1. 381. The commonest location of this pathology is:
1. A. Proximal ascending aorta
2. B. Midaortic arch
3. C. At the attachment of ligamentum arteriosum
4. D. Junction of thoracic and abdominal aorta
2. 382. This is a 27-year-old man with no prior medical history, presented with a three-month history of abdominal distension and lower extremity edema. Physical examination revealed severely elevated jugular venous pressure. He had normal left ventricular (LV) and right ventricular (RV) systolic functions. The most likely diagnosis is:
1. A. Superior mediastinum syndrome
2. B. Constrictive pericarditis
3. C. Restrictive cardiomyopathy
4. D. Cirrhosis of the liver
3. 383. This patient presented with shortness of breath and cyanosis. The most likely cause is:
1. A. Ventricular septal defect (VSD) with Eisenmenger's
2. B. Atrial septal defect (ASD) with Eisenmenger's
3. C. Tetralogy of Fallot
4. D. Primary pulmonary hypertension
4. 384. This pulmonary regurgitation (PR) signal is suggestive of:
1. A. Severe pulmonary hypertension
2. B. Mild pulmonary hypertension
3. C. Normal pulmonary artery (PA) pressure
4. D. Severe pulmonic stenosis
5. 385. The Doppler signals shown here are indicative of:
1. A. Normal LV diastolic function
2. B. Abnormal LV relaxation with probable elevated left atrial (LA) pressure
3. C. Abnormal LV relaxation with probably normal LA pressure
4. D. Advanced restrictive cardiomyopathy
6. 386. The continuous wave Doppler signal shown here is suggestive of:
1. A. Dynamic LV outflow obstruction due to systolic anterior motion (SAM)
2. B. Critical valvular aortic stenosis (AS)
3. C. Subvalvular AS due to a membrane
4. D. Flow in and out of pseudoaneurysm
7. 387. This signal was obtained from a right upper parasternal location with the patient turned to the right using a dedicated continuous wave Pedoff transducer. The likely diagnosis is:
1. A. Severe mitral regurgitation (MR)
2. B. Severe tricuspid regurgitation (TR)
3. C. Severe AS
4. D. None of the above
8. 388. The aortic valve shown in this image is:
1. A. Unicuspid
2. B. Tricuspid
3. C. Bicuspid
4. D. Quadricuspid
9. 389. A 32-year-old female with complaints of shortness of breath, pedal edema, flushing, and diarrhea had an echocardiogram. The representative end systolic and end diastolic frame of an RV inflow view is shown. What does the patient have?
1. A. Tricuspid valve prolapse potentially causing severe TR
2. B. Rheumatic involvement of the tricuspid valve
3. C. Carcinoid involvement of the tricuspid valve
4. D. None of the above
10. 390. This flow obtained from the distal aortic arch from the suprasternal notch is indicative of:
1. A. Severe AR
2. B. Aortic coarctation
3. C. Severe AS
4. D. None of the above
11. 391. This image of the LV is indicative of:
1. A. An LA thrombus
2. B. Left ventricular noncompaction
3. C. Bilobed LV
4. D. False tendon
12. 392. Saline contrast echocardiography is suggestive of:
1. A. Patent foramen ovale (PFO)
2. B. Pulmonary AV fistula
3. C. Patent foramen or pulmonary A–V fistula
4. D. No right-to-left shunting
13. 393. This transesophageal echocardiogram (TEE) image from the upper esophageal location shows:
1. A. Left atrial appendage
2. B. Left upper and lower pulmonary veins
3. C. Left and right atria
4. D. Pulmonary artery branches
14. 394. These two images obtained from the suprasternal notch are diagnostic of:
1. A. Coarctation of the aorta
2. B. Patent ductus arteriosus
3. C. Normal aortic flow
4. D. Pulmonary artery branch stenosis
15. 395. This TEE image is indicative of:
1. A. Left atrial myxoma
2. B. Right atrial myxoma
3. C. Lipomatous atrial septum
4. D. Vegetation of the tricuspid valve
16. 396. What is the abnormality seen on this transthoracic echocardiogram?
1. A. Aneurysmal left atrium
2. B. Partial absence of the pericardium
3. C. Thoracic aortic aneurysm
4. D. Loculated pleural effusion
17. 397. The amount of MR in this patient is likely to be:
1. A. 1+
2. B. 2+
3. C. 3 or 4+
4. D. Cannot quantify
18. 398. The cause of the systolic murmur in this patient is likely to be:
1. A. Rheumatic MR
2. B. Valvular AS
3. C. Hypertrophic obstructive cardiomyopathy (HOCM)
4. D. Aortic subvalvular membrane
19. 399. This flow was obtained from the LV outflow tract from the apical view using pulse wave Doppler. This patient is most likely to have:
1. A. Severe congestive heart failure
2. B. Cardiac tamponade
3. C. Constrictive pericarditis
4. D. HOCM
20. 400. This TEE image is indicative of:
1. A. Left atrial thrombus
2. B. Aortic dissection
3. C. Saccular aneurysm of the aorta with a thrombus
4. D. Aortic pseudoaneurysm
Answers for chapter 20
1. 381. Answer: C.
At the attachment of the ligamentum arteriosum. This is a classic appearance of aortic transection with partial circumference disruption of the aortic wall. In a complete transection, there will be discontinuity of aortic lumen and absence of lower limb pulses. Transection generally is fatal with immediate exsanguination into the mediastinum and the range of presentation includes discovery on TEE after a deceleration injury at one extreme to immediate death at the other extreme. The commonest location is at the junction of the arch and descending aorta where the ligamentum arteriosum is attached. Rarely, it occurs at the arch ascending aortic junction because of differential mobility of these three segments of the aorta and their attachments during rapid deceleration, as in a motor vehicle accident. In aortic dissection, the intimal flap is thinner and the rounded shape of the aortic lumen is generally maintained. A mirror image artifact is on the far side of the aorta.
2. 382. Answer: B.
Constrictive pericarditis. This image shows marked pericardial thickening around the right atrium. On dynamic imaging, the right atrial wall was tethered to the pericardium along with classic signs of constriction, including septal bounce, respirophasic variations on transvalvular flows, preserved myocardial Em velocity, and global pericardial thickening. His symptoms and physical signs resolved completely after pericardial stripping.
3. 383. Answer: A.
VSD with Eisenmenger's. There is a large VSD. Because of the size, this is nonrestrictive and resulted in a large left-to-right shunt resulting in pulmonary hypertension. There is no overriding aorta here to suggest Tetralogy of Fallot.
4. 384. Answer: A.
Severe pulmonary hypertension. The PR pressure profile reflects a PA to RV diastolic pressure gradient. Hence, this patient's PA end systolic pressure is the square of early diastolic PR velocity + RV diastolic pressure, which would be similar to the RA pressure. In this patient, this is calculated to be in the range of 80 mmHg, which would also be similar to the mean PA pressure. The PR end diastolic velocity is about 3 m/s. Hence, the PA diastolic pressure is 36 + RA pressure. This patient does not have significant pulmonary stenosis, as is shown by the accompanying systolic flow. In fact, a markedly reduced duration is indicative of low cardiac output as well as a consequence of pulmonary hypertension.
5. 385. Answer: B.
An E' of <8 cm/s and an E/A ratio of <1 is indicative of abnormal LV relaxation. In addition, mitral E/annular Em velocity ratio is 24. Normally, this is in the range of 8–12. A ratio of >15 is generally indicative of high LA pressure. However, this is applicable only in the absence of mitral stenosis. E-wave deceleration in this patient does not suggest mitral stenosis. The velocities were increased due to high cardiac output secondary to anemia. Advanced restrictive cardiomyopathy results in a much higher E/A ratio and a rapid E-wave deceleration (<150 ms).
6. 386. Answer: A.
This late peaking ejection signal, which classically occurs due to dynamic left ventricular outflow tract (LVOT) obstruction due to SAM, occurs in HOCM. SAM is not specific for HOCM as it can occur in situations like postmitral valve repair, volume contracted states, hyperdynamic LV, and severe mitral annulus calcification. Also note a lower velocity late peaking systolic signal inside the main signal. This is indicative of cavity obliteration and hence a hyperdynamic LV. Valvular AS and fixed subvalvular AS can result in a late peaking signal when they are severe or critical. A relatively low velocity signal in the presence of hyerdynamic LV and mitral flow suggestive of good LV filling are against this possibility.
7. 387. Answer: C.
Severe aortic stenosis. This is a classic signal resulting from severe aortic stenosis with the flow directed toward the transducer. The timing of the signal is during ejection, as opposed to MR and TR signals that start earlier during systole and also is less likely to pick up MR and TR signals from this location. This signal shown here is late peaking with a mean gradient of 53 mmHg indicative of severe or critical aortic stenosis.
8. 388. Answer: C.
Bicuspid. This TEE image shows a bicuspid valve with anterior and posterior cusps. The anterior cusp is a conjoint one of right and left cusps. Two commissures can be seen and these should be traced to the annulus to count the number of cusps, as many bicuspid valves have partial commissural fusion only toward the annulus. In fact, it has been shown in a pathology series that nearly 50% of so-called calcific AS cases are bicuspid. These patients may also have ascending aortic dilatation and there is association with coarctation of the aorta. Bicuspid aortic valve is common and occurs in 1–2% of the general population and needs endocarditis prophylaxis. Careful short axis evaluation of the aortic valve is mandatory for every patient referred for echocardiography.
9. 389. Answer: C.
The endsystolic and end diastolic frames of the heart show a thickened and retracted tricuspid valve with severely limited mobility suggesting fibrotic process. This is suggestive of carcinoid syndrome, especially in the light of clinical features of diarrhea and flushing. Rheumatic process and FenPhen valvulopathy may look similar, but diarrhea and flushing are not features of these. There is TV prolapse in the systolic frame.
10. 390. Answer: A.
Severe aortic regurgitation. There is a prominent holodiastolic flow reversal indicative of a retrograde flow in the aorta indicating diastolic runoff of blood from the arch or the ascending aorta. The conditions that can cause this include significant AR, aorto-pulmonary window, ruptured sinus of Valsalva, fistulous communication to any of the cardiac chambers from the aorta, and large coronary A–V fistula. Coarctation of the aorta may result in diastolic antegrade flow because of collaterals.
11. 391. Answer: D.
This is a typical appearance of a false tendon running in the middle of the LV with no pathological significance. When such tendons are present in the apex, they can be mistaken for thrombi and when these run along the anterior septum the thickness of the septum can be overestimated erroneously. This patient does not have significant LV trabeculation either in depth or extent to qualify for noncompaction. Although not all LV segments are shown, significant trabeculation denotes a noncompacted to compacted wall thickness ratio of 2.
12. 392. Answer: C.
There are bubbles in the left atrium indicative of a right-to-left shunt. However, from a single frame the level of shunting cannot be determined. Hence, the timing of appearance of bubbles in LA in relation to appearance in the RA is important. It is important to record at least 8–10 beats after the appearance of contrast in the RA. If the bubbles in the LA appear within 2–3 beats of its appearance in the RA, the shunt probably is at the atrial level; if it appears later, it is likely to be transpulmonary shunting due to pulmonary A–V fistulae. Examples of the latter include end-stage liver disease and Rendu-Weber-Osler disease. In our laboratory we perform saline contrast echo without and with Valsalva's maneuver. The shunt in PFO is conditional to the transient rise in the RA pressure and is produced by Valsalva, coughing, and pressure over the abdomen. Movement of the atrial septum to the left ascertains a higher RA pressure. PFO diagnosis rate is higher by TEE and with lower limb contrast injection, as the direction of the PFO channel is directly in line with the inferior vena cava (IVC). Hence, injection from the upper limb may be washed away by IVC flow and prevented from entering the PFO channel.
13. 393. Answer: B.
Left upper and lower pulmonary veins. A tomographic plane around 100–120 degrees with the imaging plane superior and left of the appendage shows both left-sided pulmonary veins draining into the LA. Part of the image to the imager's right is cephalad and hence this is the left upper and the one on the right is the left lower pulmonary vein. Ability to get this image depends upon atrial size, pulmonary vein locations, relation of the pulmonary veins to the esophagus, body habitus, etc., but should be obtainable in over 90% of the patients. The LA appendage is a blind pouch.
14. 394. Answer: A.
Coarctation of the aorta. This is a classical image of coarctation of the aorta. The two-dimensional image shows narrowing at the junction of the arch and descending aorta with turbulence on color flow imaging. The flow velocity across this narrowing was 3.9 m/s, indicative of a systolic gradient of 61 mmHg. This is indicative of severe coarctation. Other indicators of severity include a broader systolic signal, diastolic gradient, and nonpulsatile flow in the descending aorta. Presence of arterial collaterals may reduce the gradient but the collateral-dependent flow in the descending aorta will be nonpulsatile.
15. 395. Answer: B.
Right atrial myxoma. In this image, there is clearly a right atrial mass, which is very large. Also note a very dilated IVC with no mass inside. The differential diagnosis includes myxoma, thrombus, and metastatic tumor spreading through the IVC, such as renal cell carcinoma. The features that help to differentiate it are attachment of the mass (pedunculated attachment to the septum, likely to be myxoma), continuity of the mass in the IVC (renal cell carcinoma), presence of blood vessels in the mass on color flow (not a thrombus), presence of perfusion by transpulmonary contrast agents (thrombus has no enhancement, myxoma has mild enhancement, vascular tumors hyperenhance). This mass is too big for valve vegetation.
16. 396. Answer: C.
Thoracic aortic aneurysm. The structure behind the left atrium is the thoracic aorta, which is normally seen in parasternal long axis view. The long axis of this part of the aorta can be visualized from the left parasternal view with the left parasagittal imaging plane.
17. 397. Answer: C.
3 or 4+. This patient has a lateral wall-hugging jet reaching all the way to the roof of the left atrium. A wall-hugging jet area tends to be 40–50% smaller than a free jet area for a given regurgitant volume. In such patients, examining the size of vena contracta, proximal isovelocity surface area (PISA), and calculating the effective regurgitant orifice area would be helpful for volumetric quantitation. Although the PISA is not well visualized in this patient, the diameter of the vena contracta is about 5 mm, which is consistent with at least 3+ mitral regurgitation. The mechanism of the lateral wall-hugging jet in this patient was a tethered posterior leaflet secondary to a rheumatic process. The other mechanism to cause a laterally directed jet would be a severely prolapsing anterior mitral leaflet.
18. 398. Answer: C.
Hypertrophic obstructive cardiomyopathy. This is a typical M mode of systolic anterior motion of the mitral valve. The CD segment of the mitral valve (systolic segment) normally moves anteriorly during systole because of the translation of the LV and mitral valve anteriorly. However, a CD segment slope greater than the slope of the posterior endocardium and the systolic mitral leaflet septal contact indicates SAM, which most commonly occurs in HOCM, but can occur in other situations too. The mitral valve opening is normal in this patient with a normal ejection fraction slope with thin leaflets ruling out rheumatic mitral stenosis. Fixed aortic stenosis due to a valvular or subvalvular process does not give rise to any typical appearance of the mitral valve.
19. 399. Answer: A.
Severe congestive heart failure. The beat in the middle is of lesser amplitude and duration, which gives a markedly lower time velocity integral compared to the beats on either side. Note that the R–R intervals are regular. A lower stroke volume and a weaker pulse with every other beat are called pulsus alternans and is suggestive of severe left ventricular systolic dysfunction. The change in amplitude is too rapid for respirophasic variation, which occurs in tamponade and constriction. Pulsus alternans is not seen in HOCM as it is mostly diastolic dysfunction and the LVOT velocity is higher because of SAM-related flow acceleration.
20. 400. Answer: B.
Aortic dissection. This is a transverse section through the descending thoracic aorta. A smaller true lumen and a larger false lumen with a thrombus are seen. Also note fluid around the aorta is indicative of left pleural effusion and this should raise the possibility of leaking aneurysm. During dissection or intramural hematoma, thrombus is inside the aortic wall and is covered by the endothelium, as in this case. In a saccular aneurysm with an intraluminal thrombus, the endothelium is outside the thrombus. Pseudoaneurysm is characterized by an aneurysm bound only by adventitia outside the aortic lumen and communicating with the aorta through a narrow neck.