Anatomy and Physiology

Question 1

All of the following left ventricular wall segments may be evaluated in the parasternal long axis view EXCEPT:

A. Basal anterior interventricular septum
B. Mid-anterior interventricular septum
C. Basal inferolateral wall
D. Cardiac apex

Answer 1

D. The following left ventricular wall segments are visualized in the parasternal long-axis view: basal anterior interventricular septum, mid-anterior interventricular septum, basal inferolateral wall and mid-inferolateral wall.

The basal and mid-anterior interventricular septum wall segments are supplied by the left anterior descending coronary artery. The basal and mid-inferolateral wall segments are supplied by circumflex coronary artery or the right coronary artery.

The cardiac apex is usually not visualized because it is outside the interrogating ultrasound beam. Visualization of the apex in this view may be due to poor angulation; this is termed a false apex. The sonographer may slide the transducer down towards the cardiac apex to better visualize the cardiac apex.

Question 2

All of the following left ventricular wall segments may be evaluated in the parasternal short-axis of the left ventricle at the level of the papillary muscles EXCEPT:

A. Anterior interventricular septum
B. Anterior wall
C. Anterolateral wall
D. Cardiac apex

Answer 2

D. The following left ventricular wall segments are visualized in the parasternal short-axis of the left ventricle at the level of the papillary muscles: anterior interventricular septum, anterior, anterolateral, inferolateral, inferior and inferior interventricular septum.

The anterior interventricular septum and anterior wall are supplied by the left anterior descending coronary artery. The anterolateral wall is supplied by the circumflex coronary artery or the left anterior descending coronary artery.

The inferolateral wall is supplied by the circumflex coronary artery or the right coronary artery. The inferior wall and inferior interventricular septum are supplied by the right coronary artery.

The inferolateral wall has been referred to as the posterior wall of the left ventricle.

Question 3

All of the following wall segments may be visualized in the apical four-chamber view EXCEPT:

A. Anterolateral wall
B. Cardiac apex
C. Anterior interventricular septum
D. Lateral wall of the right ventricle

Answer 3

C. The following left ventricular wall segments are visualized in the apical four-chamber view: basal and mid-anterolateral, apical lateral, apical cap, basal and mid-inferoseptum and apical septum.

The basal and mid-anterolateral and apical lateral wall segments are supplied by the left circumflex coronary artery or left anterior descending coronary artery. The basal inferior interventricular septum is supplied by the right coronary artery. The mid-inferior interventricular septum is supplied by the right coronary artery or left anterior descending coronary artery. The apical septum and apical cap are supplied by the left anterior descending coronary artery.

The basal, lateral and apical lateral wall segments of the right ventricle are visualized in the apical four-chamber view and are supplied by the right coronary artery.

Question 4

All of the following wall segments may be visualized in the apical two-chamber view EXCEPT:

A. Anterior wall
B. Cardiac apex
C. Inferior wall
D. Right ventricular outflow tract

Answer 4

D. The basal, mid and apical anterior wall segments and apical cap of the left ventricle are visualized in the apical two-chamber view and are supplied by the left anterior descending coronary artery.

The basal, mid and apical inferior wall segments of the left ventricle are seen in the apical two-chamber view. The basal and mid-inferior wall segments of the left ventricle are supplied by the right coronary artery. The apical inferior wall segment is supplied by the left anterior descending coronary artery.

The right ventricle is not visualized in this view.

The coronary sinus, left atrial appendage and with a posterior tilt the descending thoracic aorta may be visualized in the apical two-chamber view.

Question 5

The imaginary boundaries that define the mid-left ventricle are the:

A. Mitral annulus to the tip of the papillary muscles
B. Base of the papillary muscles to the cardiac apex
C. Tip of the papillary muscles to the base of the papillary muscles
D. Aortic annulus to the edge of the mitral valve

Answer 5

C. The American Society of Echocardiography divides the left ventricle into thirds along the long-axis of the left ventricle. The base and tip of the papillary muscles is the border between the apical and basal thirds.

Question 6

The boundaries of the functional left ventricular outflow tract are best described as extending from the:

A. Anterior aortic valve annulus to the posterior aortic valve annulus
B. Anteromedial position of the tricuspid valve annulus to the pulmonic valve annulus
C. Free edge of the anterior mitral valve leaflet to the aortic valve annulus
D. Tips of the left ventricular papillary muscles to the edge of the anterior mitral valve leaflet

Answer 6

C. The American Society of Echocardiography defines a functional left ventricular outflow tract and an anatomic outflow tract. The anatomic left ventricular outflow tract stretches from the inner edge of the interventricular septum to the leading edge of the anterior mitral valve leaflet. The functional outflow tract encompasses the area along the left septal endocardial border to the aortic valve annulus and from the tip of the anterior mitral valve leaflet to the level of the posterior aortic valve annulus.

Question 7

Structures of the mitral valve apparatus include all of the following EXCEPT:

A. Mitral valve annulus
B. Sinuses of Valsalva
C. Chordae tendineae
D. Papillary muscles

Answer 7

B. The mitral valve apparatus involves the mitral valve annulus, mitral valve leaflets (anterior and posterior), chordae tendineae, papillary muscles and the left ventricular walls. Abnormalities of any of these structures may result in mitral regurgitation.

Left ventricular dilatation may result in functional mitral regurgitation.

The sinuses of Valsalva are the outpouchings located behind each aortic valve cusp.

Question 8

The normal mitral valve area is:

A. 3 to 5 cm^2
B. 4 to 6 cm^2
C. 3.5 to 4.5 cm^2
D. 5 to 8 cm^2

Answer 8

B. In normal adults, the mitral valve area is 4 to 6 cm^2. When the orifice is reduced to about 2 cm^2, which considered mild mitral valve stenosis, blood can flow from the left atrium into the left ventricle only if propelled by an abnormal pressure gradient. When the mitral valve orifice is reduced to 1 cm^2, this is considered critical mitral valve stenosis.

The normal aortic valve area is 3 to 5 cm^2.

The normal pulmonic valve area is 3.5 to 4.5 cm^2.

The normal tricuspid valve area is 5 to 8 cm^2.

Question 9

The section of the aorta that is located between the diaphragm and the iliac arteries is called the:

A. Abdominal aorta
B. Aortic isthmus
C. Descending thoracic aorta
D. Transverse aorta

Answer 9

A. The aorta is divided into segments comprising the aortic root (aortic annulus to the sino-tubular junction), ascending aorta, transverse aorta (aortic arch), aortic isthmus, descending thoracic aorta and abdominal aorta. The diaphragm is the landmark used to demarcate the descending thoracic aorta from the abdominal aorta.

75% of all aortic aneurysms are located in the abdominal aorta below the renal arteries (infra-renal). An anterior-posterior diameter of the abdominal aorta of > 3.0 cm indicates the presence of abdominal aorta aneurysm (AAA). It has been proposed that the abdominal aorta be routinely evaluated during an echocardiogram.

Question 10

The correct order for the branches of the transverse aorta (aortic arch) is:

A. Left subclavian, right subclavian, left common carotid
B. Right brachiocephalic, left brachiocephalic, left common carotid
C. Right brachiocephalic, left common carotid, left subclavian
D. Sinus of Valsalva, right innominate, left innominate

Answer 10

C. The first major branch of the transverse aorta (aortic arch) is the right brachiocephalic (right innominate), followed by the left common carotid artery and then the left subclavian artery.

The suprasternal long-axis of the aorta allows visualization of these three branches, the ascending aorta, transverse aorta (aortic arch), descending thoracic aorta, right pulmonary artery and left atrium.

Question 11

The name of the aortic segment located between the left subclavian artery and the insertion of the ligamentum arteriosum is the:

A. Aortic root
B. Sino-tubular junction
C. Transverse aorta
D. Aortic isthmus

Answer 11

D. The aortic isthmus joins the transverse aorta (aortic arch) to the descending thoracic aorta. Aortic coarctation and DeBakey type III dissection may be located at or around the aortic isthmus.

The segments of the aorta include the aortic root (aortic annulus to the sino-tubular junction), ascending aorta, transverse aorta (aortic arch), descending thoracic aorta and abdominal aorta.

75% of all aneurysms of the aorta are located in the abdominal aorta just below the renal arteries (infra-renal).

Question 12

The outpouching behind each aortic valve leaflet is called the:

A. Ligamentum arteriosum
B. Ductus arteriosus
C. Aortic isthmus
D. Sinus of Valsalva

Answer 12

D. The name of the sinuses of Valsalva are: right, left and non-coronary.
The left coronary artery originates from the left sinus of Valsalva and the right coronary artery originates from the right sinus of Valsalva.

The most common location for sinus of Valsalva aneurysm (ruptured or unruptured) is the right (69%). Associated findings for sinus of Valsalva aneurysm include ventricular septal defect, bicuspid aortic valve and aortic coarctation.

Question 13

The most likely explanation of main pulmonary artery dilatation is:

A. Bicuspid aortic valve
B. Truncus arteriosus
C. Pulmonary hypertension
D. Carcinoid heart disease

Answer 13

C. The normal end-diastolic dimension of the main pulmonary artery is 1.5 cm to 2.1 cm. The main pulmonary artery bifurcates into the right pulmonary artery branch (normal dimension: 1.0 cm to 1.4 cm) and the left pulmonary artery branch (normal dimension: 0.9 cm to 1.1 cm)

Measurements for the pulmonary artery are best made in the parasternal short-axis of the aortic valve.

For transesophageal echocardiography, the mid-esophageal aortic valve short-axis view with a multiplane angle of approximately 45 to 70 degrees is recommended. An increase in pressure (e.g., pulmonary hypertension) or an increase in flow volume (e.g, atrial septal defect) may result in main pulmonary artery dilatation. Williams syndrome is associated with supravalvular aortic stenosis (hourglass type) and pulmonary branch stenosis.

Question 14

The coronary sinus can be differentiated from the descending thoracic aorta with pulsed-wave Doppler because coronary sinus flow is predominantly diastolic while aortic flow is:

A. Equiphasic
B. Phasic
C. Predominantly diastolic
D. Predominantly systolic

Answer 14

D. On the surface of the heart, the coronary sinus encircles the heart between the ventricles and the atria. The coronary sinus collects deoxygenated blood from the coronary artery system and delivers this blood directly to the right atrium.

The thebesian valve is located in the right atrium and guards the opening of the coronary sinus.

The parasternal long-axis, apical long-axis and apical two-chamber view provide identification of the coronary sinus, which is a small, echo-free space noted in the atrioventricular groove in these two-dimensional views.

The coronary sinus may also be visualized in the apical four-chamber view with a posterior tilt.

Question 15

The left anterior descending coronary artery supplies blood to all of the following EXCEPT:

A. Anterior interventricular septum
B. Anterior wall of the left ventricle
C. Apical cap
D. Inferior wall of the left ventricle

Answer 15

D. The inferior wall of the left ventricle is supplied by the right coronary artery.

Question 16

Which left ventricular wall segment is LEAST likely to be supplied by the circumflex coronary artery:

A. Anterolateral wall of the left ventricle
B. Inferolateral wall of the left ventricle
C. Basal inferior wall of the left ventricle
D. Lateral wall of the cardiac apex

Answer 16

C. The basal inferior wall of the left ventricle is supplied by the right coronary artery.

Question 17

All of the following ventricular wall segments may be supplied by the right coronary artery EXCEPT:

A. Lateral wall of the right ventricle
B. Basal and mid-inferior walls of the left ventricle
C. Basal and mid-inferolateral walls of the left ventricle
D. Basal and mid-anterior interventricular septum

Answer 17

D. The basal and mid-anterior interventricular septum is supplied by the left anterior descending coronary artery.

Question 18

Normal pressure values in millimeters of mercury (mmHg) for the listed cardiac chambers or great vessels include all of the following EXCEPT:

A. Right atrial pressure: 2 to 8 mean
B. Right ventricle: 15 to 30 systolic; 2 to 8 diastolic
C. Pulmonary artery: 15 to 30 systolic; 2 to 12 mean diastolic
D. Aorta: 100 to 140 systolic; 3 to 12 end-diastolic

Answer 18

D. The normal end-diastolic aortic pressure is 60 to 90 mmHg.

Recently a proposed normal aortic pressure (blood pressure) is a systolic pressure < 120 mmHg and a diastolic pressure < 80 mmHg.

Pre-hypertension would be a systolic range of between 120 to 139 mmHg or a diastolic pressure range of 80 to 89 mmHg.

Stage I systemic hypertension would be considered present for a systolic range of 140 to 159 mmHg or a diastolic pressure range of 90 to 99 mmHg.

Pulmonary hypertension is considered present when the systolic pulmonary artery pressure is > 30 mmHg.

Question 19

According to the electrocardiogram (EKG), electrical systole is:

A. Onset of the QRS to the onset of the T wave
B. Onset of the T wave to the onset of the P wave
C. End of the T wave to the onset of the QRS complex
D. Onset of the QRS complex to the end of the T wave

Answer 19

D. The P wave represents atrial depolarization and contraction.

The QRS complex represents ventricular systole (ventricular depolarization) (normal value < .10 sec).

The T wave represents ventricular diastole (repolarization).

The ST segment represents the isoelectric period when the heart is refractory to electrical stimulation. Because of the normal electro-mechanical delay, actual ventricular contraction occurs during the ST segment.

The PR interval (normal range .12 to 20 sec) represents the time for the electrical impulse to travel from the SA node to the Purkinje fibers.

Question 20

All of the following are considered a part of normal ventricular diastole EXCEPT:

A. Isovolumic relaxation
B. Early passive filling
C. Atrial systole
D. Ventricular depolarization

Answer 20

D. The six phases of the cardiac cycle are: early passive filling, diastasis, atrial systole, isovolumic contraction, ventricular ejection and isovolumic relaxation.

Diastasis is the time between early and late diastole where the left atrial and left ventricular pressures equilibrate.

Left ventricular isovolumic relaxation time (IVRT) (aortic valve closure to mitral valve opening) can be measured with pulsed-wave Doppler, continuous-wave Doppler or tissue Doppler imaging.

Ventricular depolarization is considered ventricular systole.

Question 21

All of the following are components of a pulsed-wave Doppler of a pulmonary vein EXCEPT:

A. S1
B. S2
C. E
D. AR

Answer 21

C. The wave components of the pulmonary vein are S (systolic) wave,
D (diastolic) wave and the AR (atrial reversal) wave.

The S wave represents flow into the left atrium during systole and may have two components S1 and S2. The D wave represents flow through the pulmonary vein during diastole. The AR wave represents flow reversal into the pulmonary vein during atrial systole.

In significant mitral regurgitation, the pulmonary vein S wave may be reversed.

In significant diastolic dysfunction, the AR wave peak velocity may be increased (> 35 cm/s) and/or increased in duration as compared to the mitral valve A wave duration (30 msec greater than the mitral valve A wave duration).

Question 22

Which pulmonary vein is not visualized in the apical four-chamber view?

A. Right upper
B. Right lower
C. Left upper
D. Left lower

Answer 22

B. A modified suprasternal short-axis of the aorta may allow visualization of all four pulmonary veins (“crab” view) or subcostal four-chamber view with an anterior tilt.

Question 23

The eustachian valve is found in the:

A. Right atrium
B. Right ventricle
C. Left atrium
D. Left ventricle

Answer 23

A. The eustachian valve in the right atrium is a remnant of fetal circulation as it directed flow to the foramen ovale. The eustachian valve may be visualized in the parasternal right ventricular inflow tract view, parasternal short-axis of the aortic valve view and subcostal four-chamber view. The eustachian valve may be prominent in some patients. Occasionally, a eustachian valve is large enough to obstruct flow. Vegetation located on the eustachian valve has been reported.

Question 24

The Chiari network is found in the:

A. Right atrium
B. Right ventricle
C. Left atrium
D. Left ventricle

Answer 24

A. The nonpathologic entity that may be seen in the right atrium is the Chiari network. These fine filamentous structures are remnants of developmental structures of the right atrium and may be thought of as an extension of the eustachian valve.

Question 25

The crista terminals is found in the:

A. Right atrium
B. Left atrium
C. Right ventricle
D. Left ventricle

Answer 25

A. The crista terminalis is located in the right atrium and is a muscular ridge that courses anteriorly from the superior vena cava to the inferior vena cava. It divides the trabeculated anterior portion of the right atrium from the posterior, smooth-walled sinus venous segment. The crista terminalis may occasionally be seen in the apical four-chamber view at the roof of the right atrium.

Question 26

All of the following structures are located in the right atrium EXCEPT:

A. Eustachian valve
B. Crista terminalis
C. Thebesian valve
D. Moderator band

Answer 26

D. The moderator band is found within the right ventricle and can be misinterpreted as a pathologic structure. The moderator band stretches from the interventricular septum to the lateral wall of the right ventricle and contains the right bundle branch. The moderator band anchors the right ventricular anterior papillary muscle. The moderator band may be seen in parasternal, apical and subcostal views.

The thebesian valve is the rudimentary valve that guards the opening of the coronary sinus.

Question 27

The moderator band is always located in the:

A. Right atrium
B. Left atrium
C. Right ventricle
D. Left ventricle

Answer 27

C. The moderator band stretches from the right ventricular free wall to the interventricular septum. It carries the conduction system’s right bundle branch and also anchors the anterior papillary muscle.

Question 28

All of the following are true statements concerning the right ventricle EXCEPT:

A. Heavily trabeculated
B. Normal wall thickness is 0.3 to 0.5 cm
C. Normally forms the cardiac apex
D. Most anterior positioned cardiac chamber

Answer 28

C. The left ventricle normally forms the cardiac apex. Disease processes which result in right ventricular dilatation may result in the right ventricle forming the apex. The right ventricle contains the following structures: conus arteriosus, tricuspid valve, chordae tendineae, trabeculae carneae, crista supraventricularis, septal band, parietal band, moderator band and pulmonary valve orifice.

In the apical and subcostal four-chamber views, the right ventricular normally appears triangular in shape. In the parasternal short-axis views, the right ventricle normally appears oval in shape.

Question 29

All of the following are true statements concerning the left ventricle EXCEPT:

A. Bullet shaped (truncated ellipsoid)
B. Heavily trabeculated
C. Top normal thickness is approximately 1.0 cm
D. Contains two papillary muscle groups

Answer 29

B. The left ventricle’s trabeculae carneae are similar to the right ventricle’s but are not as numerous.

The normal left ventricular wall thickness range for males is 0.6 to 1.0 cm; for women the range is 0.6 to 0.9 cm.

The left ventricle is conical in shape externally, circular in shape in cross-section, contains the mitral valve, orifice of the aortic valve, trabeculae carneae, chordae tendineae and interventricular septum (membranous and muscular).

Question 30

The names of the two left ventricular papillary muscle groups are:

A. Anterior; posterior
B. Anterolateral; posteromedial
C. Medial; lateral
D. Superior; inferior

Answer 30

B. The anterolateral and posteromedial papillary muscles are best seen in the parasternal short-axis of the left ventricle.

Papillary muscle dysfunction is a generic term used to describe papillary muscle disease. Papillary muscle ischemia, infarction, rupture, fibrosis/calcification, infiltration, congenital malposition, absence of one (e.g., parachute mitral valve) and left ventricular dilatation may result in mitral regurgitation.

The posteromedial papillary muscle becomes ischemic and infarcted more frequently than does the anterolateral papillary muscle due to the fact that the posteromedial papillary muscle is supplied only by the posterior descending branch of the right coronary artery. The anterolateral papillary muscle is supplied by the left anterior descending and circumflex coronary arteries.

Question 31

When should the left atrium be measured?

A. Early diastole
B. Diastasis
C. Late diastole
D. End systole

Answer 31

D. The left atrial size is measured at ventricular end-systole when the left atrial chamber is at its greatest dimension.

Left atrial volume is preferred. The normal left atrial volume for men and women adjusted for body surface area is 22 ÷ 6 ml/m^2. The apical four-chamber view and apical two-chamber view at end-systole may be used to determine left atrial volume.

It has been proposed that measuring the left atrial volume at ventricular end-diastole may be a better way to determine increased left ventricular end-diastolic pressure (LVEDP) in patients with suspected significant diastolic dysfunction.

The left atrial ejection fraction can be determined when the left atrial end-systolic and end-diastolic volumes are determined.

Question 32

Which two-dimensional view is recommended when measuring the right atrium?

A. Parasternal right ventricular inflow tract
B. Parasternal short-axis of the aortic valve
C. Apical four-chamber
D. Subcostal four-chamber

Answer 32

C. The recommendation for a linear measurement of the right atrium is the apical four-chamber view at ventricular end-systole using the minor axis. The normal value for men and women is 2.9 to 4.5 cm.

For right atrial volume, the apical four-chamber view at ventricular end-systole should be used. The normal right atrial volume for men and women is 21 ml/m^2.

Question 33

The normal volume of clear serous fluid in the pericardial sac is:

A. 10 to 50 mL
B. 20 to 50 L
C. 200 to 500 mL
D. 200 to 500 L

Answer 33

A. The pericardium is a double-layered membrane consisting of the visceral pericardium (epicardium) and the parietal (fibrous) pericardium.

The inner layer of the heart is the endocardium. The middle (muscular) layer of the heart is the myocardium. The outer layer of the heart is the epicardium (visceral pericardium).

A clear space may be seen on an echocardiogram during ventricular systole because of the 20 to 50 mL normally present in the pericardial sac. A clear space seen throughout the cardiac cycle suggests a pericardial effusion.

Question 34

The potential space behind the left atrium where pericardial effusion could accumulate is the:

A. Sinus of Valsalva
B. Pleural potential space
C. Oblique sinus
D. Transverse sinus

Answer 34

C. In the presence of moderate or large pericardial effusions, fluid may be seen posterior to the atrium in a potential space called the oblique sinus.

Another potential space lies between the posterior aortic root and the anterior wall of the left atrium. This is called the transverse sinus.