Adult Echocardiography

Question 0

2. In the apical 4 chamber view which two walls of the left ventricle are seen

In the apical 2 chamber view which two walls of the left ventricle are seen

Answer 0

Septal and lateral

Inferior and anterior.

Question 1

1. In the parasternal long axis view, at the level of the mitral valve and papillary muscle, how many segments is the left ventricle divided into and name them

Answer 1

6

Posterior, lateral,anterior, anterior septal, septal, inferior

Question 2

3. Which walls of the left ventricle are seen in the parasternal and apical long axis views

Answer 2

Septal and posterior

Question 3

4. Where is the coronary sinus located

Where is the coronary sinus located in relation to the descending aortic

Answer 3

The coronary sinus lies in the posterior atrioventricular groove. This groove is located between the left atrium and the left ventricular walls and lies posterior to the mitral valve. In the parasternal long axis view, the coronary sinus can sometimes be seen as a small echo free circle.

The coronary sinus is located anterior to the descending aorta. If the coronary sinus is dilated, it may be mistaken for te descending aorta.

Question 4

5. Why is it important to know the location of the coronary sinus and the descending aorta.

Answer 4

The coronary sinus and the descending aorta are important landmarks that can help differentiate pericardial effusions from pleural effusions. Pericardial effusions Lie posterior to the coronary sinus and anterior to the descending aorta. In contrast, pleural effusions lie posterior to the descending aorta.

Question 5

6. Name the 3 major coronary arteries

Where are their locations on the surface of the heart.

Answer 5

Right coronary artery, left anterior descending, and circumflex arteries.

Rca- arises from the right aortic-root sinus and follows the atrioventricular junction, and descends along the posterior interventricular groove.

LAD- follows the anterior interventricular groove.

Circ- courses along the left atrioventricular junction.

Question 6

7. Name the cardiac walls supplied by each of the coronary artery’s

Answer 6

Rca- inferior wall, inferior septum, right ventricular Apex, right ventricular free wall

LAD- anterior wall, anterior septum, left ventricular Apex

Circ- lateral wall, posterior wall

Question 7

8. While scanning a 43-year-old man with a history of an old myocardial infarction, you notice that the anterior cardiac wall is akinetic. Which coronary artery is most likely to have been involved in the infarction

In the apical four chamber ofanother heart, the distal ventricular septum and left ventricular Apex are hypo-contractile. Which coronary artery is most likely to be disease

Answer 7

The left anterior descending, which supplies blood to the anterior cardiac wall, is most likely to have been involved. This artery also supplies the anterior portion of the ventricular septum and the left ventricular Apex

Again, the left anterior descending is the most likely choice. In some patients with distal septal hypo contractility, the proximal portion of the septum moves normally because it is supplied by the right coronary artery

Question 8

9. What are the normal systolic and diastolic pressures In the four cardiac chambers and a great vessels

Answer 8

Right atrial ( mean ) = 6 mmHg
Right ventricle = 25/5 mmHg
Pulmonary artery = 25/10 mmHg
Left atrial ( mean ) = 10 mmHg
left ventricular = 120/7 mmHg
Aortic = 120/80 mmHg

Question 9

10. What is the normal mean pulmonary artery wedge pressure

How is the pulmonary artery wedge pressure determined

Answer 9

The normal mean pulmonary artery wedge pressure is 10 mmHg, which is equal to the left atrial pressure

A swan/Ganz catheter is positioned in the pulmonary artery, and a small balloon is inflated at the catheters tip. The balloon is then wedged into a smaller pulmonary artery, and a pressure reading is obtained a distal to the balloon. The balloon prevents the tip of the catheter from sensing the pulmonary pressure, and the left atrial pressure is recorded at it as it is reflected across the pulmonary bed.

Question 10

11. Describe the color flow Doppler technique

Answer 10

The color flow Doppler technique is a post Doppler method for simultaneous recording and displaying flow information as well as grayscale anatomic images. M mode or two dimensional. Color flow displays usually involve two dimensional images. By convention, flow toward the probe most often appears red, and flow away from their probe most often appears blue. The display indicates the velocity and direction by changing huse of these two colors

Question 11

12. In Color flow imaging, what is a pulsed packet

Why are pulse packets important

Answer 11

To accurately determine the direction of velocity of blood flow, a group of multiple ultrasound pulses is transmitted, received, and compared with respective to phase shift. This group is called a pulse packet

The more pulses in the pulse packet, the more accurate the flow related information. However, with larger pulse packets, it takes more time to transmit, Receive, and as a result of the frame rate decreases

Question 12

13. What is the continuous wave Doppler mode

What are the main advantages and disadvantages of the continuous wave Doppler mode, compared to the pulsed wave Doppler mode

Answer 12

In the continuous wave Doppler mode, two transducer elements are used to record the flow. One element continuously transmits ultrasound signals, and the other element continuously receive such signals. The received signals are analyzed for Doppler frequency shifts, and the resulting information is displayed on the screen.

The main advantage of the continuous wave Doppler mode is its ability to record high velocity flow without aliasing. The disadvantage of this mode is that, although the flow along the ultrasound beam is recorded, the location of this flow is not known

Question 13

14. What is the most important variable and the Doppler equation

Answer 13

The most important variable in the Doppler equation is the Cosine of the angle theta. Theta denotes the angle between the ultrasound beam and the moving target, blood. As long as this angle is less than 20°, the calculated velocity is accurate. When the eagle is greater than 20°, the velocity is under estimated by the Doppler equation

Question 14

15. To visualize the anterior wall of the left ventricle, which two dimensional view would you use

To visualize the lateral all of the left ventricle, which two dimensional view would you use

Answer 14

The anterior and inferior walls of the left ventricle our best visualized in the apical two chamber view

The lateral wall of the left ventricle is best visualized in the apical four chamber view. The lateral wall can also be seen in the short axis views but the four chamber is the best

Question 15

16. On the echo cardiogram, at what point does the mitral valve normally close

On the echocardiogram at what point does the aortic valve normally open

Answer 15

The mitral valve normally closes approximately 60 ms after the onset of the QRS complex, or about halfway through the QRS complex

The aortic valve normally opens at the end of the QRS complex. This takes into account the delay between electrical and mechanical Systole , as well as the isovolumic contraction time (between mitral closure and aortic opening)

Question 16

17. What is the relationship between electrical and mechanical systole

Answer 16

Mechanical systole follows electrical systole by approximately 12 ms. The delay represents the time it takes for the electrical conductive impulse to spread and thereby cause myocardial contraction. The delay can best be appreciated during in m mode studies that examine the relationship between the electrocardiographic pattern and valvular motion

Question 17

18. What is diastasis

Answer 17

Diastasis denotes the middle portion of diastole, which occurs between early, rapid filling of the ventricles and the start of atrial contraction. The duration of diastasis varies with the heart rate. Diastasis is quite long in a patient with bradycardia and quite short in those with tachycardia

Question 18

19. How much of ventricular filling occurs during the passive phase of diastole

Answer 18

At normal pressures, approximately 70% of ventricular filling occurs during the passive face of diastole. Atrial contraction accounts for the remaining 30% of ventricular filling. Of course, these percentages will change in patients with valvular abnormalities such as mitral stenosis or ventricular compliance problems such as hypertrophic cardiomyopathy

Question 19

20. On most ultrasound machines, what is the relationship between overall gain/power and the time gain compensator (TGC)

Answer 19

Increasing the gain/power control will augment the power to the ultrasound transducer crystals. Increasing the TGC controls will augment the returned ultrasound signals. Whichever control is adjusted, the effect on the ultrasound image may be the same. For optimal image quality it is best to keep the transducer gain at 70 to 80% and use the TGC to adjust the image

Question 20

21. What causes side lobe artifacts

What is the best way to minimize side lobe artifacts

Answer 20

Side load artifacts are caused by strong reflectors outside of the main ultrasound beam. The off axis targets create reflections from weaker extra ultrasound beams alongside the main beam

The best way to minimize Side lobe artifacts is to decrease the overall gain, increase the reject level, or decrease the TGC in the area of strong reflectors. Such as the pericardium

Question 21

22. What cardiac lesion is detected by injecting agitated saline contrast material into the right side of the heart

Why does Saline contrast material rarely appear on the left side of the heart

Answer 21

Saline contrast material is injected to detect atrial shunts . It may also be used to document abnormal venous return and to detect the outline right sided intracardiac masses

Question 22

22. How is the Valsalva maneuver performed

How does the Valsalva maneuver affect the heart

Answer 22

The Valsalva maneuver is performed by inhaling halfway, Closing the mouth and nostrils, exhaling forcibly and straining against the closed mouth for about five seconds. Then opening the mouth and exhaling

During these straining phase the venous return decreases, so that the cardiac output diminishes in the reflux tachycardia occurs. Once the strain is released, the venous return increases, along with right sided cardiac pressures and the cardiac output. A reflex bradycardia also occurs

Question 23

24. What is the best cardiac view for evaluating mitral stenosis with continuous wave Doppler scanning

Answer 23

With continuous wave Doppler scanning, mitral stenosis is best evaluated from the cardiac Apex. Because apical views allow the Doppler beam and the mitral stenotic jet to be aligned in parallel fashion these yield accurate peak flow velocities

Question 24

25. How does inhalation of amyl nitrate affect the heart

Answer 24

Amyl nitrate is a vasodilator that causes flushing, reduced cardiac output, and hypotension for the first 30 to 40 seconds. During the second phase, 30 to 60 seconds, a reflex tachycardia occurs and cardiac output and ejection velocity are augmented. In general, murmurs associated with aortic or Pulmonic stenosis are increased, while those associated with mitral or aortic regurgitation are decreased

Question 25

26. When performing a two-dimensional echocardiographic exam, you notice that the image has very little gray scale quality. Which controls could you adjust to increase the gray scale quality.

Answer 25

To increase the gray-scale quality, you could change the post processing curve or the compress/reject control on most ultrasound machines. Also you could check the monitor controls (brightness and contrast) and make sure that the transmit gain is not too high.

Question 26

27. In the apical four chamber view, you have trouble differentiating an apical thrombus from an artifact. name the things that can help you differentiate these two entities.

Answer 26

Change the depth settings, because range artifacts may move with changes in depth.

Switch to higher frequency transducer, preferably one with a short focal zone

Decrease the transmit gain and time compensation controls on the near field to minimize chest wall reverberations

Question 27

28. How do you obtain an apical two-chamber view from an apical 4 chamber View

Answer 27

From the apical four chamber view rotate the transducer approximately 30° counterclockwise, until you see the left ventricle, mitral valve, and left atrium. If you see the aortic valve you have rotated the transducer too far

Question 28

29. What is the easiest way to adjust the color Doppler gain

Answer 28

With color flow Doppler turned on, increase the color gain until the background Doppler noise appears on the color display, then decrease the color gain until the background noise disappears. Normal and abnormal flow should now be displayed in an optimal manner. If the Doppler display still appears weak, switch to a lower frequency transducer, decrease the depth of field, or narrow the color sector to increase the frame rate

Question 29

30. Describe the normal mitral valve anatomy

Answer 29

The mitral valve is a bileaflet valve situated between the left atrium and the left ventricle. The valves anterior leaflet is relatively long, lies close to the aorta, and comprises one third of the valves circumference. The posterior leaflet is shorter than the anterior and is usually divided into three sections. Both the interior and the posterior leaflet attached to the ventricular papillary muscles by multiple chordae tendineae

Question 30

31. Name the four classic m mode findings associated with mitral stenosis

Describe the characteristic two-dimensional echocardiographic findings associated with mitral stenosis

Answer 30

The classic M-mode findings associated with mitral stenosis are a decreased E-F slope, decreased E wave amplitude , Multiple reverberant echoes during diastole, anterior movement of the posterior valve leaflet.

Echocardiographic findings associated with mitral stenosis include left atrial enlargement, tethering of the tips of the mitral leaflet’s, thickening of the mitral leaflet, decreased leaflet mobility in severe cases of mitral stenosis, pulmonary hypertension and right ventricular and right atrial enlargement

Question 31

32. What is the normal flow velocity, mean value and range, through the mitral valve as documented by Doppler in adults and children

Describe the changes seen in the Doppler spectral trace in patients with mitral stenosis

Answer 31

The normal velocity through the mitral valve in adults is a mean of 0.9 m/s, with a range of 0.6 -1.4 m/s. In children the velocity is slightly higher, having a mean of 1.0 m/s and a range of 0.7–1 .4 m/s

The changes seen with mitral stenosis include an increased velocity flow, an increase in flow turbulence, a decrease in the rate of drop off for early diastole slope

Question 32

33. How does mitral stenosis affect the left atrium

Why do patients with mitral stenosis usually develop atrial fibrillation

Answer 32

Mitral stenosis causes an increase in left atrial pressure, which results in the left atrial enlargement. Severe mitral stenosis can lead to pulmonary hypertension, right ventricular failure, and right atrial enlargement

Question 33

34. Name four typical physical findings associated with mitral stenosis.

What causes an opening mitral snap

Answer 33

Typical findings associated with mitral stenosis include a diastolic murmur, an opening snap, atrial fibrillation, dyspnea on exertion , Fatigue, orthopnea, hemoptysis(spitting up blood).

The opening snap occurs shortly after the second part sound. A snap is caused by the abrupt cessation of leaflet opening when the mitral valve is tethered

Question 34

35. How does mitral stenosis affect the ventricles

How does mitral stenosis affect the great vessels

Answer 34

Mitral stenosis has no effect on the left ventricle and less concurrent mitral regurgitation is present. Over time mitral stenosis will cause elevation of the right side of the cardiac pressures and will therefore lead to right ventricular enlargement, right atrial enlargement, and tricuspid regurgitation

Mitral stenosis has no effect on the aorta. In the presence of severe, long-standing mitral stenosis that results in pulmonary hypertension, the pulmonary artery may become dilated.

Question 35

36. Which is the most accurate method of calculating the mitral valve area

A. using m mode echocardiography to determine the E – F slope

B. performing two dimensional planimetry of the mitral orifice in the short axis view.

C. Determining the Doppler pressure halftime

Answer 35

Performing two dimensional planimetry of the mitral orifice in the short axis view is the most accurate way to measure the mitral orifice, provided that there is no echo drop out, the beam is perpendicular to the leaflets and is directed outward at the leaflet tips, the highest frequency transducer and Lowest gain settings possible are used.

Question 36

37. Two-dimensional echocardiography of a 55-year-old woman with an opening snap and a diastolic murmur reveals left atrial enlargement and thickening and tethering of the mitral valve leaflets. What is the most likely diagnosis

What other noninvasive test should be performed to further clarify the diagnosis

Answer 36

This patient probably has rheumatic mitral stenosis. Although she has no history of rheumatic fever, she is too young to have degenerative mitral disease, moreover her two-dimensional echocardiogram exhibits classic findings to indicate rheumatic mitral stenosis

To determine the severity of her mitral stenosis, this patient must undergo a Doppler examination, and the pressure halftime equation should be used to calculate her mitral valve area

Question 37

38. What is the normal mitral valve area

What valve areas are associated with mild, moderate, and severe mitral stenosis

Answer 37

Normal mitral valve area measures 4 – 5 cm² and is therefore smaller than the tricuspid valve

Mild stenosis = 1.5–2 .5 cm²
Moderate stenosis = 1.0–1 .5 cm²
Severe stenosis = <1 cm²

Question 38

39. What are the main echocardiographic findings associated with chronic mitral regurgitation

Answer 38

Patients with mild, chronic mitral regurgitation may have normal echocardiographic examination. Mild to severe chronic mitral regurgitation
usually causes left atrial enlargement as well as left ventricular dilatation and hypercontractility. Mitral deformities such as thick leaflets, prolapse, or stenosis may also be present

Question 39

40. What are the main echocardiographic findings associated with acute mitral regurgitation

Answer 39

Acute mitral regurgitation usually causes echocardiographic abnormalities such as valvular vegetations, torn Chordae tendineae , And flail or partial flail mitral leaflet. If the mitral regurgitation is ischemic in origin, the echocardiogram may show regional wall motion abnormalities when the patient is at rest

Question 40

41. During post Doppler examination, how does mitral regurgitation appear on spectral wave form

How is mitral regurgitation quantified with pulsed Doppler

Answer 40

During pulsed Doppler examination, mitral regurgitation appears as turbulent, broad spectrum, systolic flow within the left atrium. Because of the high velocity of the mitral regurgitation jet, the spectral trace will alias

To quantify mitral regurgitation with a pulsed Doppler instrument, the examiner “maps” The area of systolic turbulence in the left atrium. The larger the area of the regurgitant Jet, the more severe the regurgitation. It is important that the entire left atrium be mapped carefully, so that the width and the length of the jet can be documented

Question 41

42. How is mitral regurgitation quantified by color flow Doppler imaging

Answer 41

Color flow Doppler imaging, which is similar to pulsed Doppler scanning,”maps” the area of regurgitant flow. And like the pulsed Doppler approach, color flow imaging shows the entire regurgitant jet within a single cardiac cycle. The larger the size of the jet, the more severe the regurgitation. In determining the severity of mitral regurgitation, the examiner must take into account the total size, length, and width of the jet.

Question 42

43. How does mitral regurgitation affect the atria

Answer 42

Mitral regurgitation can cause left atrial enlargement. The degree of such enlargement is usually proportional to the severity of the regurgitation. Trivial or mild regurgitation rarely results in any atrial enlargement. Unlike mitral stenosis, and which atrial enlargement is due to increased pressure, mitral regurgitation causes atrial enlargement by producing volume overload

Question 43

44. How does chronic mitral regurgitation affect the ventricles

Answer 43

Mild mitral regurgitation has no noticeable effect on either ventricle. In contrast, moderate to severe chronic regurgitation results in a volume overload of the left ventricle. In the absence of systolic dysfunction the ventricles become dilated, and it’s walls become hyper-contractile. Severe chronic mitral regurgitation can also cause increased pulmonary pressures and right ventricular dilatation and hypertrophy

Question 44

45. What is the definition of mitral valve prolapse, as documented by M – mode echocardiography?

What is the definition of mitral valve prolapse, as documented by two – dimensional echocardiography?

Answer 44

As documented by m – mode echocardiography, mitral valve prolapse is defined as posterior displacement of the mitral leaflet during systole.this displacement can be either holosystolic or mild – late systolic. The prolapsing leaflet should extend more than 2–3 mm below a line connecting the echocardiographic C – D points.

As documented by two dimensional echocardiography, mitral valve prolapse is defined as systolic displacement of one or both mitral leaflet’s into the left atrium in the Parasternal or apical long axis of views

Question 45

46. Why should you refrain from diagnosing mitral valve prolapse in the presence of a large pericardial effusion?

Why should you refrain from diagnosing mitral valve prolapse from the apical four chamber viewpoint?

Answer 45

Diagnosing mitral valve prolapse in patients with large pericardial effusion’s is more of a problem with m – mode then two-dimensional echocardiography. During late systole, when the entire heart moves in an anterior direction with the posterior movement of the mitral valve may be falsely interpreted as prolapse.

Because the mitral annulus is saddle shaped, even normal mitral leaflet Appear to prolapse in the left atrium when the scene from the apical four chamber view

Question 46

47. Will rupture of a few mitral Chordae tendineae cause any serious clinical problems?

In what clinical setting is chordal rupture A potential source of diagnostic confusion?

Answer 46

Rupture of a few Chordae tendineae rarely results in loss of leaflet support, so mitral regurgitation does not usually occur. chordal rupture is typically seen in patients with coronary artery disease or bacterial endocarditis.

in patients being evaluated for endocarditis, Ruptured Chordae tendineae May be difficult to distinguish from a vegetation valvular mass. If available, a previous echocardiogram is helpful for comparison.

Question 47

48. Will a flail mitral leaflet cause significant hemodynamic problems? What symptoms will appear with a patient with this condition probably present?

Which of the two mitral papillary muscles has higher incidence of rupture? Why?

Answer 47

A flail mitral leaflet results in severe, acute mitral regurgitation. Because the left atrium does not have time to adapt to the increased hemodynamic volume, the left atrial pressure rises sharply, and patients often present with pulmonary edema. Symptoms of acute pulmonary edema include sudden breathlessness, coughing up of pink frothy liquid, and chest pain if the Edema is caused by a myocardial infarction.

The posteromedial papillary muscle has a higher rate of rupture than the anterolateral. Whereas the posteromedial papillary muscle receives its blood supply from a single coronary artery (RCA). The anterolateral papillary muscle receives a dual supply, from both the circumflex in the left anterior descending arteries.

Question 48

49. Patients with calcification of the mitral annulus commonly have mitral regurgitation. If the anatomy of the mitral leaflet is normal, what causes this regurgitation?

Answer 48

The mild regurgitation is probably caused by the fact that the annulus is “Fixed” and it is therefore unable to adapt to left ventricular/atrial changes and dimension. Normally, the mitral annular is a flexible fibrous ring, who’s shape changes to reflect alterations in the left ventricular geometry throughout the cardiac cycle.

Question 49

50. In mitral stenosis, a classic M – mode finding is flattening of the E-to-F slope. What causes this flattening?

Answer 49

In M – mode imaging, the E-to-F slope of the anterior mitral leaflet represents the rate of early diastolic filling of the left ventricle. Normally, the left atrium empties rapidly In mitral stenosis, however the filling time is prolonged, and this slow filling is reflected by the descent of the anterior leaflet. Attempts to quantify the degree of mitral stenosis on the basis of E-F slope have not proved sensitive or specific. The slope is affected by the severity of leaflet fibrosis, as well as left ventricular compliance, the heart rate, and motion of the mitral annulus during systole

Question 50

51. In patients with mitral stenosis, how does mitral regurgitation affect the Peak velocity?

Does mitral regurgitation affect the pressure halftime method of calculating the mitral valve area?

Answer 50

Inpatient with mitral stenosis,mild mitral regurgitation has no effect on the peak velocity. moderate to severe regurgitation causes a volume overload of the left ventricle and an increase in the mitral diastolic velocity

Mild to moderate mitral regurgitation does not affect the pressure halftime method of calculating the mitral valve area. Whereas the peak mitral velocity may increase, the relationship between the peak in the slope remains constant. Severe mitral regurgitation, with large increases in peak mitral velocity, invalidate The pressure halftime method

Question 51

52. Describe the normal aortic anatomy

Why is the aortic valve so resistant to regurgitation?

Answer 51

The aortic valve comprises 3 cup shaped leaflets. The right, left, non-coronary leaflets. Behind each leaflet, the aortic wall dilates to form a sinus of Valsalva. The left and right coronary arteries originate from the sinuses of the left and right aortic valve leaflets.

Compared to the mitral leaflet, the aortic leaflets are unsupported. Nevertheless, they are partly surrounded by a fibrous skeleton, which strengthens the aortic annulus. Because the leaflets are cup shaped and their edges overlap, the aortic valve is very resistant to regurgitation

Question 52

53. What is the normal aortic valve area?

What is the normal gradient across the aortic valve during systole? What is the normal velocity?

Answer 52

The normal area of the aortic valve ranges from 2.5–3 .5 cm².

The normal gradient across the aortic valve during systole is 2 – 4 mmHg in adults. The normal aortic velocity is 1.4 m/s, with the range of 0.9–1 .8 m/s. In children, the normal aortic velocity is slightly higher, at 1.5 m/s

Question 53

54. What are the primary m. – mode findings associated with aortic valvular stenosis?

What are the primary two-dimensional echocardiographic findings associated with aortic valvular stenosis?

Answer 53

The M – mode findings associated with aortic valvular stenosis are multiple, reverberant echoes during systole and diastole, owing to thickening of the valve leaflets, decreased separation of the valve leaflets, left ventricular hypertrophy.

The two dimensional echocardiographic findings associated with aortic valvular stenosis are thickening of the aortic leaflets, with decreased leaflet mobility, left ventricular hypertrophy, occasional post stenotic dilatation of the aorta

Question 54

55. In aortic valve stenosis, what changes are seen in the Doppler spectral trace?

How does the peak aortic gradient correlate with the severity of stenosis?

Answer 54

In the aortic valve stenosis, the Doppler spectral trace shows increased velocity and turbulence. In severe stenosis, the time from the onset of flow to be velocity is prolonged.

If the cardiac output is normal, A peak aortic valve gradient of more than 100 mmHg denoted severe stenosis. If the cardiac output is low, the valve area may be critically small, but the gradient may be as low as 36 mmHg ( 3 m/s). Thus, the clinician needs to know the valve area as well as the gradient.

Question 55

56. What is the best noninvasive method for quantifying aortic valve stenosis?

How does the aortic valve area correlate with the degree of stenosis?

Answer 55

The best noninvasive method for quantifying aortic valve stenosis is to use The continuity-of – flow equation to calculate the area of the Arctic valve

The various degrees of stenosis are associated with the following aortic valve area's
Normal = 2.5–3 .5 cm²
Mild = 1.5–2 .5 cm²
Moderate = 0.7–1 .5 cm²
Severe < or = 0.7 cm²

Question 56

57. How does aortic stenosis effective ventricles?

Answer 56

Aortic stenosis causes pressure overload of the left ventricle. The ventricles respond to this overload (increased wall stress) by becoming hypertrophied. Over time, the pressure overload will cause left ventricular dilatation and decrease contractility. The right ventricle is not usually affected

Question 57

58. How does aortic stenosis affect the atria?

How does aortic stenosis of the great vessels?

Answer 57

As the left ventricle thickens, ventricular compliance decreases and atrial pressure increases, leading to left atrial enlargement. As the left ventricular systolic pressure rises, the end diastolic pressure also rises. The right atrium is not usually affected

Aortic stenosis usually produces poststenotic dilatation of the aorta because of the high velocity Aortic jets impact on the aortic walls. The pulmonary artery is not usually affected.

Question 58

59. Which of the following methods is the most accurate means of calculating the aortic valve area?
60. M – mode measurement of aortic leaflet separation
61. Two-dimensional planimetry of the aortic area in the short axis view.
62. Doppler calculation of The continuity of flow equation

Answer 58

Of these three methods, Doppler calculation of the continuity of flow equation is the most accurate means of determining the aortic valve area. Measurement of aortic valve leaflet separation does not determine the aortic valve area or indicate what the third aortic Leaflet is doing. In most patients, planimetry of the aortic valve Area is impossible from the chest wall because of multiple reverberations from the calcified/fibrotic leaflets.

Question 59

60. Two-dimensional echocardiography of a 58-year-old man with systolic cardiac murmur reveals the following findings.
    Concentric left ventricular hypertrophy , mild to moderate thickening of the aortic leaflets, with decreased valvular opening, systolic Doming of the aortic leaflets on the parasternal long axis view.

what is most likely the diagnosis?

Answer 59

The most likely diagnosis is stenosis of a congenital bicuspid aortic valve. thickened leaflets and concentric hypertrophy may also be seen in patients with degenerative aortic valve stenosis, but systolic doming in the parasternal long axis view is typical of a bicuspid aortic valve.

Question 60

61. Define aortic valve sclerosis.

Define aortic valve stenosis.

Answer 60

Sclerosis denotes hardening and fibrosis of the Aortic leaflets. This condition does not produce a significant gradient, but it may cause a systolic murmur or some degree of regurgitation.

Stenosis denotes narrowing of the aorta leaflets or outflow tract. This condition is different from sclerosis, in that stenosis implies the presence of a hemodynamic gradient.

Question 61

62. What are the primary two-dimensional echocardiographic findings associated with congenital aortic valve stenosis?

In a two-dimensional echocardiographic study, what would be the major difference between the findings associated with degenerative aortic valve stenosis and those associated with rheumatic aortic valve stenosis

Answer 61

Typical findings associated with congenital aortic valve stenosis are concentric left ventricular hypertrophy, mild to moderate thickening of the aortic leaflets, systolic doming of the leaflets in the parasternal long axis view.

Although the Aorticvalve might present a similar appearance in both cases, rheumatic heart disease is almost always accompanied by coexisting mitral stenosis

Question 62

63. ??????

How does aortic regurgitation affect the stenotic gradient, as assessed by Doppler examination?

How does aortic regurgitation affect the air in the house as calculated by the continuity-of-flow equation.

Answer 62

Mild aortic regurgitation has no effect on the gradient. Moderate to severe regurgitation causes the existing gradient to increase because of volume overload of the left ventricle.

aortic regurgitation does not affect the aortic valve area, as calculated by the continuity of flow equation, because the velocities for v1 and V2 increase equally

Question 63

64. What are the main echocardiographic findings associated with chronic Aortic regurgitation

Answer 63

Patients with mild chronic aortic regurgitation may have slight aortic valve thickening and and otherwise normal echocardiogram. Those with moderate to severe chronic aortic regurgitation may present in the early disease process with left ventricular dilatation and hyper contractility and late in the disease process with impairment of ventricular function.

Question 64

65. What are the main echocardiographic findings associated with acute aortic regurgitation

Answer 64

Patients with mild acute aortic regurgitation may have a fairly normal echocardiogram. Those with moderate to severe acute aortic regurgitation have hyper contractile left ventricular wall motion, mild left ventricular dilatation, and occasional premature closure of the mitral valve owing to increase the diastolic pressure. These patients usually have some pathologic condition such as vegetations, prolapse, dissection, or trauma.

Question 65

66. ????

How does aortic regurgitation affect the atria?

How does a regurgitation affect the great vessels?

Answer 65

Regurgitation does not affect the right atrium. When chronic regurgitation and decreased left ventricular compliance result in left ventricular dilatation, the left atrium may enlarge slightly.

Your degree your dictation does not affect the great vessels. Although dilatation of the aorta causes aortic valve regurgitation, aortic valve regurgitation does not cause dilatation of the aorta.

Question 66

67. How does aortic regurgitation affect the ventricles?

Answer 66

Mild regurgitation does not affect the left ventricle. In contrast, moderate to severe regurgitation results in left ventricular dilatation because of volume overload. In such cases, left ventricular contractility is hyperdynamic. The left ventricle continues to progressively dilate until decompensation occurs and ventricular function decreases.

Question 67

68. ?????

What are three classic m-mode findings associated with aortic regurgitation?

Answer 67

Classic m-mode findings associated with aortic regurgitation include. Diastolic fluttering of the orbit leaflet, diastolic fluttering of the intraventricular septum , dilatation and hyper contractility of the left ventricle ( alternatively, hypocontractility may be present upon left ventricular decompensation) ,mitral valve pre-closure (in severe acute regurgitation).

Question 68

69. What is the most common congenital cause of aortic regurgitation?

Answer 68

Bicuspid valve is the most common congenital cause of aortic regurgitation

Question 69

70. In aortic valve endocarditis, what symptoms are patients likely to present?

What is the most common cause of a flail aortic leaflet?

Answer 69

Symptoms of aortic valve endocarditis include fever, chills/night sweats, diastolic murmur, tachycardia, dyspnea on exertion or at rest.

The most common cause of flail Aortic leaflet is endocarditis. A less common cause is trauma.

Question 70

71. Define Marfan’s syndrome

How does Marfan’s syndrome affect the Aortic valve? How does it affect the mitral valve?

Answer 70

Marfan’s syndrome is a connective tissue disease characterized by increased joint flexibility and elongation of the long bones. Ocular problems and cardiac abnormalities are often present.

Cardiac manifestations of Marfan’s syndrome include ascending aortic dilatation and mitral valve prolapse. Depending on the severity of the disease, varying degrees of aortic or mitral regurgitation maybe present

Question 71

72. Describe the anatomy of the tricuspid valve, including the name and location of each leaflet

Answer 71

The tricuspid valve is located between the right atrium in the right ventricle. It has three leaflets. The anterior, posterior, and medial or septal leaflets. These names reflect the leaflets anatomic relationships to the right ventricle. The medial leaflet is connected to the septal wall. It’s insertion is located closer to the cardiac Apex (inferiorly) then that of the anterior mitral leaflet

Question 72

73. Name the three M-mode findings associated with tricuspid stenosis.

Describe the common two-dimensional echocardiographic findings associated with tricuspid stenosis

Answer 72

The three classic M-mode findings associated with tricuspid stenosis are a decreased E – F slope, A reduced early diastolic amplitude, multiple reverberant echoes during systole and diastole.

The most common two-dimensional echocardiographic findings associated with Tricuspid stenosis are thickening and tethering (Doming) of the tricuspid leaflets, decreased leaflet mobility during diastole, mitral stenosis

Question 73

74. What is the normal velocity(mean and range) through the tricuspid valve?

Describe the changes in the Doppler spectral trace associated with tricuspid stenosis

Answer 73

The normal velocity through the tricuspid valve is a mean of 0.6 m/s, with a range of 0.4–0 .8 m/s.

In tricuspid stenosis, changes in the Doppler spectral trace include an increased velocity,an increase in flow turbulence, a decrease in the rate of drop off for the early diastolic flow(pressure halftime)

Question 74

75. How does tricuspid stenosis affect the atria?

How does tricuspid stenosis affect the ventricles?

Answer 74

Mild tricuspid stenosis may not affect the atria. In contrast, moderate to severe stenosis causes right atrial enlargement. The increased atrial pressure can also produce peripheral edema. The left atrium is not usually affected by tricuspid stenosis.

In severe tricuspid stenosis, the right ventricle may appear smaller than normal because cardiac output is reduced. The left ventricle is rarely affected by tricuspid stenosis.

Question 75

76. What are the main echocardiographic findings associated with chronic tricuspid regurgitation?

Answer 75

Mild chronic tricuspid regurgitation may yield normal echocardiographic findings. In contrast, moderate to severe regurgitation causes right ventricular volume overload. The right ventricle becomes dilated, and flattening of the septum it may be evident. The right atrium is dilated and the vena cava distended.

Question 76

77. What are the main echocardiographic findings associated with acute tricuspid regurgitation

Answer 76

Mild acute tricuspid regurgitation may yield normal echocardiographic findings. More likely however, the echocardiogram will show evidence of valvular disease such as trauma related prolapse, other valvular disruptions, or vegetative lesions. Moderate to severe regurgitation may cause hyperdynamic motion and mild dilatation of the right ventricle. The right ventricle does not have time to enlarge, as it does in chronic regurgitation. The right atrium is slightly dilated and the inferior vena cava distended.

Question 77

78. During pulsed Doppler examination, how does tricuspid regurgitation appear on spectral trace?

How is tricuspid regurgitation quantified with pulsed Doppler instrument?

Answer 77

Tricuspid regurgitation appears as turbulent systolic flow within the right atrium. Because the velocity of the tricuspid regurgitation jet is not as high as that of a mitral regurgitation jet, the spectral trace may not alias.

Tricuspid regurgitation quantified by “mapping” The area of systolic turbulence in the right atrium. The larger the area of the tricuspid yet, the more severe the regurgitation

Question 78

79. How is tricuspid regurgitation quantified by color Doppler imaging?

Answer 78

Color flow Doppler imaging (which is similar to pulsed Doppler scanning) “maps” The area of regurgitant flow. Unlike the pulsed Doppler approach, color flow imaging shows the regurgitant jet within a single cardiac cycle. The larger the jet, the more severe the regurgitation. In determining the severity of tricuspid regurgitation, the examiner must take into account the total size, length, and width of the jet.

Question 79

80. How does tricuspid regurgitation effect the atria?

Answer 79

Tricuspid regurgitation causes right atrial enlargement. The degree of such enlargement is usually proportional to the severity of regurgitation. Trivial or mild regurgitation rarely results in atrial enlargement. Unlike tricuspid stenosis, in which atrial enlargement is due to increased pressure, tricuspid regurgitation causes atrial enlargement by producing volume overload.

Question 80

81. How does tricuspid regurgitation affect the ventricles?

Answer 80

Mild tricuspid regurgitation does not noticeably affect either ventricle. Moderate to severe regurgitation results in volume overload of the right ventricle. The ventricle becomes dilated and hyper contractile in the absence of systolic dysfunction. The left ventricle is usually not affected.

Question 81

82.??????

If you already know the picture just regurgitation velocity, how can you calculate the right ventricular systolic pressure?

What is the significance of this calculation?

Answer 81

To calculate RVSP , and the tricuspid regurgitation velocity ( converted to millimeters of mercury by 4v2) and the estimated right atrial pressure.
The equation is. RVSP = TR velocity + RA pressure

This calculation provides a means of noninvasively estimating the pulmonary artery pressure. In the absence of pulmonic stenosis, the pulmonary artery pressure will be the same as the right ventricular systolic pressure.

Question 82

83. What is carcinoid heart syndrome?

how does carcinoid syndrome cause tricuspid regurgitation?

Answer 82

Carcinoid heart syndrome is a symptom complex associated with carcinoid tumor’s of the intestinal tract or pancreas. Such tumors release serotonin, and acid, tar like, compound that is deposited on the endocardial walls and valvular surfaces.

Serotonin deposits build up on the tricuspid or Pulmonic leaflets, causing them to become thickened and immobile, so that they cannot coapt properly

Question 83

84. Define tricuspid valve prolapse

What is the relationship between tricuspid valve prolapse and mitral valve prolapse?

Answer 83

Tricuspid valve prolapse denotes systolic displacement of one or more tricuspid leaflet into the right atrium. The anterior and septal tricuspid leaflets prolapse more frequently than the posterior leaflet.

Almost 90% of patients with tricuspid valve prolapse also have mitral valve prolapse.

Question 84

85. What is the incidence of tricuspid stenosis in rheumatic heart disease?

Answer 84

Approximately 10% of patients with rheumatic heart disease have some degree of tricuspid stenosis. The symptoms of tricuspid stenosis may be masked by mitral stenosis, which is almost always present

Question 85

86. Describe the anatomy of the pulmonic valve, including the name and the location of each leaflet.

What is the normal velocity through the pulmonic, as assessed by the Doppler ultrasound in both adults and children?

Answer 85

The pulmonic valve is the most anteriorly positioned cardiac valve. It lies within the right ventricular outflow tract, to the left of the aortic valve. Pulmonic valve has three leaflets. The anterior, right posterior, and left posterior leaflets. The latter two of which are referred to as the right and left leaflets.

The normal flow gradient is 1 – 3 mmHg. In adults, the normal Velocity Is 0.7 meters per second, with a range of 0.5–0 .9 m/s. And children the normal pulmonic velocity is slightly higher, at 0.8 m/s.

Question 86

87. What is the primary m – mode findings associated with pulmonic valve stenosis?

What are the primary two-dimensional echocardiographic findings associated with pulmonic valve stenosis?

Answer 86

The primary m – mode finding associated with pulmonic stenosis is an increase of more than 7 mm in the “a” dip.

The primary two-dimensional echocardiographic findings associated with pulmonic stenosis are valve thickening, decreased leaflet excursion, systolic doming, right ventricular hypertrophy, poststenotic dilatation of the pulmonary artery.

Question 87

88. During Doppler examination, what changes does pulmonic stenosis produce in the Doppler spectral trace?

How does the peak pulmonic gradient correlate with the severity of stenosis?

Answer 87

In Pulmonic stenosis, the Doppler spectral trace shows increased velocity and turbulence. And severe stenosis, the interval from the onset of flow to peak velocity is prolonged.

If the cardiac output is normal, a gradient of more than 75 mmHg denotes severe stenosis. If the cardiac output is low, the valve area may be critically small, but the gradient may be as small as 36 mmHg(3 m/s).

Question 88

89. How does pulmonic stenosis affect the ventricles?

How does Pulmonic stenosis affect the atria?

How does pulmonic stenosis affect the Great vessels?

Answer 88

Pulmonic stenosis causes pressure overload of the right ventricle. In response to this overload the ventricles become hypertrophic. Over time, the pressure overload causes right ventricular dilatation and contractility. The left ventricle is not usually effective.

Thickening of the right ventricle causes right ventricular compliance to decrease and the right atrial pressure to increase, leading to right atrial enlargement. As the right ventricle systolic pressure rises, so does the end diastolic pressure also rises. The left atrium is not often affected.

Pulmonic stenosis usually results in poststenotic dilatation of the pulmonary artery owing to the high velocity Jets impact on the arteries walls. The aorta is rarely affected.

Question 89

90. What is the most common cause of pulmonic stenosis?

How does carcinoid syndrome cause pulmonic stenosis? How does it cause pulmonic regurgitation?

Answer 89

The most common cause of Pulmonic stenosis is a congenital abnormality.

Serotonin builds up on the pulmonic and/Or tricuspid leaflets, causing them to become thickened and immobile. If they become fixed in the closed position, stenosis will result. If they become fixed in the open position (which is usually the case) regurgitation well ensue.

Question 90

91. What are the main echocardiographic findings associated with chronic pulmonary regurgitation?

Answer 90

In trivial or mild pulmonic regurgitation, the echocardiographic findings may be normal. Early in the disease process, moderate to severe regurgitation is indicated by right ventricular dilatation, paradoxic motion, and hypercontractility. Later in the disease process, impairment of right ventricular function appears.

Question 91

92. What is the most common cause of regurgitation?

How does pulmonary hypertension affect pulmonic regurgitation?

Answer 91

Pulmonic regurgitation usually affects valves that are otherwise normal. About 60% of the general population has some degree of Pulmonic regurgitation, probably owing to altered pulmonary artery geometry. Because the pulmonary lies across the aorta, they artery shape changes from circular to oblong at the site. furthermore, because pulmonic pressure is normally low, the valve may not close tightly.

Pulmonary hypertension causes the peak regurgitant velocity to increase. Normally, the regurgitant velocity is about 1 m/s. In pulmonic hypretension, however, the regurgitant velocity maybe greater than 4 m/s.

Question 92

93. How does pulmonic regurgitation affect the ventricles?

How does pulmonic regurgitation affect atria?

How does pulmonic regurgitation affect the great vessels?

Answer 92

Mild pulmonic regurgitation does not affect the right ventricle. Moderate to severe regurgitation results in right ventricular dilatation and hyper dynamic contractility from volume overload. The right ventricle may eventually become decompensated, and ventricular function may decrease. The left ventricle is not affected.

In chronic pulmonic regurgitation, the right atrium may enlarge slightly because of decreased right ventricular compliance. Pulmonic regurgitation does not affect the left atrium.

Pulmonic regurgitation does not affect the great vessels.

Question 93

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94. Describe the classic M – mode findings associated with mitral valve endocarditis.

Describe the classic M – mode findings associated with aortic valve endocarditis.

Answer 93

Classic M – mode findings associated with mitral valve endocarditis include normal, under strict and that of motion. An Echogenic “shaggy” mass on the anterior or posterior leaflet. If the vegetation is large and mobile, this mass may move independently of the leaflet.

Classic – Mode findings associated with aortic valve endocarditis are similar to those seen in mitral endocarditis. Normal, and restricted motion,an Echogenic “shaggy” mass that appears during diastole and disappears during systole. If the vegetation is large enough and mobile, it may be seen during diastole above the mitral anterior leaflet, and he left ventricular outflow tract.

Question 94

95. Describe the typical two-dimensional echocardiographic appearance and location of the endocarditic mass lesions of the mitral valve.

Describe the typical two-dimensional echocardiographic appearance and location of endocarditic mass lesions on the Aortic valve

Answer 94

????

In mitral valve endocarditis, a typical two-dimensional echocardiographic study may show thick redundant leaflets, mass lesions on the flow side of the leaflets, mobile masses in the left atrium during systole and in the left ventricle during diastole.

In aortic valve endocarditis, a typical two dimensional echocardiographic study may show thick redundant leaflets, mass lesions on the flow side of the leaflets, mobile masses in the left atrium during systole and in the left ventricle during diastole.

In aortic valve endocarditis, a typical to to mention I go cardiographic study may show thick redundantly flats, mass lesions on the flow side of the leaflets, mobile masses in the left ventricular outflow tract during diastole in an aorta during systoleof the leaflets, mobile masses in the left ventricular outflow tract during diastole in an aorta during

Question 95

96. Why are intravenous drug abusers at risk for endocarditis involving the right side of the heart?

What is the most common organism seen in the intravenous drug abuser?

Answer 95

Intravenous drug abusers are at risk for endocarditis involving the right side of the heart because they use contaminated needles or syringes to make numerous and frequent injections into the venous system.

Staphylococcus Aures is the most common organism seen in the intravenous drug abusers

Question 96

97. Define acute bacterial endocarditis

Define a subacute bacterial endocarditis

Answer 96

Acute bacterial endocarditis denotes infection of the normal valve. Before anabiotic’s became widely available, patients with acute bacterial endocarditis usually died within six weeks.

Subacute bacterial endocarditis denotes infection of an abnormal valve. Patients with mitral valve prolapse, prosthetic cardiac valve, or rheumatic heart disease are at risk for this type of endocarditis.

Question 97

98. With two dimensional echocardiography, what are the main differences between mechanical and bioprosthetic valve?

From the patients Standpoint, what are the main differences between mechanical and bioprosthetic valve?

Answer 97

With mechanical prosthetic valves, more valve masking is present, and more reverberations emanate from the valve disk, leaflets, or ball. With bioprosthetic valve, some masking is present because the central area of these valves is fabricated of a biologic material, however, comparatively few reverberations eminent from this area.

mechanical valves are extremely durable but necessitate lifelong anticoagulation. Although bioprosthetic valve’s are less durable they do not necessitate anticoagulation.

Question 98

99. Name a commonly used ball in cage prosthetic valve.

What are the advantages and disadvantages of ball in cage?

Answer 98

The Starr-Edwards valve is hey commonly used ball in cage prosthetic valve.

The advantage of ball in cage prosthetic valves is their durability. Starr-Edwards valves, commonly last for 15 - 20 years. The disadvantage is the patients must take lifelong anticoagulants. Ball and cage valves also have a higher transit valvular gradient then other prosthetic valves.

Question 99

100. Name a disk-in-cage prosthetic valve.

What are the advantages and disadvantages of disk-in-cage valves?

Answer 99

The Beall valve is a disc-in-cage prosthesis. Although such valves have a lower profile then the star-Edwards ball in cage valve, they are no longer used.

The main advantage of disc in cage valves is their durability and low profile. For example in the mitral position, the cage of a disc in the cage valve may not protrude into the left ventricular outflow tract as far as the cage of a star – Edwards valve. The disadvantages of a disc in cage valve includes a high transit valvular gradient and the fact that they cause moreholysis then other prosthetic valves

Question 100

101. Name a commonly used tilting disc prosthetic valve.

What are the advantages and disadvantages of tilting disc prosthetic valves?

Answer 100

The Bjork-Shiley valve is commonly used tilting disc prosthesis. Such valves have much better flow dynamics than valves that have a central ocular, such as the star Edwards ball in cage prosthesis.

Tilting desk valves offer good flow dynamics, characterized by a low trans valvular gradient and decreased turbulence. Disadvantages include questionable durability (disc fractures and stent breakage have been reported) and more prosthetic regurgitation then is associated with other valves.

All prosthetic mechanical valves cause some degree of stenosis and regurgitation

Question 101

102. How is a porcine (pig) prosthetic valve made?

What are the advantages and disadvantages of porcine prosthetic valves?

Answer 101

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A pig valve is preserved in glutaraldehyde and then attached to a polypropylene stent, which has a dacron sewing ring. Because the preserve the leaflets are nonviable, valve rejection is not a problem.

The main advantage of pig valve is there low thrombogenicity. Therefore, unlike mechanical valves, porcine Bioprosthesis do not necessitate anticoagulation. All but the smaller valve sizes have low transvalvular gradients. On the other hand, porcine Bioprosthesis offer less durability and longevity and mechanical valves. Over a 5–10 year period, the porcine leaflets become thickened and stenosed.

Question 102

103. Describe the appearance of a normal porcine mitral valve, as observed with two dimensional echocardiography.

Describe the appearance of flow through a normal porcine mitral valve, as observed with color flow Doppler imaging.

Answer 102

The parasternal long axis view of the porcine mitral valve shows two of the valves stents. Because valvular reverberations are less common, it is often possible to see leaflet movement between the stents. The apical views usually offer a better image of leaflet morphology and motion because, in these views, the ultrasound beam is perpendicular to the valve.

The apical views are best for assessing mitral flow with the color flow Doppler technique, because forward flows directed toward the left ventricular Apex. As it passes through the valve, the color Jet is centrally located and mostly laminar in appearance

Question 103

104. Using m-mode echocardiography to evaluate the function of a ball-in-cage (Starr Edwards) prosthetic mitral valve, where should the transducer be placed?

If the ball-in-cage valve were in the aortic position, where would the m-mode transducer be placed?

Answer 103

In evaluating a ball-in-cage (star-Edwards) prosthetic mitral valve, the m-mode transducer should be placed at the left ventricular Apex, so that the full excursion of the leaflets can be documented as the valve opens. This view also allows evaluation of the balls velocity and timing.

In assessing a ball-in-cage (Starr Edwards) prosthetic aortic valve, the m-mode transducer should be placed above the valve, either in the suprasternal or the right supraclavicular window. This placement will allow the balls excursion, velocity and timing to be documented

Question 104

105. Describe the two dimensional echocardiographic appearance of a ball-in-cage mitral valve, as seen in the parasternal long axis view.

Answer 104

The parasternal long axis use show the valves cage, which is fixed and position with the left ventricular cavity. The ventricular Side of the ball is easily visualized as it moves within the cage. The atrial (far) Side of the ball appears in correctly positioned within the left atrium. This artifact is caused by a delay that occurs when the ultrasound beam crosses the air filled ball. The slow speed of the ultrasound poles and air causes the “other side “ of the ball to appear incorrectly positioned in the left atrium

Question 105

106. Describe the appearance of flow through a normal mitral ball-in-cage valve, as observed with the color flow Doppler technique.

What is the major limitation of Chestwall echocardiography in evaluating prosthetic valves? What technique overcomes this limitation?

Answer 105

Color flow Doppler assessment of mitral ball-in-cage valves normally show flow on both sides of the ball. If flow is detected only on one side, a thrombus or vegetative mass should be suspected.

In evaluating prosthetic valves, the major limitation of Chestwall echocardiography is “masking” which makes it difficult to detect regurgitation. Even if the regurgitation is seen, the “masking” prohibits Accurate quantitation. Transesophageal echo cardiography allows excellent evaluation of the atrial side of prosthetic valves and is the best technique for evaluating regurgitation.

Question 106

107. Name seven complications of prosthetic valve dysfunction.

Answer 106

Perivalvular leakage
Bioprosthetic stenosis/degeneration
Valve dehiscence/ strut failure 
Ring abscess
Thrombus formation
Endocarditis
Hemolysis

Question 107

108. How would you evaluate a prosthetic valve for probable stenosis?

Answer 107

Evaluation of prosthetic valve stenosis is difficult, Depending on valve type, valve size, and cardiac output. Ideally, a previous Doppler study will be available for comparison of cardiac function, heart rate, and valve gradient. Normally, the mean Transvalvular gradient is 3-7 mmHg for prosthetic mitral valve and 14–20 mmHg aortic prosthetic valves.

Question 108

109. Name and describe the two layers of the pericardium.

What is the function of the pericardium?

Answer 108

The pericardium consist of a visceral and parietal layer. The visceral layer lies directly upon the external surface of the heart and is commonly referred to as the epicardium. the parietal cavity lies between the two layers.

Since surgical removal of the pericardium may not produce any ill effects, the exact function of the pericardium is unclear. In general, the pericardium limits ventricular filling , reduces the friction that results from cardiac motion, and may act as a barrier to infectious organisms.

Question 109

110. In two dimensional echocardiography, what is the best way of differentiating between pericardial effusions and Pleural effusions.

Answer 109

If the descending aorta is used as a landmark, pericardial effusions will be seen between the left atrium and the descending aorta. In some patients the descending aorta will be displaced posteriorly. On the other hand, pleural effusions will be inferior and posterior to the descending aorta and will not displace the aorta away from the left atrium.

Question 110

111. Define pericarditis.

What are the three classic physical findings associated with pericarditis and/or pericardial effusions?

Answer 110

Pericarditis is an inflammation of the pericardium. In response to this inflammation, visceral pericardium exudes serous fluid. Pericarditis is more common in men than women. It is also more prevalent in adults than young children.

Classic findings associated with pericarditis and/or pericardial effusions include chest pain, which is atypical and often positional, being most severe in the supine position and relieved by sitting up or leaning forward. A pericardial friction rub (scratchy, high-pitched sound) that classically has three components. Early diastolic filling, atrial systole, and ventricular systole. And dyspnea.

Question 111

112. Name eight etiologies of pericardial effusion’s.

Answer 111

And idiopathic, or nonspecific disorder( most common cause)

A viral infection
A bacterial infection
Uremia
Radiation therapy
acute myocardial infarction
Dressler syndrome, or delayed post myocardial infarction Milan

Post pericardiotomy syndrome

Question 112

113. What are two potential etiologies of loculated pericardial effusion’s?

Answer 112

Loculated pericardial effusion’s are quite rare but may occur in patients who have metastatic disease with pericardial involvement. Pericardial infiltration is most often seen in a lung or breast malignancy. As tumor cells invade the pericardium, sections of the pericardium become walled off , and fluid may become loculated. Sometimes, loculated effusions also occur after cardiac surgery. In these cases, pericardial adhesions may result in loculated accumulations of fluid.

Question 113

114. Define cardiac Tamponade

What are the classic physical findings associated with cardiac Tamponade?

Answer 113

Cardiac Tamponade is an impairment of diastolic filling, caused by an increase in intrapericardial effusion, although it may result from a small, rapidly accumulated effusion. For example when a ventricle is accidentally perforated during cardiac Catheterization.

The classic physical findings associated with cardiac Tamponade include pulsus paradoxus, which causes a > 10 mmHg decrease in the systolic blood pressure during inspiration.
Tachycardia
Dyspnea
Beck’s triad ( elevated venous pressure, hypotension, and a quiet precordium.

Question 114

115. What are the two dimensional echocardiographic findings associated with cardiac Tamponade?

What are the Doppler findings associated with cardiac Tamponade?

Which of these two echocardiographic techniques is more accurate?

Answer 114

In the cardiac Tamponade, Two-dimensional echocardiographic findings include right ventricular diastolic collapse, right atrial systole collapsed, right and left ventricular volume changes associated with respiration. These changes are better appreciated with M mode studies.

In cardiac Tamponade ,Doppler investigation is aimed at measuring trans valvular velocities and detecting respiration related changes and flow. Normally, mitral inflow varies by less than 10%. In Tamponade, however, the peak velocity may vary by as much as 40%. In general, Tamponade may be indicated by respiration related flow change is greater than 25% for the mitral and greater than 50% for the tricuspid valve.

Doppler flow measurement correlate better with the clinical hemodynamics of Tamponade then do two-dimensional echocardiographic secondary sign such as right ventricular wall collapse.

Question 115

116. Why might an anterior echo free space yield a false positive diagnosis of pericardial effusion?

And what clinical setting may pericardial thickening be seen?

echocardiography what is the best non-invasive diagnostic technique for evaluating pericardial thickening?

Answer 115

Loculated effusions are relatively rare. Therefore, anterior echo free spaces usually represent excess cardio fat, especially in obese patients.

Pericardial thickening may be seen in patients who have chronic pericarditis or long-term history of steroid use. Such thickening may also be observed after radiation therapy.

Echocardiography is neither sensitive nor specific in the diagnosis of pericardial thickening. This lack of reliability is due to the brightness and reflectivity of the pericardium. Moreover, the pericardium lies at a depth of 15–20 cm, which is outside the optimal focal zone of most ultrasound systems. Computer axial tomography (CAT scan) or magnetic resonance imaging (MRI) is more accurate than echocardiography in determining pericardial thickness

Question 116

117. What are the three most likely causes of fibrin or adhesions within the pericardial space?

Answer 116

Long-standing pericardial fusion’s

Metastatic disease with pericardial involvement

Hemorrhagic effusions that result in clot formation within the pericardial space

Question 117

118. What is the most common etiology of constrictive pericarditis?

what physical findings might be presented by patient with constrictive pericarditis?

What is the cause of a pericardial knock?

Answer 117

The most common etiology of constrictive pericarditis is recurrent pericarditis, which may not have a clear underlying antecedent . Repeated cycles of information, healing, and scarring cause of pericardium to become rigid and fibrotic.

Physical findings associated with constrictive pericarditis include dyspnea, ascites, a pericardial knock, jugular vein distention.

A pericardial knock occurs in early diastole and is caused by the abrupt cessation of ventricular filling

Question 118

119. Describe the m-Mode and two dimensional echocardiographic findings associated with Constrictive pericarditis.

Describe the Doppler findings associated with constrictive pericarditis.

What is the definitive method for diagnosing constrictive pericarditis?

Answer 118

In constrictive pericarditis, M-Mode findings include flatten posterior wall motion during diastole, abnormal septal motion (early diastolic bounce) and two parallel lines within the pericardium.
Two-dimensional findings include abnormal simple motion(early diastolic bounce), Immobility of the pericardium, and dilated vena cava.

In constrictive pericarditis, Doppler findings include mitral and tricuspid regurgitation, A decreased early mitral inflow velocity (>25%) during inspiration, and marked variation (>50%) in the left ventricular isovolumetric relaxation time during respiration.

Cardiac catheterization is the definitive method for diagnosing constrictive pericarditis. It is better than echocardiography in the setting because catheterization documents equalization of the right leg ventricular diastolic pressures.

Question 119

120. Define systemic hypertension

What are the physical signs of systemic hypertension

What are the vascular complications of systemic have attention

Answer 119

Systemic hypertension is persistent elevation of the systolic blood pressure above 140 mmHg and/or elevation of the diastolic blood pressure to greater than 90 mmHg. These high blood pressure readings must be obtained on three separate occasions at least one week apart.

Patients with uncomplicated hypertension are almost always asymptomatic. Headache, tinnitus, and dizziness may be seen in hypertensive patients but also occur in patients without hypertension.

The vascular complications of systemic hypertension include cerebrovascular accident, kidney disease, coronary heart disease, congestive heart failure, peripheral vascular disease, aortic dissection

Question 120

121. What are the echocardiographic findings associated with systemic hypertension?

What are the Doppler findings associated with systemic hypertension?

Answer 120

Echocardiographic findings include left ventricular hypertrophy, increased left ventricular mass, left Atrial enlargement, (Usually mild),possible in order dilatation or dissection

Doppler findings include an abnormal mitral inflow pattern featuring and a – wave greater than the E-wave and prolonged deceleration that indicates a decreased left ventricular compliance, Aortic regurgitation( in the presence of aortic dilatation).

Question 121

122. Define pulmonary hypertension.

What are the physical signs of pulmonary hypertension?

Answer 121

Pulmonary hypertension denotes A pulmonary artery pressure greater than 30 mmHg. It has many causes, including idiopathy, Chronic mitral stenosis or your dictation, pulmonary embolism, and Eisenmenger’s syndrome.

Physical signs of change include exertional dyspnea in the early stages of the disease, dyspnea at rest in the advanced stages, syncope, Weakness, and pericardial just pain.

Question 122

123. What are the echocardiographic findings associated with pulmonary hypertension?

What causes absence of an “a” wave

Answer 122

Echocardiographic findings include an enlarged right atrium and ventricle, right ventricular hypertrophy, thickening of the interventricular septum, flattening of the interventricular septum in the short axis view , an absent”a” wave and/or mid systolic closure of the pulmonic valve (flying W) in m mode.

The “a” wave occurs when atrial contraction causes the right ventricular pressure to increase, thereby deforming the closed Pulmonic valve. In patients with pulmonary hypertension, The pulmonary artery pressure is so high that, even during atrial contraction, pulmonic leaflets do not move. Therefore, no “a” wave is produced.

Question 123

124. How is the pulmonary artery pressure calculated on the basis of tricuspid regurgitant jet?

Answer 123

Right ventricular systolic pressure(RVSP) can be calculated by adding the tricuspid regurgitation velocity (inverted to mmHg by 4v2) and the estimated right atrial pressure.

Question 124

125. How is the pulmonary artery pressure assessed using the Doppler pulmonary artery acceleration time?

Answer 124

The pulmonary artery pressure can be calculated from the pulmonary artery Doppler spectral trace by measuring the systolic acceleration time. The normal systolic acceleration time is greater than 120 msec, as measured from the onset of flow to Peak velocity. In patients with pulmonary hypertension, the acceleration time is decreased. In general, and acceleration time of less than 75 msec indicates at least moderate pulmonary hypertension (in adults)

Question 125

126. Describe the three main classifications of cardiomyopathy.

What is the typical echocardiographic appearance of each classification of cardiomyopathy?

Answer 125

The three main classifications are hypertrophic (with and without obstruction),dilated(congestive), restrictive(infiltrative)

In hypertrophic cardiomyopathy, the cardiac walls are thickened both symmetrically or asymmetrically and the cardiac chambers are reduced in size.

In dilated cardiomyopathy, the left ventricle is enlarged, and contractility is decreased. Other cardiac Chambers may also be enlarged.

In restrictive cardiomyopathy, the ventricles are hypertrophied, The cardiac chambers are nearly normal in size, and the myocardium appear bright.

Question 126

127. What is the most common cause of hypertrophic cardiomyopathy?

What causes systolic anterior motion(SAM) Of the mitral valve

Answer 126

The most common cause of hypertrophic cardiomyopathy he is genetic. Just over half of all patients with hypertrophic cardiomyopathy have an AutoSomal dominant gene trait. In other patients, the disease appears to occur spontaneously.

Systolic anterior motion (Sam) of the mitral valve is caused by the venturi effect. The left ventricular outflow tract is narrowed by septal hypertrophy. As ejection occurs, the velocity in the narrow outflow tract increases, drawing the mitral leaflet toward the septum.

Question 127

128. What are the physical findings associated with obstructive cardiomyopathy?

Answer 127

The findings associated are dyspnea on exertion(most common). Occurring in 90% of symptomatic patients

Angina, which occurs in 75% of symptomatic patients

syncope,

Sudden death

Question 128

129. How does the administration of amyl nitrate affect the murmur associated with hypertrophic obstructive cardiomyopathy think?

What happens to such a murmur when the Valsalva maneuver is performed?

Answer 128

The murmur associated with hypertrophic obstructive cardiomyopathy is usually harsh, systolic, and I have a crescendo decrescendo type. It is best heard between the cardiac Apex in the left sternal border. In response to Amyle nitrate , The murmur will increase.

The Valsalva maneuver her causes an increase in systolic murmur associated with hypertrophic obstructive cardiomyopathy

Question 129

130. List for common abbreviations associated with hypertrophic cardiomyopathies and state what each abbreviation means.

Answer 129

ASH = Asymmetric septal hypertrophy

HCM = hypertrophic cardiomyopathy

HOCM = Hypertrophic obstructive cardiomyopathy

IHSS = Idiopathic hypertrophic subaortic stenosis

Question 130

131. Describe the m-Mode appearance of a hypertrophic obstructive cardiomyopathy.

Answer 130

In m- Mode, a hypertrophic obstructive cardiomyopathy is usually characterized by left ventricular hypertrophy (systemic or asymmetric), A small left ventricular cavity, systolic anterior motion of the mitral valve

Question 131

132. In the evaluation of hypertrophic cardiomyopathy, how does two-dimensional echocardiographic examination differ from m-Mode examination?

Answer 131

Two-dimensional echocardiographic examination shows the extent of the hypertrophy better than m-Mode (especially when hypertrophy is asymmetric) and also reveals apical hypertrophy. In addition, two-dimensional examination shows the hypertrophied muscles (ground glass appearance) which results from disarray of the myocardial fibers. Other findings that are better scene with two dimensional imaging include calcification/fibrosis of the mitral annulus, Mitral valve thickening, and septal scarring where the leaflets strike the interventricular septum

Question 132

133. How is pulsed Doppler examination useful in assessing hypertrophic cardiomyopathy?

How is continuous wave Doppler useful in the assessment of hypertrophic cardiomyopathy ?

Answer 132

pulsed Doppler examination, performed from the evil window, localizes the site of obstruction. When the sample volume is moved from the cardiac Apex toward the aortic valve and an obstruction is encountered, the velocity increases and changes from laminar to turbulent on the Doppler spectral trace.

Continuous wave Doppler records the peak gradient both at rest and after provocation with the Valsalva maneuver or amyl nitrate. The spectral trace often shows the late peaking systolic jet typical of obstructive cardiomyopathy

Question 133

134. How is color flow Doppler helpful in the assessment of hypertrophic cardiomyopathy?

Answer 133

The color flow Doppler technique (which is similar to the pulsed Doppler technique) can indicate an area of obstruction in he left ventricular outflow tract by returning the color display into a mosaic pattern when turbulence is detected. Color flow Doppler is also helpful in detecting and quantifying mitral regurgitation, which is common in obstructive cardiomyopathy

Question 134

135. Name five causes of dilated cardiomyopathy.

What is the most common cause of dilated cardiomyopathy in the United States?

Answer 134

Causes include idiopathic you, infection(viral, bacterial, fungal, or Parasitic) , Ischemia, toxicity resulting from alcohol abuse, lead poisoning, aids, or drugs such as adriamycin, A parapartum state.

According to some studies, alcohol is the most common cause of dilated cardiomyopathy in United States. Alcoholic cardiomyopathy most commonly occurs in 30–55-year-old men Who have a longer than 10 year history of heavy drinking.

Question 135

136. Name four classic m-Mode findings associated with dilated cardiomyopathy

Answer 135

Classic findings include a dilated left ventricle, increased E-point separation (EPSS),hypocontractile left ventricular wall motion, A B-notch on the mitral valve, a double diamond mitral valve (when the valve closes in mid diastole),decreased aortic root of motion.

Question 136

137. And dilated cardiomyopathy, what advantage does two-dimensional echocardiography have over-Mode imaging?

How does color flow Doppler imaging contribute to the diagnosis of dilated cardiomyopathy?

Answer 136

In dilated cardiomyopathy, two-dimensional echocardiography allows better global assessment of ventricular function and atrial size,and better detection of thrombi than does M-mode imaging. Two dimensional imaging is also helpful for excluding valvular heart disease, and it made a tech pericardial effusion, which are common in these patients.

Patients with dilated cardiomyopathy often have multi valvular regurgitation. Color flow imaging can quickly detect regurgitation and estimate its severity.

Question 137

138. In patients with dilated cardiomyopathy, why is biventricular enlargement often present?

Why is atrial enlargement present in these patients?

Answer 137

Biventricular enlargement is often seen in patients who have a dilated cardiomyopathy from myocarditis. The infectious organism damages both the right and left ventricular myocardium.

Whatever the etiology, the diastolic pressure pressure increases as the ventricle enlarges. To counter this increased pressure, the left atrium also enlarges.

Question 138

139. Name for causes of restrictive cardiomyopathy.

Which causes is most common?

Answer 138

Causes include:
Amyloidosis,
Sarcoidosis,
Hemochromatosis,
Glycogen storage disorders.

Amyloidosis is the most common cause of restrictive cardiomyopathy.

Question 139

140. Why is restrictive cardiomyopathy sometimes referred to as infiltrative?

Answer 139

The disease is restrictive with respect to physiology for example the hypertrophied ventricular Wall restricts filling, but the disease process is infiltrative, because it involves amyloid or sarcoid deposits within the myocardium.

Question 140

141. How does restrictive cardiomyopathy affect the atria?

Why does it have this effect?

Answer 140

In restrictive cardiomyopathy, the atria enlarges to a greater extent than in any other type of cardiomyopathy.

The biatrial enlargement is caused by the elevated filling pressures of both ventricles.

Question 141

142 Why does the myocardium appear so bright in patients with restrictive cardiomyopathy?

Answer 141

The high reflectivity (Ground glass appearance) of the myocardium results from Amyloid deposits (in amyloidosis) or iron deposits (in hemochromatosis).

Question 142

143. Describe the appearance of restrictive cardiomyopathy, as documented by two-dimensional echocardiographic imaging

Answer 142

Two-dimensional echocardiographic imaging usually reveals left ventricular hypertrophy,
a bright, reflective myocardium
A ventricular cavity that is normal or near normal in size,
Atrial enlargement,
A small to moderate pericardial effusion (cardiac Tamponade is rare)

Question 143

144. What are the Doppler findings associated with restrictive cardiomyopathy

Answer 143

In restrictive cardiomyopathy, Doppler findings include mitral and/or tricuspid regurgitation, which is usually mild, and abnormal mitral inflow patterns. The classic Doppler pattern consist of a tall E wave with rapid deceleration, and a very small A wave.

Question 144

145. Name the five types of cardiac Wall motion that can be seen echocardiographicly .

Answer 144

The five types of all motion are
Normal
Hyper contractile
Hypo contractile
Akinesis
Dyskinesia

Question 145

146. Describe the differences between a true ventricular aneurysm and a pseudoaneurysm.

Which type of aneurysm has a higher rate of rupture?

Answer 145

The walls of a true ventricular aneurysm include all three cardiac layers, the endocardium, the myocardium, and epicardium. Although the lesion May contain thrombus, the aneurysms mouth is wider than his body. In contrast, a psurdoaneurysm is a ruptured portion of the ventricle. It’s wall includes the epicardial and pericardial layers. The aneurysms almost always contain thrombus.

Question 146

147. Name eight potential complications of a myocardial infarction.

Which complication is most commonly seen?

Answer 146

Complications include 
Arrhythmias 
Aneurysm formation
Pseudoaneurysm formation
Pericardial effusion
Mural thrombus
Papillary muscle dysfunction
Ventricular septal defect
Death.

Arrhythmias are the most common complication of myocardial infarction, occurring in 90% of the cases.

Question 147

148. Name six risk factors for coronary artery disease.

Answer 147

Positive family history
Male gender
Hyperlipidemia
Increased age
Smoking
Hypertension

Question 148

149. What is Dressler syndrome

Answer 148

Dressler syndrome is a form of pericarditis that is also known as the post myocardial infarction syndrome. It occurs 6 to 8 weeks after an infarction and is characterized by potential chest pain and a pericardial effusion.

Question 149

150. Describe the post infarction changes that the myocardium might exhibit, as documented by two dimensional imaging.

Answer 149

???
Echocardiographic findings may include fixed segmental wall motion abnormality’s,
Myocardial scarring as indicated by increase brightness and decreased wall thickening,
Ventricular aneurysm which are seen in up to 22% of cases,
A pericardial effusion would usually small,
Left ventricular Nero thrombi.

Question 150

151. Two weeks after sustaining a myocardial infarction , a 45-year-old man returns to the emergency room with shortness of breath, chest pain, and a new systolic murmur. What is the most likely diagnosis?
     Why?

Answer 150

The most likely diagnosis is rupture of the papillary muscle, producing severe acute mitral regurgitation. 90% of papillary muscles rupture occur after infarction of the inferior left ventricular wall.

Question 151

152. What is a basic rule regarding thrombus in the ventricles?p

Answer 151

Basic rule is that thrombus does not form on a ventricular wall that moves normally. Approximately 40% of acute myocardial infarction’s will produce a left ventricular mural thrombus. Most thrombi of this type form between the sixth and 10th day after infarction and are found in the left ventricle Apex.

Question 152

153. How does a right ventricular infarction appear on a two-dimensional echocardiographic image

Answer 152

In autopsy series, right ventricular infarction’s account for up to 70% of inferior myocardial infarction’s but are clinically recognize in only 3% of these cases. Right ventricular free wall akinesis is the most common sensitive echocardiographic indicator of the right ventricular infarction. Other, less specific findings include right ventricular dilatation, tricuspid regurgitation, and paradoxic septal motion.

Question 153

154. In two-dimensional echocardiography,how do the findings produced by ischemic cardiomyopathy differ from those caused by viral cardiomyopathy?

Answer 153

A dilated, hypocontractile left ventricle may appear in both cases. In ischemic cardiomyopathy, however, the right ventricle is often unaffected. In viral cardiomyopathy, the right ventricle is dilated and hypocontractile

Question 154

155. What is the role of Doppler examination in ischemic heart disease?

Answer 154

???
Doppler examination is important in assessing the complications of myocardial infarction, particularly ischemic mitral regurgition, flail mitral valve with severe regurgitation, and ventricular septal defect. Right ventricular infarctions may be accompanied by tricuspid regurgitation, although this finding is not specific for such infections.

Question 155

156. What advantage does exercise echocardiography have over regular exercise electrocardiography in detecting coronary artery disease?

Answer 155

In detecting single vessel coronary artery disease, regular exercise electrocardiography has a sensitivity of about 60%. In comparison, exercise echocardiography has a sensitivity and specificity of about 90%. In patients with multi vessel coronary artery disease, this method’s sensitivity is even greater.

Question 156

157. What is a myxoma?

What are the most likely locations for cardiac myxomas?

What percentage of cardiac myxomas recur?

Answer 156

???
A myxoma is a benign tumor composed of mucopolysaccharide (mucous) cells. Most myxomas have a soft, Gelatinous appearance. Some are multilobulated , And others are more encapsulated.

In 75% of cases, cardiac myxomas form in the left atrium. The right atrium is the next most common location, followed by the left and right ventricle. Multiple myxomas occur in approximately 5% of patients.

5 to 14% of cardiac myxomas or after resection. Recurrence is usually at the origin tumor site but may also involve other intracardiac size.

Question 157

158. What symptoms and physical findings are associated with a left atrial myxoma?

Answer 157

In left atrial myxoma, symptoms are related to obstruction of the mitral orifice. They include dyspnea, fatigue, weakness, and a diastolic murmur.

Question 158

159. What is the most common primary malignant cardiac tumor?

Answer 158

The most common primary malignant cardiac tumor is the sarcoma. These tumors account for about 25% of all primary cardiac tumors and are second only to myxomas and frequency. Sarcomas have varying histologic features and may take the form of an angiosarcoma ( The most common histologic type), A rhabdomyosarcoma, or a fibrosarcoma.

Question 159

160. What is the most common benign cardiac tumor seen in children?

Answer 159

Rhabdomyomas are the most common benign cardiac tumors seen in children. These tumors, which are derived from cardiac muscle cells, are frequently multiple, are intracavitary, and may obstruct cardiac inflow or outflow. Fibromas are the second most common cardiac tumor seen in children and are often intramyocardial

Question 160

161. Name five technical maneuvers that can differentiate a cardiac mass from an artifact during echocardiography.

Answer 160

To differentiate a cardiac mass from an artifact, the examiner can decrease the overall transmit gain and time gain compensation controls,
Use multiple cardiac windows,
Change the depth view so thereby possibly changing the position of range artifacts,
Switch to a higher frequency transducer to improve resolution,
Inject contrast media which may help identify right-sided masses by outlining the lesion.

Question 161

162. With respect to symptoms and physical findings, a left atrial myxoma May mimic what other cardiac disorder?

Answer 161

They left atrial myxoma may mimic mitral stenosis. And both of these disorders, symptoms and physical findings include a diastolic murmur, dyspnea, weakness, and fatigue.

Question 162

163. How does atrial fibrillation affect the mitral valve, as documented by m-Mode imaging?

How does atrial fibrillation affect the left ventricle, as seen echocardiographically

Answer 162

As documented by m-Mode imaging, atrial fibrillation affects the mitral valve by causing irregularity of the length of the diastolic filling periods, absence of an a wave, fibrillatory waves on the mitral leaflet during diastole. These waves are best seen on the anterior leaflet.

The effects of atrial fibrillation on the left ventricle is less obvious on two dimensional echocardiography then on m-Mode imaging but may include variations in ventricular size as the diastolic filling Changes. Atrophic relation may also cause changes in the amplitude of ventricular contraction, with longer diastolic intervals having more forceful ejections.

Question 163

164. Describe the appearance of Wolf Parkinson White syndrome (WPW) as documented by m mode

Answer 163

In m-imaging, the appearance of Wolff-Parkinson-White syndrome varies, depending on whether the syndrome is type a ( involving preexcitation of the posterior left ventricular wall) or type B (involving preexcitation of the anterior right ventricular wall). Type a is characterized by early systolic contraction ( notching) of the posterior left ventricular wall. In contrast, type B is characterized by abnormal separate motion, such as posterior motion during early systole.

Question 164

165. How do frequent premature ventricular contractions affected the aortic Doppler special trace?

Answer 164

The Doppler spectral trace shows the premature ventricular contractions effect on flow. When a premature beat occurs, the diastolic interval is shortened, and little or no flow is seen. Because A compensatory pause ensues, involving a longer than normal diastole, the next beat will have a higher velocity as a result of the enlarged ventricular volume.

Question 165

166. How does atrial flutter affect the mitral valve, as documented by m-Mode imaging?

Answer 165

In M-Mode imaging, the effect of atrial flutter on the mitral valve is characterized rapid, regular flutter waves or undulations, which correspond to the atrial contractions.

Question 166

167. In assessing wall and valve motion irregularities caused by arrhythmias and conduction disturbances, which is preferred : m - Mode or two dimensional Echocardiography? Why?

Answer 166

m-Mode imaging is the best means of assessing arrhythmic changes and conduction disturbances. Compared to two dimensional echocardiography, m-mode imaging has a much higher sampling rate (Temporal resolution) , So it can record subtle or rapid changes in wall or valve motion.

Question 167

168. What are the typical m-Mode findings associated with bundle branch block?

Answer 167

Typical findings associated with bundle branch block are limited to abnormal ventricular septal contraction patterns. Left bundle branch block often produces early systolic posterior deflection of the interventricular septum. Right bundle branch block is associated with normal septal depolarization from left to right, and no abnormal septal wall motion is present.

Question 168

169. What is the most common congenital cardiac anomaly?

What is one of the most prevalent cyanotic congenital cardiac lesions?

Answer 168

Ventricular septal defect in (20% – 30% of all defects) is the most common congenital cardiac anomaly. Bicuspid aortic valves are more common in the general population (1% – 2%), But are considered a variant of normal unless stenotic.

Tetralogy of fallout is one of the most prevalent cyanotic cardiac lesions.

Question 169

170. What are the three possible deformities involved in an atrioventricular septal defect?

Answer 169

Atrioventricular septal defect can involve a:
Premum atrial septal defect
Ventricular septal defect
Cleft mitral valve

Question 170

171. What congenital cardiac lesion is commonly associated with pulmonic stenosis?
     What congenital cardiac lesion is commonly associated with bicuspid aortic valve?

Answer 170

Pulmonic stenosis is commonly associated with a ventricular septal defect

Bicuspid aortic valve is commonly associated with aortic coarctation.

Question 171

172. Name and describe the four main types of atrial septal defects.

Answer 171

Secundum defects, which are located in the mid septal area and are the most commonly observed type. (Incidence, 70%)
Primum defects, which are located in the inferior septum, close to the atrioventricular valve, and are the second most common type(incidence 20%)
Sinus venosus defects, which are located near the entrance of the superior vina cava. These defects are also associated with anomalous pulmonary venous return and account for approximately 8% of atrial septal defect.
Coronary sinus defects, which are located in the inferior septum, close to the coronary sinus, an account for only 2% of atrial septal defect.

Question 172

173. What is the main direction of flow across an atrial septal defect?

In color Doppler imaging, which echocardiographic view is best for detecting for cross in atrial septal defect?

Answer 172

Abnormal right and left ventricular pressures the direction of flow across an atrial septal defect is left – right.

In color flow Doppler imaging, the best echocardiographic view for the taking a left – right flow across an atrial septal defect is the subcostal for chamber view. In this view, shunt flow is parallel to ultrasound beam, so echocardiographic sensitivity is optimal.

Question 173

174. If the primary flow direction through a shunt is left – right, why are contrast echocardiographic studies so sensitive in detecting atrial shunts?

Answer 173

Even when Shunt flow is primarily left – right, a small right – left component is usually present at end diastole. If the contrast Study yields a negative result, performing another injection during the release stage of the Valsalva maneuver may produce a positive result, because the right sided pressures Will undergo a transient increase.

Question 174

175. What effect does an atrial septal defect have on the cardiac chambers?

Answer 174

Shunt flow across an atrial septal defect causes the right ventricular diastolic volume and the pulmonary bloodflow to increase. In addition to right ventricular dilatation resulting from volume overload, paradoxic wall motion or septal flattening is seen in the parasternal short axis view. The left ventricle is rarely affected.

Question 175

176. Describe the most common types of ventricular septal defect.

Answer 175

Perimembranous defect near that you want to go, which is the most common type, accounts for 75% of ventricular defects.
And inflow defect in the posterior portion of the septum, close to the tricuspid valve.
And outflow or supracristal defect in the right ventricular outflow tract.
A muscular defect low in the ventricle or septum is completely surrounded by muscular tissue. Multiple muscular ventricular septal defect make coexist.

Question 176

177. Which technique, Doppler or contrast echocardiography, is more useful and detecting a ventricular septal defect?

Answer 176

Doppler imaging is more useful than contrast echocardiography in detecting a ventricular septal defect. A pulsed or color flow approach should be used to locate the defect, and continuous wave studies are performed for estimating the gradient between the ventricles. Because blood is almost always shunted from left – right, contrast echocardiography has limited success into taking these effects.

Question 177

178. What is the primary direction of flow across a ventricular septal defect?

Describe the physiology of Eisenmenger syndrome.

Answer 177

At normal ventricular pressure, the primary direction of flow across a ventricular septal defect is left – right.

In Eisenmenger’s syndrome, a long-standing left – right shunt, in the form of a ventricular or atrial septal defect, causes pulmonary hypertension. As a result the shunt reverses direction, becoming a right – left

Question 178

179. How does a ventricular septal defect in effect the cardiac chambers?

Answer 178

Small ventricular septal defect do not usually affect either the right or left Cardiac chambers. Moderate to large ventricular septal defect caused the right ventricle to enlarge as a result of volume overload. Right ventricular hypertrophy can also result from pressure overload of the right ventricle. The atria are rarely affected by a ventricular septal defect.

Question 179

180. What is a patent ductus arteriosus (PDA) ?

Which echocardiographic view and technique is best for assessing a patent ductus arteriosus?

Answer 179

A patent ductus arteriosus is an anomaly in which the ductus arteriosus fails to close after birth. The ductus arteriosus is a fetal communication between the pulmonary artery in the discending aorta. In the fetal circulation, the ductus shunts blood away from the lungs, toward The aorta.

The parasternal short axis view, at the level of the aorta, is the best echocardiographic View for detecting a patent ductus arteriosus. Color flow Doppler imaging is the best technique for detecting shunt flow. Usually, blood flows through the shunt in a left – right direction from the aorta to the pulmonary artery during diastole.

Question 180

181. In coarctation of the aorta, which portion of the aorta is usually involved?

How is the severity of an aortic coarctation quantified?

Answer 180

Although coarcted may involve any portion of the aorta, this anomaly usually occurs just distal to the origin of the left subclavian artery.

The severity of obstruction at the coarcted site can be quantified with continuous wave Doppler. From the aortic suprasternal notch, the Doppler beam can be aligned with the descending aorta, lowering the peak gradient to be measured. Typically, forward flow is also present at the coarcted site during diastole. Such flow is known as diastolic runoff .

Question 181

182. What is Ebstein’s anomaly?

What congenital lesion is often associated with Ebstein’s anomaly?

Answer 181

Ebstein’s anomaly is congenital malformation and apical displacement of one or more tricuspid valve leaflets. Although the degree of leaflet displacement varies, at least part of the morphologic right ventricle becomes “atrialized” .The tricuspid annulus is positioned normally, and moderate to severe tricuspid regurgitation is usually present.

Secundum arterial septal defect are often associated with Ebstein’s anomaly.

Question 182

183. Which echocardiographic views are the most helpful in assessing Ebstein’s anomaly?

What condition disturbance is associated with Ebstein’s anomaly?

Answer 182

Either the apical or the subcostal four chamber view is best for visualizing displacement of the tricuspid leaflets and Ebstein’s anomaly. When the anomaly is mild, these views also allow accurate measurement of the distance between the insertions of the mitral and tricuspid leaflets. If these insertions are separated by more than 8 mm, some degree of tricuspid leaflet malposition is present.

Patients with Ebstein’s anomaly have a heightened incidence of Wolff-Parkinson-White syndrome, usually with a right accessory pathway.

Question 183

184. Describe the three types of aortic dissection.

Which types are usually associated with aortic regurgitation?

Answer 183

Type one. Which originates in the proximal a sending aorta and extends into the descending aortic.

Type two. Which originates in the proximal a sending aorta and is confined to the Ascending aortic.

Type Three. Which origin aids in the descending aorta and extends into the abdominal aorta. Alternatively, in rare cases, type III dissection extends toward aortic arch.

Aortic regurgitation is seen in both type one and type two aortic dissection ors, because these types involve the aortic root.

Question 184

185. Describe the two-dimensional echocardiographic appearance of a sinus Valsalva aneurysm.

Answer 184

Sinus a Valsalva aneurysms involve the right coronary sinus and 70% of cases, The non-coronary sinus is 25% of cases, and he left coronary sinus is 5% of cases. Two-dimensional echocardiography best reveal such aneurysms in the parasternal short axis view, at the aortic level. Because aneurysms rarely involve more than one sinus, identification of the affected sinus is facilitated by comparing the sizes of wall thicknesses of all three sinuses. An aneurysmal sinus is larger than normal and has thin walls. These aneurysms can rupture, and if this complication occurs, color flow Doppler imaging is very useful in identifying the direction and volume of flow.

Question 185

186. What are the echocardiographic findings associated with aortic dissection?

What is the best echocardiographic technique for evaluating an aortic dissection?

Answer 185

Echocardiographicly, aortic dissection is associated with logo or generalized dilatation of the aorta . The aortic wall had a double layered appearance either anteriorly or posteriorly. The intimal flap appears as a thin, mobile structure that divides the order into a true and a false channel.

Transesophageal echo choreography is the best technique for diagnosing an aortic dissection and evaluating it’s extent.

Question 186

187. What echocardiographic findings may help differentiate miscellaneous aortic dilatation from Marfan syndrome?

Answer 186

Most patients (70%) with Marfan’s syndrome have mitral valve prolapse. Marfan syndrome is a connective tissue disease in which the chief cardiac abnormalities are aortic aneurysm, your dictation, and mitral valve prolapse. Dissection is common and accounts for the majority of premature deaths.

Question 187

188. In the presence of a ventricular septal defect, how would you calculate the right ventricular systole pressure(RVSP)

Answer 187

In the absence of aortic stenosis, the right ventricular systolic pressure can be calculated by measuring the gradient between the ventricles on the basis of the velocity across the ventricular septal defect (VSD);

2. Converting the result to mmHg with the Bernoulli equation (4v2)
3. Subtracting this gradient from the systolic blood pressure (SBP)

The equation is: RSVP = SBP - VSD gradient

Question 188

189. A 32-year-old female presents with atypical chest pain. Her blood pressure is 112/50, height 6 foot and weight 115 pounds. A echocardiogram is performed which shows mitral valve prolapse and what is the most likely diagnosis of the patient?

What additional cardiac structures should be evaluated?

Answer 188

From the physical description of this patient and the findings on echocardiogram of mitral valve prolapse she may have Marfan syndrome.

The aortic valve and aorta should be evaluated for the presence of valvular regurgitation, dilatation and possible dissection.

Question 189

190. A 39-year-old male with no cardiac history enters the doctors office complaining of flulike symptoms for one week. A previously undocumented systolic murmur is heard. An echocardiogram reveals an abnormally thick anterior mitral valve leaflet and mild mitral regurgitation. What is the most likely cause of these echo findings?

What additional test will be helpful in diagnosing this patient?

Answer 189

With a new mumur and the Echo finding of mitral valve thickening in a young person, the most likely diagnosis is mitral valve endocarditis

Blood cultures will be helpful in identifying the organism and a transesophageal echocardiogram will further assess the extent of mitral leaflet beginning

Question 190

191. A 55-year-old female complains of increasing dyspnea on exertion for three months. Her physical examination reveals jugular venous distention, ascites and a pericardial knock. What is the most likely clinical diagnosis?

Answer 190

This patient may have constrictive pericarditis. The dyspnea, ascities and jugular venous distention could all result from a restriction to a diastolic filling. A pericardial knock is a classic physical findings associated with constriction.

Question 191

192. A 32-year-old female complains of fatigue and her chest x-ray reveals cardiomegaly. An echocardiogram is ordered. Right atrial and ventricular enlargement appears on the echocardiogram. Additionally, there is a flattened interventricular septum, M – mode findings of pulmonic valve mid systolic closure and an absent a-wave. Identify the cardiac abnormality consistent with these findings.

Answer 191

These echocardiographic findings are consistent with pulmonary hypertension. A microcavitation (contrast) Study should be performed to rule out any atrial level shunt as the cause of the pulmonary hypertension.

Question 192

193. A 22-year-old male complains of chest pain following exercise. An echocardiogram displays concentric left ventricular hypertrophy (2.5 cm), A small LV cavity size. Systolic motion of the mitral leaflet (SAM) and pericardial effusion are not observed. What is the most likely diagnosis for this patient?

What additional noninvasive test may help in diagnosing this patient?

Answer 192

The findings of concentric left ventricular hypertrophy and a small LV cavity size is diagnostic of hypertrophic cardiomyopathy.

In order to identify the presence or absence of an obstructive component, an amyl nitrate challenge should be performed while the left ventricular outflow tract is interrogated by continuous wave Doppler.

Question 193

194. ?????
     A 38-year-old male is sent To the echocardiography lab for evaluation after complaining of severe dyspnea on exertion for two months. M – mode findings include a dilated left ventricle, increased E point to septal separation (EPSS), B – notch on the mitral valve and overall hypocontractile left ventricular wall motion. I didn’t find a cardiac abnormalities of this patient.

Answer 193

These M — mode findings alone help to identify a patient with a dilated cardiomyopathy.

Question 194

195. After a chest x-ray revealed cardiomegaly, a 58-year-old female, with a primary complaint of increasing dyspnea on exertion, sent for an echocardiogram. The echocardiogram demonstrates left ventricular hypertrophy with bright myocardial appearance, left atrial enlargement and a small pericardial fusion. What is this patient’s most likely cardiac diagnosis?

Answer 194

The echocardiographic findings are most consistent with diagnosis of infiltrative (restrictive) cardiomegaly.

Question 195

196. A 58-year-old female visits the doctor with a complaint of shortness of breath. Upon physical examination, a diastolic (rambling) murmur is detected. The patient denies any history of rheumatic fever. What three cardiac abnormalities might be present this patient?

Answer 195

Mitral stenosis (or tricuspid stenosis) . Even with no history she may have had rheumatic fever as a child and now has rheumatic heart disease.

Left atrial myxoma is mimic mitral stenosis with regard to both physical findings and symptoms.

Aortic regurgitation. If the aortic regurgitation jet hits the mitral valve anterior leaflet, the MV’s opening can be restricted. As a result, a rumbling diastolic murmur (Austin Flint) , Rather than a typical “blowing” diastolic murmur, will be heard

Question 196

197. A 31-year-old male with a history of uncontrolled hypertension enters the emergency room with severe chest pain that he describes as “ripping” . What is a likely cardiac diagnosis for this patient?

Which noninvasive examination would be useful to confirm the diagnosis?

Answer 196

Although this patient may be experiencing a myocardial infarction, history of hypertension and “ripping” chest pain also indicate the possibility of aortic dissection.

Transesophageal echo cardiography would be the next preferred noninvasive test as it is the fastest to perform and most sensitive method and diagnosing aortic dissection’s.

Question 197

198. ?????
     An 18-year-old male complains of palpitations. His chest x-ray reveals cardiomegaly and as a result, an echocardiogram is ordered. The echo reveals right atrial and ventricular enlargement. The tricuspid valve appears at all I just placed towards apex. What is this patient’s most probable cardiac abnormality?

What additional test should be performed in the echo lab?

Answer 197

This patient probably has Ebstein’s anomaly.

A microcavitation (bubble or contrast) Study should be performed to identify the presence or absence of an associated atrial septal defect.