URR Protocols Questions Part 2
Feedback: LA pressure = systolic BP - MR peak pressure gradient MR pressure gradient = 4 (5 x 5) = 100mmHg; LA pressure = 110mmHg - 100mmHg = 10mmHg
.With systemic blood pressure of 110/70mmHg and mitral regurgitation velocity of 5m/s, what is the left atrial pressure? A: 25mmHg B: 30mmHg C: 100mmHg D: 10mmHg
Feedback: 3D echo evaluation is most beneficial in patients with myxomatous mitral valve disease, atrial septal defect, transcatheter interventions. The 3D evaluation is performed on the ASD before and after intervention has been completed.
3D echocardiography would be most beneficial in an adult patient with: A: an atrial septal defect B: persistent left SVC C: atrial fibrillation D: pericardial effusion
Feedback: Surface rendering - convert the volume data into a list of polygons which represents the anatomical surface of interest; helpful for evaluation of chamber volumes, EF%, valves and atrial septum Volume rendering - besides the anatomical surface, the details beneath the surface can also be visualized; helpful for evaluating LV segmental wall motion and cardiac masses
3D surface rendering is preferred for evaluating __________, while 3D volume rendering is preferred for ___________. A: adult patients, pediatric patients B: valve characteristics, segmental wall motion C: the aortic valve, the mitral valve D: segmental wall motion, cardiac mass formation
Feedback: Aneurysms caused by syphilis most commonly form in the ascending aorta 10-25 years after the infection. Syphilitic aortitis is characterized by extensive calcification of the dilated ascending aorta. Wall calcification can be seen on a chest x-ray.
A patient presents for an echo due to a prior history of syphilis and an abnormal chest x-ray. The script states "rule out aneurysm". What portion of the aorta should you closely evaluate for the most likely location of a related aneurysm? A: abdominal aorta B: aortic arch C: descending thoracic aorta D: ascending aorta
Feedback: In patients with a VSD the RVSP is calculated using the velocity across the VSD. RVSP = systolic BP - 4(V)2 RVSP = 120 - 4( 5 x 5 ) RVSP = 120 - 100 = 20mmHg
A patient presents with a murmur since birth, occasional chest pain and systemic BP of 120/80. A diagnosis of a VSD is made with echocardiography, showing a peak velocity of 5m/s. What is the RVSP in this patient? A: 16mmHg B: 20mmHg C: 40mmHg D: 100mmHg
Feedback: The largest/longest segment of the thoracic aorta can be viewed on the apical 2 chamber view. A transverse view of the thoracic aorta is identified on the parasternal long axis view but only allows a limited evaluation. The very proximal segment of the descending aorta is visible on the SSN view but the vessel courses parallel to the ultrasound beam. 2D measurements are most accurate when the beam is perpendicular to the structure for the best reflection.
A patient presents with an order for an echo to evaluate the diameter of the descending thoracic aorta. What echo view can be used to best accomplish this task? A: apical 2 chamber B: apical 5 chamber C: suprasternal notch D: parasternal long axis
Feedback: When LV function is significantly depressed, it is important to determine the cause. Evaluation of the right ventricular function can help to differentiate dilated cardiomyopathy from end stage ischemic disease (CAD) as the cause. In most cases LV systolic function depressed and RV systolic function also depressed = dilated cardiomyopathy LV systolic function depressed and RV systolic function still normal = ischemic disease (CAD)
A patient presents with severely depressed LV function and an EF% of 22%. How can you determine if coronary artery disease or dilated cardiomyopathy is the cause of the reduced LV function? A: evaluate right ventricular systolic function B: measure the E-point-septal separation C: measure the thickness of the LV wall D: more than one of the above
Feedback: Patients with Marfan syndrome have a history of aortic root dilatation, aortic dissection and MVP. Serial exams are used to follow the size of the aortic root to assess the increased risk for dissection.
A patient with a history of Marfan syndrome presents for his annual echo. What measurement is most important for you to obtain during today's exam? A: aortic root diameter B: dp/dt C: LV wall thickness in diastole D: peak velocity across the pulmonic valve
Feedback: The CW and PW Doppler tracings should demonstrate the closing click of the aortic valve and the opening click of the mitral valve, then measure the time between the clicks. When using tissue Doppler, the IVRT is measured from the end of the S' wave to the onset of the E' wave.
All of the following methods can be used to assess the isovolumic relaxation time, except: A: Planimetry measurement of the LVOT and mitral valve annulus, then divide the numbers B: PW Doppler sample placed in LVOT with >5mm sample gate used to record tracing C: Tissue Doppler tracing of the mitral annulus D: CW Doppler cursor placed between the aortic and mitral valves to obtain tracing
Feedback: Decreased motion of the LV can cause early closure of the aortic valve. This will shorten the "box" created from the cusp separation as ejection time is reduced.
Aside from the m-mode recording of the left ventricular motion, what other m-mode tracing can provide information regarding left ventricular systolic function? A: m-mode of descending aorta motion B: m-mode of aortic valve cusp separation C: m-mode of tricuspid valve motion D: m-mode of pulmonic valve cusp separation
Feedback: Qp/Qs compares the stroke volume in the systemic and pulmonary systems. This ratio is used to determine the effect of the shunt flow on the right heart.
Comparison of the stroke volume in the LVOT to the stroke volume in the RVOT is performed to assess ____________. A: Left ventricular diastolic function B: Left ventricular systolic function C: Shunt flow from VSD D: Left atrial pressure
Feedback: Cough, Valsalva maneuver, and abdominal compression maneuvers are an important part of a saline contrast echo. They are used to try to force contrast through a suspected atrial septal defect. The patient should perform the maneuver as soon as the contrast enters the right atrium.
Cough, Valsalva maneuver, and abdominal compression maneuvers are an important part of: A: a perfluorocarbon contrast echo B: a dobutamine stress echo C: a saline contrast echo D: a thallium stress test
Feedback: Global longitudinal strain is measured from apical views. It can detect early changes associated with LV systolic dysfunction.
Global longitudinal strain is measured from: A: subcostal views B: apical views C: parasternal views D: more than one of the above
Feedback: The contraction velocity of the LAA can be used to evaluate the risk for LA thrombus formation. PW Doppler sample volume positioned approximately 1 cm proximal to the entry of the appendage into the body of the LA. Normal contraction velocity of the LAA is about 0.4 m/s. Lower velocities are associated with an increased risk of thrombus formation.
How is the contraction velocity of the left atrial appendage evaluated? A: PW Doppler sample volume positioned in the center of the left atrial appendage B: M-mode sample line positioned approximately 1 cm proximal to the entry of the appendage into the body of the LA C: M-mode sample line positioned approximately across the left atrium and the body of the left atrial appendage D: PW Doppler sample volume positioned 1 cm proximal to the entry of the appendage into the body of the LA
Feedback: RVSP = systolic BP - 4 ( VSD velocity) 2 RVSP = 140 - 4 (4.3 x 4.3) RVSP = 140 - 74 = 66mmHg
If the BP reading is 140/80mmHg in a patient with the VSD shown on the image [shows peak velocity through defect is 4.3 and no TR is shown], what is the right ventricular systolic pressure? A: 7mmHg B: 66mmHg C: 73mmHg D: unable to calculate the pressure without the TR velocity
Feedback: Peak Pressure Gradient = 4 (V)2 = 4 (5 x 5) = 100mmHg (The other numbers given in the question are distractors)
If the systemic BP is 120/80, LVOT velocity is 1m/s and the aortic valve velocity is 5m/s, what is the peak pressure gradient at the valve? A: 100mmHg B: 4mmHg C: 25mmHg D: 64mmHg
Feedback: Because the atrial and ventricular septums are perpendicular to the US beam in the subcostal view, the US system will best demonstrate the presence of flow toward and away from the probe.
In order to detect and evaluate shunt flow across the septum, the ________________ view is the best choice. A: Parasternal long axis B: Apical 4 chamber C: Parasternal short axis D: Subcostal
Feedback: Because the left arm would drain into the persistent left SVC to reach the heart, the contrast would enter the coronary sinus and then the RA. Normally contrast injected into the left arm would enter the left innominate, SVC and then RA.
In order to diagnose a persistent left SVC, contrast should be injected in the ________________ and it will be seen in the ______________ before entering the right heart if the exam is positive. A: left arm, pulmonary veins B: left arm, SVC C: left arm, coronary sinus D: right arm, left atrium
Feedback: The parasternal short axis (PSAX) is the best view to visualize all of the LV wall segments. The inferior and anterior walls are seen on the Apical 2 chamber view.
In order to evaluate a possible infarct of the inferior wall seen in the parasternal short axis view, what additional view will help diagnose the abnormality? A: Subcostal B: Apical 2 C: Apical 5 D: Apical 4
Feedback: The LV ejection time is measured from when the AV opens until it closes. LVET increases with increasing aortic stenosis while an increase in heart rate can decrease LVET.
Left ventricular ejection time is measured on the m-mode tracing of the _______________. A: left ventricle at the mid ventricle B: aortic valve C: mitral valve D: left ventricle at the basal level
Feedback: The LV ejection time is measured on the m-mode tracing from when the AV opens until it closes. LVET increases with increasing aortic stenosis, while an increase in heart rate or decrease in LV function can decrease LVET.
Measuring the left ventricular ejection time is most helpful when assessing patients with suspected _____________. A: aortic stenosis B: a VSD C: mitral stenosis D: pulmonary HTN
Feedback: Severe MS produces a waveform with very little slope between E and A points. This waveform shape can resemble the shape produced from aortic insufficiency. Flow through a VSD will occur during systole and is recorded from the right ventricle. Pulmonic insufficiency is also recorded from within the right ventricle.
Proper cursor placement for evaluating mitral stenosis is important because the Doppler tracing from severe mitral stenosis can be confused with a waveform produced from _________________. A: Pulmonic insufficiency B: Aortic insufficiency C: Midmuscular VSD D: Perimembranous VSD
Feedback: Stress echo can be used to assess CAD, changes in LVOT flow gradients with exercise, and diastolic dysfunction. It is most helpful in assessing CAD because it can prevent unnecessary heart catheterization on patients with normal exams.
Stress echocardiography is most helpful in the assessment of suspected _______________. A: elevation of LVOT flow gradients with subaortic stenosis B: congestive heart failure C: coronary artery disease D: pulmonary HTN
Feedback: The ASE recommends that the width of the chamber be assessed from the Apical Focused RV view for the most accurate measurement. The apical 4 chamber view is optimized to demonstrate the RV. The measurement can be taken at the basal or mid ventricular level.
The ASE reports the most accurate measurement technique of the right ventricle is obtained in the ____________ . A: Parasternal long axis view B: Subcostal view C: Apical Focused RV view D: Parasternal short axis view
Feedback: The Bernoulli equation is used to calculate the peak instantaneous pressure.
The Bernoulli equation is used to calculate: A: the mean pressure B: the peak instantaneous pressure C: the valve area D: the peak instantaneous velocity
Feedback: The Bruce protocol is used during a stress test. It provides guidelines on stages of exercise and assessment of the patient. There are 7 stages of increasing exercise that last 3 minutes each. The patient is monitored by EKG and BP measurements. Echo imaging can be performed before and after the treadmill exercise
The Bruce protocol is used to evaluate: A: left ventricular assist devices B: coronary artery disease C: adult congenital heart disease D: transcatheter valve replacement position
Feedback: The formula represents the calculation of the Right Ventricular Systolic Pressure or RVSP. This is an important indicator of the presence/absence of pulmonary HTN.
The equation 4 (V x V) + RA pressure = ?? is used to calculate the systolic pressure of ___________. A: the left ventricle B: the right ventricle C: across an ASD D: across a VSD
Feedback: The apical four chamber view demonstrates the basal and mid anterolateral walls along with the mid and basal inferoseptal walls. The cardiac apex and apical septum are normally visualized on this view. The lateral RV wall can also be evaluated in this view.
The motion of which of the following wall segments can be evaluated on the apical four chamber view? A: lateral right ventricular wall B: basal inferolateral wall C: mid anteroseptal wall D: basal anteroseptal wall
Feedback: Peak pressure gradient = (v)2 x 4 = (3 x 3) x 4 = 36mmHg
The peak velocity across the aortic valve is 3m/s. What is the peak pressure gradient across the valve? A: 6mmHg B: 12mmHg C: 46mmHg D: 36mmHg
Feedback: The vena contracta measurement for tricuspid regurgitation should be performed in the parasternal RV inflow view. The PISA radius should be measured in the apical 4 chamber view.
The vena contracta measurement for tricuspid regurgitation should be performed: A: in the parasternal RV inflow view B: in the apical 4 chamber view C: only on patients with atrial fibrillation and poor CW Doppler evaluation D: in the parasternal RV outflow view
Feedback: The E' velocity is compared to the mitral E velocity to obtain the E/E' ratio.
Tissue Doppler of the mitral annulus is performed to produce what two numbers? A: Pressure half time of the annulus B: E' and A' velocities C: E and A velocities D: D and E velocities
Not sure what the picture looked like, but see picture here for VSD https://thoracickey.com/ventricular-septal-defect-7/
Use your mouse to place your cursor over the portion of the septum that would demonstrate shunt flow across a perimembranous defect and click to mark that area.
Feedback: In order to diagnose a persistent left SVC, contrast should be injected in the venous system of the left arm. The PLAX view is used (not apical 4) so that the coronary sinus and RV are visible on the same image. Contrast will be seen in the coronary sinus before entering the right heart if the exam is positive.
What abnormality is demonstrated using saline contrast while performing the parasternal long axis view of the heart? A: atrial septal defect B: pulmonary arteriovenous malformation C: ventricular septal defect D: persistent left SVC
Feedback: The coronary sinus is dilated in this patient. If a persistent left SVC is present and connected to the coronary sinus, the patient should have microbubbles injected into the LEFT arm. If the abnormal connection is present, the bubbles will reach the RA first through the coronary sinus instead of the normal right sided SVC.
What additional testing technique can be performed to confirm the abnormal findings on the video [showing a dilated coronary sinus]? A: saline bubble study B: stress echo C: MUGA scan D: nuclear stress exam
Feedback: Fluid posterior to the coronary sinus but anterior to the descending aorta = pericardial effusion Fluid posterior to the coronary sinus and descending aorta = pleural effusion
What echocardiographic view is best for differentiation of a pleural and pericardial effusion? A: subcostal B: parasternal long axis C: apical 2 chamber D: parasternal short axis
Feedback: Myocardial Dyssynchrony Testing uses 2D, pulsed or tissue Doppler to evaluate dual chamber pacer therapy (cardiac resynchronization therapy). Most commonly PW Doppler of the LVOT and RVOT are performed to evaluate IVCT. A >40ms difference is abnormal. The pacemaker can usually be adjusted to coordinate right and left ventricular contraction for a better overall systolic contraction
What is myocardial dyssynchrony testing primarily used for? A: congenital defects of the myocardium B: pediatric patients with heart failure C: to evaluate patients immediately after coronary bypass D: cardiac resynchronization therapy
Feedback: In patients with a VSD the right ventricular systolic pressure is equal to the peak velocity through the defect squared, then multiplied by 4. Then subtract this pressure value from the systolic systemic pressure. RVSP = 110 - [(3 x 3)(4)] = 110 - 36 = 74mmHg
What is the RVSP for the patient in the video [shows VSD] with a peak velocity of the blood flow demonstrated is 3m/s and a systemic blood pressure of 110/70mmHg? A: 36mmHg B: 74mmHg C: 34mmHg D: 106mmHg
Feedback: The ductus arteriosus is a portion of the fetal circulation that shunts blood away from the lungs by connecting the pulmonary artery to the descending aorta. After birth the ductus should close. If the ductus remains patent, flow will reverse with elevated left heart pressures. The main pulmonary artery will demonstrate inflow during the entire cardiac cycle. The color jet will be similar in appearance to pulmonary insufficiency but continuous and the origin of the flow will be in the MPA. The MPA and branches are best seen in the high PSAX view.
What is the best echocardiographic view to diagnose a patent ductus arteriosus? A: Parasternal long axis B: Parasternal short axis C: Apical D: Subcostal
Feedback: The PISA method allows for accurate assessment of MR in a mechanical valve. The PISA radius can be measured without issues from valve masking. Posterior shadowing and reverberation artifact (valve masking) can inhibit color display and limit assessment of regurgitation in other views
What is the best method to evaluate the severity of mitral regurgitation in a mechanical mitral valve? A: parasternal long axis, PISA method B: subcostal 4 chamber, regurgitant jet area C: parasternal long axis, vena contracta method D: apical 4 chamber view, PISA method
Feedback: The cardiac muscle will require increased arterial flow with exercise. This will cause increased ischemia in areas with CAD that may have appeared normal at rest.
What is the main advantage of stress echocardiography over a resting transthoracic exam? A: Stress echo provides improved assessment of ischemic heart disease. B: Stress echo provides higher resolution images for identifying subtle areas of abnormal wall motion. C: Stress echo exams allow for the use of contrast to better delineate flow patterns. D: Stress echo exams allow for assessment of myocardial strain in patients in heart failure.
Feedback: Left atrial pressure = systolic blood pressure - peak gradient MR peak MR gradient = 4 (MR peak velocity)2
What measurements are necessary to calculate the left atrial pressure? A: MVA and mitral regurgitation velocity B: Pulmonary artery pressure and S velocity from pulmonary vein C: Tricuspid regurgitation velocity and right atrial pressure D: Mitral regurgitation velocity and systolic BP
Feedback: The subcostal view is used to evaluate abdominal situs. The aorta, stomach and spleen should be on the left and the liver and IVC on the right.
What transducer position is preferred for evaluation of abdominal situs? A: parasternal B: suprasternal C: subcostal D: apical
Feedback: EX: AV velocity 4m/s, BP 100/70; Pressure gradient = 4 (4 x 4) = 64mmHg; LV peak systolic pressure 64mmHg + 100mmHg = 164mmHg
What two measurements do you need to estimate the peak pressure in the left ventricular during systole? A: aortic peak velocity and systolic blood pressure B: aortic mean pressure gradient and left atrial pressure C: tricuspid regurgitation velocity and right atrial pressure D: aortic peak velocity and left atrial pressure
Feedback: The PSAX view of the base of the heart which demonstrates the origin of the coronary arteries from the aorta (coronary ostia).
What view would best demonstrate the left and right coronary ostia? A: apical 4 chamber view B: parasternal short axis view C: subcostal long axis view D: parasternal long axis view
Feedback: When evaluating LV inflow, an apical 4 chamber view should be performed. The sample volume is placed at the leaflet tips, with the cursor line parallel to the flow moving trough the valve.
When evaluating LV inflow, how should the Doppler waveform be obtained? A: Apical 5 chamber, sample volume just proximal to the aortic valve B: Apical 4 chamber, sample volume at the level of the MV annulus C: Apical 4 chamber, sample volume at the level of the MV leaflet tips D: Parasternal long axis, sample volume at the level of the MV leaflet tips
Feedback: When evaluating the aortic root with m-mode and 2D imaging, the measurement should be taken at end diastole to obtain the greatest diameter. The left atrium should be measured in end systole. The aortic cusp separation is measured at the onset of systole when the valve first opens. The EPSS measurement is measured in early diastole. The E-point occurs during the rapid filling phase in the first part of diastole.
When evaluating the ________________ with m-mode and 2D imaging, the measurement should be taken at end diastole to obtain the greatest diameter. A: E-point septal separation B: aortic cusp separation C: aortic root D: left atrium
Feedback: When measuring the LV length for volume assessment, the apical caliper centered and perpendicular to the LV long axis. The second caliper is placed at the level of the mitral annulus. Keep in mind that the apical views are demonstrated with the most inferior portion of the heart at the top of the screen. Cephalad means toward the patient's head. Placing the cursor more cephalad on the image would mean placing it above the MV, in the left atrium. Proximal to the MV would also indicate placement in the left atrium.
When measuring the LV length for volume assessment, the apical caliper is centered and perpendicular to the LV long axis. The second caliper is placed: A: just proximal to the MV leaflet tips B: at the level of the mitral annulus C: just apical to the MV leaflet tips D: just cephalad to the MV leaflet tips
Feedback: The heart rate will begin to drop after 60 seconds. Obtaining the post exercise images when the heart rate begins to normalize can reduce the accuracy of the exam.
When performing a stress echocardiogram with a treadmill, the post-exercise images must be obtained within __________ after the treadmill has stopped for the most accurate evaluation of potential coronary artery disease. A: 30 seconds B: 60 seconds C: 90 seconds D: 3 minutes
Feedback: The agitated saline is injected into the venous system and should fill the right atrium/ventricle. Contrast will normally fill the right side of the heart and if it moves across the atrial septum, bubbles will be demonstrated in the left atrium. The Valsalva maneuver can help to increase venous pressure to move the contrast from the right atrium into the left atrium. A left to right shunt will demonstrate blood that is shunted from the left atrium into the right atrium which will cause the contrast to dissipate in the area of the incoming blood flow (negative contrast effect).
When performing an agitated saline contrast exam to evaluate a patient for a suspected ASD, what cardiac chamber should be evaluated closely for the presence of the contrast? A: left ventricle B: left atrium C: right atrium D: right ventricle
Feedback: Spectral Doppler measurements should be made at the modal (densest) margin of the flow signal. Multiple samples may be taken at the same site. Use the highest quality and highest velocity signals for final measurements. Do not report Doppler flow information from waveforms with poor definition or of marginal quality.
When reporting spectral Doppler information for an echocardiogram: A: record the highest quality and highest velocity signals for the final measurements B: always record the highest velocity obtained from all signals C: the frequency of the transducer used for the exam should be indicated in the report D: each waveform must be classified as triphasic, biphasic or monophasic
Feedback: Aortic insufficiency can lead to a hypercontractile ventricle. This will cause a false increase in the peak velocity and peak pressure gradient across the valve. The mean pressure gradient is the most accurate Doppler parameter to assess AS in this type of patient. Pressure half time is used to assess aortic insufficiency.
Which Doppler flow parameter is most accurate when assessing aortic stenosis in a patient with significant aortic regurgitation? A: mean pressure gradient B: pressure half time C: peak systolic velocity D: peak pressure gradient
Feedback: The motion of all three leaflets can be evaluated and the valve opening assessed. Doppler evaluation is preferred from the apical 5 or 3 chamber view. Severe stenosis is best evaluated from the suprasternal notch view using CW Doppler.
Which echocardiographic view provides the best 2D evaluation of aortic stenosis? A: Parasternal short axis B: Apical 5 chamber C: Parasternal long axis D: Suprasternal notch view
Feedback: The most definitive method for diagnosis of myocarditis, amyloidosis, hemochromatosis and sarcoidosis is through direct specimen evaluation from a biopsy.
Which evaluation technique is the best method for diagnosis of hemochromatosis? A: myocardial biopsy B: transesophageal echo C: Thallium stress test D: contrast echo
Feedback: If the PSAX images are of good enough quality to see the valve opening for proper tracing, planimetry is the preferred method of MVA assessment. In most cases the pressure half time must be used to assess the MVA due to suboptimal 2D imaging.
Which method is the most accurate for measurement of the mitral valve area? : A: pressure half time B: mitral valve continuity equation C: planimetry D: deceleration time
Feedback: Valve masking limits Doppler evaluation of a mechanical MVR in the apical view. The masking occurs posterior to the valve on the image but the PISA radius is measured above the valve.
Which method of mitral regurgitation assessment is most accurate when evaluating a mechanical MVR in the apical 4 chamber view? A: vena contracta B: color Doppler jet size C: peak pressure gradient by CW Doppler D: PISA radius
Feedback: RVSP = Pulmonary Artery Pressure = TR PPG + RA pressure
Which of the following can be used to assess the pulmonary artery systolic pressure? A: peak pressure gradient of mitral regurgitation B: peak pressure gradient of tricuspid regurgitation and right ventricular pressure C: right atrial pressure and mean pressure gradient of tricuspid regurgitation D: right atrial pressure and peak pressure gradient of tricuspid regurgitation
Feedback: The bubbles will aid in locating shunt flow between the chambers of the heart or anomalies of circulation in the right heart. LV thrombus is best evaluated with perfluorocarbon contrast.
Which of the following cardiac abnormalities would benefit from an agitated saline contrast exam? A: atrial septal defect B: persistent left SVC C: suspected left ventricular thrombus D: more than one of the above
Feedback: Stress testing is helpful for suspected diastolic dysfunction in patients with dyspnea on exertion. E velocity measurements across the mitral valve and E' velocity at the septal annulus should be taken before and after exercise. Normal results are indicated when both the E and E' velocities increase with no change in the E/E' ratio. Diastolic dysfunction is indicated when the E velocity increases but the E' velocity is unchanged. This leads to an increased E/E' ratio.
Which of the following correctly describes how to assess for diastolic dysfunction on a stress echo? A: measure the left atrial volume before and after exercise B: measure the pulmonary vein flow velocities before and after exercise C: measure the E and E' velocities before and after exercise D: measure the left ventricular volume before and after exercise
Feedback: When changing from the parasternal long axis view of the left heart to visualize the parasternal short axis view, the transducer should be rotated about 90 degrees clockwise.
Which of the following correctly describes how to manipulate the transducer from the parasternal long axis view of the left heart to visualize the parasternal short axis view? A: angle lateral with slight rotation B: 90 degree clockwise rotation C: angle medial with slight rotation D: 90 degree counterclockwise rotation
Feedback: In the PLAX view, the left atrium should be measured from leading edge to leading edge, from the aortic sinus to the posterior atrial wall
Which of the following correctly describes how to measure the left atrium in the parasternal view? A: leading edge to leading edge, from the aortic sinus to the posterior atrial wall B: leading edge to leading edge, from the LVOT to the posterior atrial wall C: outer edge to outer edge, from the aortic sinus to the posterior atrial wall D: outer edge to inner edge, from the aortic sinus to the posterior atrial wall
Feedback: Decreasing the wall filter will allow for lower velocity flow to be more easily displayed. The sweep speed should be increased to spread out the flow properties of the venous flow. This allows proper visualization of the S and D velocities along with the peak a-wave and duration.
Which of the following correctly describes how to perform a Doppler evaluation of the pulmonary venous flow? A: decrease the wall filter and increase the sweep speed B: decrease the wall filter and the sweep speed C: increase the wall filter and decrease the sweep speed D: increase the wall filter and the sweep speed
Feedback: The flow in the hepatic veins is parallel to the ultrasound beam which provides a better Doppler signal. The flow in the IVC is perpendicular to the beam which limits Doppler evaluation.
Which of the following correctly describes why the hepatic vein is more commonly evaluated with Doppler to assess venous inflow into the right atrium than the inferior vena cava? A: The IVC is commonly affected by extrinsic compression that can change the flow pattern where the hepatic veins do not respond to extrinsic compression B: The flow in the hepatic veins is parallel to the ultrasound beam which provides a better Doppler signal C: The flow in the hepatic veins is perpendicular to the ultrasound beam which provides a better Doppler signal D: Respiratory variation in flow is not easily identified in the IVC but is easily evaluated in hepatic vein flow
Feedback: Normal pulmonary vasculature is low resistance and results in slower acceleration with the maximum velocity occurring later in the ejection cycle than the aortic valve. The duration of pulmonary flow is longer than left ventricular ejection time. The velocity curve is more rounded than the aortic valve. If pulmonary vascular resistance increases, the pulmonary waveform looks more like the aortic valve with a sharper velocity curve and earlier peak velocity.
Which of the following describes a difference in the normal Doppler tracings obtained at the aortic and pulmonic valves? A: the maximum velocity of the pulmonary valve occurs later in the ejection cycle than the aortic valve B: The aortic velocity curve is more rounded than the pulmonic valve C: The pulmonary acceleration time is much shorter than the aortic acceleration time D: the maximum velocity of the pulmonary valve occurs earlier in the ejection cycle than the aortic valve
Feedback: The apical 4 chamber view should demonstrate all four chambers. The long axis of the heart from the base of the left atrium to the apex of the left ventricle is demonstrated. The image should consist of about 2/3 left ventricle and 1/3 left atrium. The LV should taper to an ellipsoid shape at the apex. If the LV is rounded, the LV is foreshortened and the transducer should be rotated or angled to elongate it
Which of the following describes an apical view that is suboptimal? A: All four chamber are demonstrated on the image B: The LV apex is rounded C: The LV cavity is an ellipsoid shape D: The image should consist of about 2/3 left ventricle and 1/3 left atrium
Feedback: Fills less than <25% LVOT diameter = Mild; Fills 25 -65% LVOT diameter = Moderate; Fills more than >65% of the LVOT diameter = Severe
Which of the following describes how color Doppler is used to quantify aortic insufficiency? A: Evaluate the peak velocity of the flow B: Evaluate the pressure 1/2 time of the waveform C: Evaluate the width of the jet in relation to the LVOT diameter D: Evaluate the width of the jet within the aortic root
Feedback: In a patient with atrial fibrillation and AS, the variation in the R-R intervals will cause variation in the aortic velocity. The longer the R-R interval, the higher the next aortic velocity will be on the tracing. Averaging the velocity information from 5 or more beats should provide the most accurate velocity information in these patients.
Which of the following describes the appropriate method for using Doppler to evaluate suspected aortic stenosis in a patient with atrial fibrillation? A: never record peak velocities from the waveform obtained after a long R-R interval B: always record peak velocities from the waveform obtained after a long R-R interval C: it is not possible to record an accurate peak velocity of aortic outflow in a patient with atrial fibrillation so only the pressure gradients should be reported D: record the velocity from a tracing obtained while the patient performs the Valsalva strain
Feedback: When performing the SSN view, the patient should be in the supine position with the neck extended. In some cases you may also need to place a small pillow under the patient's shoulders to hyperextend the neck
Which of the following describes the best patient position for obtaining the suprasternal notch view? A: supine with neck extended B: left lateral decubitus with neck turned 45 degrees to left C: right lateral decubitus with neck turned 45 degrees to left D: left lateral decubitus with neck turned 45 degrees to right
Feedback: The modified suprasternal short axis view (crab view) can also be used to evaluate the four pulmonary veins emptying into the left atrium.
Which of the following describes the correct change in transducer position from the subcostal four chamber view in order to view the four pulmonary veins emptying into the left atrium? A: rotate 60 - 90 degrees counter clockwise B: angle slightly anterior C: rotate 30 - 60 degrees clockwise D: rotate 30 - 60 degrees counter clockwise
Feedback: The apical 4 chamber view should be optimized to provide a focused RV view. The preferred method of assessment of the right ventricular size is to measure the width at the base and middle of the chamber in this view.
Which of the following describes the preferred method of assessment of the right ventricular size? A: measure the anterior-posterior dimension in the parasternal long axis view B: measure from the apex to the tricuspid valve annulus in the apical 4 chamber view C: measure the width at the base and middle of the chamber in the apical 4 chamber view D: measure the anterior-posterior dimension in the parasternal short axis view
Feedback: Qp/Qs is used to assess the amount of flow being shunted from the left to right heart through a defect. This is performed by evaluating outflow of both sides of the heart.
Which of the following does not require assessment of the Qp/Qs ratio? A: 18yr old with patent ductus arteriosus B: 50yr old with septum primum ASD C: 28yr old with muscular VSD D: 66yr old with tricuspid regurgitation
Feedback: Tissue Doppler of the mitral annulus is used to provide quantitative analysis of the ability of the LV tissues to relax in diastole.
Which of the following exam techniques is best for the quantitative evaluation of left ventricular diastolic dysfunction? A: tissue velocity imaging B: stress echo C: color Doppler D: myocardial strain imaging
Feedback: PISA measurements are limited to evaluation of patients with a single MR jet. You are not able to obtain accurate area of flow convergence with multiple MR jets present.
Which of the following is a limitation of the PISA assessment of mitral regurgitation? A: not valid for patients with mitral stenosis B: can only be used to assess mitral regurgitation C: not accurate in patients with multiple jets of mitral regurgitation D: not valid for patients with pulmonary stenosis
Feedback: Unstable angina refers to chest pain that occurs with the patient at rest. Stable angina refers to controlled angina (reduced with rest or nitroglycerin). Unstable angina is a contraindication for a stress test.
Which of the following is an appropriate reason to cancel a treadmill stress test for a patient? A: patient has unstable angina B: patient has moderate mitral regurgitation C: patient has suspected coronary artery disease D: patient has varicose veins
Feedback: Point-Of-Care Ultrasound Study (POCUS) is a limited, focused ultrasound exam. It can be performed to evaluate cardiac symptoms. It is usually performed bedside to evaluate acute symptoms like chest pain or shortness of breath. Images are taken to evaluate pericardial effusion, LV global and regional function
Which of the following is not a standard part of a Point of Care Ultrasound? A: evaluate the patient for pericardial effusion B: evaluate the patient for global wall motion abnormalities C: evaluate the patient for regional wall motion abnormalities D: evaluate the patient for significant valvular stenosis
Feedback: The velocity and PPG indicate severe stenosis, but the valve area is too large to correlate with the other signs of severe stenosis. If the Doppler cursor is placed too close to the aortic valve, the LVOT peak velocity will be higher than what it would be at the correct location. This will cause the calculation of a larger or overestimated AVA or underestimated level of stenosis. The peak aortic velocity and pressure gradient will not match the level of stenosis indicated by the AVA. The continuity equation corrects for changes in ejection fraction. A change in EF% will not affects the calculated AVA.
Which of the following is the most likely cause for the findings below? aortic valve peak velocity = 4.2m/s aortic valve peak pressure gradient = 70mmHg Aortic valve area = 1.4cm2 A: the patient has a low ejection fraction B: the findings are consistent with severe aortic stenosis C: the LVOT PW Doppler sample was obtained too far from the aortic valve D: the LVOT PW Doppler sample was obtained to close to the aortic valve
Feedback: The Simpson method of assessing EF% is the most accurate, as long as echo views are of good quality with good endocardial visualization.
Which of the following measurements is the most accurate predictor of left ventricular function? A: Simpson EF% B: Left ventricular mass C: M-mode EF% D: dp/dt
Feedback: TEE exams are useful for evaluation of prosthetic valves. Small perivalvular leaks and vegetation formation are best evaluated on TEE exams. TEE exams do not demonstrate the apex of the heart very well. The IVC would not be evaluated for thrombus on TEE.
Which of the following patients would benefit the most from a transesophageal echo exam? A: Suspected IVC thrombus B: Muscular VSD at the left ventricular apex C: St Jude AVR with suspected stenosis D: Suspected apical left ventricular thrombus
Feedback: Ventriculography is used to visualize ventricular wall motion and ventricular outflow tracts. After LV mass and volume are determined from single planar or biplanar ventricular angiograms, end-systolic and end-diastolic volumes and ejection fraction can also be calculated.
Which of the following procedures can be performed during a left heart catheterization? A: pulmonary angiography B: right ventricle systolic pressure assessment C: ventriculogram D: pulmonary capillary wedge pressure assessment
Feedback: Ventriculography can be performed during a left heart catheterization. The procedure is used to visualize ventricular wall motion and ventricular outflow tracts, including subvalvular, valvular, and supravalvular regions. It is also used to estimate severity of mitral valve regurgitation and determine its pathophysiology. After LV mass and volume are determined from single planar or biplanar ventricular angiograms, end-systolic and end-diastolic volumes and ejection fraction can be calculated.
Which of the following procedures uses the injection of iodinated contrast to assess left ventricular function? A: contrast echocardiogram B: intracardiac ultrasound C: left heart catheterization D: pulmonary angiography
Feedback: An aortic dissection is when a portion of the intimal wall becomes loose and creates a flap of tissue within the aorta. The patient is at an increased risk of aortic aneurysm/rupture. The intimal flap and associated false lumen may also cause narrowing of the aortic lumen. Due to the variable probe position, location in proximity to the aorta and increased resolution of the higher frequency probes, TEE is the best choice for diagnosis of a dissection. CT is a radiology exam not a sonographic technique
Which of the following sonographic exam techniques is best for the evaluation of aortic dissection? A: cat scan of the chest B: stress echocardiography C: transesophageal echo D: contrast echo
Feedback: The left ventricular apex is normally not well visualized on the standard PLAX view that includes the basal and mid left ventricular segments, aortic valve, aortic root, both mitral leaflets, left atrium, coronary sinus and a small portion of the right ventricle.
Which of the following structures is normally NOT well visualized on the parasternal long axis view? A: coronary sinus B: posterior mitral valve leaflet C: left ventricular apex D: sinotubular junction
Feedback: All of the above choices are techniques used to assess the presence/absence of a mass versus an artifact but the most accurate would be the use of contrast. Optison, Levovist and Definity are examples of microbubble contrast agents used in echo to define the borders of the endocardium and the mass.
Which of the following techniques can be used to most accurately differentiate a left sided cardiac mass from a sonographic artifact? A: Adjust compression, gain and add B color to enhance the image. B: Switch to a higher frequency transducer. C: Use microbubbles to delineate the chamber characteristics. D: Use multiple 2D views and planes to evaluate the area.
Feedback: The anterior and septal leaflets are identified on the apical 4 chamber and PSAX view. The anterior and posterior leaflets are seen on the PLAX RV inflow view.
Which of the following views will demonstrate the anterior leaflet of the tricuspid valve? A: Apical 4 B: Parasternal right ventricular inflow C: Parasternal short axis D: All of the above
Feedback: The anterior and septal leaflets are identified on the apical 4 chamber and PSAX view. The anterior and posterior leaflets are seen on the PLAX RV inflow view.
Which of the following views will demonstrate the posterior leaflet of the tricuspid valve? A: Parasternal short axis B: Parasternal right ventricular inflow C: Apical 4 chamber D: Subcostal 4 chamber
Feedback: Flow entering the LV from the aortic regurgitation and through the MV can result in shortened pressure half time measurement and underestimated MV stenosis.
Which of the following would cause an incorrect assessment of the mitral valve area using the pressure half time measurement? A: significant aortic regurgitation B: the presence of any degree of mitral regurgitation C: pulmonary valve stenosis D: 2mm muscular or perimembranous VSD
Feedback: The septal (medial) and anterior leaflets are visible on the apical 4 chamber view.
Which of the tricuspid leaflets are evaluated in the apical 4 chamber view? A: anterior and posterior B: posterior and septal C: lateral and anterior D: septal and anterior
Feedback: The parasternal short axis (PSAX) is the best view to visualize all of the LV wall segments. The septal and lateral walls are seen on the Apical 4 chamber view.
Which sonographic view best demonstrates the anterolateral wall of the left ventricle? A: Apical 2 B: Subcostal C: Apical 4 D: Parasternal long axis
Feedback: A right heart catheterization is more accurate for predicting the PA systolic pressure than echocardiography.
Which technique is the preferred method for predicting the pulmonary artery systolic pressure? A: right heart catheterization B: transthoracic echo Doppler evaluation C: transesophageal echo Doppler evaluation D: contrast enhanced Doppler evaluation
Feedback: TEE provides the best resolution and provides the ability to view the valve from numerous angles which reduces limitations from shadowing from the valvular apparatus.
Which type of exam will provide the best assessment of prosthetic valve function? A: MUGA scan B: contrast echo C: transesophageal echo D: dedicated CW Doppler
Feedback: The subcostal 4 chamber view provides the best view to measure the right ventricular wall thickness. 2D imaging relies on perpendicular incidence of the beam for best reflection and resolution. The right ventricular free wall will be nearly perpendicular to the beam in the subcostal 4 chamber view.
Which view is preferred for performing the measurement of the right ventricular wall thickness? A: parasternal long axis B: subcostal 4 chamber C: apical 4 chamber D: parasternal short axis
Feedback: The aortic valve is located at the base of the heart which is located more superiorly and medially in the chest than the mitral valve. When imaging the AV in the parasternal short axis view, you must tilt the transducer inferior and lateral to view the mitral valve
While attempting to perform the parasternal short axis views of the aortic valve, the cardiologist enters the room and requests a parasternal short axis view of the mitral valve. How do you manipulate the transducer from your current position to provide the requested view? A: tilt slightly inferior/lateral B: tilt the probe superior, toward the patient's right shoulder C: angle slightly superior/medial D: move medially
Feedback: In patients with a persistent SVC, blood from left arm drains directly into coronary sinus through the brachiocephalic vein. This leads to a dilated coronary sinus. The abnormality is best demonstrated in the longitudinal suprasternal notch view. The best way to diagnose is to inject saline contrast into left arm, it will fill the coronary sinus BEFORE the RA.
While performing an echocardiogram, you note that the coronary sinus is significantly dilated and the rest of the study seems normal. What will be the most likely next step in evaluating this patient? A: Stress echo to see if exercise reduces the size of the coronary sinus. B: Saline contrast exam to evaluate the flow in the coronary sinus. C: Cardiac CT to evaluate the pericardium for restrictive motion. D: Microbubble contrast to evaluate the interatrial septum for defect.
Feedback: PW Doppler is most accurate when the sample can be obtained with the incident beam (and cursor) parallel to the direction of flow. The apical 4 chamber view allows the Doppler cursor to be at a 0 degree angle to the flow which produces the most accurate Doppler shift information.
Why is the apical 4 chamber view preferred for the Doppler evaluation of the mitral valve? A: The mitral valve is most anterior in this view which allows the use of higher frequencies to improve the accuracy of the sample. B: PW Doppler is most accurate when the sample can be obtained with the incident beam at a 0 degree angle to the flow. C: During most cardiac exams, the parasternal views are for m-mode evaluation and the apical views are used for Doppler evaluation. D: PW Doppler is most accurate when the sample can be obtained with the incident beam at a 90 degree angle to the flow.
Feedback: The contraction velocity of the LAA can be used to evaluate the risk for LA thrombus formation, usually in cases of mitral stenosis. PW Doppler sample volume positioned approximately 1 cm proximal to the entry of the appendage into the body of the LA. Normal contraction velocity of the LAA is about 0.4 m/s. Lower velocities are associated with an increased risk of thrombus formation.
Why is the contraction velocity of the left atrial appendage measured? A: to determine the severity of mitral stenosis B: to assess risk of thrombus formation C: to determine the severity of mitral regurgitation D: to assess the risk of developing diastolic dysfunction
Feedback: The IVC should be evaluated in the longitudinal plane from the subcostal approach. A quick sniff or inspiration should be performed to assess IVC collapse to estimate RA pressure.
Why is this view [shows IVC in subcostal] performed as a part of the protocol for a standard echo exam? A: To evaluate the effects of cardiac motion on venous return B: To assess right atrial pressure C: To rule out coarctation D: To rule out the presence of ascites in the abdomen
Feedback: Four parameters are used to evaluate patents with normal EF%. The E/A ratio is important with depressed EF% or myocardial disease with preserved EF% Diastolic Dysfunction with: septal E' <7cm/s, lateral E' < 10cm/s E/E' ratio >14 LAVI >34ml/m2 TR peak velocity >2.8m/s
You are evaluating a patient for LV diastolic dysfunction. Systolic function and the myocardium appear normal. Which of the following parameters is used to grade dysfunction? A: E/A ratio B: mitral regurgitation peak velocity C: left atrial volume index D: peak E velocity of the tricuspid valve
Feedback: If a patient has an abnormal EF% with less than three primary parameters available, the pulmonary vein S/D ratio may be used to confirm the diagnosis. A ratio < 1 indicates increased LAP
You are evaluating a patient with an EF% of 33% for diastolic dysfunction. The left atrial volume index and tissue Doppler measurements are recorded. The exam is suboptimal for documenting an accurate TR velocity. What other parameter is recommended to aid in diagnosis of diastolic dysfunction in this patient? A: mitral regurgitation velocity B: S/D ratio of the pulmonary veins C: systemic blood pressure D: isovolumic contraction time
Feedback: Index of myocardial performance = time from MV closure to MV opening - ejection time of LVOT / ejection time of LVOT Normal values 0.34 - 0.44 Severely abnormal 0.82 - 1.3 indicates myocardial dysfunction
You are performing the index of myocardial performance for the left ventricle. You have measured the time from mitral valve opening to mitral valve closing. What other parameter should you measure to complete the calculation? A: mean pressure gradient across the LVOT B: LVOT ejection time C: mean pressure gradient across the mitral valve D: mitral valve pressure half time
Feedback: The two chamber view demonstrates the anterior and inferior walls.
You perform an echo on a patient with a history of emphysema. The only echocardiographic window available is the apical window. The cardiologist reviews the exam and asks you to get a better view of the inferior wall. What view will you repeat and try to optimize? A: Right parasternal B: Apical 2 chamber C: Apical 4 chamber D: Apical 5 chamber
