Valvular Heart Disease

Question 1

The most common etiology of mitral stenosis in adults is:

A. Congenital
B. Left atrial myxoma
C. Rheumatic fever
D. Severe mitral annular calcification

Answer 1

C. Rheumatic fever is the most common cause of mitral valve stenosis (99%). Congenital (e.g., parachute mitral valve), left atrial myxoma and severe mitral annular calcification are possible etiologies for mitral valve stenosis but are not as common as rheumatic fever. Rarely, mitral valve stenosis is a complication of malignant carcinoid heart disease, systemic lupus erythematosus, rheumatoid arthritis and the mucopolysaccharides of the Hunter-Hurley phenotype. In rheumatic fever, the mitral valve leaflet tips thicken and there is commissural fusion as well as thickening and shortening of the chordae tendineae.

Question 2

The cardiac valves listed in decreasing order as they are affected by rheumatic heart disease are:

A. Aortic, pulmonic, tricuspid, mitral
B. Mitral, aortic, tricuspid, pulmonic
C. Pulmonic, aortic, tricuspid, mitral
D. Tricuspid, mitral, pulmonic, aortic

Answer 2

B. The mitral valve is the most common valve affected in rheumatic heart disease, followed by the aortic valve, tricuspid valve and rarely the pulmonic valve. Rheumatic fever results in four forms of fusion of the mitral valve apparatus leading to stenosis: (1) commissural, (2) cuspal,
(3) chordal and (4) combined.

Question 3

Signs and symptoms of mitral stenosis secondary to rheumatic heart disease include:

A. Angina pectoris
B. Cyanosis
C. Pulmonary hypertension
D. Vertigo

Answer 3

C. Pulmonary hypertension is commonly associated with mitral stenosis because of (1) passive backward transmission of the elevated left atrial pressure, (2) arteriolar constriction and (3) organic obliterative changes in the pulmonary vascular bed. Eventually, right ventricular pressures increase which may lead to right ventricular failure.

Question 4

Patients with mitral stenosis, left atrial enlargement and atrial fibrillation are at increased risk for the development of:

A. Left atrial myxoma
B. Left atrial thrombus
C. Left ventricular dilatation
D. Left ventricular thrombus

Answer 4

B. Thromboembolism is an important complication of mitral stenosis. The tendency for embolization correlates inversely with cardiac output and directly with age and the size of the left atrium with 80% of patients in whom systemic emboli develop are in atrial fibrillation.

Question 5

Conditions that may lead to clinical symptoms that mimic those associated with rheumatic mitral stenosis include:

A. Aortic stenosis
B. Left atrial myxoma
C. Pericardial effusion
D. Ventricular septal defect

Answer 5

B. A mobile left atrial myxoma may prolapse into the mitral valve orifice during ventricular diastole and obstruct flow into the left ventricle mimicking mitral stenosis.

Question 6

The equation used in the cardiac catheterization laboratory to determine mitral valve area is the:

A. Gorlin
B. Bernoulli
C. Doppler
D. Continuity

Answer 6

A. In most patients with mitral stenosis a detailed echocardiographic examination including two-dimensional echocardiography, a Doppler study with color flow Doppler provides the information required for optimal patient care. Cardiac catheterization may not be necessary to evaluate mitral stenosis hemodynamics including mitral valve area. Cardiac catheterization is required to evaluate coronary artery disease.

Question 7

The M-mode being demonstrated below is an example of:

A. Mitral valve prolapse
B. Mitral stenosis
C. Left atrial myxoma
D. Aortic regurgitation

Answer 7

B. The three classic M-mode findings for mitral stenosis are:

• Thickened mitral valve leaflets
• Decreased mitral valve E-F’ slope
• Anterior motion of the posterior mitral valve leaflet

Question 8

A strong indication for mitral stenosis on two-dimensional echocardiography is an anterior mitral valve leaflet that exhibits:

A. Coarse, chaotic diastolic motion
B. Diastolic doming
C. Reverse doming
D. Systolic bowing

Answer 8

B. Diastolic doming of the anterior mitral valve leaflet is an important two-dimensional finding in patients with rheumatic mitral valve stenosis. This classic finding is thought to be caused by commissural fusion.

Question 9

Two-dimensional echocardiographic findings for rheumatic mitral stenosis include all of the following EXCEPT:

A. Hockey-stick appearance of the anterior mitral valve leaflet
B. Increased left atrial dimension
C. Reverse doming of the anterior mitral valve leaflet
D. Thickened mitral valve leaflets and subvalvular apparatus

Answer 9

C. Mitral stenosis is almost always caused by rheumatic involvement of the mitral valve. The mitral valve leaflets are thickened with diastolic doming (hockey-stick appearance) of the mitral valve. The left atrium is enlarged. In the parasternal short-axis of the mitral valve leaflets, the orifice of the mitral valve has a fish-mouth appearance.

Reverse doming of the anterior mitral valve may be seen in patients with severe aortic regurgitation.

Question 10

The most accurate method for determining the severity of mitral valve stenosis is:

A. Determining the maximum velocity across the mitral valve by pulsed-wave Doppler
B. Measuring the E-F slope of the anterior mitral valve leaflet by M-mode
C. Measuring the thickness of the mitral valve leaflets
D. Performing planimetry of the mitral valve orifice by two-dimensional echocardiography

Answer 10

D. Obtaining the measurement of the mitral valve area by planimetry from the short-axis view of the mitral valve is an accurate method for quantifying the severity of mitral valve stenosis. The short-axis view of the mitral valve demonstrates the orifice of the stenotic valve and provides the opportunity for determining the degree of mitral valve stenosis.

Question 11

Critical mitral valve stenosis is said to be present if the mitral valve area is reduced to:

A. < 1.0 cm^2
B. 1.0 to 1.5 cm^2
C. 1.5 to 2.5 cm^2
D. 2.5 to 3.5 cm^2

Answer 11

A. Severe critical mitral valve stenosis is present when the mitral valve area is <1.0 cm^2. Mitral valve operation is recommended in these patients. Mitral valve area of 1.1 to 1.5 cm^2 is considered moderate stenosis and 1.6 to 2.5 cm^2is mild.

The normal mitral valve area is 4 to 6 cm^2.

Question 12

Typical echocardiographic findings in a patient with isolated rheumatic mitral stenosis include all of the following EXCEPT:

A. D-shaped left ventricle
B. Dilated left ventricle
C. Left atrial enlargement
D. Left atrial thrombus

Answer 12

B. In pure isolated mitral stenosis, the left ventricle does not become dilated. It may dilate if mitral valve regurgitation accompanies the stenosis. A D-shaped left ventricle which persists throughout ventricular systole and ventricular diastole suggests a right ventricular pressure overload. A D-shaped left ventricle during ventricular diastole which becomes circular in shape during ventricular systole suggests a right ventricular volume overload.

Question 13

Secondary echocardiographic/Doppler findings in patients with rheumatic mitral stenosis include all the following EXCEPT:

A. Abnormal interventricular septal wall motion
B. Increase right heart dimensions
C. Increased tricuspid regurgitant jet velocity
D. Left ventricular dilatation

Answer 13

D. Because of the increase pulmonary artery pressure, the right ventricle and the right atrium will eventually dilate. As pulmonary artery pressure increases, the tricuspid valve systolic regurgitant peak velocity will follow. Abnormal septal wall motion due to right ventricular volume and/or pressure overload will lead to septal flattening and/or paradoxical septal motion.

Question 14

The classic cardiac Doppler features of mitral valve stenosis include all the following EXCEPT:

A. Increased E velocity
B. Increased mitral valve area.
C. Increased pressure half-time
D. Turbulent flow

Answer 14

B. The expected cardiac Doppler findings in rheumatic mitral valve stenosis are increase velocities, turbulent flow and increased pressure half-time. The increased mitral inflow E velocity corresponds to the increased transmitral pressure gradient. The turbulent flow is due to the disturbance of flow caused by the valvular stenosis. The prolonged Doppler pressure half-time corresponds to the decrease in mitral valve area.

Question 15

The abnormal mitral valve pressure half-time for patients with mitral valve stenosis is:

A. 0 to 30 msec
B. 30 to 60 msec
C. 60 to 90 msec
D. 90 to 400 msec

Answer 15

D. The abnormal range for the pressure half-time (PHT) in a patient with mitral valve stenosis is 90 to 400 msec. Mitral valve stenosis is considered severe when the pressure half-time is 220 msec or longer and the mitral valve area is 1.0 cm^2 or smaller.

MVA (cm^2) = 220 ÷ PHT (msec)

Question 16

A deceleration time of 800 msec was obtained by continuous-wave Doppler in a patient with rheumatic mitral valve stenosis. The pressure half-time is:

A. 220 msec
B. 232 msec
C. 400 msec
D. 800 msec

Answer 16

B. The pressure half-time can be determined by the formula:
Pressure half-time (msec) = Deceleration time x 0.29

In this example, the pressure half-time is 800 msec x 0.29 = 232 msec

Mitral valve area (cm?) = 220 ÷ Pressure half-time

For this question: Mitral valve area (cm^2) = 220 ÷ 232 msec = .95 cm^2

Question 17

Doppler mean pressure gradient across a stenotic mitral valve of 22 mm Hg is obtained. The severity of the mitral stenosis is:

A. Mild
B. Moderate
C. Moderately severe
D. Severe

Answer 17

D. Mild mitral stenosis is present when the mean pressure gradient of < 4 mm Hg, moderate 4 to 10 mm Hg and severe > 10 mm Hg.

Tracing the continuous-wave Doppler spectral waveform will allow computation of the peak velocity, peak pressure gradient, mean pressure gradient and velocity time integral.

Question 18

Mitral stenosis is considered to be severe by all the following criteria EXCEPT:

A. Mean pressure gradient ≥ 10 mm Hg
B. Mitral valve area ≤ 1.0 cm^2
C. Mitral valve Doppler A wave peak velocity > 1.3 m/s
D. Pressure half-time > 220 msec

Answer 18

C. In the Doppler evaluation of mitral valve stenosis severity, the mitral valve A wave peak velocity is usually ignored.

Question 19

Two-dimensional echocardiographic examination reveals thin mobile mitral valve leaflet tips and a Doppler E velocity of 1.8 m/s with a pressure half-time of 180 msec in an elderly patient. The most likely diagnosis is:

A. Abnormal relaxation of the left ventricle
B. Aortic regurgitation
C. Moderate to severe mitral annular calcification
D. Rheumatic mitral stenosis

Answer 19

C. In mitral stenosis due to severe mitral annular calcification, the Doppler and secondary echocardiography findings are similar to rheumatic mitral stenosis. This type of mitral obstruction is referred to as “functional” mitral stenosis.

Question 20

All of the following are possible etiologies of anatomic mitral regurgitation EXCEPT:

A Mitral annular calcification
B. Mitral valve prolapse
C. Ruptured chordae tendineae
D. Dilated cardiomyopathy

Answer 20

D. Mitral regurgitation caused by segmental or global abnormalities without structural abnormalities of the mitral valve is termed functional mitral regurgitation and is commonly seen in patients with dilated cardiomyopathy or ischemic cardiomyopathy.

Question 21

All of the following are causes for chronic mitral regurgitation EXCEPT:

A Rheumatic heart disease
B. Cleft mitral valve
C. Ruptured papillary muscle
D. Mitral annular calcification

Answer 21

C. Papillary muscle rupture is a rare complication of acute myocardial infarction and generally occurs during the second to third day following infarction. Rupture of the posteromedial papillary muscle is three times more common than rupture of the anterolateral papillary muscle. This is because the anterolateral papillary muscle is supplied by branches of the left anterior descending coronary artery and circumflex coronary artery. The posteromedial papillary muscle is supplied only by the posterior descending coronary artery.

The most common cause of acute mitral regurgitation is rupture of the chordae tendineae due to mitral valve prolapse.

Question 22

The most common presenting symptom of significant chronic mitral regurgitation is:

A. Dyspnea
B. Hemoptysis
C. Systemic embolization
D. Ascites

Answer 22

A. The patient with significant chronic mitral regurgitation presents with the signs and symptoms of congestive heart failure: dyspnea, orthopnea, paroxysmal nocturnal dyspnea, fatigue, cough and weight gain due to the reduction of stroke volume and cardiac output as well an increase in pulmonary artery pressures.

Question 23

Congestive heart failure in a patient with significant chronic mitral regurgitation occurs because of increased pressure in the:

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

Answer 23

A. Congestive heart failure (inability of the heart to meet the metabolic demands of the body) can occur in patients with significant chronic mitral regurgitation due to the increase in left atrial pressure. The signs and symptoms of congestive heart failure include dyspnea, orthopnea, paroxysmal nocturnal dyspnea, fatigue, cough and weight gain.

Question 24

Possible signs and symptoms associated with acute severe mitral regurgitation include:

A. Hemoptysis
B. Anasarca
C. Pulmonary edema
D. Systemic embolization

Answer 24

C. Edema is the accumulation of fluid in cells, tissues or body cavities. Pulmonary edema is the accumulation of fluid in the lungs. In patients who develop severe acute mitral regurgitation, the left atrial pressure is reflected back into the pulmonary circuit. Because there is a rapid rise in pulmonary pressures at the venous level, fluid is forced out of the pulmonary capillaries and veins into the lungs.

Question 25

Chronic significant mitral regurgitation may result in all of the following EXCEPT:

A Left atrial enlargement
B. Left ventricular enlargement
C. Left ventricular volume overload pattern
D. Mitral annular calcification

Answer 25

D. Chronic significant mitral regurgitation may lead to a volume overload in which the left atrium and the left ventricle bear the burden. If significant, the left ventricle will eventually fail because of the volume overload. The left ventricular volume overload pattern is left ventricular dilatation with hyperkinetic wall motion.

Mitral annular calcification is a common reason for the systolic murmur of mitral regurgitation in the elderly.

Question 26

The most likely heart sound to be heard in patients with significant chronic pure mitral regurgitation is:

A. Loud S1
B. Fixed split S2
C. S3
D. Ejection click

Answer 26

C. The third heart sound (S3) (also referred to as the protodiastolic gallop or ventricular gallop) is the result of rapid filling and stretching of an abnormal left ventricle. It is frequently an early sign of left ventricular failure. The third heart sound may be present in patients with mitral regurgitation, aortic regurgitation, ventricular septal defect and patent ductus arteriosus. An S3 may also be a normal variant found especially in young adults.

Question 27

The classic description of the murmur of chronic mitral regurgitation is:

A Holosystolic murmur heard best at the apex radiating to the axilla
B. Continuous machinery-like murmur
C. Systolic ejection murmur heard best at the right upper sternal border
D. Diastolic decrescendo murmur heard best at the left sternal border

Answer 27

A. The character of the murmur of mitral regurgitation depends upon whether the mitral regurgitation is mild, moderate or severe. It also depends on whether the anterior or posterior mitral valve leaflet is involved. In patients with posterior mitral valve leaflet defects, the direction of the regurgitant jet may be anterior and the mitral regurgitation murmur is best heard in the aortic area. In patients with mitral valve prolapse, the murmur may be crescendo and late systolic.

Question 28

Cardiac magnetic resonance imaging provides all of the following information in the evaluation of mitral regurgitation EXCEPT:

A Regurgitant volume
B. Left ventricular volumes
C. Detailed visualization of the mitral valve apparatus
D. Left ventricular mass

Answer 28

C. Echocardiography provides reliable and detailed information concerning the mitral valve apparatus and function.

Question 29

M-mode and two-dimensional findings associated with significant chronic mitral regurgitation include all of the following EXCEPT:

A. Fine diastolic flutter of the mitral valve
B. Left atrial enlargement
C. Left ventricular enlargement
D. Left ventricular volume overload pattern

Answer 29

A. Fine diastolic flutter of the mitral valve may indicate aortic regurgitation.
The two components of left ventricular volume overload are:

(1) left ventricular dilatation and (2) hyperkinetic left ventricular wall motion.

Question 30

The M-mode shown is demonstrating:

A. Normal
B. Left ventricular volume overload pattern
C. Right ventricular volume overload pattern
D. Acute myocardial infarction

Answer 30

B. The two components of the left ventricular volume overload pattern are:

(1) left ventricular dilatation and (2) left ventricular wall hyperkinesis.

Question 31

Systolic bowing of the inter-atrial septum toward the right atrium throughout the cardiac cycle may be an indication of:

A. Mitral regurgitation
B. Tricuspid atresia
C. Tricuspid regurgitation
D. Tricuspid stenosis

Answer 31

A. The inter-atrial septum may bow toward the right atrium in significant mitral regurgitation because left atrial pressure is markedly greater than right atrial pressure.

The inter-atrial septum may bow towards the left atrium throughout the cardiac cycle in patients with increased right atrial volume and/or pressure (e.g., significant tricuspid regurgitation, tricuspid stenosis, tricuspid atresia).

Question 32

In patients with significant pure mitral regurgitation, the E velocity of the mitral valve pulsed-wave Doppler tracing is:

A. Decreased
B. Increased with inspiration
C. Increased
D. Unaffected

Answer 32

C. In the presence of mitral regurgitation, the velocity of antegrade mitral flow is increased because regurgitant flow is added to the normal mitral flow. Regurgitation produces an increased “v” wave in the left atrial pressure curve, resulting in an increased left atrial-left ventricular pressure difference in early diastole. This leads to an increased forward flow velocity (mitral E wave) in early diastole > 1.2 m/s.

Question 33

The effect significant mitral regurgitation has on the pulsed-wave Doppler tracing of the pulmonary veins may be described as:

A. S wave increases, D wave decreases
B. S wave increases, D wave decreases
C. S wave reverses, D wave increases
D. Unaffected

Answer 33

C. In severe mitral regurgitation, the S wave is blunted or even reversed and the D wave is increased.

Question 34

An accepted method for determining the severity of mitral regurgitation by continuous-wave Doppler is spectral:

A. Jet density
B. Length
C. Velocity
D. Width

Answer 34

A. By comparing the mitral inflow spectral density (strength) to the spectral jet density (strength) of the mitral regurgitation a semi-quantitative approach to the severity of mitral regurgitation can be achieved. A soft density with a parabolic flow signal suggests mild mitral regurgitation. A dense triangular continuous-wave tracing suggests the presence of severe mitral regurgitation.

Question 35

In patients with significant mitral regurgitation, the continuous-wave Doppler tracing of the regurgitant lesion may demonstrate a(n):

A. Asymmetrical shape of the mitral regurgitation flow velocity
spectral display
B. Jet area of < 20%
C. Jet duration of < 85 msec
D. Symmetrical shape of the mitral regurgitation flow velocity spectral display

Answer 35

A. In patients with significant mitral regurgitation, the continuous-wave Doppler spectral display may demonstrate a dense, asymmetrical (triangular, tapered) shape which indicates a rapid rise in left atrial pressure due to the significant mitral regurgitation.

In patients with significant tricuspid regurgitation the continuous-wave Doppler spectral display may demonstrate a similar pattern (e.g., dense, asymmetrical) due to a rapid rise in right atrial pressure.

Question 36

The peak mitral regurgitation velocity as determined with continuous-wave Doppler reflects the:

A Direction of the regurgitant jet
B. Etiology of the mitral regurgitation
C. Maximum pressure difference between the left atrium and left ventricle
D. Severity of the mitral regurgitation

Answer 36

C. The maximum velocity of the mitral regurgitant jet tells the examiner the maximum peak pressure difference between the left atrium and the left ventricle. The maximum velocity of the mitral regurgitation is generally 4 to 6 m/s since the pressure difference between the left atrium and the left ventricle is normally approximately 100 mm Hg during ventricular systole.

Question 37

In patients with severe acute mitral regurgitation, the continuous-wave Doppler peak velocity of the regurgitant jet is:

A. Decreased
B. Dependent largely upon left ventricular global systolic function
C. Increased
D. Unaffected

Answer 37

A. In most cases the mitral regurgitation peak velocity is expected to fall between 4 to 6 m/s and is therefore not useful for determining the severity of mitral regurgitation. In patients with severe acute mitral regurgitation, the peak velocity may be < 4 m/s owing to an elevated left atrial pressure that reduces the pressure difference between the left ventricle and left atrium during ventricular systole. In addition, there may be tapering (triangular-shaped, asymmetrical) of the continuous-wave Doppler configuration.

Question 38

In patients with significant mitral regurgitation, the isovolumic relaxation time may be:

A. Increased
B. Decreased
C. Affected by respiration
D. Unaffected

Answer 38

B. The isovolumic relaxation time (IVRT) is the period from aortic valve closure to mitral valve opening. The isovolumic relaxation time can be measured using pulsed-wave Doppler, continuous-wave Doppler or tissue Doppler imaging. With severe mitral regurgitation, the isovolumic relaxation time may be < 60 msec. This is due to the increase in left atrial pressure which causes the mitral valve to open sooner than normal. The normal isovolumic relaxation time is 76 + 13 msec for adults over 40 years of age.

Question 39

A color flow Doppler method for semi-quantitating mitral regurgitation is regurgitant jet:

A. Area
B. Height
C. Length
D. Turbulence

Answer 39

A. The regurgitant jet area (RJA) compared to the left atrial area
(LAA) provides a semi-quantitative measure of the severity of mitral regurgitation. A RJA/LAA ratio of < 20% suggests mild mitral regurgitation while a RJA/LAA ratio > 40% indicates severe mitral regurgitation. The jet area may be used alone with a regurgitant jet area < 4 cm^2 indicating mild mitral regurgitation and > 8 cm^2 indicating severe mitral regurgitation. The above methods) is best to apply to central jets with the color velocity scale set to between 50 to 60 cm/s. The color gain can influence jet area. The blood pressure should be known since changes in blood pressure may change the jet area. It is important to note that the duration of the mitral regurgitation when using regurgitant jet area. Pulsed-wave Doppler, continuous-wave Doppler or color M-mode may be used to determine jet duration.

Question 40

All of the following are useful color-flow Doppler techniques in the evaluation of mitral regurgitation EXCEPT:

A. Vena contracta width
B. PISA diameter
C. Peak velocity
D. Jet area

Answer 40

C. A vena contracta width of ≥ 0.7 cm indicates severe mitral regurgitation.
A PISA diameter of ≥ 0.9 cm indicates severe mitral regurgitation. A regurgitant jet area > 8 cm^2 indicates severe mitral regurgitation. Color flow Doppler demonstrates the mean velocity. In general, the peak velocity of mitral regurgitation is between 4 to 6 m/s and is determined with continuous-wave Doppler. In most cases, the peak velocity of the mitral regurgitation is not used to determine severity since the peak velocity represents the pressure gradient between the left ventricle and left atrium during ventricular systole. One exception is in the presence of severe mitral regurgitation (e.g., flail mitral valve due to papillary muscle rupture where a peak velocity of < 4 m/s may be obtained due a reduced systolic left ventricle - left atrial systolic pressure gradient.

Question 41

Quantitative approaches to determine the severity of mitral regurgitation include all of the following EXCEPT:

A. Regurgitant volume
B. Regurgitant fraction
C. Regurgitant jet area
D. Effective regurgitant orifice

Answer 41

C. Regurgitant volume (RV), regurgitant fraction (RF) and effective regurgitant orifice (ERO) can be determined by using two-dimensional echocardiography with pulsed-wave Doppler. The proximal isovelocity surface area (PISA) method allows determination of regurgitant volume and effective regurgitant orifice. A regurgitant volume of ≥ 60 mL, a regurgitant fraction ≥ 50% and an effective regurgitant orifice ≥ 0.40 cm^2 indicate the presence of severe mitral regurgitation.

Question 42

Cardiac Doppler evidence of severe mitral regurgitation includes all of the following EXCEPT:

A. Dense, triangular continuous-wave Doppler tracing
B. Mitral valve E wave velocity < 1.0 m/sec
C. Pulmonary vein systolic flow reversal
D. Regurgitant jet area/left atrial area ratio > 40%

Answer 42

B. With significant mitral regurgitation, the mitral valve E velocity will be increased (> 1.2 m/sec) due to the increased early diastolic pressure gradient between the left atrium and left ventricle. Mitral valve repair or replacement may be indicated in patients with significant mitral regurgitation when there is evidence of progressive ventricular dilatation, an end-systolic dimension > 45 mm, or a reduction in left ventricular global systolic function.

Question 43

All of the following are true statements concerning mitral regurgitation EXCEPT:

A. Mitral regurgitation may be acute, chronic or intermittent
B. Mitral regurgitation may result in an increase in preload
C. Severity of mitral regurgitation is not affected by afterload
D. Regurgitant jet area, vena contracta width and proximal isovelocity surface area are recommended when determining severity

Answer 43

C. Afterload is the resistance to the ejection blood and can affect the severity of mitral regurgitation. An excellent example is when attempting to determine the severity of mitral regurgitation in the operating room when the patient is under anesthesia. The severity of mitral regurgitation is usually less than reported preoperatively. Noting the blood pressure and infusing isoproterenol may be required in the operating room to determine the severity of mitral regurgitation.

Question 44

Diastolic mitral regurgitation is associated with:

A. Flail mitral valve
B. Mitral valve prolapse
C. Severe aortic regurgitation
D. Severe tricuspid regurgitation

Answer 44

C. Although mitral regurgitation is generally thought to occur during
systole, it may also occur during diastole. Diastolic mitral regurgitation is due to a positive left ventricular to left atrial pressure gradient. Other causes of diastolic mitral regurgitation include atrioventricular (AV)
block, atrial flutter, atrial fibrillation and disorders associated with
reduced ventricular compliance such as in restrictive cardiomyopathy or severe diastolic dysfunction.

Question 45

The most common symptoms of mitral valve prolapse include all of the following EXCEPT:

A. Atypical chest pain
B. Palpitations
C. Syncope
D. Ascites

Answer 45

D. The vast majority of patients with mitral valve prolapse are asymptomatic. The symptoms of congestive heart failure (dyspnea, orthopnea, paroxysmal nocturnal dyspnea, fatigue, cough, weight gain) may occur in patients with mitral valve prolapse who have significant mitral regurgitation. Panic attacks have been associated with mitral valve prolapse but this association has not been confirmed using the new, stricter criteria for the presence of mitral valve prolapse. Mitral valve prolapse appears to exhibit a strong hereditary component.

Question 46

The complications of mitral valve prolapse include all of the following EXCEPT:

A. Increased risk of infective endocarditis
B. Significant mitral regurgitation
C. Mitral valve repair and replacement
D. Valvular stenosis

Answer 46

D. Other complications of mitral valve prolapse include cerebral embolic events and cardiac arrhythmias (e.g, paroxysmal supraventricular tachycardia, atrial fibrillation). Mitral valve prolapse appears to be the most common reason for mitral valve repair in the United States due to isolated significant mitral regurgitation. There may be an increased risk of sudden death in patients with mitral valve prolapse with severe mitral regurgitation, complex ventricular arrhythmias, QT interval
prolongation and a history of syncope and palpitations.

Question 47

The associated auscultatory findings for mitral valve prolapse include:

A. Ejection click
B. Friction rub
C. Mid-systolic click
D. Pericardial knock

Answer 47

C . The classic auscultatory findings for mitral valve prolapse are mid-systolic click and late systolic murmur. The mid-systolic click is thought t o originate from the tensing of the chordae tendineae and the late systolic murmur originates from the mitral regurgitation.

Question 48

A keyword that is often used to describe the characteristics of the valve leaflets in mitral valve prolapse is:
A. Dense
B. Doming
C. Redundant
D. Sclerotic

Answer 48

C. The terms redundant, thick and myxomatous are used to describe the valve leaflets in patients with classic mitral valve prolapse due to myxomatous degeneration. In non-classic mitral valve prolapse, the mitral valve leaflets are normal in thickness (< 5 mm).

Question 49

The term myxomatous degeneration is associated with mitral valve:

A. Flail
B. Prolapse
C. Stenosis
D. Vegetation

Answer 49

B. Classic mitral valve prolapse is characterized by an increase in the amount of loose myxomatous tissue in the spongiosa component (the middle layer of the leaflet) which encroaches on the fibrosa
(the ventricular surface of the leaflet). The associated redundancy or myxomatous degeneration in the valve leaflet and chordae tendineae permit prolapse during ventricular systole. The terms thick, redundant or myxomatous may be used to describe a mitral valve prolapse if the valve leaflet thickness is > 5 mm. This is called classic mitral valve prolapse.

Question 50

Echocardiographic characteristics of mitral valve prolapse include all of the following EXCEPT:

A. Increased mitral valve annulus diameter
B. Systolic bowing of the mitral valve leaflets towards the left atrium
C. Thickened, redundant, myxomatous leaflets
D. Diastolic doming of the mitral valve leaflets

Answer 50

D. Mitral valve prolapse is defined as systolic displacement (> 2 mm) of one or both mitral valve leaflets in to the left atrium above the plane of the mitral annulus. The parasternal long-axis view is the recommended view due to the fact the mitral annulus is saddle-shaped. The mitral annulus may be markedly dilated in patients with mitral valve prolapse. M-mode may be useful to determine whether the mitral valve prolapse
is mid to late systolic or holosystolic.

Question 51

The gold standard two-dimensional echocardiographic view recommended to diagnose the presence of mitral valve prolapse is:

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

Answer 51

A. Because the mitral annulus is saddle-shaped, the parasternal long-axis is the recommended view. A systolic displacement (> 2 mm ) of one or both leaflets into the left atrium suggests mitral valve prolapse. If the prolapsing leaflets) are > 5 mm in thickness, classic mitral valve prolapse is present. If the prolapsing leaflets) are < 5 mm in thickness,
non-classic prolapse is present. Use of the apical four-chamber view as the gold standard view for several years resulted in the over-diagnosis of mitral valve prolapse (5 to 15%). Using the stricter criteria described above, the prevalence of mitral valve prolapse is 1.7 to 2.4%. Mitral valve prolapse is twice as frequent in women than in men but significant mitral regurgitation occurs more frequently in older men (> 50 years of age) with mitral valve prolapse than in young women with mitral valve prolapse.

Question 52

Secondary causes of mitral valve prolapse include all of the following EXCEPT:

A. Atrial septal defect
B. Bicuspid aortic valve
C. Cardiac tamponade
D. Primary pulmonary hypertension

Answer 52

B. A disease process that increases right ventricular dimension will decrease the left ventricular dimension thus causing the mitral valve to prolapse into the left atrium during ventricular systole (e.g., atrial septal
defect, primary pulmonary hypertension). Moderate to large pericardial effusion may exaggerate valve motion resulting in false positive mitral valve prolapse. Patients who are obese rarely present with mitral valve
prolapse because of increased left ventricular volumes.

Question 53

All of the following are associated with mitral valve prolapse ЕХСЕРТ:

A. Mitral regurgitation
B. Tricuspid valve prolapse
C. Aortic valve prolapse
D. Pulmonary atresia

Answer 53

D. The mitral regurgitation may be mid to late systolic or holosystolic. Tricuspid valve prolapse may be present in up to 50% of patients with mitral valve prolapse. Aortic valve prolapse is uncommon but may
be found in patients with mitral valve prolapse (10% of patients with classic mitral valve prolapse) or with bicuspid aortic valve.

Question 54

Which of the following is most commonly associated with mitral valve prolapse?

A. Left heart volume overload
B. Left heart pressure overload
C. Right heart pressure overload
D. Right heart volume overload

Answer 54

A. Mitral valve prolapse may result in significant chronic mitral regurgitation. Significant chronic mitral regurgitation initially results in left atrial dilatation, left ventricular dilatation and the left ventricular
volume overload pattern (left ventricular dilatation with hyperkinetic wall motion). With time, pulmonary hypertension may develop.

Question 55

There is posterior mitral valve prolapse present. With color flow Doppler on, which direction will the mitral regurgitation jet be baffled?

A. Anterior
B. Posterior
C. Inferior
D. Cephalad

Answer 55

A. Anterior mitral valve prolapse will baffle the jet posterior. Prolapse of both mitral valve leaflets will result in a central jet.

Question 56

Flail mitral valve can be differentiated from severe mitral valve prolapse on two-dimensional echocardiography because flail mitral valve leaflet demonstrates:

A. A thicker mitral valve
B. Chronic mitral regurgitation
C. Leaflet tip that points toward the left ventricle
D. Leaflet tip that points toward the left atrium

Answer 56

D. A flail mitral valve leaflet will present on two-dimensional echocardiography with exaggerated motion and the tip of the affected leaflet loses its point of coaptation and moves into the left atrium with its tip pointing superiorly into the left atrium. Severe mitral regurgitation is associated with flail mitral valve although the jet may
be baffled in such a way as to “hug” the valve leaflet and left atrial wall. This will make the regurgitant jet appear to be smaller with color flow Doppler on (coanda effect).

Question 57

Mitral valve chordal rupture usually results in:

A. Aortic regurgitation
B. Mitral regurgitation
C. Pulmonary regurgitation
D. Tricuspid regurgitation

Answer 57

B. The most common cause of chordae tendinee rupture is mitral valve prolapse. Other causes include rheumatic heart disease, infective endocarditis, connective tissue disorders, myocardial infarction,
hypertrophic cardiomyopathy and trauma. Ruptured chordae tendineae may result in flail mitral valve leaflet and mitral regurgitation. The severity of the mitral regurgitation is dependent upon the number of chordae tendinee ruptured and if the ruptured chordae tendineae are primary, secondary or tertiary. If the mitral regurgitation is significant, the patient may present with acute pulmonary edema and congestive heart failure.

Question 58

A common finding associated with a regurgitant murmur in the elderly is:

A. Aortic valve stenosis
B. Mitral annular calcification
C. Mitral valve stenosis
D. Mitral valve vegetation

Answer 58

B. The mitral annulus decreases in diameter by 25% during ventricular systole. Mitral annular calcification prevents that reduction during ventricular systole which allows blood flow back into the left atrium. Severe mitral annular calcification can result in obstructing blood flow during ventricular diastole resulting in functional mitral stenosis.

Question 59

On M-mode and two-dimensional echocardiography dense echoes are noted posterior to normal mitral valve leaflets. The probable diagnosis is mitral valve:

A. Annular calcification
B. Aneurysm
C. Papilloma
D. Vegetation

Answer 59

A. The mitral valve annulus is part of the fibrous skeleton of the heart and begins to develop fibrosis and calcification by the age of 65 years. Echocardiography demonstrates a mass of dense and highly reflective echoes behind the posterior mitral valve leaflet. Mitral annular calcification may be accelerated by the presence of certain disease states such as systemic hypertension, aortic stenosis, diabetes, chronic renal failure and hypertrophic cardiomyopathy.

Question 60

The etiology of aortic valve stenosis includes all the following ЕХСЕРТ:

A. Bacterial
B. Congenital
C. Degenerative
D. Rheumatic

Answer 60

A. Acquired aortic valve stenosis may be due to degenerative senile calcification or rheumatic fever. Congenital aortic valve stenosis may be unicuspid, bicuspid, tricuspid, or it may be due to a dome-shaped diaphragm. Quadricuspid aortic valve has been described, is usually not stenotic but may be regurgitant.

Question 61

The most likely etiology of aortic valve stenosis in a 47-year-old patient is:

A. Annular
B. Congenital
C. Endocarditis
D. Degenerative

Answer 61

B. Differentiation of congenital (bicuspid) and acquired aortic valve stenosis may be difficult. An indication of a congenital etiology is the age of the patient. Patients with bicuspid aortic valve usually become
symptomatic between the ages of 20 and 50, while senile aortic stenosis occurs at a much later age.

Question 62

The cardinal symptoms of valvular aortic stenosis include all the following EXCEPT:

A. Angina pectoris
B. Congestive heart failure
C. Anasarca
D. Syncope

Answer 62

C. The cardinal symptoms of valvular aortic stenosis, which commence most commonly in the sixth decade of life, are angina pectoris, syncope and congestive heart failure. Once these symptoms become manifest, the prognosis is poor. Survival curves show that the interval from the onset of symptoms to the time of death is about two years in patients with heart failure, three years in those with syncope and five years in those with angina.

Question 63

The murmur of aortic stenosis is described as:

A. Holosystolic murmur heard best at the cardiac apex
B. Holodiastolic decrescendo murmur heard best at the right sternal border
C. Systolic ejection murmur heard best at the right upper sternal border
D. Diastolic rumble

Answer 63

C. The mid-systolic murmur of aortic valve stenosis is heard best at the right upper sternal border but is often well transmitted along the carotid vessels and to the apex. The murmur of aortic stenosis is harsh
and rasping, crescendo-decrescendo in shape at the right upper sternal border. High-frequency components may selectively radiate to the apex (the Gallavardin phenomena). A reversal of S2 or absent S1 is
associated with the auscultatory findings in these patients.

Question 64

The pulse that is characteristic of significant valvular aortic stenosis is:

A. Pulsus alternans
B. Pulsus bisferiens
C. Pulsus paradoxus
D. Pulsus parvus et tardus

Answer 64

D. The arterial pulse associated with significant valvular aortic stenosis is one that rises slowly and is small and sustained (pulsus parvus et tardus). Pulsus parvus et tardus may be best detected by palpation of the right carotid artery.

Pulsus alternans is alternating weak and strong beats and is associated with severely reduced global ventricular systolic function.

Pulsus bisfierens is two beats within one and is associated with hypertrophic obstructive cardiomyopathy or severe aortic regurgitation.

Pulsus paradoxus is a drop in blood pressure with inspiration by more
than 10 mm Hg and is associated with cardiac tamponade.

Question 65

The aortic valve area considered critical aortic valve stenosis:

A. < 3 cm^2
B. < 2 cm^2
C. < 1.5 cm^2
D. ≤ 0.75 cm^2

Answer 65

D. The aortic valve should be replaced in symptomatic patients with hemodynamic evidence of severe obstruction (aortic valve area ≤ 0.75 cm^2 or ≤ 4 cm^2/m^2). The normal aortic valve area is 3 to 5 cm^2. A recent recommendation states that an aortic valve area of < 1 cm^2 should be considered severe aortic stenosis.

Question 66

The formula used to determine aortic valve area in the cardiac catheterization laboratory is the:

A. Bernoulli equation
B. Continuity equation
C. Doppler equation
D. Gorlin equation

Answer 66

D. In patients with valvular aortic stenosis, the peak-to-peak pressure gradient, mean pressure gradient and aortic valve area are calculated in the cardiac catheterization laboratory. The Gorlin equation for aortic
valve are (AVA) is:

AVA (cm^2) = (CO ÷ SEP) ÷ (43.3 x √MPG)

It should be noted that the peak-to-peak gradient calculated in the cardiac catheterization laboratory will usually be lower than the Doppler maximum peak instantaneous pressure gradient calculated
in the echocardiography laboratory. The mean pressure gradient and aortic valve area are comparable.

AVA, aortic valve area; CO, cardiac output; SEP, systolic ejection period; MPG, mean pressure gradient

Question 67

All of the following may be measured in the cardiac catheterization laboratory when evaluating aortic stenosis ЕХСЕРТ:

A. Peak velocity
B. Maximum peak instantaneous pressure gradient
C. Peak-to-peak pressure gradient
D. Mean pressure gradient

Answer 67

A. Historically the peak-to-peak pressure gradient, mean pressure gradient and aortic valve area are measured in the cardiac catheterization laboratory when evaluating aortic stenosis.

It is important to note that cardiac Doppler measures the maximum peak instantaneous pressure gradient. The Doppler maximum peak instantaneous gradient is nearly always larger than the cardiac catheterization peak-to-peak pressure gradient. Comparing mean
pressure gradient and aortic valve area is important when evaluating cardiac Doppler and cardiac catheterization information since these values should be similar in aortic stenosis.

Question 68

The Doppler maximum peak instantaneous pressure gradient in a patient with aortic stenosis is 100 mm Hg. The cardiac catheterization peak-to-peak pressure gradient will most likely be:

A. Equal to 100 mm Hg
B. Higher than 100 mm Hg
C. Lower than 100 mm Hg
D. Dependent upon respiration

Answer 68

C. Cardiac catheterization historically measures the peak-to-peak pressure
gradient, mean pressure gradient and aortic valve area in the evaluation of aortic stenosis. Doppler measures the maximum peak instantaneous pressure gradient, mean pressure gradient and aortic valve area by the continuity equation. The Doppler maximum peak instantaneous
pressure gradient will nearly always be greater than the cardiac catheterization peak-to-peak pressure gradient in aortic stenosis.

The Doppler mean pressure gradient and aortic valve area should be compared to the cardiac catheterization laboratories mean pressure gradient and aortic valve area because the values should be similar.

Question 69

An effect of significant aortic valve stenosis on the left ventricle is:

A. Asymmetrical septal hypertrophy
B. Concentric left ventricular hypertrophy
C. Eccentric left ventricular hypertrophy
D. Protected in significant aortic valve stenosis

Answer 69

B. In significant aortic valve stenosis, left ventricular wall thickness is increased due to a pressure overload. When the capacity to develop left ventricular hypertrophy has been exhausted, the left ventricle dilates. Thus, left ventricular cavity dimension, wall thickness and global left ventricular systolic function should be measured in aortic
valve stenosis.

Question 70

Pathologies that may result in a left ventricular pressure overload include all the following EXCEPT:

A. Discrete subaortic stenosis
B. Mitral valve stenosis
C. Systemic hypertension
D. Valvular aortic stenosis

Answer 70

B. Left ventricular hypertrophy results from left ventricular pressure overload. Physiologic hypertrophy may occur in competitive athletes. Eccentric left ventricular hypertrophy (hypertrophy with dilatation) may occur in volume overload cases (significant chronic aortic regurgitation, significant chronic mitral regurgitation).

Asymmetric hypertrophy is the non-uniform increase in wall thickness (e.g., hypertrophic cardiomyopathy).

Question 71

The characteristic M-mode findings for aortic valve stenosis include all the following EXCEPT:

A. A lack of systolic flutter of the aortic valve leaflets
B. Diastolic flutter of the aortic valve leaflets
C. Reduced leaflet separation in systole
D. Thickening of the aortic valve leaflets

Answer 71

B. The characteristic M-mode echocardiographic findings in aortic valve
stenosis are marked thickening of the leaflets and reduced leaflet separation in systole. Thickening and/or calcification of the leaflets alone does not necessarily indicate hemodynamically important aortic
valve stenosis. Measurements of aortic valve leaflet separation by M-mode echocardiography correlate poorly with the clinical severity of aortic valve stenosis, with aortic valve gradients and with valve orifice
areas measured at cardiac catheterization.

Diastolic flutter of the aortic valve is associated with severe aortic regurgitation.

Question 72

Possible two dimensional echocardiographic findings in significant aortic valve stenosis include all the following EXCEPT:

A. Aortic valve calcification
B. Left ventricular hypertrophy
C. Post-stenotic dilatation of the ascending aorta
D. Post-stenotic dilatation of the descending aorta

Answer 72

D. Two dimensional echocardiography is also useful in determining the severity of left ventricular hypertrophy, evaluating left ventricular global and segmental systolic function, detecting subvalvular obstruction
and evaluating the status of the other cardiac valves in patients with valvular aortic stenosis.

Question 73

In the parasternal long-axis view, severe aortic valve stenosis is defined as an aortic valve leaflet separation that measures:

A. ≥ 14 mm
B. ≤ 12 mm
C. ≤ 10 mm
D. ≤ 8 mm

Answer 73

D. De Maria and colleagues reported that aortic leaflet separation of ≤ 8 mm, measured from the parasternal long-axis view, was reliable with a predictive value of 82% for severe aortic valve stenosis in patients with normal global left ventricular systolic function. They also observed that
aortic leaflet separation of > 20 mm reliably excluded the diagnosis of aortic valve stenosis.

Question 74

Secondary echocardiographic findings associated with severe valvular aortic stenosis include all the following EXCEPT:

A. Decreased left ventricular systolic function (late in course)
B. Left ventricular hypertrophy
C. Post-stenotic dilatation of the ascending aorta
D. Right ventricular hypertrophy

Answer 74

D. In addition, left ventricular mass will also be increased. Left ventricular mass in grams may be calculated by M-mode with the formula:

0.8 x 1.04 [LVIDd + IVSd + PWLVd)^3 - LVIDd^3] + 0.6

The upper limit for men is 115 g/m^2 and for women is 95 g/m^2.

LVIDd, left ventricular internal dimension end-diastole;
IVSd, interventricular septum end-diastole;
PWLVd, posterior wall left ventricular end-diastole.

Question 75

The two-dimensional view which best visualizes systolic doming of the aortic valve leaflets is the:

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

Answer 75

B. Systolic doming, a feature commonly seen in a stenotic, non-calcified bicuspid aortic valve, is best visualized in the parasternal long-axis view. The parasternal and subcostal short-axis views of the aortic valve are the only two imaging planes in which a bicuspid valve can be reliably diagnosed because the shape of the systolic aortic valve opening can be evaluated. The normal trileaflet aortic valve will triangular in shape
when open during ventricular systole in the parasternal and subcostal short-axis views. A bicuspid aortic valve appears “football-shaped” (elliptical) when open during ventricular systole as viewed in the parasternal and subcostal short-axis views of the aortic valve.

Question 76

Cardiac Doppler parameters used to assess the severity of valvular aortic stenosis include all the following EXCEPT:

A. Aortic pressure half-time
B. Aortic velocity ratio
C. Mean pressure gradient
D. Peak aortic valve velocity

Answer 76

A. In addition, the peak pressure gradient and cardiac output should be assessed in patients with valvular aortic stenosis. Severe aortic valve stenosis Doppler parameters are:

• Peak velocity > 4.0 m/sec*
• Peak pressure gradient > 64 mm Hg*
• Mean pressure gradient > 50 mm Hg*
• Aortic valve area ≤ 0.75 cm^2
• Aortic velocity ratio ≤ 0.25
• Assumes normal global left ventricular systolic function

Question 77

Of the transvalvular pressure gradients that can be measured in the echocardiography laboratory, the most useful in examining
aortic valve stenosis is probably:

A. Mean diastolic gradient
B. Mean systolic gradient
C. Peak instantaneous pressure gradient
D. Peak-to-peak gradient

Answer 77

B. Clinically, the mean systolic gradient may be the most useful expression of aortic valve gradient, as it is directly comparable to the mean gradient measured in the cardiac catheterization laboratory.

The aortic valve area calculated in the cardiac catheterization laboratory should be similar to the aortic valve area determined in the echocardiography laboratory.

It should be noted that cardiac catheterization hemodynamic evaluation for aortic stenosis is not usually necessary since that can be accomplished in the echocardiography laboratory. The principal role of cardiac catheterization in patients with aortic stenosis is the evaluation of coexisting coronary artery disease.

Question 78

A Doppler mean pressure gradient of 18 mm Hg is calculated in a patient with valvular aortic stenosis. The severity o f the aortic stenosis is:

A. Mild
B. Moderate
C. Moderately severe
D. Severe

Answer 78

A. Assuming normal global left ventricular systolic function, a mean pressure gradient of < 30 mm Hg usually indicates mild aortic valve stenosis while a mean pressure gradient > 50 mm Hg is severe. Tracing the continuous-wave Doppler tracing of the aortic valve will provide the aortic valve peak velocity, peak pressure gradient, mean pressure gradient and velocity time integral.

Question 79

The onset of flow to peak aortic velocity continuous-wave Doppler tracing in severe valvular aortic stenosis is:

A. Increased
B. Decreased
C. Decreased with expiration
D. Increased with inspiration

Answer 79

A. As valvular aortic stenosis increases in severity, the acceleration time (onset of flow to peak velocity) becomes longer.

An asymmetric triangular contour with an early peaking of the continuous-wave Doppler aortic stenosis jet usually indicates mild aortic stenosis.

Symmetric and a rounded velocity contour with a late peaking velocity (peak > 50% of total ejection time) of the continuous wave Doppler spectral waveform is usually seen in severe aortic stenosis.

Question 80

The severity of aortic valve stenosis may be underestimated if only the maximum velocity measurement is used in the following condition:

A . Anemia
B. Doppler intercept angle of 0°
C. Low cardiac output
D. Significant aortic regurgitation

Answer 80

C. A potential pitfall in the cardiac Doppler evaluation of aortic valve stenosis is low cardiac output. When there is pump failure, the maximum velocity across the valve may not be high, therefore leading to an underestimation of the severity of aortic valve stenosis. In cases where there is poor global left ventricular systolic function, the aortic valve area as derived by the continuity equation should be calculated. In addition, dobutamine may be used to improve global left ventricular systolic function during the Doppler examination. Planimetry of the aortic valve orifice may be attempted in the short-axis view of the aortic valve using transthoracic echocardiography or transesophageal echocardiography.

The Gorlin equation will underestimate the severity of aortic valve stenosis in patients with low cardiac output.

Question 81

The echocardiographer may differentiate between the similar systolic flow patterns seen in coexisting severe aortic valve stenosis and mitral regurgitation by all the following EXCEPT:

A. Aortic ejection time is shorter that the mitral regurgitation time
B. Mitral regurgitation flow always lasts until mitral valve opening, whereas aortic valve stenosis flow does not.
C. Mitral diastolic filling profile should be present during recording of the mitral regurgitation, whereas no diastolic flow is observed in aortic valve stenosis.
D. Since both are systolic flow patterns, it is not possible to separate mitral regurgitation from aortic valve stenosis.

Answer 81

D. If two high-velocity signals of mitral regurgitation and severe aortic valve stenosis, coexist, the two jets must be clearly differentiated. The aortic ejection time is always shorter than the mitral regurgitation time because no aortic flow occurs during the isovolumic contraction and the relaxation periods. Even though mitral regurgitation may not occur until mid-systole, as with occasional cases of mitral valve prolapse, regurgitation lasts until the mitral valve opens. Simultaneously recorded diastolic signals are also helpful for differentiating these two high-velocity systolic flows; the mitral diastolic filling profile should be present during the recording of mitral regurgitation, whereas no diastolic flow or aortic regurgitation is observed during the recording of aortic valve stenosis.