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ASE Questions Flashcards

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USMLE® Step 1 flashcards
1
Q

Describe rhumatic mitral valve changes?

A

Preferential thickening and calcification of the subvalvular region and leaflet tips

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2
Q

21 year old female underwent sugical palliation of cyanotic heart disease in early childhood.

What is the flow disturbance demonstrated by color Doppler in this case?

A

Fontan Fenestration

  • patient has a lateral tunnel Fontan baffle in the atrium with a fenestration
  • Flow disturbance is a right-to-left shunt into the functional LA
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3
Q

Describe the pathoanatomy of the mitral valve?

A

Prolapse of the middle scallop (P2) of the posterior leaflet

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4
Q

Patient with history of bicuspida aortic valve and posterior leaflet MVP, presents with SOB. Systolic murmur heard over anterior chest wall.

How would transmitral flow be identified?

A
  • peak diastolic velocities reflect the pressure difference (in early diastole) between the aorta and the LV –> typically higher than the transmitral diastolic velocities (which represent the difference between the LV and LA in diastole)
    • Transmitral flow pattern
      • Diastolic flow signal with peak velocities of < 1.5 m/s
    • Aortic regurgitation flow pattern
      • highly unlikely that a peak AR velocity would be < 1.5m/s
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5
Q

What can commonly be mistaken for transaortic flow utilizing the right parasternal non-imaging Doppler flow profile?

A

Eccentric, anterior MR jet

  • that hugs the wall of the LA just behind the ascending aorta
  • may be mistake for AS by color profile and auscultation
  • Posterior leaflet prolapse (with anteriorly directed jet) is a common cause of this jet
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6
Q

Differentiate MR from AS on spectral profile

A
  • MR
    • begins before aortic valve opening (holosystolic)
    • longer duration
    • represents gradient between LA and LV –> MR jet velocity should be higher than the transaortic velocity
  • AS
    • represents gradient between LV and Aorta –> AS jet velocity should lower than transmitral velocity
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7
Q

What are changes that occur with chamber filling and velocity as a result of a PVC?

A
  • Following PVC –> long diastolic filling period typically results in an increase in transaortic flow
  • However, LA also fills during diastole
    • LV-to-LA pressure difference may not change for this reason
    • therefore MR jet velocity may not always increase
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8
Q

What are major echocardiographic findings for HOCM?

A
  • Severe SAM
  • Absolute septal wall thickness > 15 mm
  • LV septal-to-posterior wall thickness ratio ≥ 1.3
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9
Q

What are primary structural abnormalities of the mitral valve in HCM patients?

A
  • Hypertrophy of the papillary muscles
    • resutling in anterior displacement of the papillary muscles
  • Intrinsic increase in mitral leaflet
    • area
    • elongation
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10
Q

What is the sensitivity and specificity for TEE in diagnosing SBE?

TTE?

A

TEE has sensitivity (96%) and specificity (92%) for vegetations

  • TTE has sensitivity 62%
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11
Q

What is recommended as the first line diagnostic study to diagnose prosthetic valve endocarditis and assess for complications?

A

TEE

  • In most cases, TEE is not indicated as the initial examination in the diagnosis of native valve endocarditis
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12
Q

Does a negative TEE exclude the diagnosis of SBE?

A

No

  • negative TEE does not have enough diagnostic accuracy to rule out vegetative SBE
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13
Q

What are potential sources of false-negative TEE findings in the assessment for SBE?

A
  • Vegetations that are smaller than the limits of resolution
  • Previous embolization of vegetation
  • Inadequate views to detect small abscesses

****Particularly important in setting of prosthesis as this can create blind spots –> if clinical suspicion is high (and TEE results are negative) –> repeat study in 7-10 days

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14
Q

In the post pump assessment after mitral valve repair for MR, What finding is most likely to be associated with an increased incidence of failure of the mitral valve repair from late regurgitation?

A

Coaptation zone height, less than 10mm

  • > 10 mm has been associated with the lowest risk of return of MR of more than 2+ in long term follow up studies
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15
Q

What is an appropriate afterload state finding to assess the degree of MR post-repair?

A

SBP > 100 mmHg

  • most appropriate time to image after repair is when:
    • patient is off CPB
    • Intravascular volume is replete
    • loading conditions are similar to those in the ambulatory state
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16
Q

This TV finding in patients undergoing surgery for MR has been associated with late progressive TR and worse outcomes?

A

Tricuspid annular enlargement

  • usually measured at > 4 cm in 4-chamber TEE view
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17
Q

Patient presenting with dyspnea has chronic A-fib, and had prior radiation therapy for Hodgkin’s disease.

Describe the findings and diagnosis

A

Fibroelastoma

  • typically round, symmetrical, mobile massess adherent to valvular structures that have a homogenous appearance and density typical of non-calcified tissue
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18
Q

What adverse events are associated with Fibroelasoma’s?

A
  • Embolic events
    • act as a nidus for platlet-fibrin aggregates
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19
Q

Describe dystrophic calcification

A
  • appears as an echo density usually involving the cardiac skeleton (annulus of the cardiac valves), valve leaflets, or ventricular myocardium
  • Identifiable causes:
    • prior radiation
    • chronic renal failure
    • localized myocardial injury (prior MI)
  • Lesions are usually sessile
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20
Q

Describe Lambl’s excrescence

A
  • Incidentally discovered mobile, usually fialmentous, small masses commonly seen on the edges of valve leaflets
  • Usually less than 2-3mm in length and 1 mm in diameter
  • Not known to be associated wtih embolic events
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21
Q

What are absolute contraindications to TEE?

A
  • Active/Recent esophageal bleeding
  • Recent esophageal trauma/surgery
  • Esophageal
    • perforation or laceration
    • tumor or abscess
    • stricture (symptomatic)
    • diverticulum
      • thin walled structures may be perforated by the probe
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22
Q

In the presence of an aortic prosthesis, what are limitations of TTE and TEE?

A
  • Acoustic shadowing or “blind spots” created by prosthesis
    • TTE –> posterior aortic root blind spot
    • TEE –> anterior aortic root blind spot
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23
Q

What is an appropriate indication for TEE in the setting of mechanical mitral valve prosthesis?

A

Evaluation of the etiology of hemolysis

  • Evaluation for paravalvular defect
  • Occluder of a mechanical MVR can be assessed for abnormal motion
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24
Q

What is a potential limitation to Echo in the diagnosis of ascending aortic dissection?

A

“blind spot” in the distal ascending aorta

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25
Q

What is the gold standard in diagnosis of ascending aortic dissection/

A

retrograde aortogram

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26
Q

Define propagation speed

A
  • speed at which a wave moves through a medium
  • determined by the medium that the sound wave is traveling through
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27
Q

What is one acoustic variable that is not determined by sound source?

A

propagation speed

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28
Q

Name acoustic variables are determined by the sound source

A
  • Frequency
  • Period
  • Amplitude
  • Intensity
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29
Q

Define frequency

A

number of cycles per unit time

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30
Q

Define period

A

time per cycle

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31
Q

Define amplitude

A

maximum variation of an acoustic variable or voltage

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32
Q

Define intensity

A

power divided by area

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33
Q

What device transforms electrical energy into mechanical or acoustic energy?

A

Transducer

  • Piezoelectric crystals convert electrical current into vibrations (sound) and also on the receive side convert vibrations (sound) back to electrical signals
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34
Q

What is the length of the near field from the transducer called?

What factors influence this?

A
  • Near zone length
  • Dependent upon the diameter of the transducer and the propagation wavelength
    • NZL = d2/4λ
      • λ = wavelength
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35
Q

Calculate the near zone length (NZL):

  • transducer with diameter of 7 mm
  • operating frequency 3 MHz
A
  • NZL = d2/4λ
    • λ = wavelength = c/f
      • c = velocity of US in soft tissue = 1.54 mm/usec
  • NZL = d2 f / 4c
  • NSL = (7)2 x 3 / 4 (1.54)
  • NSL = 147 / 6
  • NSL = 24 mm

f = frequency

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36
Q

Describe the artifact

A

Grating lobes artifact

  • mimics a clot in the left atrium
  • create ghost images of high contrast structures off axis to the sound beam
  • created due to the division of a small transducer face into a large number of small elements
  • these small elements produce US energy at high angles compared to the main beam
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37
Q

Define refraction

A
  • change of US direction on passing form one medium to another
  • results in an artifactual image being placed adjacent to the real structure
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38
Q

Define enhancement artifact

A

occurs behind low attenuating structures (fluid filled structures) and results in a hyperintense signal

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39
Q

Define reverberation

A
  • results from mulitple echos created beween two structures in close proximity to each other
  • appears as echogenic lines equally spaced apart from each other
  • the result of reflection of US energy between the structures before the next pulse is generated
  • Often seen in fluid filled structures
40
Q

Describe the type of artifact created by these tranducers:

  • Phased array
  • Mechanical
A
  • Phased array –> grating lobes artifact
  • Mechanical –> side lobe artifact
41
Q

Describe the findings and relation to the pulmonary venous flow pattern

A
  • E and A fusion
    • can be seen in rapid heart rates when diastolic filling time is lost
    • sufficient PR prolongation (A wave starts before the E wave finishes)
  • PVD
    • ​since S1 is a manifestation of atrial relaxation, prolonged AV conduction –> S1 and S2 components more distinct, as S1 tends to come earlier
42
Q

Describe the findings and common association

A
  • Sinus venosus ASD
  • Partial anomalous pulmonary venous return
43
Q

What is a common association with sinus venosus ASD?

Why?

A
  • Partial anomalous pulmonary venous return
  • typical location of a sinus venosus ASD is the superior, posterior portion of the atrial septum, near the entrance of the right-sided pulmonary veins
    • anomalous pulmonary venous drainage of the RUPV –> RA is frequently seen
44
Q

What is a common associated finding with primum ASD?

A

Cleft mitral valve

45
Q

What is the Sphericity Index of the LV?

A
  • calculated from A4C view as the ratio between long axis length to short axis diameter
  • carries significant prognostic importance in cardiomyopathy
46
Q

What is the Sphericity index in a normal ventricle?

A

Sphericity Index ≥ 1.5

47
Q

Describe the diagnosis

A

False Tendon of the LV

48
Q

Name the parameter of systolic function that is least dependent on preload?

A

End systolic volume

  • preload is the force that acts to stretch the myocardial fibers at end diastole and is related to end diastolic volume and end diastolic pressure
  • If EDV is progressively increased but the contractile state is unchanged, the LV will contract to the same ESV
49
Q

What are the recommended views for measurement of LV diameters by TEE?

A

ME 2-chamber and TG 2-chamber views

50
Q

Describe the view

What leaflets of the tricuspid valve are identified by the large and small arrows?

A
  • RV-inflow view
    • properly oriented as no LV cavity is seen
  • Anterior (large arrow) and Posterior (small arrow) leaflets
    • RA seen below with ostium of coronary sinus and Eustachian valve seen - these structures are located posteriorly
51
Q

Describe the findings and diagnosis

A

Congenitally corrected transposition (L-transposition)

  • AV valve leading to the ventricle on the left side of this A4C view (morphological RV) is displaced apically
  • Significant trabeculation is noted in this chamber - also consistent with an antomical RV
  • EKG
    • absence of septal Q waves and the presence of Q waves in the inferior leads because septal activation is abnormal in this condition
52
Q

Describe the relation of the aorta and pulmonary artery in congenitally corrected transposition of the great vessels (L-transposition)

A

Aorta is situated anterior and leftward of the pulmonary artery

  • Can be visualized from High PSAX view
53
Q

What are common associated abnormalities with congenitally corrected transposition of the great vessels (L-transposition)?

A
  • AV conduction defects
    • Incidence of AV block with this lesion is 1-2% per year
  • TR
  • PS
    • valvar or suvalvular
54
Q

What is the size of the smallest left-sided vegetation that can be detected by two-dimensional TTE?

A

5mm (0 -25% sensitivity)

> 10 mm (84-100% sensitivity)

55
Q

What is the size of the smallest left-sided vegetation that can be detected by two-dimensional TEE?

A

1 mm

56
Q

A typical vegetation during the acute phase of endoarditis is defined as?

A
  • discrete echolucent mass
  • adherent to native valves or intracardiac prosthetic devices
  • high-frequency motion independent of the underyling structure
  • mass can be imaged in multiple views
57
Q

What is the most likely location of IE in a patient with a membranous VSD?

A

septal leaflet of the TV

58
Q

What view is best utilized to visualize the posterior leaflet of the TV when right-sided endocarditis is suspected?

A

subcostal SAX view of the TV

59
Q

A patient has S. aureus bacteremia but negative TTE and no clinical signs of IE according to the modified Duke criteria. What is the likelihood that the diagnosis of IE would be missed if TEE is not performed?

A

15%

60
Q

What is the most frequent location of an abscess in patients presenting with IE?

A

Aortic root

61
Q

What is most likely to be confused with a mitral annular abscess on TTE?

A

Caseous calcification of the mitral annulus

62
Q

By TEE, what is the best view to determine the location and extent of an aortic root abscess?

A

ME SAX view at 45-60 degrees

63
Q

What is an early sign of an aortic root abscess in the setting of native aortic valve IE?

A

abnormal thickness of the aortic root ( > 10 mm)

64
Q

After complete resolution of a vegetation, what proportion of affected valves retain normal structure and function?

A

10%

  • majority of valves show nodular changes, thickening, or disruption of the leaflets after healing
65
Q

What are two features that distinguish a vegetation on the eustachian valve from the normal eustachian valve?

A
  • Abnormal thickness of > 5 mm
  • High-frequency motion independent of the underlying structure
66
Q

What is the negative predictive value of multiplane TEE for ruling out IE?

A

> 85% (87%-98%)

67
Q

Describe features of a mitral valve aneurysm?

A
  • localized bulging of the mitral leaflet toward the LA with:
    • systolic expansion and
    • diastolic collapse
68
Q

What is one feature that can help differentiate between IE and APLA syndrome vegetations?

A

presence of valvular tissue destruction

69
Q

Describe the findings and diagnosis

A

persistent left SVC

  • vegetation at the orifice of the coronary sinus
70
Q

5 different patients with MR jet (panel 5 is TEE image).

What panel is most likely to be found in a patient with MR, PR interval on EKG 175ms, SBP 100 mmHg, normal LV systolic funciton (LVEF 65%). No LVOTO, AS or MVP?

A

#4

  • Chronic MR
    • absence of LV systolic dysfunction, LVOTO, MVP and AV block
    • PV of MR jet is consistent with SBP 100 mmHg
71
Q

Describe the findings and diagnosis

A

Chronic MR

  • No MVP, LVOTO, AS, LV systolic dysfunciton or AV block
72
Q

5 different patients with MR jet (panel 5 is TEE image). What jet is most likely:

  • diminished LV systolic function
  • pronounced 1st degree AV block
A

#2

  • 1st degree AV block and/or LV systolic dysfunction –> diastolic MR (may occur as well)
  • Diastolic MR occurs before onset of QRS
73
Q

Describe the findings and diagnosis

A

Chronic MR with diastolic MR in setting of:

  • 1st degree AV block and
  • LV systolic dysfunction
74
Q

5 different patients with MR jet (panel 5 is TEE image). What jet is most likely:

  • Severe AS (PG 90 mmHg)
  • SBP 120 mmHg
  • LVEF 70%
  • LAP = 10 mmHg
A

#5

  • Severe AS and preserved LV systolic function –> MR jets with very high velocity
    • LVSP = SBP + P2P cath gradient (or mean gradient on Echo)
    • LVSP = SBP + (0.67 x PG)
    • LVSP = 180 mmHg
    • Peak LA-to-LV gradient = 180 - 10 = 170 mmHg
    • MRpeak jet velocity corresponds to 170 mmHg = 4 (6.5)2
75
Q

Describe the findings and diagnosis

A

Severe MR in the setting of:

  • Severe AS
  • Preserved LV systolic function (LVEF 70%)
76
Q

Describe the findings and diagnosis

A

MR

  • occurs only in late systole
  • may occur in:
    • MVP
    • SAM / LVOTO
77
Q

Describe the findings and diagnosis

A
78
Q

Sound waves are mechanical vibrations that produce:

A

rarefactions and compressions

79
Q

What are ways to improve aliasing?

A
  • CW transducer
  • Increase PRF (scale) to the maximum setting for the depth you are imaging at
  • Switch to a high PRF
  • Utilize a lower frequency transducer
  • Adjust the baseline to allow for imaging the maximum velocity
80
Q

Define period

A

time to complete one cyclce

81
Q

Describe the Doppler color flow map seen with “aliasing” and “flow direction shift”?

A

light red to light blue –> aliasing

dark red to dark blue –> flow direction shift

82
Q

What is the effect of the diameter of ultrasound crystals in regards to far-field divergence ?

A
  • Inversely related
    • larger –> diverge less in the far field
    • smaller –> diverge more in the far field
83
Q

What is the effect of the frequency in regards to far-field divergence ?

A
  • Inversely related
    • higher –> diverge less in the far field
    • lower –> diverge more in the far field
84
Q

In color flow Doppler, how is a variance map different from a velocity map?

A

Green is added when turbulent flow is encountered

85
Q

When encountering a possible ultrasound artifact by imaging, what would be the first step to prove or disporve that it is real or an artifact?

A

Change the depth setting

  • common artifact is caused by range ambiguity artifact –> quick check is to hold the transducer still and change the depth setting
86
Q

What artifact results in ghost images of high contrast structures, off axis to the sound beam?

A

Grating lobes​

87
Q

Which letter demonstrates the best lateral resolution in the image above from an ultrasound phantom?

A

A

  • lateral resolution is best where the beam is the narrowest
88
Q

What is the wavelength of sound in soft tissue from a 3 MHz transducer?

A

λ = wavelength = c/f

  • c = 1540 m/s –> 1.54 mm/s
  • f = 3 MHz
  • λ = 1.54 / 3 = 0.51 mm
89
Q

In an echo machine what is the maximum value that the duty factor can achieve?

A

100%

90
Q

The magnitued of the first component of the pulmonary vein systolic velocity (S1) is most closely related to:

A

LA relaxation

  • absent in patients with A-fib
91
Q

As LV chamber stiffness increases, what happens to mitral inflow velocity?

A

Decelertation time becomes shorter​

  • one of the principal measures of diastolic function
  • parameter is dependent on the rate at which pressure equilibration between the LA and LV takes place
92
Q

What is the most likely post-operative problem that would produce a murmur post-AVSD (AV canal) repair?

A

Mitral regurgitation

93
Q

This lesion is commonly associated with congenitally corrected transposition of the great arteries?

A

VSD

94
Q

What lesion by fetal echocardiogram is least likely to be diagnosed prenatally?

A

Secundum ASD

  • these lesions cannot be detected due to the presence of the patent foramen ovale and the significant amount of blood flow that typically crosses the patent foramen ovale in fetal circulation
  • making it difficult to assess for a secundum ASD
95
Q

Describe the findings and diagnosis

  • 13 year old girl with decreased exercise tolerance
A

Fibroma

  • median age of presentation ~ 13 years
  • singular, large, well-circumscribed, hyperechoic lesions associated with the ventricular free wall or septum
  • Calcification can be seen –> important diagnostic clue
    • focal necrosis or cystic degeneration can also be present
  • distor the ventricular myocardium and cause outflow obstruction

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