspid valve
2. B. Normal bioprosthetic valve
3. C. Vegetation on a bioprosthetic valve
4. D. Avulsion of the tricuspid valve
2. 362. This 31-year-old woman with no other medical history had two episodes of transient ischemic cerebral attacks, the first one after a long duration of air travel and the second one during straining in the restroom. The most likely cause of this patient's attacks is:
1. A. Paradoxical embolism
2. B. Vagally mediated atrial fibrillation
3. C. Left atrial thrombus
4. D. None of the above
3. 363. This 35-year-old patient with AIDS and bicuspid aortic valve has Staphylococcus bacteremia. The parasternal long axis color flow image is suggestive of:
1. A. Right coronary artery flow
2. B. Pulmonary vegetation
3. C. Fistulous communication between aorta and right ventricle (RV)
4. D. None of the above
4. 364. This patient's bilateral Staphylococcus lung abscesses are likely due to:
1. A. Tricuspid valve endocarditis
2. B. Pulmonary valve endocarditis
3. C. Catheter-related infection of superior vena cava and right atrium (RA)
4. D. None of the above
5. 365. The structure indicated by the arrow is:
1. A. Coronary sinus
2. B. Inferior vena cava
3. C. Atrial septal defect
4. D. None of the above
6. 366. This patient's stroke is likely due to:
1. A. Left atrial thrombus
2. B. Left atrial myxoma
3. C. Mitral valve endocarditis
4. D. Patent foramen ovale (PFO)
7. 367. The structure indicated by the arrow is:
1. A. Main pulmonary artery (PA)
2. B. Ascending aorta
3. C. Descending aorta
4. D. None of the above
8. 368. This patient with a prosthetic tricuspid valve has evidence of:
1. A. Normal function
2. B. Stenosis
3. C. Regurgitation
4. D. Endocarditis
9. 369. The mass in the left atrium in this patient is most likely:
1. A. Thrombus
2. B. Myxoma
3. C. Metastatic lung carcinoma
4. D. Lipomatous septum
10. 370. The short axis view of the heart is indicative of:
1. A. Severe pulmonary hypertension
2. B. Severe tricuspid regurgitation (TR) with normal PA pressure
3. C. RV infarct
4. D. RV dysplasia
11. 371. The surgical procedure that this patient underwent is most likely to be:
1. A. Orthotropic heart transplantation
2. B. Mitral valve repair with annuloplasty
3. C. Maze procedure
4. D. Septal myectomy for hypertrophic obstructive cardiomyopathy
12. 372. This TR signal is from a patient with moderate TR. The most likely mechanism of TR is:
1. A. Pulmonary hypertension with annular dilatation
2. B. Flail tricuspid valve
3. C. Tricuspid valve prolapse
4. D. Cannot make a mechanistic diagnosis
13. 373. This image of the aortic arch from the suprasternal view is suggestive of:
1. A. Patent ductus arteriosus (PDA)
2. B. Coarctation of the aorta
3. C. Severe aortic regurgitation
4. D. Aortic pseudoaneurysm
14. 374. A 42-year-old woman presented with complaints of shortness of breath. An echocardiogram was obtained. Dynamic images showed an LV ejection fraction of 50% with abnormal appearance of the apex. Filling pressures were high, valves were normal. She had normal electrocardiogram, comprehensive and complete blood count except an eosinophil count of 20%. The appearance of the LV apex is suggestive of:
1. A. LV apical thrombus
2. B. LV noncompaction
3. C. Apical hypertrophic cardiomyopathy
4. D. Endomyocardial fibrosis
15. 375. The TR velocity profile shown here is suggestive of:
1. A. Normal PA pressure
2. B. Mild pulmonary hypertension
3. C. Severe pulmonary hypertension with good RV function
4. D. Severe pulmonary hypertension with poor RV function
16. 376. The amount of tricuspid regurgitation in this patient is:
1. A. Mild
2. B. Moderate
3. C. Severe
4. D. Cannot quantify
17. 377. The patient in question 376 is likely to have:
1. A. Normal PA pressure
2. B. Mild pulmonary hypertension
3. C. Moderate or severe pulmonary hypertension
18. 378. The type of surgical procedure performed on this patient's mitral valve is likely to be:
1. A. Mitral annuloplasty
2. B. Alfieri procedure
3. C. Replacement with a bioprosthetic valve
4. D. Replacement with a mechanical valve
19. 379. What intervention can potentially change the mitral inflow pattern as shown in this image?
1. A. Diuresis
2. B. Control of severe hypertension
3. C. Correction of severe anemia
4. D. All of the above
20. 380. What is the abnormality shown here?
1. A. Thoracic aortic aneurysm
2. B. Cor triatriatum
3. C. Artifact
4. D. Dilated left PA
Answers for chapter 19
1. 361. Answer: C.
Vegetation on a bioprosthetic valve. This is a short axis view of the tricuspid valve, best obtained from proximal gastric location, with clockwise probe rotation at about 20–30°. The sewing ring of the prosthetic valve is clearly seen here and there is a mass attached to the leaflets indicative of vegetation.
2. 362. Answer: A.
Paradoxical embolism. The transesophageal echocardiogram image shows the interatrial septum with a large PFO in its typical location. The color flow shows left to right flow. This flow would reverse under situations of increased RA pressure such as straining, coughing, and right heart failure. The orientation of the opening is favorable for thrombi originating in the inferior vena cava region to traverse the PFO to the left atrium even in the absence of raised RA pressure.
3. 363. Answer: C.
Fistulous communication between the aorta and the right ventricle. In addition to the fistulous communication, the image also shows aortic regurgitation. Fistulous communications generally result from rupture of an aortic root abscess. This may result in communications to the RA, RV, PA, or the left ventricular outflow tract (LVOT). Other local complications include abscess of mitral aortic intervalvular fibrosa, leaflet aneurysm, and perforation of the anterior mitral leaflet. One may also get an abscess in the ventricular septum, causing a ventricular septal defect after rupture.
4. 364. Answer: B.
Pulmonary valve endocarditis. This is a midesophageal image showing the aortic valve in short axis in the center and the RV inflow and outflow wrapped around it akin to the short axis of the aortic valve from a parasternal view. There is a large mass attached to the pulmonary valve consistent with vegetation. This is the likely source of his lung abscesses.
5. 365. Answer: A.
Coronary sinus. This is a low esophageal view partially cutting through the posterior A–V groove showing the coronary sinus.
6. 366. Answer: A.
Left atrial thrombus. This patient has a large left atrium with spontaneous echocontrast, with large masses originating from the left atrial appendage suggestive of thrombi. These are protruding into the body of the left atrium. These masses were highly mobile and the patient had rheumatic mitral stenosis, although the mitral valve is not visualized here. Note that this patient is in sinus rhythm. In patients with mitral stenosis, thrombi can form despite being in sinus rhythm because of stasis in a large atrium, another possible mechanism being paroxysmal atrial fibrillation. Myxoma generally arises from the atrial septum, and mitral vegetations generally arise from the atrial side of the leaflets and generally do not grow to such a massive size.
7. 367. Answer: A.
Main pulmonary artery. This view is obtained from the midesophageal view, with anterior structures displayed away from the transducer and superior structures to the right. This is a typical tomographic view showing RVOT, pulmonary valve, and main pulmonary artery. Part of the LVOT and aortic valve is seen posterior to this. Pulling the probe up slightly will show the distal PA and proximal branches can be seen from a much more proximal location in the esophagus from a horizontal plane.
8. 368. Answer: B.
Stenosis. This is suggested by the increased transvalvular velocity associated with a slow deceleration time. The peak diastolic gradient is 16 mmHg, mean gradient is 8 mmHg, and the pressure half-time is markedly prolonged at 250–300 ms, suggesting severe tricuspid stenosis. The pressure half-time method is not validated for calculating the effective orifice area of either native or prosthetic tricuspid valves. Generally a mean transvalvular gradient of >5 mmHg is suggestive of severe tricuspid stenosis. As the gradient is flow dependent, it varies with the phase of respiration.
9. 369. Answer: A.
Thrombus. The differential diagnosis is between thrombus and left atrial myxoma. In this patient with a giant left atrium, who is likely to be in atrial fibrillation, this is more likely to be a thrombus. The fact that the mass in not pedunculated, and has a homogenous acoustic characteristic, favors a diagnosis of thrombus, although the possibility of myxoma cannot be excluded. If vascularity is shown in the mass by color flow imaging or contrast echocardiography with transpulmonary agents, then it would suggest myxoma. Lipomatous septum is dumbbell-shaped with sparing of the fossa ovalis. Lung carcinoma propagates to the left atrium through pulmonary veins and the mass generally originates in one of the pulmonary veins.
10. 370. Answer: A.
Severe pulmonary hypertension. Note that this is a systolic frame and the interventricular septum is flattened, indicating an RV pressure closer or equal to the LV pressure. The ventricular septum responds passively to the transmural pressure and hence generally is convex to RV both in systole and diastole because of the higher LV pressure. Severe TR with normal PA pressure would cause diastolic flattening of the septum, and the septum would be rounded in systole as the LV pressure is higher. In RV dysplasia, RV is dilated, thin walled with occasional aneurysms, and the septum would be flattened in diastole. In RV infarct, PA pressure would be normal.
11. 371. Answer: A.
Orthotropic heart transplantation. The ridge-like projection seen on the posterior left atrial wall is the site of anastomosis between donor and recipient left atria. The pulmonary venous side of the atria belongs to the recipient. The other anastomotic sites are the ascending aorta, superior and inferior vena cava, and the pulmonary artery. Mitral annuloplasty ring will be seen posteriorly immediately superior to the base of the mitral leaflet and is rounded in crosssection. Classical maze or radiofrequency maze performed for atria fibrillation does not generally result in such ridge-like projections. The upper ventricular septum does not have a thin scooped-out appearance to suggest septal resection.
12. 372. Answer: C.
Tricuspid valve prolapse. The density of the signal depends on the number of scatterers or the amount of regurgitant flow at the time the signal is generated. The increasing density of the signal from early to late systole suggests an increasing regurgitant volume through systole, which typically occurs in valve prolapse. In severe pulmonary hypertension, not only will the TR velocity be in the vicinity of 4 m/s but there is no differential signal density. Here, the TR velocity reflects normal PA pressure. The flail valve causes severe TR from the very beginning of systole.
13. 373. Answer: A.
Patent ductus arteriosus. This is the classic appearance of PDA with a communication between the distal arch and the origin of the left pulmonary artery. This view is helpful in diagnosing PDA as well as evaluating the morphology, length, and diameter of the PDA, which are important for planning percutaneous PDA closure.
14. 374. Answer: D.
Endomyocardial fibrosis. There is complete obliteration of the left ventricular apex and this associated with hypereosinophilia is suggestive of eosinophilic myocarditis resulting in obliterative thrombofibrotic process in the apex. The accompanying color flow image shows the color stopping short of the apex confirming the obliteration. In apical HCM, the LV cavity will be spade shaped. In noncompaction, color gets in between the trabeculae. The LV apical thrombus generally occurs in association with apical aneurysm and could either be protruding or layered. None of these obliterate the LV apex to the extent seen here.
15. 375. Answer: D.
Severe pulmonary hypertension with poor RV function. TR velocity is 4 m/s. This is consistent with an RA–RV gradient of 64 mmHg and PA systolic pressure of 80 mmHg in the absence of pulmonary stenosis. A very slow rise of TR velocity indicates a slow rise of RV pressure in early systole suggestive of RV dysfunction. The TR velocity profile lends itself to calculate RV dp/dt. In this patient, the time taken for the TR velocity to rise from 1 to 3 m/s was 160 ms, corresponding to an RV dp/dt of 200 mmHg/s. RV dp/dt depends upon RV contractile function, PA pressure, and LV contractile function. Normal RV dp/dt with normal PA pressure is 200–250 mmHg/s but rises to 1000 mmHg/s in the presence of severe pulmonary hypertension associated with good RV contractile function.
16. 376. Answer: C.
Severe. This is severe as judged by jet size, vena contract, and proximal isovelocity surface area (PISA) radius. In addition, the two-dimensional image shows lack of tricuspid leaflet coaptation, leading to wide-open TR. The mechanism is tricuspid annular dilatation and hence is functional, probably secondary to previous pulmonary hypertension due to mitral valve disease resulting in RV and RA dilatation, thus stretching the tricuspid annulus. This is repairable with tricuspid annuloplasty. Also note the partly seen mitral prosthesis. TR quantitations by using the three components of the jet are not well validated.
17. 377. Answer: C.
Moderate or severe pulmonary hypertension. In patients with wide-open TR, the tricuspid valve may be fairly nonrestrictive, allowing RV and RA to behave virtually as a single chamber during systole. In such a situation, the TR pressure gradient cannot reliably be calculated using the simplified Bernoulli equation as a considerable amount of energy may be expended in causing acceleration of the TR jet. In addition, RA pressure may be very high, leading to underestimation of PA pressure. In this example, one can count the number of aliases to estimate the TR velocity at the vena contracta. There are four aliases corresponding to a velocity of 69 × 4, that is, 2.76 cm/s. Although the pressure gradient is 30 mmHg, the patient is likely to have very high RA pressure, that is, 20–30 mmHg, and because of wide-open TR the TR pressure gradient would have underestimated the pressure gradient. Hence, the PA systolic pressure is at least moderate but more likely to be in the severe range in the absence of pulmonary stenosis. In such patients careful examination of the pulmonary regurgitant jet to get an estimate of PA diastolic pressure would be helpful.
18. 378. Answer: D.
Replacement with a mechanical valve. This prosthesis probably is a bileaflet valve in view of the two areas of reverberations seen in the left atrium. A bioprosthetic valve would show struts in the periphery and thin leaflets in the center unless calcified. An annuloplasty ring is an echo dense structure at the base of the mitral leaflet on the left atrial side with intact leaflets. This ring can be partial or complete. An Alfieri stitch can be central or asymmetric and is simply a stitch that focally unites the tips of anterior and posterior leaflets and converts the mitral orifice into a double orifice, best seen in short axis view.
19. 379. Answer. D.
All of the above. Preintervention mitral flow is indicative of high left atrial pressure. This pattern is seen despite a heart rate of 92/min, as faster heart rates result in atrial predominance of ventricular filling. Postintervention mitral flow is suggestive of impaired left ventricular relaxation, which is consistent with normal or low mean left atrial pressure. Note that the heart rate is slower at 62/min. This patient had dilated cardiomyopathy with severe functional mitral regurgitation, which responded to diuresis and afterload reduction with a reduction of LV size and elimination of mitral regurgitation. Uncontrolled hypertension will reduce LV ejection performance, increase LV size, and give rise to MR, as myopathic ventricles are exquisitely sensitive to afterload. As these patients have little or no functional reserve, anemia has a serious and deleterious effect on hemodynamics because of a reduction in oxygen-carrying capacity and a demand for higher cardiac output.
20. 380. Answer. A.
Thoracic aortic aneurysm. Thoracic aorta runs posterior to the left atrium, is rounded, and on dynamic imaging is pulsatile. Turning the imaging plane by 90 degrees would show the long axis of the descending aorta. The membrane of Cor triatriatum separates the pulmonary venous chamber from the lower part of the atrium and is best seen from parasternal long axis and apical views. The location is across the left atrium. Left pulmonary artery is not seen in the posterior mediastinum.