Echo

Question 1

1. A 32 year old female presents with atypical pain. Her blood pressure is 112/50, height is 6’ and weight is 115lbs. An echocardiogram is performed which shows mitral valve prolapse. What is the most likely diagnosis for this patient?
2. Which additional structures should be evaluated?

Answer 1

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

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

Question 2

1. A 39 year old male with no cardiac history enters the doctors office complaining of flu like 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 the echo findings?
2. What additional tests will be helpful in making the diagnosis of this patient?

Answer 2

1. With a new murmur and the echo finding of mitral valve thickening in a young person, the most likely diagnosis is mitral valve endocarditis
2. Blood cultures will be helpful in identifying the organism and a TEE will further assess the extent of mitral leaflet thickening

Question 3

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 3

The patient may well have constrictive pericarditis. The dyspnea, ascites and jugular venous distention could all result from a restriction to diastolic filling.

A pericardial knock ( loud3rd heart sound) is a classic physical finding associated with constriction

Question 4

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 4

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

Question 5

1. A 22 year old male complains of chest pain following exercise. An echocardiogram displays concentric left ventricular hypertrophy (2.5cm) and 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?
2. What additional noninvasive tests may help in diagnosing this patient?

Answer 5

1 the findings of concentric left hypertrophy and a small LV cavity size is diagnostic of hypertrophic cardiomyopathy

2. In order to identify the presence of an obstructive component, an amyl nitrite or valsalva challengeshould be performed while the left ventricular outflow tract is interrogated by CW Doppler

Question 6

A 38 year old male is sent to the echo 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 seperation (EPSS), B-notch on the mitral valve and overall hypocontractile left ventricular wall motion. What type of cardiac abnormality do these findings suggest?

Answer 6

M-mode findings of a dilated left ventricle, increased Epoint to septal seperation (EPSS), B- notch on the mitral valve and overall hypocontractile left ventricular wall motion identify a pay with dilated cardiomyopathy

Question 7

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

Answer 7

Left ventricular hypertrophy (with an bright myocardium), left atrial enlargement and a small pericardial effusion are echo findings most consistent with a diagnosis of infiltration (restrictive) cardiomyopathy

Question 8

A 56 year old female visits her doctor with the complaintof shortness of breath. Upon physical examination, a low frequency diastolic (rumbling) murmur is detected. The patient denies any history of rheumatic fever. What three cardiac abnormalities might be present in this patient?

Answer 8

1. Mitral stenosis (or tricuspid stenosis). Even with no known history she may have had rheumatic fever asa child and now has rheumatic heart disease
2. Left atrial myxomS mimic mitral stenosis with regard to both physical findings and symptoms
3. 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 the typical “ blowing” AR diastolic murmur, will be heard

Question 9

1. A 31 year old male with a history of uncontrolled systemic hypertension enters the emergency room with severe chest pain that he describes as “ripping” what is a likely cardiac diagnosis for this patient?
2. Which noninvasive examination would be useful to confirm the diagnosis?

Answer 9

1. Although this patient may be experiencing a myocardial infarction, the history of age, hypertension and “ripping” chest pain indicate the possibility of and aortic dissection
2. TEE would be the preferred noninvasive test as it is the fastest to perform and most sensitive method in diagnosing aortic dissections. Chest CT is also good while TTE is not sensitive or specific

Question 10

1. 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 appears abnormally displaced towards the apex. What is the patient’s most probable cardiac abnormality?
2. what additional tests should be performed in the echo lab?

Answer 10

1. This patient probably has ebstein’s anomaly. Often patients with Ebtstein’s anomaly are asymptomatic and this finding is a surprise when an echocardiogram is performed for something like evaluating a murmur
2. A microcavitation ( saline bubble or contrast) study should be performed to identify the presence or absence of an associated atrial septal defect.

Question 11

1. In the parasternal short axis view, at the level of the mitral valve and papillary muscle, how many segments is the left ventricle divided into?
2. Name the ventricular segments seen in the parasternal short axis view.

Answer 11

1. In the parasternal short axis view at the level of the mitral valve (basal) and papillary muscle (mid- cavity). The left ventricle is divided into six segments (based on the ASE 17 segment model)
2. The ventricular segments are the
   (1) inferolateral
   (2) anterolateral
   (3) anterior
   (4) anteriorseptal
   (5) inferiorseptal
   (6) inferior

Question 12

1. In the apical four chamber view, which two walls of the left ventricle are seen?
2. In the apical two chamber view, which two walls of the left ventricle are seen?

Answer 12

1. In the apical four chamber view, the inferoseptal and anterolateral walls of the left ventricle Are seen
2. In the apical two chamber view, the anterior and inferior walls of the left ventricle are seen

Question 13

1. Which walls of the left ventricle are seen in the parasternal and apical long axis view?
2. Which two aortic leaflets are seen in these views?

Answer 13

1. The anteroseptal and inferolateral walls of the left ventricle are seen in the parasternal and apical long axis views
2. The right and noncoronary leaflets are seen in these views. The right leaflet is on the top (superior) and the noncoronary is on the bottom (inferior)

Question 14

1. Where is the coronary sinus located in the parasternal long axis view?
2. Where is the coronary sinus located in relation to the descending aorta?
3. How would you angle to view the coronary sinus in the apical four chamber view?

Answer 14

1. The coronary sinus lies in the posterior atrioventricular groove (AV) groove. This groove is located between the left atrial and 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
2. The coronary sinus is located anterior to the descending aorta. If the coronary sinus is dilated, it may be mistaken for the descending aorta
3. From the apical four chamber view you would angle posterior in order to visualize the coronary sinus which is located posterior the the mitral annulus.

Question 15

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

2, what would cause the coronary sinus to become dilated?

Answer 15

1. 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. Pleural effusions lie posterior to the descending aorta
2. The coronary sinus dilates due to increased pressure in the right atrium ( as in severe tricuspid regurgitation) or increased flow into the coronary sinus as in some congenital malformations (as is Persistent Left Superior VenaCava) (PLSVC)

Question 16

1. Name the three major coronary arteries?

2. Where are the coronary arteries located on the surface of the heart?

Answer 16

1. The three major coronary arteries are the right, left anterior descending (LAD), and circumflex arteries. The latter two arteries branch from the left main coronary artery, [which is not considered a major artery because it is very short]
2. The coronary arteries are located on the outer, epicardial surface of the heart as follows:
   The right coronary artery (RCA) arises from the right aortic-root sinus, follows the right atrioventricular junction, and descends along the posterior interventricular groove.
   The left anterior descending coronary artery (LAD) follows the anterior interventricular groove.
   The circumflex coronary artery (Circ) courses along the left atrioventricular junction

Question 17

Name the cardiac walls supplied by each of the coronary arteries

Answer 17

Based on the ASE 17 segment model

Right coronary artery

a) inferior wall
b) inferoseptal
c) right ventricular apex
d) right ventricular free wall

Left anterior descending artery

a) anterior wall
b) anteroseptal
c) left ventricular apex

Circumflex artery

a) anterolateral wall
b) inferolateral wall

Question 18

1. While scanning a 43 year old male with a history of an old myocardial infarction, you notice that the anterior wall is a kinetic. Which coronary artery is most likely to have been involved in the infarction?
2. In the apical four chamber view of another patient, the distal ventricular septum and left ventricular apex are hypocontractile. Which coronary artery is most likely to be diseased?

Answer 18

1. The left anterior descending (LAD) coronary artery, 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
2. Again, the left anterior descending (LAD) coronary artery is the most likely choice. In some patients with distal septal hypocontractility, the proximal portion of the septum moves normally because it is supplyby the right coronary artery.

Question 19

1. What are the normal systolic and diastolic pressures in the four cardiac chambers and the great vessels
2. When is the pressure in the left ventricle at its lowest?

Answer 19

1. Normal pressures
   Right atrial(mean) 6mmHg
   Right ventricular 25/5mmHg
   Pulmonary artery 25/10mmHg
   Left atrial (mean) 10mmHg
   Left ventricular. 120/7mmHg
   Aortic. 120/80mmHg
2. The left ventricle pressure is lowest in early diastole just after the mitral valve opens. After that the left ventricular pressure rises as the chamber fills in diastole.

Question 20

1. What is the normal mean pulmonary artery wedge pressure?

2. How is the pulmonary artery wedge pressure determined?

Answer 20

1. The normal mean pulmonary artery wedge pressure is 10mmHg, which equals the left atrial pressure. The PA wedge pressure is not the same as the PA pressure
2. A Swan-Ganz catheter is positioned in the pulmonary artery, and a small ballon is inflated at the catheter’s tip. The ballon is then floated and wedged into a smaller pulmonary artery. A pressure reading is obtained distal to the ballon. The inflated balloon prevents the tip of the catheter from sensing the pulmonary pressure, and the left atrial pressure is recorded as it is reflected across the pulmonary bed.

Question 21

1. to visualize the anterior wall of the left ventricle, which two dimensional view would you use?

@. to visualize the anterolateral wall of the left ventricle which two dimensional view would you use?

Answer 21

1. the anterior and inferior wall of the left ventricle are best visualized in the apical two chamber view
2. the anterolateral 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 view is best

Question 22

!. on the EKG, at what point does the mitral valve normally close
2. on the EKG , at what pint does the aortic valve normally open?

Answer 22

1. the mitral valve normally closes approximately 60 milliseconds after the onset of the QRS complex or about halfway through the QRS complex
2. the aortic valve normally opens at the end of the QRS complex. this answer takes into account the delay between electrical and mechanical systole, as well as the isovolumic contraction time (between mitral closure and aortic opening)

Question 23

1. what is the relationship between electrical and mechanical systole?
2. what is diastasis?

Answer 23

1. mechanical systole follows electrical systole by approximately 12 milliseconds. This 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 M mode studies that examine the relationship between the eletrocardiographic pattern and valvular motion.
2. Diastasis denoted the middle portion of diastole, whcich 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 patients with bradycardia and quite short in those with tachycardia.

Question 24

1. How much of ventricular filling occurs during the passive phase of diastole?
2. Name the four phases of diastole

Answer 24

1. at normal pressures, approximately 70% of ventricular filling occurs during the passive phase of diastole: atrial contraction accounts for the remaining 30% of ventricular filling. Ofcourse, these percentages will change in patients with valvular abnormalities such as mitral stenosis or ventricular compliance problems such as hypertrophic cardiomyopathy
2. the four phases of Diastole are:
   Isovolumic relaxation time (closure of AV to opening of MV)
   Early filling (passive)
   Diastasis
   Atrial contraction (active)

Question 25

1. What causes side lobe artifact?

2. What is the best way to minimize side lobe artifact?

Answer 25

1. Side lobe artifacts are caused by strong reflectors outside the main ultrasound beam. These off axis targets create reflections from weaker extra ultrasound beams alongside the main beam.
2. The best way to minimize side lobe artifacts is to decrease the overall gain, increase the reject level, of decrease the TGC in the area of strong reflectors (such as the pericardium)

Question 26

1. What cardiac lesion is detected by injecting agitated saline contrast material into the right side of the heart?
2. Why does saline Contrast material rarely appear on the left side of the heart?

Answer 26

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

2. after being injected into a peripheral vein, saline contrast material advances into the right atrium. Alternatively, the contrast material may be injected directly into the right atrium through a Swan-Ganz catheter, The mixed bubbles are too large to pass through the pulmonary bed. If bubbles are seen in the left atrium and the left ventricle within three to five heartbeats after injection, an atrial level communication should be suspected.

Question 27

1. how is the Valsalva maneuver performed?

How does the Valsalva maneuver affect the heart?

Answer 27

1. The Valsalva maneuver is performed in two phases
   (strain and release)
   Inhaling halfway
   Closing the mouth and nostrils
   exhaling forcefully, straining against the closed mouth for about 5-10 sec
   opening the mouth and exhaling
2. During straining phase, the venous return decreases, so that the cardiac output diminishes and a reflex 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.