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What valve separates the areas of greatest pressure differences? - Correct Answer- Mitral valve What valve separates the areas of the lowest pressure differences? - Correct Answer- Tricuspid valve Where does the LAD lie on the heart? - Correct Answer-Anterior interventricular groove (sulcus) What aortic cusp is superior in PLAX view? - Correct Answer-RCC What aortic cusp is posterior in PLAX view? - Correct Answer-NCC From the left parasternal window which of the following are you most likely to get accurate velocity measurments? - Correct Answer-Pulmonary artery What view gives the most accurate velocities of the PV/pulmonary artery? - Correct Answer-PSAX; short axis What is the red flow traveling to the RA that you can sometimes see from the inflow view? - Correct Answer-IVC What are the tricuspid leaflets seen in the inflow view? - Correct Answer-anterior and posterior Where is the LAA located on TTE? - Correct Answer-Sometimes can be seen in AV level short axis, but is better visualized in an apical 2 chamber view The coronary arteries come off the: - Correct Answer-Sinuses of Valsalva What is the most anomalous artery? - Correct Answer-Right coronary During which phase do the coronaries fill? - Correct Answer-early diastole True/False --- The coronary arteries can fill during systole - Correct Answer-False When is TAPSE measured? - Correct Answer-Between end diastole and peak systole This is the transition between the sinuses of Valsalva and the tubular portion of the ascending aorta - Correct Answer-STJ (sinotubular junction)
What can sometimes be seen below the RPA in a SSN view? - Correct Answer-Left atrium The best images of the ascending aorta are often obtained from which transducer window? - Correct Answer-suprasternal Name the vessels coming off the arch and most proximal or distal. - Correct Answer- Innominate (proximal), left carotid and left subclavian (distal) What cardiac pathology is associated with bicuspid aortic valves? - Correct Answer- Coarctation of the aorta Which window do you use to look for the secondary finding in bicuspid valves? - Correct Answer-Suprasternal arch; suprasternal notch Where do most aortic coarctations occur? - Correct Answer-aortic isthmus How can we specifically identify the location of an aortic isthmus? - Correct Answer- After the take-off of the left subclavian artery Where are the pulmonary veins located? Where are they best visualized? - Correct Answer-Feed into the LA and are best visualized in 4 chamber What pulmonary veins are viewed in apical 4 chamber? - Correct Answer-Lower pulmonary veins What pulmonary veins are viewed in apical 5 chamber? - Correct Answer-Upper pulmonary veins From the apical 4 chamber view how do you rotate the transducer to obtain the apical LAX? - Correct Answer-clockwise 120 degrees Where is the coronary sinus located? - Correct Answer-posterior AV groove Which view do you use to evaluate the coronary sinus? - Correct Answer-PLAX To visualize the coronary sinus in the apical 4 chamber view you should tilt the transducer: - Correct Answer-posterior Which valve sits at the opening of the coronary sinus? - Correct Answer-Thebesian What valve sits at the opening of the IVC? - Correct Answer-Eustachian Where is the Chiari network located? - Correct Answer-Right atrium
Does venous return increase or decrease with inspiration? - Correct Answer-decrease Mitral valve velocity during inspiration: - Correct Answer-decreases Tricuspid valve velocity during inspiration: - Correct Answer-increases What occurs after the R wave on ECG? - Correct Answer-IVCT What occurs after the T wave on ECG? - Correct Answer-IVRT On the wiggers diagram, when is the mitral valve open? - Correct Answer- 4 - 1 What is the duration of the IVCT and IVRT? - Correct Answer-70 msec The duration of the IVRT will be increased with: - Correct Answer-Bradycardia During the cardiac cycle this event never happens: - Correct Answer-A) Ao valve is open & mitral valve is open What is the correct order for the cardiac cycle? - Correct Answer-Mechanical diastole, electrical diastole, electrical systole, mechanical systole When is the LA volume the highest? - Correct Answer-Systole When is the LV volume the highest? - Correct Answer-Diastole When do we make LA measurements? - Correct Answer-End systole When do we make LV measurements? - Correct Answer-End diastole What percent of the blood volume is plasma? - Correct Answer-54% What percent of the blood volume is red blood cells? - Correct Answer-45% What percent of the blood volume is white blood cells and platelets? - Correct Answer- 1% What are the normal pressures in the pulmonary artery? - Correct Answer-25/ Where is the O2 saturation the lowest? - Correct Answer-Coronary sinus When carries oxygenated blood? - Correct Answer-Veins What carries deoxygenated blood? - Correct Answer-Arteries What is the best cath technique for LV function? - Correct Answer-LV angiogram
What is PCW measuring? - Correct Answer-Left atrial pressure Where is the Swan-Ganz placed in the heart? - Correct Answer-Right side What catheter is used when measuring PCW (Left atrial pressure)? - Correct Answer- Swan-Ganz What type of gradient does cath lab use? - Correct Answer-Peak-to-peak In cath lab, to determine AS where are the catheters placed? - Correct Answer-One in the LV and one in the Ao OR one in the LV and "pulled back" across the Ao Valve or one catheter with two separate sensors What does low frequency mean? - Correct Answer-better penetration What does high frequency mean? - Correct Answer-better resolution Tissue harmonic imaging results in: - Correct Answer-thicker valve leaflets Apical swirling of echo contrast for LVO is caused by: - Correct Answer-High MI What causes the attenuation of contrast? - Correct Answer-Amount of contrast injected is too high or was injected too fast Sonographers should do peer to peer reviews how often for quality/technical review? - Correct Answer-2 times per month Whose responsibility is it to obtain the informed consent prior to a TEE? - Correct Answer-Physician A secondary finding in aortic stenosis is? - Correct Answer-left ventricular hypertrophy In aortic stenosis is pulse pressure wide or narrow? - Correct Answer-Narrow (pulse pressure is the difference between systolic and diastolic pressures-- it is wide in AI and narrow in AS) What is severe for aortic jet velocity? - Correct Answer-Greater than or equal to 4 What is severe for the mean gradient when assessing AS? - Correct Answer-Greater than or equal to 40 What is severe for AVA when assessing AS? - Correct Answer-< 1. What is severe for indexed AVA when assessing for AS? - Correct Answer-< 0.
The normal aortic valve area is: - Correct Answer- 3 - 4cm NOTE: less than 1 is severe stenosis What number occurs with severe stenosis? - Correct Answer-< 1.0 cm Using the continuity equation when would the severity of AS be underestimated? - Correct Answer-LVOT measured too large Which pressure is obtained during doppler? - Correct Answer-Peak or peak instantaneous (for AS it's the highest gradient anytime during systole) Echo gradients are usually higher/lower than cath gradients - Correct Answer-higher PS does/does not cause pulmonary hypertension. - Correct Answer-does NOT Specifically, with VSD PS saves the lungs so no pulmonary HTN is present What is the most common cause of PS? - Correct Answer-congenital What syndrome presents with PS, HCM, and an ASD (30%)? - Correct Answer-Noonan syndrome Describe Noonan Syndrome and what valvular stenosis it is associated with - Correct Answer-Classified as cardiofacial syndrome with PS, HCM, and an ASD (30%) What will M-mode show if PS is present? - Correct Answer-Increase in the pulmonic "a" dip of more than 7mm (only useful for severe PS) What is the normal pulmonary velocity? - Correct Answer-1 m/sec If you note a pulmonary velocity that measures 4 m/sec (64 mm Hg gradient) what would this represent? - Correct Answer-Severe PS In pulmonary hypertension, what happens to the "a" dip? - Correct Answer-it disappears Asked if unable to obtain PS gradient from the parasternal window where else can you go? - Correct Answer-subcostal short axis What murmur is associated with MS? - Correct Answer-Diastolic rumble with opening snap What physical sign is commonly seen with MS? - Correct Answer-A fib How can the leaflets appear during MS? - Correct Answer-hockey stick appearance
What cardiac valve is the second most common to be affected by rheumatic heart disease? - Correct Answer-Aortic (Tricuspid 20% of the time) Patients with mitral stenosis often develop: - Correct Answer-A fib What does a hockey stick leaflet indicate? - Correct Answer-Rheumatic MS With atrial fibrillation mitral stenosis velocity calculations are best performed: - Correct Answer-averaged over 5-10 beats NOTE: Not unable to measure in afib, but overall more difficult In the PSAX view which method is used to assess the MV area? - Correct Answer- Planimetry Given a mitral pressure half-time of 400 m/sec what would the area be? - Correct Answer-0.5 cm Given a mitral deceleration time of 400 m/sec calculate the mitral valve pressure half- time: - Correct Answer- 116 What is the most common cause of TS? - Correct Answer-rheumatic fever What does carcinoid TS mean? - Correct Answer-Fixed body of leaflets What does rheumatic TS mean? - Correct Answer-Tethered leaflet tips What is the difference between carcinoid and rheumatic regarding TS? - Correct Answer-Carcinoid is fixed body of leaflets Rheumatic is tethered leaflet tips What does carcinoid heart disease result from? - Correct Answer-Increased serotonin production from a carcinoid tumor (intestinal tract (40%) or appendix (25%) What is the most common type of VSD in adults? - Correct Answer-membranous Which anomaly goes with aortic dissection? - Correct Answer-Marfan syndrome What type of murmur is associated with sinus of valsalva aneurysm? - Correct Answer- High pitched, Diastolic blowing murmur What kind of murmur would you hear in a patient with a rupture of a sinus of Valsalva aneurysm? - Correct Answer-Continuous
With TR, we can note what? - Correct Answer-IVC dilation Systolic flow reversal of bubbles in the IVC---TR or tamponade? - Correct Answer-TR If flow reversal of bubbles is seen in the IVC during systole, it is _________________ regurgitation - Correct Answer-tricuspid What is the most common valvular problem associated with carcinoid syndrome? - Correct Answer-TR NOTE: Carcinoid increases serotonin ---> gets filtered by lungs which is why the left valves are not affected. What does CVP (central venous pressure) refer to? - Correct Answer-IVC pressure close to the RA Hepatic venous flow reversal indicates _____________ TR. - Correct Answer-severe To assess systolic hepatic reversal, we should do what to the sweep speed? - Correct Answer-Turn down (make waveforms smaller to visualize more) We will see triangular shaped, severe TR during what condition? HINT: Remember what disease affects right heart or right valve specifically - Correct Answer-Carcinoid NOTE: TR truncated during systole Given a TR velocity of 4.0 m/sec what is the RVSP? - Correct Answer-70mmHg When given no info on CCI for calculating RVSP, what number do we automatically use? - Correct Answer- 8 (Add 8) What is the biggest segment on the MV leaflets? HINT: A1, A2, A3, P1, P2, P3 - Correct Answer-P2 = biggest A vena contracta might be seen in which type of cardiomyopathy? - Correct Answer- Dilated What is the term for when a regurgitation jet "hugs" the wall? - Correct Answer-Coanda effect
If you suspect severe MR where else should you look? - Correct Answer-Pulmonary vein The greatest source of error in measuring PISA is with: - Correct Answer-radius of the flow convergence Which of the following is used in echo to measure dP/dt? - Correct Answer-Mitral regurgitation dP/dt measurement of mitral regurgitation assesses what? - Correct Answer-LV systolic function What is the normal LV dP/dt? - Correct Answer-> 1200 mmHg/sec What is Marfan syndrome? - Correct Answer-congenital connective tissue disease causing aortic dilatation and MVP In Marfan syndrome why does aprtic dissection and MVP occur? - Correct Answer- Decreased fibrillin What is Ehlers-Danlos syndrome? - Correct Answer-A connective tissue disease; like Marfan patients you need to look for MVP, dilated Ao, and dissection Severe aortic aneurysms are greater than: - Correct Answer-5.0 cm Know Debakey/Sanford classifications - Correct Answer-Pg. 100 in book Mitral regurgitation may lead to: - Correct Answer-left atrial enlargement What can we hear that is associated with MVP? - Correct Answer-Mid systolic click with or without a systolic murmur Can we, as sonographers, diagnose MVP from an apical 4 chamber view? - Correct Answer-No Can we diagnose MVP in the presence of a large pericardial effusion? - Correct Answer-No If shown an apical 4 chamber image with obvious MVP, the answer is MVP unless it specifically says: - Correct Answer-Do not call MVP from this view With MVP, in what direction do the jets travel? - Correct Answer-Opposite the affected leaflet(s) Libman-Sachs (systemic lupus erythematosus) is seen in patients with? - Correct Answer-Lupus
- SAM (systolic anterior motion of the MV)
- IHSS (idiopathic hypertrophic subaortic stenosis - SAM & ASH)
- HCM (hypertrophic cardiomyopathy)
- HOCM (hypertrophic obstructive cardiomyopathy - SAM & HCM) What is the most common type of hypertrophic cardiomyopathy? - Correct Answer-ASH Which cardiomyopathy is autosomal dominant? - Correct Answer-hypertrophic Apical Hypertrophic Cardiomyopathy is known as: - Correct Answer-Typical Ace of Spades on 2-D; More common in Japan; thick apex In hypertrophic cardiomyopathies, how can the myocardium appear? - Correct Answer- "Bright" appearance from fiber disarray What is the ratio for assessing asymmetric hypertrophy? - Correct Answer-> 1.3: NOTE: Septal to posterior wall LVOT obstruction causes the aortic valve to: - Correct Answer-close in mid systole If Mitral inflow shows an A wave greater than the E, this means: - Correct Answer- abnormal relaxation What type of jet is associated with HOCM? - Correct Answer-Dagger shaped; late peaking Does Inderal (beta blocker) increase SAM? - Correct Answer-No, decreases heart rate, reduces SAM with exercise NOTE: SAM is increased with increase in HR. ( amyl nitrate and Valsalva will increase SAM). Systolic anterior motion of the mitral valve occurs in severe MS 61 year old patient with IHSS and a resting gradient of 144 mm Hg. Admitted to the hospital with chest pain. The next day the resting gradient was 15 mm Hg. What happened? - Correct Answer-Left ventricular infarct What views do we use when assessing strain? - Correct Answer-Apical 4, 2, and long axis (3 chamber) Global Longitudinal Strain in patients with HOCM is typically - Correct Answer--10% What type of cardiomyopathy is chagas disease associated with? - Correct Answer- Dilated (congestive)
What is the pathophysiology of congestive (dilated) cardiomyopathy? - Correct Answer- Thin walled, but dilated chambers What type of pulse is associated with congestive (dilated) cardiomyopathy? - Correct Answer-Pulsus alternans NOTE: Alternating strong and weak pulse (pressure) We see pulsus alternans in what type of cardiomyopathy? - Correct Answer-We see it in really bad, dilated cardiomyopathies What is the cause of a B-notch on M-mode? - Correct Answer-Increased LVEDP What are some of the echo signs associated with congestive (dilated) cardiomyopathy?
- Correct Answer-1. Multichamber enlargement
- Globally impaired LV contractility
- B-notch on mitral valve M-mode (increased LVEDP)
- Reduced aortic root excursion
- Thrombus may be present
- Small pericardial effusion may be present
- Increased E-point to septal separation (>7mm)
- Reduced mitral valve excursion (double diamond on M-mode) What is the 2-D appearance post-transplant? - Correct Answer-Double atria What would you see on the ECG with a post heart transplant? - Correct Answer-2 P waves on ECG What is the most common type of restrictive (infiltrative) cardiomyopathy? - Correct Answer-Amyloidosis Amyloid and sarcoid are what type of cardiac abnormalities? - Correct Answer- Infiltrative What is the meaning of hemochromatosis? - Correct Answer-Excessive iron What type of cardiomyopathy presents with a "ground glass" appearance? - Correct Answer-Restrictive (infiltrative) What cardiomyopathy involves abnormal proteins? - Correct Answer-Amyloidosis How are abnormal proteins associated with Amyloidosis described? - Correct Answer-A translucent waxy protein build up on the myofibrils
What is the murmur of a pericardial effusion? - Correct Answer-friction rub *****Know classic M-mode pattern of a pericardial effusion***** - Correct Answer-Pg. 139 - 141 in book What is the grading criteria for a small pericardial effusion? - Correct Answer-Posterior fluid; < 1 cm What is the grading criteria for a medium pericardial effusion? - Correct Answer-Anterior and posterior; 1-2 cm What is the grading criteria for a large pericardial effusion? - Correct Answer- Surrounding the heart; > 2 cm What to do if tamponade is suspected? - Correct Answer-immediate interpretation This condition requires emergent pericardiocentesis: - Correct Answer-Tamponade During a pericardiocentesis, where is the needle inserted? - Correct Answer-Subcostal approach into the posterior pericardial space What 3 signs make up becks triad? - Correct Answer-Elevated venous pressure Hypotension Quiet Heart What can the ECG show if tamponade is present? - Correct Answer-Electrical alternans The most sensitive way to diagnose cardiac tamponade is: - Correct Answer- Respiratory variation What does Doppler usually show if tamponade is present? - Correct Answer- Respiratory variation in transvalvular flow > 25% What cardiac condition would prevent diastolic right ventricular collapse? - Correct Answer-Pulmonary hypertension We can produce a false positive diagnosis of tamponade is there is an: - Correct Answer-Unstable sample volume *****Know pg. 145 in book***** - Correct Answer-Ok What other pericardial abnormality also causes impaired ventricular filling? - Correct Answer-Constrictive pericarditis Pericardial knock; leads to tamponade
With this condition we can note flat LV posterior wall motion in diastole - Correct Answer-Constructive pericarditis With this condition we can see a septal shift/bounce with inspiration - Correct Answer- Constructive pericarditis When constructive pericarditis is suspected, we should look for what? - Correct Answer- Septal bounce What will the Doppler of constructive pericarditis look like? - Correct Answer-Similar to restrictive cardiomyopathy but with respiratory variation A huge dilated PA, severe TR and RV enlargement best describes? - Correct Answer- pulmonary hypertension What is Eisenmenger's syndrome? - Correct Answer-Phenomenon that occurs from long-standing L to R shunt that leads to Pulmonary Vascular Resistance...eventually the magnitude of the shunt become "equal" and then reversed with a net R to L shunt (increase pulmonary arterial pressure leads to intimal and medial hyperplasia) What is represented with a decreased "A" wave and a flying W? - Correct Answer- Pulmonary hypertension by M-mode With a small pulmonary emoboli the heart may be? - Correct Answer-normal With a large pulmonary emboli the heart will be? - Correct Answer-RV/RA will dilate, PHTN or RV systolic dysfunction may be present *****Know pg. 150***** - Correct Answer-Ok Given tricuspid regurgitation with 60 mm Hg gradient grade the severity of pulmonary hypertension: - Correct Answer-Severe What is the normal pulmonary artery pressure? - Correct Answer- 18 - 40 mmHg What is a mild pulmonary artery pressure? - Correct Answer- 40 - 54 mmHg What is a moderate pulmonary artery pressure? - Correct Answer- 55 - 64 mmHg What is a severe pulmonary artery pressure? - Correct Answer-> 65 mmHg Your patient has PHTN with a dilated IVC (3 cm) which collapsed 50% with sniff. Estimate the RA pressure: - Correct Answer-8 mmHg The size of aneurysms during systole: - Correct Answer-increase
What does hyperkinesis mean? - Correct Answer-More than normal What does hypokinesis mean? - Correct Answer-Less than normal What does akinesis mean? - Correct Answer-No motion, no thickening What does dyskinesis mean? - Correct Answer-Motion is opposite the normal direction Which of the following terms refers to a decrease in wall motion? - Correct Answer- Hypokinesis How many segments of a wall have to be affected before calling wall motion abnormality? - Correct Answer-1 segment What is the IVS motion in a patient with LBBB? - Correct Answer-Dyskinetic or paradoxical What walls does the LAD feed? - Correct Answer-anterior anteroseptal LV apex What walls does the left circumflex feed? - Correct Answer-Anterolateral inferolateral What walls does the right coronary feed? - Correct Answer-Inferior Inferoseptal RV apex RV free wall From where do the coronary arteries originate? - Correct Answer-In the left and right sinus of valsalva What is meant by right dominance? - Correct Answer-When the RCA gives rise to the posterior descending artery; (85% of the time) Which coronary supplies the interatrial septum? - Correct Answer-Right (also usually supplies the SA and AV nodes) Which coronary artery feeds the inferoseptal wall? - Correct Answer-right coronary artery What medicine is used during a nuclear stress test? - Correct Answer-Thallium TRUE/FALSE With multi-vessel disease, stress echo is better than nuclear scans - Correct Answer-True
What are the indications for a stress echo? - Correct Answer-1. Aid in diagnosis of chest pain
- Determine severity/prognosis of CAD
- Guide post MI rehab
- Evaluate cardiac arrhythmias
- Screen high risk or asymptomatic patients with multiple risk factors What are the contraindications for a stress echo? - Correct Answer-Recent acute MI Unstable angina Acute aortic dissection Severe aortic stenosis Acute pulmonary embolus Uncontrolled arrhythmias What would be a contraindication to performing a stress test on an athlete with chest pain? - Correct Answer-Unstable angina This drug may be given at peak dose if the target heart rate is not reached: - Correct Answer-Atropine When the 2D image appears to have three atria. It might mean that the patient has a: - Correct Answer-Cor triatrium What is Cor triatrium? - Correct Answer-This is a congenital malformation where there is a membrane above the level of the mitral valve. In severe cases there is supravalvular stenosis This occurs when the interatrial septum fails to close during fetal development: - Correct Answer-ASD What is the shunt flow of an ASD normally? - Correct Answer-Left-to-right What is the most common type of ASD? - Correct Answer-Ostium secundum (70%) NOTE: Mid septal area This type of ASD is located in the inferior septal area (20%) - involved with AV septal defects (endocardial cushion) - Correct Answer-Primum This type of ASD is located in the superior septal area (8%) - associated with anomalous pulmonary venous return (80%) - Correct Answer-Sinus venosus This type of ASD is located in the inferior septal area close to the coronary sinus (2%) - Correct Answer-Coronary sinus
