Technique

Question 1

All of the following will increase the frame rate and improve temporal resolution EXCEPT decreasing the:

A. Image depth
B. Field of view
C. Number of focuses
D. Transmit gain

Answer 1

D. Using write zoom and decreasing the line density may also increase the frame rate and improve temporal resolution.

Question 2

All of the following decrease with increasing transmit frequency
ЕХСЕРТ:

A. Depth of penetration
B. Attenuation
C. Beam width
D. Spatial pulse length and pulse duration

Answer 2

B. The formula to determine attenuation for soft tissue is approximately 0.5 x transmit frequency. Increasing the transmit frequency increases attenuation and decreases the depth of penetration.

Because the beam width decreases with increasing transmit frequency, lateral resolution improves. (a narrower beam width results in improved lateral resolution).

Because the spatial pulse length and pulse duration decrease with increasing transmit frequency, axial resolution is improved (shorter pulses results in improved axial resolution).

Question 3

Which transmit frequency would most likely be useful for an adult echocardiogram?

A. 2.5 MHz
B. 3.5 MHz
C. 5.0 MHz
D. 7.5 MHZ

Answer 3

A. Because adult echocardiography requires significant depth of penetration, lower frequencies are required.

Lower transmit frequencies result in greater depth of penetration due to less attenuation but result in poorer axial resolution (due to increased spatial pulse length and pulse duration) and poorer lateral resolution (due to wider beam widths).

Question 4

Tissue harmonic imaging improves all of the following EXCEPT:

A. Frame rate
B. Depth of penetration
C. Beam width
D. Side lobe artifacts

Answer 4

A. Tissue harmonics transmits a low frequency (e.g., 1.8 MHz) and displays the second harmonic which will be a higher frequency (e.g., 3.6 MHz).

The advantages of harmonic include improved depth of penetration due to the lower transmit frequency, improved lateral resolution due to the higher frequency resulting in a narrower beam width and less side lobe artifact because of the narrower beam width. Tissue harmonic imaging will also result in less reverberations close to the transducer.

Question 5

All of the following are true statements concerning pulsed-wave
(PW) Doppler EXCEPT:

A. Utilizes two elements
B. Range resolution (range discrimination) is the primary advantage
C. Aliasing is a primary disadvantage
D. Preferred modality to evaluate diastolic function

Answer 5

A. Pulsed-wave Doppler uses one element to transmit and receive.

The diastolic function values of the mitral valve E/A ratio, deceleration time, A wave duration and pulmonary venous flow are best evaluated with pulsed-wave Doppler.

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

Question 6

The primary advantage of continuous-wave (CW) Doppler is:

A. Range resolution
B. Range discrimination
C. Aliasing will not occur
D. Range ambiguity

Answer 6

C. Continuous-wave Doppler utilizes two elements with one continuously transmitting and one element continuously receiving. There is no sampling rate with continuous-wave Doppler so aliasing will not occur.

Pulsed-wave Doppler utilizes one element to send and receive which results in a sampling rate. If the Doppler sampling rate is exceeded (PRF/2), aliasing will occur.

Laboratory accreditation now requires that the dedicated (Pedoff) continuous-wave probe be used to evaluate aortic stenosis supplementing the continuous-wave imaging information.

Question 7

All of the following are true statements concerning color flow
Doppler EXCEPT:

A Pulsed-wave Doppler technique
B. Multigate
C. Mean velocity displayed
D. Normal flow does not alias

Answer 7

D. Because the pulse repetition frequency (PRF) is lower in color flow
Doppler, normal flow may alias.

Question 8

Which color flow Doppler map will display the color green to indicate turbulent flow?

A. Intensity
B. Directional
C. Variance
D. Hue

Answer 8

C. A mosaic with green indicates turbulent flow with the variance map on.
A mosaic flow pattern without the color green will be seen when the hue map is on.

Question 9

All of the following are ways to increase the color flow Doppler frame rate and improve temporal resolution EXCEPT decrease:

A. Field of view
B. Color gain
C. Image depth
D. Line density

Answer 9

B. Color gain will not affect the frame rate but it is an important instrument control since it determines the amount of color flow displayed. For example, increasing the color gain may increase the jet area of a regurgitation jet.

The velocity scale should be set at between 50 to 60 cm/s for a color flow Doppler exam. Increasing the color velocity scale increases the pulse repetition frequency (PRF) which will result in less color flow displayed.

When examining low velocity flow (e.g., pulmonary vein flow, patent foramen ovale), the color flow velocity scale should be set lower than 50 cm/s because the pulse repetition frequency (PRF) will be decreased resulting in more color flow displayed.

Question 10

Which Doppler intercept angle will result in the maximum flow velocity?

A. 0
B. 30
C. 60
D. 90

Answer 10

A. In order to maximize the peak velocity the sonographer needs to be parallel (0 degrees) to flow. Moving the intercept angle towards 90 degrees will result in a lower peak velocity which may cause an underestimation of the true peak velocity.

Question 11

The Doppler high-pass filter eliminates:

A. Peak velocity flow
B. Strong amplitude signals
C. Spectral broadening
D. Window fill-in

Answer 11

B. The spectral (PW, CW) Doppler wall filter is considered a high-pass filter because it eliminates high (strong) amplitude signals (e.g., wall motion) and low velocity flow.

The Doppler wall filter should be at 200 to 400 Hz for normal flow.
Increasing the wall filter is important when evaluating high velocity flow (e.g., aortic stenosis, mitral regurgitation).

The color flow Doppler velocity scale serves as a filter. Increasing the color flow velocity scale will decrease the amount of color flow displayed. Decreasing the color flow velocity scale will increase the amount of color flow displayed. It is recommended that the color flow velocity scale be set at between 50 to 60 cm/s for adult echocardiograms.

Question 12

Increasing the pulsed-wave Doppler sample gate length will result in:

A. Increased peak velocity
B. Increased spectral broadening
C. Better determination of laminar flow
D. Lower frame rates

Answer 12

B. For cardiac Doppler, a small sample gate (2 to 4 mm) is preferred unless searching for flow (e.g., pulmonary vein flow). Increasing the sample gate length may result in an increase in spectral broadening and window fill-in.

Question 13

The sonographer may avoid pulsed-wave Doppler aliasing by all of the following techniques EXCEPT:

A. Increase the velocity scale
B. Decrease the Doppler transmit gain
C. Decrease image depth
D. Shift the zero baseline

Answer 13

B. An appropriate Doppler transmit gain setting should allow for an only of mild saturation of the display background.

Increasing the velocity scale will increase the pulse repetition frequency
(PRF) which will increase the Nyquist limit (PRF/2) and is useful when trying to demonstrate the peak velocity appropriately.

Decreasing the image depth allows more pulses to be emitted (increases PRF) which increases the Nyquist limit (PRF/2).

Shifting the zero baseline may aid in displaying flow that is aliasing. The appropriate baseline setting is two-thirds of the display should be displaying the flow that is being featured.

Question 14

What is the standard sweep speed for M-mode echocardiography and cardiac Doppler?

A. 25 mm/s
B. 50 mm/s
C. 100 mm/s
D. 150 mm/s

Answer 14

B. The standard sweep speed is 50 mm/s. The sweep speed should be increased to 100 mm/s when measuring especially when making cardiac Doppler measurements.

The sweep speed may be decreased (e.g., 50 mm/s to 25 mm/s) when evaluating for respiratory variation of the atrioventricular valve flow (e.g., cardiac tamponade, constrictive pericarditus).

Question 15

All of the following are ways in which the sonographer can improve the lateral resolution while imaging EXCEPT:

A. Increase the transducer diameter
B. Increase the number of focuses
C. Increase the transmit frequency
D. Utilize harmonic imaging

Answer 15

A. Increasing the number of focuses, transmit frequency and harmonic imaging will decrease beam width and improve lateral resolution.

Increasing the transducer diameter will decrease the beam width overall and improve lateral resolution but the sonographer usually cannot alter the transducer diameter.

Question 16

Which instrument control directly affects the dynamic range?

A. Transmit gain
B. TGC
C. Compression
D. Image depth

Answer 16

C. Dynamic range is the range of echo amplitudes (shades of gray) displayed. Increasing the compression will increase the number shades of gray displayed.

Transmit gain can be used to increase the amplitude of the signal transmitted which will result in stronger amplitude signals received.

TGC (time gain compensation) compensates for attenuation and allows the sonographer to control the amplitude of signals displayed horizontally.

Image depth determines the number of pulses emitted (pulse repetition frequency; PRF). Increasing the image depth will decrease the pulse repetition frequency and the frame rate resulting in poorer temporal resolution.

Question 17

Of all of the resolutions, which resolution is most difficult for the sonographer to improve during an examination?

A. Spatial (axial resolution; lateral resolution)
B. Temporal
C. Contrast
D. Elevational

Answer 17

D. Elevational (slice thickness) resolution is dependent upon the thickness of the beam width. Increasing the frequency and focusing may help reduce the beam thickness but the use of matrix transducers may be the best way to improve elevational (slice thickness) resolution.

Increasing the transmit frequency, focusing, harmonics improve spatial (axial, lateral) resolution.

Decreasing the field of view (display width), decreasing image depth, decreasing line density, decreasing the number of focuses increases the frame rate and improves temporal resolution.

Altering the compression, post-processing curves, changing the monitor’s brightness and contrast controls improves contrast resolution.

Question 18

Multiple echoes equally spaced are called:

A. Reverberation
B. Refraction
C. Side lobes
D. Propagation speed error

Answer 18

A. Reverberation can occur when there are two or more strong reflectors which lie in the path of the pulse. Reverberations are usually located close to the transducer (e.g., in the apex in the apical four-chamber) because sound is reflected between the transducer and the skin surface. Prosthetic heart valves and pacer wires may also result in reverberation.

Question 19

The image artifact associated with displaying double images of a structure due to the change in the direction of the sound beam is called:

A. Reverberation
B. Refraction
C. Acoustic shadowing
D. Range ambiguity

Answer 19

B. Refraction may result in side-by-side double images. Occasionally double images of the aortic valve will be seen in the parasternal short-axis view of the aortic valve. Double images of structures are commonly seen when acquiring subcostal short-axis views.

Question 20

The image artifact which may cause the sonographer to fail to detect prosthetic mitral valve regurgitation from the apical window is:

A. Enhancement
B. Shadowing (flow masking)
C. Comet tail
D. Grating lobes

Answer 20

B. The highly reflective prosthetic valve will cause most of the sound energy to be reflected back to the transducer. Using off-axis views, parasternal views (e.g., parasternal short-axis) and a dedicated continuous-wave transducer (Pedoff probe) may improve detection of prosthetic mitral valve regurgitation. Additionally, examining for the flow convergence (PISA) may be useful in determining the presence and severity of prosthetic mitral valve regurgitation.

Enhancement is the increase in the strength of echoes caused by an intervening structures of low attenuation.

Comet tail is a type of everberation associated with a highly reflective structure such as a bullet or surgical clip.

Grating lobes and side lobes are extraneous sound beams.

Question 21

Agitated saline contrast may be used to evaluate all of the following EXCEPT:

A. Aortic regurgitation
B. Left to right atrial septal defect
C. Tricuspid regurgitation
D. Patent foramen ovale

Answer 21

A. Agitated saline contrast is commonly used to evaluate left to right, right to left intracardiac shunts and aorto-pulmonary shunts, detect the presence and severity of right-sided regurgitation and verify cardiac anatomy.

Agitated saline contrast is an important method to evaluate for the presence of patent foramen ovale. Often the Valsalva maneuver or cough must be performed by the patient during the agitated saline contrast exam to enhance the shunt.

Question 22

Left ventricular opacification may be accomplished by all of the following contrast agents EXCEPT:

A. Agitated saline
B. Optison
C. Definity
D. Imagent

Answer 22

A. Transpulmonary agents allow for the evaluation of left ventricular global and segmental function. The inability to visualize two or more segments may be an indication to use transpulmonary agents.

Question 23

A swirling of transpulmonary contrast is noted at the apex of the left ventricle. The sonographer should:

A. Decrease the transmit gain
B. Inject the contrast at a slower rate
C. Call the nurse
D. Use respiratory maneuvers

Answer 23

A. A swirling appearance may occur due to increased transmit gain, too little contrast being injected or poor systolic function. The sonographer should try to reduce the transmit gain which reduces the mechanical index (MI), move the transmit focus and/or inject more contrast faster.

Question 24

A maneuver which results in a decrease in venous return is:

A. Inspiration
B. Squatting
C. Straight leg raising
D. Valsalva

Answer 24

D. During the strain phase of the Valsalva maneuver, intrathoracic pressure increases, which causes venous return to decrease. The strain phase of the Valsalva maneuver may induce or enhance the obstruction in hypertrophic cardiomyopathy. The release phase of the Valsalva maneuver will initially result in an increase in venous return which may be useful when evaluating for patent foramen ovale with agitated saline contrast.

Question 25

A maneuver that will result in tachycardia and a transient decrease in blood pressure is:

A. Inhalation of amyl nitrite
B. Squatting
C. Standing to supine
D. Straight leg raising

Answer 25

A. Amyl nitrite is a vasodilator which initially results in a decrease in venous return, an increase in heart rate and a decrease in blood pressure. It may be used to provoke obstruction in hypertrophic cardiomyopathy.

Question 26

Possible pharmacologic treatments for hypertrophic obstructive cardiomyopathy include:

A Propranolol
B. Epinephrine
C. Dobutamine
D. Lasix

Answer 26

A. Propranolol is the mainstay of medical therapy. Beta blockade may prevent the increase in outflow obstruction that accompanies exercise although resting gradients are largely unchanged. It decreases the determinants of myocardial oxygen consumption and thus angina pectoris and perhaps exerts an antiarrhythmic action. Angina pectoris generally responds more favorably to treatment with a beta blocker than does dyspnea. It has also been suggested that beta blockade may prevent sudden death, but its efficacy for this purpose has not been established. Beta blockade also blunts the chronotropic response limiting the demand for increased myocardial oxygen delivery. Beta-adrenoceptor blockade may also have a beneficial effect on diastolic ventricular filling.

Question 27

All of the following cardiac pathologies are best evaluated with cardiac Doppler in the apical views EXCEPT:

A. Mitral stenosis
B. Mitral regurgitation
C. Atrial septal defect
D. Aortic stenosis

Answer 27

C. In most cases, the apical window allows for the Doppler (pulsed-wave, continuous-wave, color flow) sound beam to be parallel to blood flow for mitral stenosis, mitral regurgitation, aortic stenosis, aortic regurgitation, tricuspid stenosis, tricuspid regurgitation, discrete subaortic stenosis, hypertrophic cardiomyopathy and supravalvular stenosis.

The apical four-chamber view may be used to evaluate atrial septal defect and patent foramen ovale if color flow Doppler is on (with color flow velocity scale decreased) or if agitated saline contrast is injected.

Question 28

Which two-dimensional view would be most useful to use when evaluating pulmonary stenosis and pulmonary regurgitation?

A. Parasternal long-axis of the left ventricle
B. Parasternal short-axis at the aortic valve
C. Apical four-chamber
D. Suprasternal long-axis

Answer 28

B. Pulmonary stenosis and pulmonary regurgitation may be evaluated in the parasternal long-axis of the right ventricular outflow tract view, parasternal short-axis of the cardiac base and subcostal short-axis of the cardiac base.

The subcostal short-axis view of the aortic valve is a useful view when evaluating pulmonary stenosis and pulmonary regurgitation.

Occasionally in adults a superior tilt from the apical five-chamber view allows evaluation of pulmonary stenosis and pulmonary regurgitation.

Question 29

Which two-dimensional view is likely to be LEAST useful when evaluating for atrial septal defect with cardiac Doppler?

A. Parasternal short-axis of the aortic valve with color flow Doppler
B. Apical four-chamber with color flow Doppler
C. Subcostal four-chamber
D. Apical two-chamber view

Answer 29

D. Traditionally the preferred view for atrial septal defect is the subcostal four-chamber view. A right parasternal approach may also be attempted.

A dilated right ventricle seen in the parasternal long-axis does suggest a right ventricular volume overload with atrial septal defect a possible differential diagnosis. Other pathologies which may result in right ventricular volume overload include Ebstein’s anomaly, significant tricuspid regurgitation, significant pulmonary regurgitation and arrhythmogenic right ventricular cardiomyopathy (ARVC).

Question 30

All of the following two-dimensional views may be useful when evaluating for the presence of perimembranous ventricular septal defect EXCEPT:

A. Parasternal long-axis
B. Parasternal short-axis of the aortic valve
C. Apical five-chamber
D. Subcostal four-chamber

Answer 30

D. The perimembranous ventricular septal defect lies beneath the right aortic valve cusp. The perimembranous ventricular septal defect may close with tricuspid valve tissue. This may result in ventricular septal aneurysm.

The subcostal four-chamber view may be useful when evaluating for a trabecular (muscular) and inlet ventricular septal defect.

Question 31

The four acoustic windows for transthoracic echocardiography are:

A. Parasternal, long-axis, short-axis, subcostal
B. Parasternal, apical, subcostal, suprasternal
C. Long-axis, short-axis, four-chamber, suprasternal
D. Apical, subcostal, short-axis, parasternal

Answer 31

B. The usual order of a routine transthoracie echocardiogram is parasternal, apical, subcostal and suprasternal.

The three planes for two-dimensional echocardiography are long-axis, short-axis and four-chamber.

Question 32

The three two-dimensional planes used to examine the heart with transthoracic echocardiography are:

A. Parasternal, apical, subcostal
B. Long-axis, short-axis, five-chamber
C. Long-axis, short-axis, apical
D. Long-axis, short-axis, four-chamber

Answer 32

D. The long-axis plane of the heart extends from the right shoulder to the left hip. The transducer index mark is directed towards the right shoulder to acquire a long-axis plane of the heart. The short-axis plane extends from the left shoulder to the right hip. The transducer index mark is directed towards the left shoulder to acquire a short-axis plane of the heart. The four-chamber plane can be acquired from the apical window or subcostal window. The transducer index mark will be directed towards the left shoulder.

Question 33

The measurement of the left ventricular outflow tract diameter during early ventricular systole is an important measurement in all of the following calculations EXCEPT:

A. Stroke volume
B. Aortic valve area
C. Mitral valve area
D. Right ventricular systolic pressure

Answer 33

D. The measurement of the left ventricular outflow tract allows for the calculation of the cross-sectional area of the left ventricular outflow tract.

The cross sectional area of the left ventricular outflow tract is necessary when determining stroke volume with cardiac Doppler, aortic valve area by the continuity equation, mitral valve area by the continuity equation, Qp/Qs and regurgitant volume.

Right ventricular systolic pressure can be determined by acquiring the peak velocity of tricuspid regurgitation, ventricular septal defect or patent ductus arteriosus.

Question 34

The preferred two-dimensional view for determining the presence of bicuspid aortic valve is the:

A. Parasternal long-axis
B. Parasternal short-axis of the aortic valve
C. Apical five-chamber
D. Apical long-axis

Answer 34

B. The normal aortic valve has three cusps (right coronary cusp, left coronary cusp, non coronary cusp). In the parasternal short-axis view of the aortic valve, the normal aortic valve will appear triangular in shape when open during ventricular systole. A bicuspid aortic valve will appear elliptical (“football”) shaped during ventricular systole in the parasternal short-axis of the aortic valve. A unicuspid aortic valve will appear circular during ventricular systole in the parasternal short-axis view of the aortic valve. A quadricuspid aortic valve will appear “box-shaped” during ventricular systole when examined in the parasternal short-axis of the aortic valve. The doming of the aortic valve is best seen in the parasternal long-axis view suggests the presence of a bicuspid aortic valve. Eccentric closure of the bicuspid aortic valve and post-stenotic dilatation may be seen in the parasternal long-axis view as well.

Question 35

All of the following may be evaluated with cardiac Doppler in the apical five-chamber view EXCEPT:

A. Valvular aortic stenosis
B. Hypertrophic cardiomyopathy
C. Discrete subaortic stenosis
D. Patent foramen ovale

Answer 35

D. The apical four-chamber, subcostal four-chamber and parasternal short-axis of the aortic valve are possible approaches to use when evaluating patent foramen ovale. Usually agitated saline contrast is required with the Valsalva maneuver or cough when evaluating for patent foramen ovale.

Question 36

All of the following may be evaluated using the apical window EXCEPT:

A Pulmonary vein flow
B. Isovolumic relaxation time
C. Left atrial volume
D. Mitral valve prolapse

Answer 36

D. The apical four-chamber view is useful when evaluating pulmonary vein flow with pulsed-wave Doppler. Usually the right upper pulmonary vein is interrogated with an increased sample volume length placed 0.5 to 1.0 cm into the orifice of the pulmonary vein.

Isovolumic relaxation time may be acquired in the apical five-chamber view with the Doppler beam placed between the aortic valve and mitral valve.

Left atrial volume can be determined in the apical four-chamber and apical two-chamber. The normal left atrial volume is 22 +/- 6 ml/m^2.

It is recommended that the parasternal long-axis be used to determine the presence of mitral valve prolapse. The apical windows aid in confirming the diagnosis of mitral valve prolapse and in determining mitral regurgitation.

Question 37

The two-dimensional view of choice for evaluating the inferior vena cava and hepatic veins is the:

A Parasternal long-axis
B. Parasternal short-axis of the aortic valve
C. Apical four-chamber
D. Subcostal four-chamber

Answer 37

D. The inferior vena cava is an important component of the routine transthoracic echocardiographic examination because it allows the estimation of the right atrial pressure. A normal inferior vena cava dimension (< 1.7 cm) with normal collapse with a sniff > 50% reduction in diameter during the sniff) suggests a normal right atrial pressure (5 mm Hg). The hepatic veins are important when evaluating for tricuspid regurgitation, cardiac tamponade, constrictive pericarditis and restrictive cardiomyopathy.

Question 38

The two-dimensional view of choice for the evaluation of coarctation of the aorta is the:

A. Parasternal long-axis
B. Parasternal short-axis of the aortic valve
C. Apical five-chamber
D. Suprasternal long-axis of the aorta

Answer 38

D. The most common location for aortic coarctation is the aortic isthmus.

The suprasternal long-axis view of the aorta is also useful in the evaluation of supravalvular aortic stenosis, valvular aortic stenosis, aortic aneurysm, aortic dissection and aortic debris (e.g., atherosclerosis). The suprasternal short-axis of the aorta allows for visualization of the superior vena cava.

Evaluation of the aortic valve in the parasternal short-axis of the aortic valve should be included in a patient with aortic coarctation since 50 to 80% of aortic coarctation have a bicuspid aortic valve.

Question 39

All of the following are true statements concerning M-mode echocardiography EXCEPT:

A. Primary method currently of determining the presence and severity of cardiac pathology
B. Excellent temporal resolution
C. Standard sweep speed is 50 mm/s
D. Excellent axial resolution

Answer 39

A. The primary role of M-mode echocardiography today is the measurement of cardiac dimensions. Color M-mode may be useful in the timing of systolic events (e.g., mitral regurgitation) and diastolic events (e.g., aortic regurgitation), in the evaluation of diastolic function and strain (e.g., curved M-mode).

Question 40

All of the following are primary advantages of transesophageal echocardiography EXCEPT:

A. Superior resolution with high transmit frequencies
B. Absence of lung and rib artifact
C. Preferred test for infective endocarditis
D. Preferred test for mitral valve stenosis

Answer 40

D. Transesophageal echocardiography indications include:

1. Evaluate for source of embolism (e.g., left atrial thrombus located in left atrial appendage)
2. Prosthetic valve abnormalities (e.g., mitral valve replacement regurgitation)
3. Intracardiac/extracardiac tumors
4. Infective endocarditis
5. Aortic dissection
6. Congenital heart disease
7. Poor quality transthoracic exam
8. Mechanical life support
9. Chest trauma
10. Intraoperative

Mitral stenosis is usually is adequately evaluated with transthoracic echocardiography. Transesophageal may be useful in patients with mitral stenosis and left atrial thrombus or mitral stenosis pre and post-balloon valvuloplasty.

Question 41

Below is a mid-esophageal four-chamber view. The arrow is pointing out the:

A. Anterior mitral valve leaflet
B. Posterior mitral valve leaflet
C. Septal leaflet of the tricuspid valve
D. Posterior leaflet of the tricuspid valve

Answer 41

B. A multiplane rotation to 0 degrees allows for the four-chamber to be obtained when the transesophageal probe is placed in the mid-esophageal position. Mitral valve disease (e.g., mitral stenosis, mitral regurgitation) may be evaluated. Slight posterior angulation of the probe may allow for visualization of the coronary sinus. Slight anterior angulation allows for the evaluation of the left ventricular outflow tract. Caution should be used when evaluating the apex in this four-chamber view because it is often foreshortened.

AMVL, anterior mitral valve
PMVL, posterior mitral valve
RA, right atrium
LA, left atrium
RV, right ventricle
LV, left ventricle

Question 42

Below is a transesophageal short-axis view of the aortic valve obtained with probe placed at a mid-esophageal level and the multiplane set at between 30 to 45 degrees. The arrow is pointing out:

A. Left atrial appendage
B. Pulmonary valve
C. Right ventricular outflow tract
D. Right atrium

Answer 42

C. This view allows for evaluation of the aortic valve cusps, origin of the left main coronary artery, right main coronary artery and left atrium. With slight angulation (turning the transducer laterally and angling superiorly) the left atrial appendage and left superior pulmonary vein can be evaluated.

LA, left atrium
RA, right atrium
RVOT, right ventricle outflow tract
N, non-coronary cusp
L, left coronary cusp
R, right coronary cusp

Question 43

Below is a transesophageal transgastric short-axis of the left ventricle. The arrow is pointing out:

A. Anterolateral papillary muscle
B. Posteromedial papillary muscle
C. Moderator band
D. Ectopic chordae

Answer 43

B. The transgastric view short-axis of the left ventricle allows for the evaluation of left ventricular global and segmental function, left ventricular dimensions and wall thickness.

PM, posteromedial papillary muscle
AL, anterolateral papillary muscle
LV, left ventricle
RV, right ventricle

Question 44

All of the following may lead to a misdiagnosis for the presence of aortic dissection with transesophageal echocardiography EXCEPT:

A. Linear artifact
B. Mirror-image
C. Aberrant right subclavian artery
D. Thickened mitral valve

Answer 44

D. Linear artifacts can be caused by ultrasound reflection in the left atrium. Mirror image artifact are often caused by aorta-lung interface and appear as a “double-barreled” aorta. Aberrant right subclavian artery is a common variant where the right subclavian artery arises anomalously from the descending thoracic aorta and passes behind the trachea and esophagus.