Ventricular Function Flashcards
An increased mitral valve E point to septal-separation (EPSS) may indicate:
A. Increased left ventricular end-diastolic pressure
B. Pulmonary hypertension
C. Reduced ejection fraction
D. Left atrial myxoma
C. The anterior mitral valve normally makes contact or closely approaches the interventricular septum in early ventricular diastole. With reduced ejection fraction there is an increase in the EPSS independent of left ventricular size. An EPSS value of ≥ 20 mm represents an ejection fraction of < 30%.
Patients with mitral stenosis or significant aortic regurgitation should be excluded.
A mitral valve B-notch (bump) suggests increased left ventricular end-diastolic pressure (LVEDP).
Premature closure of the mitral valve (usually found in patients with severe acute aortic regurgitation) indicates increased left ventricular end-diastolic pressure (LVEDP).
The formula used to determine fractional shortening is:
A. EDV - ESV
B. (EDV - ESV) ÷ EDV x 100
C. (EDD - ESD) ÷ EDD x 100
D. CSA x VTI
EDV, end-diastolic volume;
ESV, End-systolic volume;
EDD, end-diastolic dimension;
ESD, end-systolic dimension;
CSA, cross-sectional area;
VTI, velocity time integral
C. A method used to evaluate global left ventricular systolic function is fractional shortening. The normal range for men: 25 to 43%; women: 27 to 45%.
The formula used to determine ejection fraction is:
A. EDV - ESV
B. (EDD - ESD) ÷ EDD x 100
C. (EDV - ESV) ÷ EDV × 100
D. CSA x VTI
EDV, end-diastolic volume;
ESV, end-systolic volume;
EDD, end-diastolic dimension;
ESD, end-systolic dimension,
CSA, cross-sectional area,
VTI, velocity time integral
C. The normal ejection fraction is ≥ 55% for men and women.
• Mildly abnormal: 45 to 54%
• Moderately abnormal: 30 to 44%
• Severely abnormal: < 30%
An ejection fraction of 42% is determined with two-dimensional echocardiography. This indicates ________ global left ventricular
systolic function.
A. Normal
B. Mildly abnormal
C. Moderately abnormal
D. Severely abnormal
C. A normal ejection fraction is ≥ 55% for men and women.
• Mildly abnormal is 45 to 54%
• Moderately abnormal is 30 to 44%
• Severely abnormal is < 30%
Which of the following methods is recommended to determine left ventricular volumes?
A. Biplane area-length
B. Biplane Simpson’s method of discs
C. Teichholtz
D. Cubed
B. Simpson’s method of discs (MOD) is the best method primarily because it does not assume a certain chamber geometry. The two views recommended to measure left ventricular ejection fraction are the apical four-chamber view and the apical two-chamber. Care must be taken not to foreshorten the ventricle.
Simpson’s method of discs (MOD) may also be used to determine right ventricular volumes, left atrial volumes and right atrial volumes.
Teichholtz is the M-mode method used to determine left ventricular volume.
The formula used to determine stroke volume by Doppler is:
A. EDV - ESV
B. (EDD - ESD) ÷ EDD × 100
C. (EDV - ESV) ÷ EDV x 100
D. CSA x VTI
EDV, end-diastolic volume;
ESV, end-systolic volume;
EDD, end-diastolic dimension;
ESD, end-systolic dimension,
CSA, cross-sectional area;
VTI, velocity time integral
D. Left ventricular stroke volume by Doppler is determined as the product of the left ventricular outflow tract cross-sectional area (CSA) multiplied by the left ventricular outflow tract velocity time integral (VTI) obtained with pulsed-wave Doppler in the apical five-chamber view or apical long-axis view.
End-diastolic volume (EDV) - end systolic volume (ESV) is the formula for stroke volume when using M-mode to two-dimensional echocardiography.
In patients with dilated cardiomyopathy, the index of myocardial performance (IMP) will be:
A. Normal
B. Increased
C. Decreased
D. Dependent upon blood pressure
B. IMP = (IVCT + IVRT) ÷ ET where IMP is IVCT is isovolumic contraction time; IVRT is isovolumic relaxation time; ET is ejection time.
With poor global ventricular systolic function, the IVCT increases, the IRT increases and the ET shortens.
The normal value is 0.39 +/- 0.05 and is increased in patients with dilated cardiomyopathy ( > 0.59).
_________ is a direct measure of myocardial contractile function.
A. Strain
B. EPSS
C. E-F slope
D. Deceleration time
A. Strain is the change in length during myocardial contraction and is expressed as a percentage and is based on tissue Doppler imaging techniques.
Strain rate is the rate of deformation (change in length) and is expressed in 1/s.
Both strain and strain rate may be useful parameters when evaluating ventricular segmental and global systolic function and identifying myocardial disease processes (e.g., hypertrophic cardiomyopathy,
Fabry’s disease).
The rate at which the left ventricular pressure rises in ventricular systole is referred to as:
A. dv/dt
B. dP/dt
C. dt/dP
D. dd/tP
B. The rate at which the left ventricular pressure increases (dP/dt) is a measure of left ventricular contractility. A continuous-wave Doppler tracing of mitral regurgitation is obtained and one takes two points along the slope of the mitral regurgitation flow, calculates the pressure gradient between the left ventricle and the left atrium at each point and divides by the time between these two points. For convenience, one can make the first determination at 1 m/sec and the second at 3 m/sec.
Using the simplified Bernoulli equation, the 1 m/sec point is 4 mm Hg and the 3 m/sec is 36 mm Hg. Then, one can calculate dP/dt by dividing the difference, or 32 mm Hg, by dt in milliseconds. The normal value is > 1200 mm Hg/sec and the abnormal value is < 1000 mm Hg/sec.
A pulsed-wave Doppler tracing of the mitral valve inflow at the leaflet tips is obtained with the following information: E/A ratio is 0.7; deceleration time is 320 msec; a tissue Doppler at the mitral annulus demonstrated an E’ peak velocity of 6 cm/s and an E/E’ ratio is calculated to be 7. The diastolic grade is:
A. Normal diastolic function
B. I
С. ІІ
D. III or IV
B. A reduced E/A ratio ≤ 0.75, increased deceleration time > 220 msec, a tissue Doppler E’ velocity of < 8 cm/s and a E/E’ ratio of < 8 suggests Grade I. Grade I represents impaired relaxation and suggests normal diastolic filling pressures.
A pulsed-wave Doppler tracing of the mitral valve inflow at the leaflet tips is obtained with the following information: E/A ratio is 1.2, deceleration time is 200 msec, tissue Doppler of the mitral annulus peak E’ wave velocity is 7 cm/s, E’/A’ ratio is .6 and a E/E’ ratio of 12 is calculated. The diastolic grade is Grade:
A. I
В. II
С. ІІI
D. IV
B. Grade II is pseudonormalization and suggests impaired relaxation with mild to moderate reduction in ventricular compliance and mild to moderate increase in filling pressures. The strain phase of the Valsalva maneuver may be used to unmask the pseudonormalization flow pattern. Tissue Doppler of the mitral annulus is useful because it will demonstrate E’/A’ reversal (E/A’ ratio < 1) in patients with pseudonormalization.
A pulsed-wave Doppler tracing of the mitral valve inflow at the leaflet tips is obtained with the following information: E/A ratio is 2.3, deceleration time is 123 msec, Valsalva maneuver demonstrated no change in the E/A ratio, tissue Doppler of the mitral valve annulus demonstrates an E’ wave peak velocity of 3 cm/s and an E/E’ ratio of 33 is calculated. The diastolic grade is grade:
A. I
В. II
С. ІІI
D. IV
D. The restrictive filling pattern can be subdivided into reversible restrictive (grade III) and fixed restrictive Grade IV). If there is a change in the pulsed-wave Doppler E/A ratio to Grade II or Grade I during the Valsalva maneuver, then the diastolic grade is reversible restrictive (Grade III). If there is less than a 10% change in the E/A ratio, fixed restrictive (Grade IV) is reported out.
The restrictive filling pattern suggests impaired relaxation, marked reduction in ventricular compliance with significant elevation of filling pressures.
Which maneuver is most useful to use when trying to determine the presence of Grade II (pseudonormalization) or when determining between Grade III (reversible restrictive) and Grade
IV (fixed restrictive):
A. Valsalva
B. Mueller
C. Leg raising
D. Squatting
A. The strain phase of the Valsalva maneuver decreases venous return which reduces preload decreasing the filling pressures transiently.
Grade II will return to Grade I during the strain phase of the Valsalva maneuver. Grade III (reversible restrictive) will return to Grade II or Grade I during the strain phase of the Valsalva maneuver. Grade IV (fixed restrictive) E/A ratio will change less than 10% with the strain phase of the Valsalva maneuver.
The most common etiology for ischemic heart disease is coronary artery:
A. Aneurysm
B. Atherosclerosis
C. Embolus
D. Spasm
B. Atherosclerosis, the principal cause of death in Western civilization, is a progressive disease process that generally begins in childhood and has clinical manifestations in middle to late adulthood.
The most specific echocardiographic finding for ischemic heart muscle is:
A. Abnormal diastolic wall motion at the ischemic segment
B. Alterations in systolic wall thickening
C. Normal diastolic wall motion
D. Normal systolic wall motion
B. Probably the most specific finding for ischemic heart muscle is alteration in systolic thickening. Normal myocardial muscle increases in thickness with systolic contraction. When the blood supply to the heart muscle is disrupted as in acute myocardial ischemia or myocardial infarction the result is a reduction in systolic wall thickening.
A wall segment of the heart that is without systolic wall thickening is best described as:
A. Hypokinetic
B. Akinetic
C. Dyskinetic
D. Hyperkinetic
B. A qualitative assessment of left ventricular systolic segmental function can be made with echocardiography. Hyperkinetic refers to increased systolic wall thickening as compared with normal systolic wall thickening. (e.g., normal response to exercise). Hypokinetic refers to decreased systolic wall thickening. Akinetic is the absence of systolic wall thickening. Dyskinetic refers to a wall segment that moves the opposite of normal.
The correct term for describing decreased ventricular systolic wall thickening is:
A. Hyperkinetic
B. Hypokinetic
C. Akinetic
D. Dyskinetic
B. A qualitative method for analyzing systolic wall thickening uses the following numbers and descriptive terms:
1 - Normal or Hyperkinetic
2 - Hypokinetic (decreased systolic wall thickening)
3 - Akinetic (absence of systolic wall thickening)
4 - Dyskinetic (moving in the opposite direction of normal during ventricular systole)
5 - Aneurysmal (diastolic deformation)
A systolic wall motion score of 3 is assigned to a certain segment of left ventricular muscle indicates:
A. Normal
B. Hypokinetic
C. Akinetic
D. Dyskinetic
C. For segmental systolic wall function a wall motion score index has been proposed. Each segment is judged by a scheme that assigns a 1 for a normal (or hyperkinetic such as is seen in stress echocardiography post-exercise) segment, 2 for hypokinesis, 3 for akinesis, 4 for dyskinesis and 5 for aneurysmal.
The left ventricular wall motion score index is then derived by adding the scores and dividing by the number of segments evaluated. A normal wall motion score index is 1. A wall motion score index of 2 is significantly abnormal.
In determining the size of myocardial infarction echocardiography generally:
A. Is unpredictable
B. Overestimates recent myocardial infarction and underestimates old myocardial infarction
C. Predicts the exact size of infarct
D. Underestimates recent myocardial infarction and overestimates old myocardial infarction
B. As a general rule echocardiography tends to overestimate recent myocardial infarction and to underestimate old myocardial infarction. The explanation may be in part a result of stunning in the acute myocardial infarction setting. The tethering effect may explain the underestimation of old myocardial infarction.
The normal response of non-infarcted myocardium in a patient with acute myocardial infarction is:
A. Hyperkinesis
B. Hypokinesis
C. Akinesis
D. Dyskinesis
A. In acute myocardial infarction two-dimensional echocardiography will demonstrate abnormal systolic wall thickening of the affected wall segments) with hyperkinesis of the opposing walls).
The echocardiographic appearance of necrotic myocardium secondary to myocardial infarction includes all of the following EXCEPT:
A. Akinetic wall segment
B. Echogenic wall segment
C. Thin ventricular wall
D. Wall motion score of 1
D. After the initial myocardial infarction healing starts, the necrotic myocardium is replaced within a few weeks by a scar of fibrous tissue.
The resulting echocardiographic appearance of an old myocardial infarction is that of a thin, akinetic myocardial wall segment that is more echogenic (bright) than the surrounding healthy myocardium.
The definition of stunned myocardium is:
A. Myocardium after cardiopulmonary resuscitation
B. Myocardium after electrical cardioversion
C. Myocardium that is hyperkinetic post-myocardial infarction
D. Reperfused viable myocardium that is not functioning
D. Stunned myocardium is a term used to describe ischemic muscle that is reperfused and is still viable but not functioning
Hibernating myocardium is:
A. Myocardium that is hyperkinetic post-myocardial infarction
B. Reperfused viable myocardium that is functioning
C. Viable myocardium at rest but not functioning with exercise
D. Viable myocardium that is nonfunctioning because of chronic ischemia
D. Hibernating myocardium is viable muscle that is nonfunctioning because of chronic ischemia. Reperfusion may restore function.
Stress echocardiography methods that may be used to detect hibernating myocardium include:
A. Cold pressure
B. Handgrip
C. Low-dose dobutamine
D. Treadmill
C. It has been demonstrated that low-dose dobutamine improves hibernating myocardium but as the dose of dobutamine increases the hibernating wall motion decreases. (biphasic response).
A possible etiology for pericardial effusion is:
A. Acute myocardial infarction
B. Mitral valve prolapse
C. Pulmonary regurgitation
D. Mitral valve stenosis
A. Pericardial effusion is common after acute myocardial infarction occurring in approximately 25% of these patients and usually develops within one to three days after presentation. The pericardial effusion is usually small to moderate in size and can be loculated.
A pericardial effusion develops in a patient two weeks post-myocardial infarction. This suggests ___________ syndrome.
A. Dressler’s
B. Down
C. Marfan
D. Williams
A. Pericarditis which develops greater than two weeks post-myocardial infarction suggests Dresser’s syndrome. Dressler’s syndrome is a delayed form of pericarditis post-myocardial infarction occurring 2 to 12 week after the infarction.
Down syndrome is associated with complete atrioventricular septal defect.
Marfan syndrome is associated with dilatation of the aortic annulus, sinus of Valsalva and ascending aorta, mitral valve prolapse, aortic regurgitation, mitral regurgitation and aortic dissection.
Williams syndrome is associated with supravalvular aortic stenosis (hourglass type) and peripheral pulmonary stenosis.
Echocardiographic findings in the post-myocardial infarction patient include:
A. Mitral annular calcification
B. Mural thrombus
C. Valvular stenosis
D. Ventricular septal aneurysm
B. Mural thrombus is associated with ischemic heart disease due to the presence of abnormal wall motion (e.g., akinesis). Thrombus formation usually occurs within the first week after the infarction, are most often found at the cardiac apex and occur because of akinesis of the infarcted wall. A high frequency transducer should be used and transpulmonary contrast may be indicated.
A thrombus shape that is associated with embolization is:
A. Spherical
B. Flat
C. Eccentric
D. Pedunculated
D. A thrombus is a distinct mass which protudes into the cavity, can be sessile, pedunculated or flat. Flat, immobile thrombus have less tendency to embolize. Thrombus that protrude into the cavity that are mobile and pedunculated are prone to embolize.
The infarction most commonly associated with left ventricular
aneurysm is:
A. Anterior
B. Inferior
C. Lateral
D. True posterior
A. Anterior myocardial infarctions commonly produce left ventricular aneurysms. 90% of left ventricular aneurysms form at the cardiac apex due to anterior infarction. Aneurysms appear as a thin, bulging wall which is akinetic and may have dyskinetic motion. Often spontaneous echo contrast (“smoke”) or thrombus may be found within the aneurysm.
Echocardiography differentiates a pseudoaneurysm from a true ventricular aneurysm by the:
A. Diastolic motion of the aneurysm
B. Length of the aneurysm
C. Width of the border of the aneurysm
D. Width of the neck of the aneurysm
D. Pseudoaneurysm is myocardial rupture contained by the pericardium. The echocardiographic criterion that differentiates a pseudoaneurysm from a true aneurysm is the width of the neck of the aneurysm. That portion of the pseudoaneurysm communicating with the left ventricular cavity is smaller than the diameter of the pseudoaneurym itself. The neck to maximum diameter ratio is < 0.5 in pseudoaneurysm.
Another criterion for the echocardiographic diagnosis is that during ventricular systole the cavity of the left ventricle gets smaller while the pseudoaneurysm frequently expands. Color flow Doppler can assist in this assessment.
The expected Doppler finding in a patient with ventricular septal rupture is:
A. Laminar low-velocity flow during diastole on the left side of the interventricular septum
B. Laminar high-velocity flow in diastole on the right side of the septum
C. Turbulent high-velocity flow in diastole on the right side of the septum
D. Turbulent high-velocity flow in systole on the right side of the interventricular septum
D. Ventricular septal rupture usually occurs within the first week of acute myocardial infarction. It is more common in elderly women who have not had a previous myocardial infarction. Nearly one-half of the patients who develop ventricular septal rupture have single vessel disease.
Doppler echocardiography is an excellent means of detecting a ruptured interventricular septum. Turbulent, high-velocity flow can be detected in systole on the right side of the interventricular septum in both the short-axis and four-chamber views. Such a study can be reliable and specific for a ventricular septal rupture.
Possible mechanisms in the development of mitral regurgitation following acute myocardial infarction include all of the following EXCEPT:
A. Fibrosis of the papillary muscle
B. Incomplete closure of the mitral valve
C. Mitral valve stenosis
D. Papillary muscle rupture
C. Mitral regurgitation can occur post-myocardial infarction (20%) because the spatial relationship of the mitral valve apparatus has been disrupted which can result in tenting of the mitral valve or pseudo-mitral valve prolapse Other causes include fibrosis of the papillary muscle or partial or complete papillary muscle rupture.
The type of myocardial infarction which most often involves the right ventricle is:
A. Anterior
B. Lateral
C. Inferior
D. Anterolateral
C. The right ventricle is affected primarily when inferior infarction occur. The situation usually arises when the proximal portion of the right coronary artery is obstructed interrupting blood flow to the right ventricular branches as well as to the inferior wall of the left ventricle.
The right ventricle will be dilated with segmental wall motion abnormality present. Tricuspid regurgitation may be present and low velocity (< 2 m/s) due to poor global right ventricular systolic function.
The principal echocardiographic/Doppler findings of right ventricular infarction include all of the following EXCEPT:
A. Abnormal motion of the right ventricular free wall
B. Right ventricular dilatation
C. Right ventricular hypertrophy
D. Tricuspid regurgitation
C. Principal echocardiographic abnormalities noted with right ventricular infarction are segmental wall motion abnormality of the right ventricular free wall, reduced global right ventricular systolic function and dilatation of the right ventricle. Tricuspid regurgitation is present probably due to tricuspid annulus dilatation. The tricuspid regurgitant jet will probably be low (< 2 m/s) because of low pulmonary artery pressures. A right ventricular infarct may cause a right-to-left shunt through a patent foramen ovale.
Which of the following mitral valve flow patterns provides risk stratification post-myocardial infarction?
A.. Normal for age
B. Impaired relaxation (Grade I)
C. Pseudonormal (grade II)
D. Restrictive (Grade III-IV)
D. Patients with increased risk for future cardiac events post-myocardial infarction include a left ventricular ejection fraction of < 40%, left atrial enlargement, moderate mitral regurgitation and a restrictive diastolic filling pattern.
The four most common two-dimensional views acquired during a stress echocardiogram are the parasternal long-axis, parasternal short-axis of the left ventricle at the level of the papillary muscles, the apical four-chamber view and the:
A. Apical five-chamber
B. Apical long-axis
C. Subcostal short-axis at the cardiac base
D. Apical two-chamber
D. The apical views are usually acquired first post-exercise.
Newer ultrasound devices now allow the inclusion of additional two-dimensional views. Evaluation of mitral regurgitation and diastolic function may be added once the two-dimensional views have been acquired.
The primary indication for stress echocardiography is:
A. Evaluation for coronary artery disease
B. Evaluation of ejection fraction
C. Assessment of cardiac valve abnormalities
D. Diagnosis of shunt lesions
A. The primary indication for a stress echocardiogram is for the detection of coronary artery disease. Exercise (e.g., treadmill, bicycle) or pharmacologic agents (e.g., dobutamine) are used to increase the heart rate with pre- and post-images acquired and evaluated for evidence of coronary artery ischemia.
For exercise echocardiography the images post-exercise need to be acquired within _________ from the time the patient exercise is completed.
A. 5 minutes
B. 60 seconds
C. 60 minutes
D. 3 hours
B. Wall motion abnormalities induced by exercise can resolve quickly so the post-exercise images need to be acquired within 60 seconds or sooner post-exercise. Explaining the exam and its purpose to the patient, practicing the routine of leaving the treadmill with the patient and marking the approximate location of the parasternal and apical windows are important techniques to help acquire the post-exercise images within 60 seconds or less.
Which of the following pharmacologic agents increases contractility and increases heart rate?
A. Propranolol
B. Verapamil
C. Dobutamine
D. Digitalis
C. Dobutamine is the most common drug used in the United States for pharmacologic stress echocardiography because it increases oxygen demand via increasing contractility (positive inotrope) and increasing heart rate (positive chronotrope).
The most common medication used in performing pharmacological stress echocardiography is:
A. Dobutamine
B. Dipyridamole
C. Propranolol
D. Adenosine
A. Dobutamine is the most commonly used technique and is important when assessing myocardial viability. Dipyridamole (similar to adenosine) is a vasodilator which increases blood flow to the coronary arteries and may be used for pharmacological stress echocardiography.
A positive stress echocardiogram consists of:
A. Normal wall motion pre and post exercise
B. Normal wall motion to akinesis
C. Improved ejection fraction
D. Normal left atrial dimension peak exercise
B. Positive stress echocardiograms include normal wall motion to akinesis, dyskinesis or hypokinesis, absence of hyperkinesis, worsening of a wall motion abnormality (e.g., hypokinetic to akinetic), left ventricular dilatation, reduced ejection fraction, left atrial dilatation, increased severity of mitral regurgitation and/or systemic hypotension.
Patients with increased diastolic filling pressures post-exercise will demonstrate:
A. Normal mitral E/A ratio
B. E/E’ ratio > 10
C. Increased mitral deceleration time
D. Normal tricuspid regurgitation peak velocity
B. Evaluation of diastolic function is feasible during a stress echocardiogram. Evaluating the mitral valve peak E velocity and deceleration time may be useful as well as tissue Doppler of the mitral annulus and evaluation of the E/E’ ratio may be able to predict increased filling pressures. The medial annulus of the mitral valve is suggested when using tissue Doppler post-exercise.
