PTE Masters Practice Question Material Flashcards
Most common pathologic finding in patients with MVR 2/2 degenerative MV disease?
posterior leaflet prolapse
What are the three leaflets of the tricuspid valve?
What is above the junction of septal and posterior leaflets?
What is labeled as 1-4?
Anterior, Posterior, Septal Leaflets
Coronary sinus and then IVC
what is the formula for axial resolution?
1/2 spatial pulse length
Another word for Azimuthal resolution?
Lateral resolution
What is duty factor?
a unitless number which describes the amount of time that the ultrasound machine is producing sound. The percent of “On” time
What are structures 1-5?
What structure runs under the left atrial appendage?
1 - Inferior Wall
2 - Anterior Wall
3 - Circumflex Coronary Artery
4 - Left Atrial Appendage
5 - Left Atrium
What does a low pass filter do?
When is it used?
Filters out high velocities.
Used in tissue doppler
What is the grading system for hypokinesis/akinesis/dyskinesis?
Grade 1 - Normal with endocardial thickening > 30 %
Grade 2 - Slightly decreased with endocardial thickening 10-30%
Grade 3 - Severe hypokinesis with endocaradial thickening < 10%
Grade 4 - Akinesis with absolutely no endocardial thickening
Grade 5 - Dyskinesis (outward endocardial movement during systole with thinning of the wall during systole.
Why does TEE underestimate 3D volumes compared to cardiac MRI?
TEE does not visualize the apex well
How to tell a pseudoaneurysm vs a true aneurysm?
Pseudoaneurysm: Abrupt transition, acute angle, narrow neck, ratio of neck diameter to aneurysm diameter < 0.5
Aneurysm: Gradual tapered transition, wide angle, wide neck, Ratio of neck diameter to aneursym diameter > 0.5
What two arteries might supply the inferiolateral wall?
RCA or Cx
Cuttoffs for degree of Left Ventricular Hypertrophy in men and women?
See Attached Image
What is an enhancement artifact?
Occurs when ultrasound travel through a medium with a lower rate of attenuation than the surrounding soft tissue.
Happens in LV because blood in Left ventricle has lower acoustic impedance than surrounding soft tissue.
Other name for comet tail artifact?
Ring Down artifact, Reverberation artifact.
What view allows visualization of cross sectional view of the superior vena cava?
Midesophageal Ascending aortic short axis view.
What view can the pulmonary artery bifurcation be seen in?
Midesophageal Ascending Aortic Short Axis View
Over what velocities in the Left Atrial Appendage is a thrombus unlikely?
Above 40-45 cm/sec
NPV of 100% if velocity > 55 cm/sec
What are the cutoffs for pericardial effusion sizes for mild moderate severe?
Which ASD is associated with mitral valve prolapse?
Ostium Secundum
Which ASD is associated with trisomy 21?
Ostium Primum
Which ASD is associated with anomalous pulmonary venous return?
Sinus Venosus
Which ASD is associated with a persistent left superior vena cava?
Coronary Sinus
What is Annulus Reversus?
What does it occur in?
Septal e’ > lateral e’
Happens in constrictive pericarditis because the lateral mitral annulus has been “tethered” by the constricting pericardium
What pressure does mitral peak A wave velocity correlate with?
LVEDP
What LA max volume index supports the diagnosis of elevated left atrial pressure?
> 34 ml/m2
Does percutaneous coronary revascularization increase risk of post infarct VSD?
No. It has been shown to decrease risk of rupture.
Risk factors for increase risk of mechanical complications (Rupture of free wall, septum, or papillary muscle rupture) following MI?
Absence of collateral flow
Large infarct size
No prior angina or MI
ST segment elevation of Q wave development on initial EKG
Peak CK MB > 150 international units/L
Age > 70
Female gender
Anterior location of infarction
Abscense of beta blockers
In a ME 4 chamber name the leaflets of the tricuspid valve.
Septal leaflet next to septum
Anterior or posterior leaflet next to free wall depending on where it is being sliced through
Another name for damping material?
Backing material
What happens to spacial pulse length due to damping?
Decreased spatial pulse length
What is the Q factor? What does damping do to it?
Q factor = resonant frequency/bandwidth. Damping decreases Q factor.
What is the material of most Piezoelectric cyrstals?
Lead Zirconate Titanate
What is the temperature at which a crystal looses its function?
Curie temperature (not the critical temperature)
What determines the pulsed-wave ultrasound beam frequency?
What determines the frequency of a continuous wave ultrasound beam?
Thickness of a piezoelectric crystal and the velocity of sound through the crystal.
For continuous wave it is the electrical frequency of the excitation voltage applied to the crystal.
What are the two variables for acoustic impedance?
Impedance = density * velocity
What are acceptable pressure gradients across the PA anastomosis is acceptable following a lung transplant?
Pulmonary venous anastomosis diameter?
Peak systolic pulmonary venous velocity?
20 mmHg
> 0.5 cm
< 100 cm/sec
What is the frequency range of most echocardiography machines?
2-10 MHz
What is the left atrial appendage velocity for 100% negative predictive valve for thrombus?
55 cm/sec
What is the formula for resonant frequency (RF) of the piezoelectric crystal?
RF = V/2T
V is velocity of sound in crystal
T is thickness of crystal.
How to distinguish between constrictive and restrictive pericarditis?
normal or elevated propagation velocity Vp on color M-mode
Are Tissue doppler velocities of the lateral mitral annulus affected by loading conditions?
No
What are 1-3 in image?
- Pulmonic Valve
- Aorta
- Innominate Vein - brachiocephalic vein
What is a Cor Triatriatum Sinister?
is a rare congenital condition in which the left atrium is subdivided by a fibromuscular membrane into two distinct chambers, a posterosuperior and anteroinferior chamber.
What is Cor Triatriatum Dexter?
right atrium is divided into two chambers by a membrane
What is the primary form of attenuation in soft tissue?
Absorption which accounts for > 80% of attenuation in soft tissue.
Explain the anatomy of a Fontan in terms of blood flow
What is a chiari network associated with?
PFO and paradoxical embolism
Is Right atrial diastolic collapse alone consistent with pericardial tamponade?
No
What are the three diseases on a continuum of cardiac eosinophilia?
Hypereosinophilic syndrome, endomyocardial fibrosis, and loffler endocarditis.
Most common location of traumatic aortic injury?
Aortic Isthmus which is the insertion of the ligamentum arteriosum near the left subclavian artery.
What is 1-3?
- Pulmonic Valve
- Aorta
- Innominate Vein (Brachiocephalic Vein)
What refers to the strength of an ultrasound beam and it’s ability to cause cavitation of bubbles?
Mechanical Index of an ultrasound.
Left Ventricular Non-compaction has what ratio of non-compacted to compacted myocardium?
2:1 at end systole in the TTE parasternal Short axis view.
What % of patients with hypertrophic cardiomyopathy have LVOT obstruction?
25%
Normal LV Dp/dt?
1610 +/- 290 mmHg/sec
Which walls are most involved with Left Ventricular Noncompaction?
Apical and Mid Inferior, inferiolateral and anteriolateral.
What is the most common Primary Malignant Cardiac tumor?
Most common primary malignant cardiac tumor in children?
Most common benign cardiac tumor?
Angiosarcoma
Rhabdomyoma
Myxoma
What is the cutoff for aneurysmal interatrial septum diagnosis in setting of bulging of septal plane in setting of absence of chronically elevated left and right atrial pressures?
> 15 mm
Which wall is usually spared in hypertrophic cardiomyopathy?
Basal inferolateral wall
What are the indications for surgery on HOCM?
LVOT obstruction with resting peak instantaneous gradient of > 30 mmHg
Angina/Dyspnea, and or syncope resulting in significant impairement in quality of life
Persistent symptoms despite appropriate medical treatment.
What is the blood flow in D-TGA?
What about L-TGA?
D-TGA there are two circuits
RA to TV to RV to aortic valve to aorta. Then also Pulmnoary vein to LA to MV to LV to Pulmonic Valve to pulmonary artery to lungs to pulmnoary veins and then back to LA
L-TGA there is one circuit
RA to MV to LV to Pulmonic valve to PA to Lungs to Pulmonary veins to LA to TV to RV to Aorta.
What is the surgical repair of D transposition of the great arteries?
Jatene Procedure.
What is a normal pulmonary vein flow velocity stay under?
< 1 m/s
What is the 3 beat rule?
If contrast is in LA within 3 beats following release of positive pressure breath than it is positive and shunt present
What problem may be expected in TOF repaired patient when they are an adult?
RV volume overload due to severe pulmonic insufficiency.
Valve destroyed in transannular patch repair of RV outflow tract.
What Ar-A duration indicates an increased LVEDP?
Ar-A duration > 30 milliseconds
Under what LA volume Index is LV relaxation likely normal or impaired?
< 34 ml/m2
what parameter of sound wave is determined by both source and the medium through which it travels?
Wavelength
What is annulus Reversus?
Where the septal e’ > lateral e’
As in constrictive pericarditis
Is a TAVR or surgical AVR have a higher incidence of stroke?
Complete heart block?
TAVR has higher incidence of stroke.
slightly higher incidence of complete heart block with TAVR.
Does Fulminant or Acute nonfulminant myocarditis have thick walls?
Fulminant myocarditis has thick walls. Rapid onset, full recovery likely.
Acute nonfulminant myocarditis has normal to thin walls, dilated chamber size, gradual onset and progresses to dilated cardiomyopathy.
AVA cutoffs for aortic stenosis?
Mild >1.5
Modearte 1-1.5
Severe > 1.0
Equation for wavelength, velocity and frequency of sound?
Wavelength = V/Frequency = 1540/Frequency
E/Vp > what predicts a PCWP > 15 mm Hg in patients with decresaed LVEF?
> 2.5
Causes of hypotension during liver transplant by phase?
Dissection Phase: Hypovolemia from ascites drainage, compression of major vessles, blood loss, fluid shifts
Anhepatic phase: Inadequate preload 2/2 loss of venous return (most common), endotoxemia resuilting in RV and LV systolic dysfunction
Reperfusion phase: Hypovolemia, metabolic derangements, PE, Pulmonary HTN, RV and LV dysfunction
What should be done about TR if greater than mild on preimplantation of LVAD?
Should be addressed surgically.
TR does not improve with LVAD placement
TR jet peak velocity > what is consistent with a grade 2 diastolic dysfunction?
> 2.8 m/sec
What is the goal blood pressure after a continuous flow VAD placement?
60-85 mmHg mean arteral pressure
When is a decrease in pump speed of LVAD contraindicated?
If an aortic root thrombus is present and the aortic valve does not open.
Decrease in pump speed could cause aortic valve opening and flushing out of thrombus.
What are cutoff values for normal mitral annular e’ in the septal and lateral walls?
Septal e’ > 7 cm/sec, lateral e’ > 10 cm/sec
What kind of LVAD makes doppler interrogation of inflow velocities impossible?
HeartWare continuous flow LVAD
What wall is always of normal thickness in patients with HOCM?
Basal inferolateral wall.
What does a mitral E/A decrease > 50% after a 10 second valsalva mean for LV relaxation and LAP?
LV relaxation is impaired and LAP is increased.
What valve in the aortic position is most likely to have significant presure recovery?
19 mm Saint Jude mechanical valve.
Mitral deceleration time < what has a reasonable accuracy for prediction of increased LV diastolic pressures?
<160 msec
When to measure LVOT diameter in cardiac cycle for calculation of the area of the LVOT?
mid systole.
What is the normal and pseudonormal patient’s isovolumentric relaxation time (IVRT)?
60-110 ms
What happens to IVRT with restrictive diastolic dysfunction?
Decreassed
Equation for mitral valve area from pressure half time?
Mitral valve area = 220/PHT
Identify anatomy of 1-4.
1 - coronary sinus
2 - Body of P3 of mitral valve leaflet
3 - Body of A2 Scallop,
4 = Circumflex coronary artery
What is an avalon catheter?
Veno-venous bi-caval dual lumen catheter designed to enable optimal ECMO
What is the optimal positioning of an Impella ventricular assist device?
Optimal distance from annulus to inlet is 3.5 cm
What are the names of the cusps of the pulmonary valve?
Which ones are closes to aortic valve?
Anterior, left, and right cusps
The left and right are adjacent to the aortic valve
What disease is associated with biventricular apical thrombi?
Loeffler eosinophilia, hypereosinophilic syndrome, and endomyocardial fibrosis.
What happens to Color M-mode Vp with any kind of diastolic dysfunction?
Reduced. normal is > 55 cm/s
What sinus surrounds the left atrial appendage?
Transverse sinus
Which modality and time in cardiac cycle is LA size best measured?
Transthoracic at end of LV systole
What is the matching layer of an ultrasound probe?
What is the ideal thickness of this layer?
It is the layer of the ultrasound probe that facilitates improved transpmission from the probe to the tissue..
Ideal matching layer has a thickness of 1/4 the wavelength.
What is Barlow’s syndrome associated with?
Bileaflet mitral valve prolapse and myxomatous mitral valve
What is Turner’s syndrome associated with?
Coarctation of aorta, bicuspid aortic valve, aortic Stenosis, hypoplastic left heart syndrome
What is shone complex associated with?
Parachute mitral valve, supramitral ring, valvular aortic stnnosis, subaortic stenosis, and aortic coarctation
What is formula for EROA calculation?
EROA = 2pier^2 x Velocity alias / Velocity of peak MR
EROA cutoffs for moderate?
EROA 0.2-0.4 cm^2
What abnormality is associated with a sail-like anterior leaflet of the tricuspid valve and an ostium secundum asd?
Ebstein’s anomaly.
What abnormality is associated with a defect in the elastin gene, and with sudden death with sedation and anesthesia?
William’s syndrome
Formula for myocardial performance Index?
MPI = (IVCT - IVRT)/ET
IVCT = Isovolumetric contraction time
IVRT = Isovolumetric Relaxation time
ET = Ejection Time
What syndrome is associated with isolated pulmonic stenosis?
Noonan’s syndrome
What syundrome is the pulmonic valve often stenotic in?
Alagille syndrome.
What are the 5 functions of the reciever for post processing?
Order of these 5 functions.
1 Amplification
2 Compensation (time gain compensation)
3 - compression
4 Demodulation
5 Rejection
Order is alphabetical.
How many pap muscles in RV?
3
Which muscle in the posterior pharynx may cause some normal resistance when inserting a TEE probe?
Cricopharyngeus muscle
What is the rate of copmlications from TEE procedure in ambulatory setting?
1 in 500
GI perforation occurs about 2 in 10,000 patients.
What % of biological prosthetic valves have trace to mild regurgitation?
10%
What is responsible for the pathogenesis of Rheumatic valvular disease?
Molecular mimicry.
What is Bechet syndrome?
Rare blood vessel inflammatory disease that can be associated with sinus of valsalva aneurysms
What is Lutembacher syndrome associated with?
Ostium secundum ASD and mitral stenosis
what is Scimitar syndrome associated with?
Inferior sinus venosus ASD
What is the ligament of Marshall?
Coumadin Ridge
Where does the ramus intermedius as a variant coronary artery come from?
Trifurcation of the left main coronary artery.
What syndrome is associated with isolated narrowing of the sinotubular junction?
William’s syndrome
How many cm from the teeth of an average adult to the upper esophageal, mid esophageal, transgastric, and deep transgastric?
Upper - 25 cm
Mid esophageal - 35 cm
Transgastric 40 cm
Deep transgastric 50 cm
Rounded symmetrical CWD jet with an acceleration time of > what is associated with severe prosthetic aortic stenosis?
> 100 ms
Incidence of PFO?
25-30%
Anterior mitral valve leaflet longer than what is a risk factor for SAM?
> 20 mm
Maximum Vena contracta on color flow after watchman device so they can stop anticoagulation?
5 mm
What syndrome is associated with ypoplastic left heart syndrome?
Kabuki syndrome.
Most common cause of TR?
Functional MR 2/2 RV enlargement
Best aliasing velocities for measurement of vena contracta?
50-60 cm/sec
What is normal global longitudinal strain?
Normal is -17 to - 20%
What procedure is used to repair Ebstein’s anomaly?
The cone procedure.
Deploy what valve with pacing for patient’s who won’t tolerate rapid ventricular pacing?
C-sept distance and AL/PL ratio for increasing risk of SAM?
C-sept distance of 2.5 cm
AL/PL less than 1.3
What coronary does the ramus intermedius come off?
Variant coronary artery resulting from trifurcation of the left main coronary artery.
What is the Mitral Valve to Aortic Valve angle below which increases the risk of SAM?
120 deg
What type of ASD is associated with MVP?
Ostium Secundum ASD
Pressure Half Time cutoffs for severe PR?
< 100 ms
Where to best place left atrial appendage closure device through interatrial septmu?
Inferior and posterior
What happens to velocity of ultrasound through a medium with changes in density and stiffness?
Increase velocity with decrease in density and increase in stiffness.
What is Scimitar syndrome associated with?
Inferior Sinus Venosus ASD
What Effective orifficcd area to BSA predicts severe patient prosthesis mismatch in the aortic position?
0.65 cm2/m2
What is the normal transtricuspid E wave velocity?
120-229 ms
What is cuttoff for severe aoritic regurgitation pressure half time?
< 200 ms
EROA greater than what for severe aortic regurgitation?
0.3 cm2
What measurements are needed for LV mass calculation?
LV internal end-diastolic diameter, inferolateral wall thickness, interventricular septal thickness.
What is lutembacher syndrome a combination of?
Mitral stenosis and ASD
What is the most common cause of MR in western countries?
P2 prolapse
GI tract perforation rate from a TEE?
2 in 10,000
What are the four load-independent measures of systolic function?
End-systolic elastance, preload recruitable stroke work, preload adjusted max power, strain rate
What is the EOA/BSA for a patient prosthesis mismatch for a prosthetic mitral valve replacement?
< 1.2 cm2/m2
What RVOL is consistent with severe aortic regurgitation?
60 cc
Ostium criteria for the watchman procedure for left atrial appendage?
Width of ostium 17-31 mm and length must be equal to or greater than the ostium width.
What is the most common variant of total anomalous pulmonary venous return?
Supracardiac
What is backing material composed of?
Tungsten powder and araldite
DIlation of sinuses of valsalva and sinotubular junction is what type of leaflet motion?
1b
What is the mean aortic valve gradient for which there is severe prosthetic aortic valve stenosis?
> 35 mmHg
Most common type of VSDs?
Perimembranous.
What is the most common congenital defect recognized at birth?
Recognized in adults?
VSD at birth
Bicuspid aortic valve in adults
What acceleration time to ejection time is indicative of severe aortic stenosis in prosthetic?
> 0.4
What mean gradient is consitent with severe mitral stenosis?
> 10 mm Hg
What is the reverse piezoelectric effect?
Conversion of electrical signal to sound
most common frequency of TEE transducer?
5-7 megahertz
What does the sinus venousus become?
Crista terminalis, Eustachian valve, The thebesian valve
What determines wavelength, frequency, and velocity? Sound source or medium?
Wavelength is determined by both
Frequency is determined by source
Velocity is determined by medium
What syndrome is associated with TOF?
Alagille syndrome.
What is the mean gradient for moderate mitral stenosis?
5-10 mmHg
Over what RV MPI by continuous wave doppler indicates RV dysfunction?
> 0.4
RV MPI by tissue doppler of > what indicates RV dysfunction?
> 0.55
What is myocardial perfusion index calculation?
(IVCT + IVRT)/ET
A vena contracta to PV annulus ratio > what is correlated with severe PR on cardiac MRI?
0.5
For what patient is a PA catheter contraindicated?
LBBB in a patient without a pacemaker
when and how to measure sinotubular junction?
Leading edge to leading edge at end diastole
When to measure aortic annulus?
Mid systole leading edge to leading edge
What is lower limit of 2D LV ejection fraction in men and women?
52% in men and 54% in women
