echo pathology (1-180) PART ONE

Flattening of the IVS is least likely to be associated with which of the following? A. 3mm muscular VSD B. Pulmonary HTN C. Congestive heart failure D. Large ASD

A. 3mm muscular VSD As the pressure within the right ventricle increase with pulmonary HTN, it can eventually meet and exceed the pressure within the left ventricle. Once the pressure in the right ventricle exceeds the pressure in the left, the interventricular septum will flatten in diastole and demonstrate bowing into the left ventricle in systole. Flow through a VSD moves quickly back out the RVOT to the lungs and usually has no effect on the right heart unless the VSD is very large.

All of the following can be used to describe mitral valve prolapse, except: A. >3mm thickness of the leaflet tips in systole B. leaflet falls >2mm above the annular plane in systole C. myxomatous degeneration D. leaflet redundancy

A. >3mm thickness of the leaflet tips in systole The myxomatous degeneration of the leaflets tips causes increased thickness >5mm seen in diastole.

How does severe chronic mitral regurgitation affect the isovolumic relaxation time? A. Decrease B. Varies with patient age and history of coronary artery disease C. No change D. Increase

A. Decrease

A patient presents with a script for an echo due to a suspected parachute mitral valve. Which of the following is an expected finding on the exam? A. Decrease E-F slope and increased E velocity B. Multiple left ventricular wall motion abnormalities causing mitral regurgitation C. Atrial fibrillation and loss of the A peak on Doppler D. systolic anterior motion of the mitral valve with a flail posterior leaflet

A. Decrease E-F slope and increased E velocity Parachute MV refers to when only a single papillary muscle forms and attaches to MV leaflets. The defect causes symptoms and Doppler findings similar to mitral stenosis.

Which grade of diastolic dysfunction is most commonly associated with chronic systemic HTN? A. Grade I abnormal relaxation B. Grade II pseudonormalization C. Grade III reversible restrictive D. Grade IV irreversible restrictive

A. Grade I abnormal relaxation

Which statement regarding m-mode of the aortic valve is true? A. Mitral regurgitation can lead to early systolic closure of the aortic valve and a shortened left ventricular ejection time. B. The aortic valve leaflets may demonstrate fluttering in systole due to the presence of mitral regurgitation. C. The left ventricular ejection time is obtained by measuring the maximum cusp separation on the tracing. D. The aortic cusp separation measurement taken on m-mode is an accurate method for assessing the degree of aortic stenosis.

A. Mitral regurgitation can lead to early systolic closure of the aortic valve and a shortened left ventricular ejection time. The aortic cusp separation is measured by placing calipers on the inner AP dimension of the "box" on the tracing. The aortic cusp separation measurement taken on m-mode is NOT an accurate method for assessing the degree of aortic stenosis. The left ventricular ejection time is obtained by measuring the time that the AV leaflets are open during systole. Due to cardiac structure and MR jet location, the AV leaflets are not vibrated by the MR jet.

A 20yr old male presents for an echo with visible distension of the jugular veins. Which of the following is the least likely cause for this symptom? A. Mitral stenosis B. Constrictive pericarditis C. Tricuspid stenosis D. Pulmonary HTN

A. Mitral stenosis Jugular distension is caused by increased central venous pressure and can be related to right heart failure. Cardiac tamponade, constrictive pericarditis, pulmonary HTN, tricuspid stenosis, significant tricuspid regurgitation and the valsalva maneuver can all lead to jugular vein distension.

Which of the following is true regarding mitral regurgitation (MR)? A. The larger the residual opening between the mitral leaflets during ventricular systole, the lower the pressure gradient of the MR jet. B. Assessment of the MR jet peak pressure gradient is used to calculate the left ventricular diastolic pressure. C. Higher velocity jets indicate more severe regurgitation. D. The left atrial diastolic pressure is added to the MR pressure gradient to obtain the left atrial systolic pressure.

A. The larger the residual opening between the mitral leaflets during ventricular systole, the lower the pressure gradient of the MR jet. The larger the residual opening between the mitral leaflets during ventricular systole, the lower the pressure gradient of the MR jet

Which of the following statements regarding ventricular septal defects is true? A. The membranous type of VSD is located at the junction of the left ventricular outflow tract and the muscular portion of the septum. B. Multiple inlet defects can cause the muscular septum to have a swiss cheese appearance. C. In small to medium defects, flow normally occurs from the right ventricle to the left ventricle during systole. D. The muscular type of VSD is the most common.

A. The membranous type of VSD is located at the junction of the left ventricular outflow tract and the muscular portion of the septum. Multiple muscular VSDs have been known to cause a "swiss cheese" appearance of the ventricular septum. In small to medium defects, flow normally occurs from the left ventricle to the right ventricle during systole. The perimembranous type of VSD is the most common. The membranous type of VSD is located at the junction of the left ventricular outflow tract and the muscular portion of the septum.

Which of the following statements regarding myxomas is false? A. They are benign tumors most commonly seen in males. B. They most commonly form in the left atrium. C. Resection is required but recurrence can occur. D. They are benign tumors made of mucous cells.

A. They are benign tumors most commonly seen in males. Myxomas are benign tumors of the heart that are composed of mucous cells. They usually form in the left atrium with septal attachment. They are three times more common in females.

A 22yr old patient presents for an echo and you identify biventricular wall thickening, mild pericardial effusion and thickening of the leaflets of all four valves. Which of the following is the most likely cause for these findings? A. amyloidosis B. hypertrophic cardiomyopathy C. carcinoid disease D. rheumatic fever

A. amyloidosis The biventricular wall thickening and thickening of all four valves should lead you to considering an infiltrative disease such as amyloidosis. Hypertrophic cardiomyopathy can cause biventricular wall thickening but does not affect the valves. Carcinoid disease causes thickening of the valves but will not affect the wall thickness.

A congenital malformation of the left atrium involving a membrane that crosses the atrium above the level of the fossa ovalis and limits flow through the mitral valve is called _____________________________. A. cortriatriatum B. supravalvular mitral ring C. double outlet mitral valve D. cleft mitral valve

A. cortriatriatum The membrane can suggest the presence of 3 atrial chambers on 2D evaluation.

A patient presents for a 6 month follow up echocardiogram for a reported aortic peak velocity of 3.3m/s and AVA of 1.4cm2. On today's exam, the CW evaluation demonstrates an aortic peak velocity of 2.5m/s with the same AVA. Which of the following could explain the variation in measurements? A. decrease in EF% from last exam B. PW Doppler used to assess the aortic velocity on previous exam C. progressing hypertrophic cardiomyopathy D. progressing restrictive cardiomyopathy

A. decrease in EF% from last exam The continuity equation compensates for changes in cardiac output when calculating the AVA.

A patient presents for a follow up scan due to a history of moderate aortic insufficiency noted on an exam 6 months ago. Which of the following would be an expected finding on the exam? A. hypercontractile left ventricle B. hypertrophic left ventricle C. atrophied left ventricle D. pulmonary artery dilatation

A. hypercontractile left ventricle Moderate AI will lead to volume overload of the LV which presents as a dilated chamber with increased contractility. If the AI becomes more severe, eventually the patient will go in to heart failure with reduced LV contractility.

A left ventricular myectomy is most commonly used to treat which of the following disorders? A. hypertrophic obstructive cardiomyopathy B. myxoma formation C. double outlet mitral valve D. chronic systemic HTN

A. hypertrophic obstructive cardiomyopathy A left ventricular myectomy is performed to reduce septal thickness and the LVOT gradient. The septum is surgically thinned.

All of the following are findings displayed on m-mode tracings from a patient with hypertrophic cardiomyopathy, except: A. increased EPSS measurement B. systolic anterior motion of the mitral leaflet C. left ventricular wall thickness >1.3cm D. mid-systolic notching of the aortic valve

A. increased EPSS measurement The EPSS measurement will remain normal or decrease with HCM. LV cavity size decreases due to wall thickening.

An 8mm vena contracta is measured on a mitral regurgitation(MR) jet. What is the expected Doppler finding in the pulmonary veins of the same patient? A. increased systolic flow reversal B. increased D wave C. increased S and D wave D. decreased systolic flow reversal

A. increased systolic flow reversal Mitral regurgitation occurs during systole. A vena contracta measurement greater than 7mm indicates severe MR. Significant MR will inhibit pulmonary venous inflow and can cause increased flow reversal into the veins during systole.

What happens to the amplitude of the E wave on the Doppler display of a patient with mitral stenosis? A. increases B. decreases C. remains unchanged

A. increases M-mode demonstrates valvular motion over time. The mitral valve motion will be decreased as it becomes more stenotic. This will present as a decreased E wave amplitude on the m-mode evaluation. Doppler evaluates the velocity of flow across the mitral valve. The stenosis will cause an increase in the velocity across the MV leaflets leading to an increase in the amplitude of the E wave on the Doppler tracing.

When considering treatment options for an aneurysm of the left ventricle, the most important information the surgeon needs to see in the pre-op echo report is: A. motion of unaffected wall segments B. size of the aneurysm C. presence/absence of thrombus D. presence of bypass grafts within affected segment

A. motion of unaffected wall segments

Which of the following conditions is the most likely cause for a false positive diagnosis of MVP on m-mode evaluation? A. pericardial effusion B. muscular VSD C. Primum ASD D. mitral regurgitation

A. pericardial effusion Pericardial effusion can cause displacement of the cardiac structures into a different axis. This can lead to incorrect line placement at an off axis angle which could present as prolapse on the tracing.

All of the following are characteristics of constrictive pericarditis, except: A. pericardial rub B. jugular vein distension C. ascites/effusion D. pericardial knock

A. pericardial rub Acute pericarditis will cause a rubbing murmur due to the friction with inflamed layers of pericardium throughout the cardiac contraction. Constrictive pericarditis is caused by chronic inflammation of the pericardium that leads to fibrosis of the layers. The layers become restrictive to cardiac motion and can produce a knocking sound in diastole. The restricted cardiac motion and chronic inflammation can lead to decreased diastolic filling with SVC/IVC distention and fluid retention in the body in the form of effusion and ascites.

While obtaining a PW Doppler tracing of the mitral valve, you notice the E peak is moderately taller than the A peak on the waveform and it has a shorter than normal deceleration time. Which of the following will cause this finding? A. restrictive cardiomyopathy B. loss of atrial compliance C. pulmonary HTN D. decreased cardiac output

A. restrictive cardiomyopathy The restrictive motion of the left ventricle will lead to a shortened deceleration time of the E wave and increased E/A ratio.

Propranolol can be used to treat: A. subaortic stenosis caused by hypertrophic cardiomyopathy B. vegetation formation on the tricuspid valve C. mitral valve prolapse D. carcinoid disease

A. subaortic stenosis caused by hypertrophic cardiomyopathy HOCM can be treated with a medication called Propranolol. It is a beta blocker that can prevent increased flow gradients with exercise but has no effect on resting gradients.

The peak velocity of aortic regurgitation indicates the maximum pressure gradient between: A. the aorta and the left ventricular in diastole B. the left ventricle and the left atrium in diastole C. the left ventricular and the left atrium in diastole D. the aorta and the left ventricular in systole

A. the aorta and the left ventricular in diastole

A 60yr old patient presents for an echo and the script states there is a loud S3. All the following could explain the abnormal heart sound, except? A. tricuspid stenosis B. VSD C. severe aortic insufficiency D. severe mitral regurgitation

A. tricuspid stenosis Third Heart Sound (S3): Caused by the oscillation of blood back and forth between the walls of the ventricles due to the rapid inflow of blood from the atria; Normal heart sound in a child or young adult After age 40, a third heart sound is usually abnormal and correlates with dysfunction or volume overload of the ventricles Indicates rapid ventricular filling due to pregnancy, anemia, CHF, dilated cardiomyopathy, severe valvular regurgitation, left to right shunting and high cardiac output

Mitral valve prolapse is defined as any systolic displacement of the mitral valve leaflets ____________above the annular plane. A. >1mm B. >2mm C. >3mm D. >5mm

B. >2mm

Why does a patient with an ASD and Eisenmenger syndrome have an increased risk of stroke? A. Eisenmenger syndrome causes increased right heart pressures and increased pressure in the jugular veins that leads to blood stasis and potential embolus formation. B. An embolism in the right atrium could pass through the ASD to the left heart and travel to the brain C. Eisenmenger syndrome causes the formation of small clots at the defect that can embolize to the brain. D. Thrombus is more likely to form in the left atrium when the flow is shunted right to left

B. An embolism in the right atrium could pass through the ASD to the left heart and travel to the brain Eisenmenger syndrome refers to a significant increase in right heart pressures that causes shunt flow across the septum to reverse and move from the right to left chamber. If flow is moving from the right atrium through an ASD to the left atrium, an embolism can enter the heart from the IVC and be transported into the systemic circulation. This embolism can lead to a stroke, infarct or occlusion of the small arteries distally.

Which of the following is least likely to lead to holodiastolic flow reversal in the descending thoracic aorta? A. Aortopulmonary window B. Aortic insufficiency with a pressure half time >500ms C. Patent ductus arteriosus D. Ruptured sinus of valsalva

B. Aortic insufficiency with a pressure half time >500ms Moderate/Severe AI can lead to holodiastolic flow reversal in the descending thoracic aorta. If the holodiastolic flow reversal is identified in the thoracic aorta, the proximal abdominal segment should also be evaluated. Severe AI demonstrates a pressure half time <200ms.

A cardiac murmur is auscultated with the patient supine. The murmur gets louder when the patient stands next to the table. These findings are most suggestive of? A. Aortic insufficiency B. Hypertrophic cardiomyopathy C. Rheumatic valve disease D. Bicuspid aortic valve without stenosis

B. Hypertrophic cardiomyopathy Murmurs related to obstruction can be enhanced with any maneuver that increases contractility of the ventricle. The Valsalva maneuver and moving from supine to standing will decrease venous return allowing for increased contractility of the ventricle.

Which of the following is least likely to lead to a false positive MVP diagnosis? A. off axis evaluation B. Idiopathic hypertrophic subaortic stenosis C. multiple PVCs D. mild to moderate pericardial effusion

B. Idiopathic hypertrophic subaortic stenosis IHSS will cause systolic anterior motion of the mitral valve which is the opposite direction of the motion of the leaflets with MV prolapse. The other choices listed can lead to a display of exaggerated posterior motion of the MV leaflets in systole.

Which of the following is true regarding an Austin Flint murmur? A. It is associated with significant mitral regurgitation causing mitral valve fluttering seen on the m-mode tracing. B. It is associated with severe aortic regurgitation causing compression/vibration of the anterior mitral valve leaflet in diastole C. It is associated with a large VSD causing paradoxical interventricular septal motion seen on the m-mode. D. It is associated with severe aortic stenosis causing vibration of the aortic root in systole; Seen on the m-mode tracing of the aortic root.

B. It is associated with severe aortic regurgitation causing compression/vibration of the anterior mitral valve leaflet in diastole The Austin Flint murmur is specifically related to severe aortic insufficiency, which occurs during the diastolic portion of the cardiac cycle.

Which type of complex congenital heart disease corrects itself? A. D-Transposition B. L-Transposition C. Pulmonary atresia D. Ebstein anomaly

B. L-Transposition

Which of the following is unaffected by isolated moderate mitral stenosis? A. Pulmonary veins B. Left ventricular wall thickness C. Right ventricular chamber size D. Main pulmonary artery

B. Left ventricular wall thickness

A patient presents for an echo with a history of cor pulmonale. Which of the following is an expected finding on the exam? A. Constrictive pericarditis B. Pulmonary HTN C. Congestive heart failure D. Pulmonary valve stenosis

B. Pulmonary HTN Cor pulmonale refers to enlargement of the right ventricle and increased pressure due to disease of the lungs or of the pulmonary blood vessels.

You perform an echo on a 55yr old male and identify tricuspid stenosis. What's the most likely cause for this finding? A. Congenital malformation B. Rheumatic fever C. Atherosclerotic formation over time D. Carcinoid disease

B. Rheumatic fever Congenital malformation is not a cause for the "adult" condition. Carcinoid disease and atherosclerosis etiology are much more rare. Rheumatic fever is the most common cause for tricuspid stenosis in adults.

A 26yr old patient presents with shortness of breath and decreased pedal pulses. You identify supravalvular stenosis and coarctation of the aorta on an echo exam. Which of the following is the most likely cause for these findings? A. Down syndrome B. Takayasu arteritis C. Atherosclerosis D. Marfan syndrome

B. Takayasu arteritis Takayasu arteritis is a rare type of vasculitis and causes blood vessel inflammation. It can lead to multiple areas of stenosis at various locations within the aorta. Atherosclerosis could potentially cause the same findings but not at 26yrs of age.

A patient presents with a recent onset of fever, cough, dyspnea and chest pain when lying down. Which of the following is the most likely cardiac diagnosis? A. carcinoid disease B. acute pericarditis C. constrictive pericarditis D. rheumatic mitral stenosis

B. acute pericarditis The recent onset of symptoms indicates an acute disease process. Positional chest pain is the most common symptom of acute pericarditis.

While performing an m-mode tracing of the mitral valve, consistent vibrations are seen in the anterior leaflet during diastole with the absence of a true A wave. Which of the following is the most likely the cause of this characteristic on the m-mode? A. mitral valve prolapse B. atrial fibrillation C. mitral stenosis D. aortic regurgitation

B. atrial fibrillation Atrial fibrillation will cause this m-mode characteristic. Aortic regurgitation may have a softer vibratory affect, but the A wave will still be present on the tracing. MVP causes a bowing of the anterior leaflet with a posterior "dip" on the m-mode during systole.

A 28yr old male presents for an echo due to a systolic murmur and has no other cardiac symptoms. Due to patient habitus, 2D imaging is significantly limited but the EF% appears normal. The aortic valve velocity is 4m/s with a peak pressure gradient of 64mmHg, and no aortic insufficiency is detected. Which of the following is the most likely etiology of the aortic stenosis? A. degenerative disease B. bicuspid aortic valve C. infective endocarditis D. Marfan syndrome

B. bicuspid aortic valve

Severe acute aortic regurgitation: A. causes a rapid increase in chamber size of the left ventricle B. causes a rapid increase in left ventricular diastolic pressures C. causes a rapid increase in left ventricular systolic pressures D. causes delayed opening of the mitral valve in diastole

B. causes a rapid increase in left ventricular diastolic pressures

A patient with a history of moderate pulmonary HTN is referred for a 6 month follow up. The tricuspid regurgitation velocity on today's exam is 2.2m/s with a dilated IVC with <50% collapse with respiration. Which of the following is true regarding these findings? A. no change in the moderate level of pulmonary HTN B. congestive heart failure has manifested C. restrictive cardiomyopathy is present which causes variation in right heart pressure D. pulmonary embolism has most likely occurred since the prior exam

B. congestive heart failure has manifested A dilated IVC with reduced sniff response indicates an RA pressure of 15mmHg. The RVSP is approximated at 34mmHg, which indicates only mild pulmonary HTN. 4 (2.2 x 2.2) + 15 = 34mmHg The decrease in the RVSP can be related to decreased RV function. Mild PHTN 30-40mmHg; Moderate PHTN 40 - 70mmHg

All of the following can cause an increase in the E point septal separation measurement, except? A. congestive heart failure B. hypertrophic cardiomyopathy C. dilated cardiomyopathy D. chronic moderate aortic insufficiency

B. hypertrophic cardiomyopathy Dilatation of the left ventricle leads to increased E point septal separation. Occlusion of the LAD will lead to decreased septal motion/decreased EF% causing LV dilatation. Chronic moderate AI, dilated cardiomyopathy and CHF will result in an enlarged LV.

What effect does dilated cardiomyopathy have on the heart rate? A. decreased B. increased C. unable to determine without more information D. no change

B. increased The heart tries to compensate for the decreased output by increasing the heart rate.

Premature ventricular contractions cause: A. decreased E-F slope on m-mode tracing B. loss of the A wave on Doppler tracing of mitral valve C. loss of the E wave on Doppler tracing of mitral valve D. decreased E point septal separation on m-mode

B. loss of the A wave on Doppler tracing of mitral valve A PVC will cause the loss of the A wave on MV Doppler tracing due to premature closure of the MV. The E-wave will be tall with a steep E-F slope. The EPSS is usually normal or decreased due to PVC.

A 55yr old male patient presents with the following chamber measurements by echocardiography: LA = 4.3cm RA = 2.8cm RVd = 3.0cm LVd = 5.0cm Which of the following should be expected on the color and Doppler evaluation? A. pulmonary HTN B. mild - mod mitral regurgitation C. moderate aortic regurgitation D. 6mm VSD

B. mild - mod mitral regurgitation The left atrium is mildly enlarged at 4.3cm. Chronic mild to moderate mitral regurgitation can cause this slight increase in chamber size. A 6mm VSD and aortic regurgitation will cause the LV to dilate first then the LA.

A patient presents with hemoptysis, orthopnea, dyspnea and a rumbling diastolic murmur. The most likely cardiac diagnosis is? A. mitral valve prolapse B. mitral stenosis C. tricuspid stenosis D. tricuspid atresia

B. mitral stenosis The rumbling diastolic murmur occurs with the flow across the thickened, calcified mitral valve. In some cases of MS a snapping sound may also be heard when the mitral valve opens at the onset of diastole. The difficulty breathing and hemoptysis are related to the congestion of the pulmonary flow and pulmonary veins caused by the mitral stenosis.

Which of the following is least likely to be an associated finding in a patient with a dissection of the ascending aorta and arch? A. pericardial effusion B. patent ductus arteriosus C. aortic insufficiency D. pleural effusion

B. patent ductus arteriosus Pleural and pericardial effusions are signs of impending rupture in patients with a suspected aortic dissection. AI is common in cases of dissection of the ascending aorta.

What is the most common type of VSD? A. muscular B. perimembranous C. outlet D. inlet

B. perimembranous Membranous - most common, near AV Muscular - muscular portion of IVS, single or multiple Outlet/Supracristal - in the RVOT Inlet - posterior septum, near TV

A patient presents for an echo and you identify right ventricular enlargement, right ventricular hypertrophy and tricuspid regurgitation. The left heart chambers are normal in size. Which of the following can lead to these findings? A. SVC stenosis B. pulmonary HTN C. malignant HTN D. 2mm VSD with left to right shunting

B. pulmonary HTN

A patient presents 2hrs post motor vehicle accident with multiple bruises to the anterior chest and chest pain with mild shortness of breath. Which cardiac structure is most commonly evaluated first for the effects of the trauma? A. interventricular septum B. right ventricle C. coronary artery origins D. left ventricle

B. right ventricle

Jugular vein distention is a clinical sign of: A. persistent left SVC B. tricuspid stenosis C. mild mitral stenosis D. severe aortic insufficiency

B. tricuspid stenosis Tricuspid stenosis causes increased right heart pressures, which can lead to a back log of flow and dilated jugular veins.

You perform an echo and the only abnormal finding present is mild mitral regurgitation. What do you expect the peak pressure gradient to be for the mitral regurgitation(MR)? A. 64mmHg B. Unable to determine due to variation in MR gradients in different patients. C. 100mmHg D. 50mmHg

C. 100mmHg In the normal heart (with normal pressures) the pressure difference between the LA and LV is about 100mmHg. The isolated finding of MR in a normal heart will be equivalent to the normal pressure difference between the chambers.

Which of the following lists an expected finding on tissue Doppler evaluation of the septal annulus in a patient with constrictive pericarditis? A. E/A = 2.5 B. E' = 6cm/s C. E' = 10cm/s D. E/E' = 12

C. E' = 10cm/s E' and E/E' are usually normal in patients with constrictive pericarditis. E' > 8cm/s, E/E' <8 E/A ratio is usually greater than 1.5 in patients with constrictive pericarditis but this is a PW Doppler finding, not tissue Doppler.

A patient presents for an echo due to shortness of breath, malaise and the presence of Osler nodes and Janeway lesions. The referring physician most likely suspects: A. Ebstein anomaly B. Dilated cardiomyopathy C. Infective endocarditis D. Rheumatic fever

C. Infective endocarditis Signs of Infective Endocarditis: Osler nodes - painful red lesions on the hands and feet; immunologic response Roth spots - retinal hemorrhage with pale center Janeway lesions - non-painful microabscesses on the hands and feet; caused by bacterial emboli

Which of the following statements is NOT true regarding Takayasu arteritis? A. Most commonly caused by abnormal fibrous tissue formation, not atherosclerosis development. B. It can cause supravalvular stenosis and/or coarctation. C. It is classified as a single, focal, fibrous stenosis immediately superior to the aortic valve. D. It can occur in the ascending or descending aorta in multiple locations.

C. It is classified as a single, focal, fibrous stenosis immediately superior to the aortic valve. Takayasu arteritis is a rare type of vasculitis and causes blood vessel inflammation. It can lead to multiple areas of stenosis at various locations within the aorta.

5. What is the first cardiac chamber to be affected by mitral stenosis? A. Right atrium B. Left ventricle C. Left atrium D. Right ventricle

C. Left atrium

Which cardiac chamber is usually unaffected in cases of significant mitral stenosis without regurgitation? A. Right atrium B. Right ventricle C. Left ventricle D. Left atrium

C. Left ventricle If there is no associated mitral regurgitation, the left ventricle will experience a decrease in flow volume and will be relatively affected by the mitral stenosis.

Which type of valvular regurgitation usually demonstrates the highest pressure gradient? A. Aortic insufficiency B. Pulmonary insufficiency C. Mitral regurgitation D. Tricuspid regurgitation

C. Mitral regurgitation The greatest pressure difference between chambers occurs between the left ventricle and left atrium. Mitral regurgitation will demonstrate the pressure gradient on Doppler evaluation.

Which of the following is referred to as hereditary hemorrhagic telangiectasia and is associated with pulmonary arteriovenous malformations? A. Uhl Anomaly B. Ehlers-Danlos Syndrome C. Osler-Weber-Rendu Disease D. Kearns-Sayre Syndrome

C. Osler-Weber-Rendu Disease Osler-Weber-Rendu Disease AKA hereditary hemorrhagic telangiectasia results in vascular dysplasia that leads to hemorrhages and AV malformations (pulmonary). This disorder can be diagnosed using an agitated saline contrast exam.

A biventricular pacemaker uses lead wires to stimulate the ventricular contractions. What are the final positions of the lead wires for this procedure? A. Right atrium and coronary sinus B. Right ventricle and right atrium C. Right ventricle and coronary sinus D. Left atrium and right atrium

C. Right ventricle and coronary sinus Cardiac Resynchronization Therapy AKA Biventricular Pacemaker: Normally seen in patients with significant heart failure. In patients with heart failure, blood moves through the heart and body at a slower rate and pressure in the heart increases. A delay between the contraction of the right and left ventricles often occurs with heart failure which reduces the overall function of the contraction. A Biventricular Pacemaker is a battery-powered device that is surgically implanted under the skin. Usually 2 or 3 leads (wires) are used. The wires pass through SVC and right atrium to the right ventricle for pacing and through the coronary sinus to pace the left ventricle.

A parachute mitral valve and a bicuspid aortic valve are identified on an echo exam of a 25yr old male. Which of the following correlates with these findings? A. Kearns-Sayre Syndrome B. Williams Syndrome C. Shone's Complex D. Noonan Syndrome

C. Shone's Complex Shone's Complex is diagnosed when a combination of an LV inflow and LV outflow obstruction are present. Examples: Supravalvular ring OR Parachute MV AND Bicuspid AV OR Coarctation of the Aorta

Left ventricular hypertrophy is least likely to be caused by? A. subvalvular aortic stenosis B. supravalvular aortic stenosis C. aortic regurgitation D. rheumatic aortic stenosis

C. aortic regurgitation Mild aortic insufficiency usually has no effect on chamber size. Moderate to severe AI can cause LV dilatation due to volume overload. The other three choices can lead to increased afterload and chronic pressure overload causing thickening of the LV walls.

A 42yr old male presents for an echocardiogram 2 weeks post pericardiectomy due to constrictive pericarditis. What is an expected finding on the exam? A. difficulty visualizing the coronary sinus and posterior atrial borders for measurement B. mild global decreased left ventricular function C. increased cardiac motion in the chest D. increased reverberation artifact between the ventricular walls and the diaphragm

C. increased cardiac motion in the chest The pericardium helps to contain the cardiac motion in the chest. When it is removed, the heart can demonstrate increased motion within the chest.

A patient presents for an echo to rule out a complete atrioventricular canal defect. All of the following are a part of a complete AV canal defect, except? A. primum ASD B. common atrioventricular valve C. parachute mitral valve D. inlet VSD

C. parachute mitral valve An ostium primum ASD and inlet VSD make up the complete AV canal defect commonly seen with patients with Trisomy 21 (Down syndrome). A common atrioventricular valve is also seen with this type of AVSD.

Which of the following patients would benefit from the placement of an intra-aortic balloon pump? A. patient with significant cyanosis B. patient with Libman Sacks endocarditis C. patient with dilated cardiomyopathy D. patient with suspected patent foramen ovale

C. patient with dilated cardiomyopathy The balloon pump is used to increase flow in the aorta and its branches (coronaries)

_______________ is defined as an abnormal connection of the left subclavian vein to the coronary sinus. A. DiGeorge syndrome B. Ebstein malformation C. persistent left SVC D. persistent right SVC

C. persistent left SVC 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 contrast into left arm, it will fill the coronary sinus BEFORE the RA

All of the following are m-mode findings in a patient with hemodynamically significant aortic regurgitation, except: A. diastolic fluttering of the anterior mitral leaflet B. diastolic fluttering of the interventricular septum C. premature closure of the aortic valve in diastole D. premature closure of the mitral valve in diastole

C. premature closure of the aortic valve in diastole The aortic valve is already closed in diastole when the regurgitation is occurring, so early closure of the AV is not possible. The fluttering of the IVS or the MV leaflet is caused by the turbulence of the jet of regurgitation. Significant aortic insufficiency will cause the LV to refill rapidly in diastole causing early closure of the MV.

Which of the following will decrease after a mitral commissurotomy in a patient with isolated mitral stenosis? A. mitral regurgitation B. A wave velocity C. pressure half time D. mitral valve area

C. pressure half time The pressure half time should decrease as the valve opens more freely.

What level of pulmonary HTN is present with an acceleration time of 50msec for the pulmonary valve Doppler tracing? A. mild B. moderate C. severe D. none

C. severe Acceleration times of RVOT flow with pulmonary HTN Normal AT = > 120ms Mild = 80 -100ms Moderate = 60 - 80ms Severe = <60ms

All of the following can be associated with premature closure of the mitral valve, except A. atrial fibrillation B. first degree atrioventricular block C. severe mitral stenosis D. ruptured aortic fenestration

C. severe mitral stenosis When normal sinus rhythm is disrupted the MV can close early. A ruptured aortic fenestration will cause the acute onset of significant aortic regurgitation that will cause early closure of the MV.

When interrogating the mitral valve, the leaflets appear to move normally but the left ventricular inflow is restricted by a ridge of tissue surrounding the mitral annulus. Which of the following describes these findings? A. cleft mitral valve B. cortriatriatum C. supravalvular ring D. parachute mitral valve

C. supravalvular ring Supravalvular ring inhibits LV inflow just proximal to the valve. The ridge of tissue is located between the valve annulus and the fossa ovalis.

Which of the following is associated with a diastolic murmur? A. VSD B. persistent left SVC C. tricuspid stenosis D. tricuspid regurgitation

C. tricuspid stenosis Flow moves across the tricuspid valve in diastole. If the valve is stenotic, a murmur may be heard. Tricuspid regurgitation occurs during systole, which produces a systolic murmur. Flow moves through a VSD, from the left ventricle to the right ventricle, during systole. A persistent left SVC most commonly causes a dilated coronary sinus with no associated murmur.

All of the following are considered critical findings on an echocardiogram, except: A. flail mitral leaflet B. aortic dissection C. two flail chordae of the anterior leaflet of the mitral valve D. left ventricular apical thrombus

C. two flail chordae of the anterior leaflet of the mitral valve There are multiple chordae tendinae that connect each mitral leaflet to the papillary muscles. The disruption of 2 chordae should not cause any change in the flow within the heart or present a critical risk to the patient.

A patient enters the ER with a fever of 103 degrees and admitted history of IV drug use. They also demonstrate a recent onset of extreme dyspnea. A VQ scan of the lungs demonstrates an emboli lodged in the right bronchial artery. What is the most likely source of the emboli? A. thrombus formation in the left heart due to decreased cardiac function with dilated cardiomyopathy B. arteritis causing inflammation of the cerebral arteries C. vegetation on the tricuspid valve D. vegetation on the mitral valve

C. vegetation on the tricuspid valve If a cardiac source produced the emboli to the brain, then it must come from the left side of the heart. If a cardiac source produced the emboli to the lungs, then it must come from the right side of the heart.

In a patient with a patent ductus arteriosus, normal intracardiac pressures can be assumed if the peak pressure gradient across the ductus is equivalent to ____________. A. 64mmHg B. 80mmHg C. 50mmHg D. 100mmHg

D. 100mmHg The average normal pressure difference between the aorta and pulmonary artery is approximately 100mmHg. The peak velocity across the ductus should be about 5m/s with normal intracardiac pressures.

Which of the following is the most likely E/A ratio in a patient with severe acute aortic regurgitation? A. 0.6 B. 1.0 C. 1.4 D. 2.2

D. 2.2 Severe acute aortic regurgitation will cause a restrictive filling pattern on the mitral valve Doppler tracing (E/A >1.5). The significant amount of blood flowing back into the LV through the aortic valve will inhibit normal inflow from the mitral valve.

You perform an echo and the only abnormal finding present is mild pulmonic regurgitation. What do you expect the peak pressure gradient to be for the regurgitant jet? A. 15mmHg B. 1mmHg C. 10mmHg D. 5mmHg

D. 5mmHg In the normal heart (with normal pressures) the pressure difference between the RV and MPA is about 5mmHg. The isolated finding of PI in a normal heart will be equivalent to the normal pressure difference between the RV and the MPA.

Which of the following correctly describes the mitral valve Doppler tracing of a patient with hypertrophic cardiomyopathy? A. varies with systemic blood pressure B. E/A ratio >2.0 C. E/A ratio 1.0 D. E/A ratio <0.8

D. E/A ratio <0.8 HCM causes a stiffer left ventricle with abnormal relaxation that causes a short E wave and tall A wave (E/A ratio <0.8).

_______________________ can cause _______________ closure of the mitral valve. A. Pulmonary HTN, delayed B. Increased left atrial pressure, early C. Mitral regurgitation, delayed D. Increased left ventricular diastolic pressures, early

D. Increased left ventricular diastolic pressures, early Increased LV diastolic pressures will limit the LV inflow during diastole and can cause early closure of the MV.

A small linear reflection is noted at the junction of the aortic leaflets in diastole. The patient has no cardiac symptoms. They also have negative serial bacterial cultures that were performed over the last week following the echocardiogram results. What was most likely demonstrated on the echo? A. Chiari network B. Aberrant strand C. Crista terminalis D. Lambl's excrescence

D. Lambl's excrescence These tiny fibrous strands most commonly form on the aortic valve and lead to an increased risk for an embolic event. They can be mistaken for a vegetation and should be correlated with clinical findings.

Occlusion of the _______________________ artery is the most likely cause for the formation of a muscular VSD in the anterior septum after a myocardial infarction. A. Posterior descending B. Left circumflex C. Marginal obtuse D. Left anterior descending

D. Left anterior descending The LAD supplies the anterior septum. Occlusion of this vessel can lead to abnormal motion of the wall segment. A defect may form in the weakened segment.

Pectus excavatum is most commonly associated with what cardiac abnormality? A. mitral stenosis B. Tetralogy of Fallot C. VSD D. MVP

D. MVP Pectus excavatum, also known as sunken or funnel chest, is a congenital defect in which several ribs and the sternum grow abnormally, causing a concave structure of the chest wall. MVP has been associated with this bony defect of the chest.

What type of regurgitation is most commonly seen first in developing dilated cardiomyopathy? A. Tricuspid regurgitation B. Pulmonary insufficiency C. Aortic insufficiency D. Mitral regurgitation

D. Mitral regurgitation MR is the most common valvular regurgitation with DCM due to stretched papillary muscles.

________________ is associated with syncope due to decreased oxygenated blood flow reaching the brain. A. Chronic mild aortic insufficiency B. Pulmonary HTN C. Aortic coarctation distal to the left carotid origin D. Moderate/severe aortic stenosis

D. Moderate/severe aortic stenosis Significant aortic stenosis will decrease the amount of oxygenated blood pumped out through the aortic root. The right carotid artery is a branch of the innominate artery that originates from that aortic arch. The left carotid artery is a direct branch of the aortic arch. If LV outflow is reduced, oxygenated blood to the brain will be reduced and can lead to cerebral ischemia.

All of the following statements are true regarding mitral annular calcification(MAC), except? A. MAC provides an increased risk for an embolic event. B. MAC can lead to posterior shadowing that inhibits mitral regurgitation evaluation. C. Tissue Doppler evaluation of diastolic dysfunction can be inhibited by calcification of the mitral annulus. D. Most patients with moderate or greater mitral annular calcification also demonstrate anatomic mitral stenosis.

D. Most patients with moderate or greater mitral annular calcification also demonstrate anatomic mitral stenosis. MAC can cause FUNCTIONAL stenosis at the level of the mitral valve caused by limited motion of the annulus.

Which of the following statements best describes the method for differentiating atherosclerotic aortic stenosis and rheumatic aortic stenosis? A. Rheumatic aortic stenosis usually produces a more significant amount of calcification of the aortic valve than atherosclerotic formation. B. Rheumatic aortic stenosis usually produces a more significant reduction in the aortic valve area than atherosclerotic formation. C. Atherosclerotic aortic stenosis almost always occurs with atherosclerotic mitral stenosis. D. Rheumatic aortic stenosis almost always occurs with rheumatic mitral stenosis.

D. Rheumatic aortic stenosis almost always occurs with rheumatic mitral stenosis. Rheumatic heart disease affects both the aortic and the mitral valve. Usually in cases where both aortic stenosis and mitral stenosis are present, the patient has a history of rheumatic fever.

A patient presents with a recent history of MI. The current visit to the ER is to complain of leg pain and black discoloration of three toes on the right foot. These findings are most suggestive of what complication of myocardial infarction? A. Thrombus in the IVC B. Flail mitral leaflet C. Tricuspid valve endocarditis D. Thrombus in the left ventricle

D. Thrombus in the left ventricle The leg pain and blackened toes indicate a possible embolic source in the arterial system. The recent history of a myocardial infarction indicates ischemia and abnormal wall motion of the LV. The echo most likely will demonstrate an abnormal LV segment with adjacent thrombus formation that is the source for emboli to the legs.

Congenital pulmonary stenosis is most commonly associated with which of the following? A. Tricuspid atresia B. ASD C. Patent ductus arteriosus D. VSD

D. VSD

Which of the following syndromes is characterized by either early systolic notching of the posterior wall or notching of the interventricular septum? A. Dressler B. Eisenmenger C. Marfan D. Wolff-Parkinson-White

D. Wolff-Parkinson-White Wolff-Parkinson-White syndrome is a condition characterized by abnormal electrical pathways in the heart that cause a disruption of the heart's normal rhythm. These extra connections can disrupt the coordinated movement of electrical signals through the heart, leading to arrhythmia and changes to wall motion.

A patient with atrial fibrillation that also has mitral stenosis will demonstrate ___________________________. A. a significant drop in pulmonary pressure B. a significant decrease in left ventricular contractility C. a significant increase in left ventricular diastolic pressure D. a significant decrease in cardiac output

D. a significant decrease in cardiac output Mitral stenosis and atrial fibrillation will decrease left ventricular inflow, which would significantly decrease left ventricular outflow.

Severe aortic regurgitation demonstrates: A. a flat slope B. a peak velocity >5m/s C. a very faint waveform pattern due to turbulence D. a significant difference between the peak velocity at the onset and the end of the regurgitation

D. a significant difference between the peak velocity at the onset and the end of the regurgitation A significant difference between the regurgitant velocity at the start of the regurgitation and the end of the regurgitation indicates a steep slope which correlates with severe regurgitation.

A patient presents for an echo due to a systolic ejection murmur. The aortic valve is thickened but appears to have normal mobility. Doppler evaluation demonstrates a velocity of 1.65m/s. Which of the following best describes these findings? A. infective endocarditis of the aortic valve B. mild degenerative aortic stenosis C. congenital aortic stenosis D. aortic sclerosis

D. aortic sclerosis The aortic velocity is considered normal when it is <2.5 m/s. The thickening of the valve cusps indicates sclerosis without stenosis.

Infarction of the __________________ wall segment most commonly leads to ventricular aneurysm formation. A. basal septal B. basal or mid inferior C. mid septal D. apical anterior

D. apical anterior Infarction of the anterior apical wall segment most commonly leads to ventricular aneurysm formation.

A patient recently underwent a mitral valve commissurotomy. Which of the following is an expected finding on the 6 month follow up scan? A. decreased leaflet thickening B. increased pressure half time C. decreased mitral regurgitation D. decreased left atrial size

D. decreased left atrial size A commissurotomy is performed to widen the valve opening. The leaflets will still be thickened and the amount of MR will most likely increase with the abnormally shaped opening.

Which of the following describes the effects of hypothyroidism on the heart? A. hypercontractility and increased cardiac output B. infiltrative cardiomyopathy C. carcinoid deposits on right heart valves D. globally decreased left ventricular function

D. globally decreased left ventricular function Hypothyroidism refers to decreased function of the thyroid gland. This can lead to global hypokinesis of the left ventricle, pericardial effusion and possible myxedema.

An alcohol induced septal ablation is used to treat which of the following cardiac abnormalities? A. perimembranous VSD B. papillary fibroelastoma C. coronary artery disease D. hypertrophic obstructive cardiomyopathy

D. hypertrophic obstructive cardiomyopathy Septal ablation refers to the use of alcohol to produce a focal infarction in the septal tissues to cause myocardial thinning and paradoxical motion. This reduces the flow gradient in the outflow tract.

If the peak velocity of the E wave on the mitral tracing is 1.2m/s and the tissue Doppler assessment of the septal annulus indicates a peak velocity of E' of 6cm/s, the LV diastolic filling pressures are ________________. A. decreased B. unable to be estimated without more information C. normal D. increased

D. increased 1.2m/s = 120cm/s E/E' = 120/6 = 20 E/E' <10 is normal, >15 indicates increased LV filling pressures

A patient is referred for an echo for pre-surgical clearance for a hip replacement. The only pertinent cardiac history is a 6 year history of systemic HTN. What will be the most likely findings on the exam? A. right ventricular free wall >0.5cm thickness B. interventricular and interatrial septum > 1.1cm thickness C. dilated aortic root and aortic insufficiency D. interventricular septum and inferior wall > 1.1cm thickness

D. interventricular septum and inferior wall > 1.1cm thickness Systemic HTN can provide a constant increase in pressure for the LV to work against during systole. This will lead to diffuse progressive thickening of the left ventricular walls.

A patient with a history of rheumatic fever presents with a mid systolic click heard with a grade 2 late systolic murmur. What is the most likely finding on the echocardiogram for this patient? A. isolated mitral regurgitation B. isolated mitral stenosis C. isolated mitral valve prolapse D. mitral valve prolapse with mitral regurgitation

D. mitral valve prolapse with mitral regurgitation MVP usually causes abnormal closure of the mitral leaflets which leads to MR. The mid-systolic click represents the prolapse of the valve and the late systolic murmur is the related leakage.

Which of the following can lead to incorrect measurement of the peak aortic valve velocity causing incorrect results when using the continuity equation? A. Measuring the peak of the mitral regurgitation jet instead of the aortic valve flow B. Premature ventricular contractions C. Atrial fibrillation D. A and B E. All of the above

E. All of the above The rhythm abnormalities listed will cause variation in the systolic flow through the aortic valve. Mitral regurgitation can demonstrate a high velocity flow profile that can be mistaken for the aortic flow profile. The EKG can be used to differentiate the MR jet from the AV flow.