Miscellaneous

Question 1

All of the following are expected echocardiographic/Doppler finding in the elderly EXCEPT:

A. Mitral annular calcification
B. Aortic valve sclerosis
C. Mild left atrial dilatation
D. Mitral valve E/A ratio of 1.5

Answer 1

D. With aging the mitral valve E/A ratio declines with age with the range for > 70 years of age being 0.6 to 1.3.

Question 2

All of the following are findings for ankylosing spondylitis EXCEPT:

A. Dilatation of the aortic annulus
B. Dilatation of the sinuses of Valsalva
C. Thickened aortic valve leaflets with aortic regurgitation
D. Acute myocardial infarction

Answer 2

D. Ankylosing spondylitis is characterized by inflammation of the joints with aortitis, pericardial, effusion and reduced global left ventricular systolic function as possible additional echocardiographic/Doppler findings.

Question 3

All of the following are possible sources of systemic embolism EXCEPT:

A. Aortic regurgitation
B. Aortic atherosclerotic plaque
C. Left atrial myxoma
D. Left ventricular apical thrombus

Answer 3

A. Atheroma of the aorta can be a source of embolism especially if thick (> 4 mm in the ascending aorta and aortic arch; > 5 mm in the descending thoracic aorta) or protruding.

Question 4

Thickening of the aortic valve leaflets with normal systolic excursion with a Doppler peak velocity of less than 2 m/s is the definition for aortic valve:

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

Answer 4

C. Aortic valve sclerosis occurs primarily in the elderly and may be the result of valvular stress, primary degeneration or generalized atherosclerosis and may progress to aortic stenosis. Aortic regurgitation is the expected Doppler finding.

Question 5

All of the following are normal characteristics of a normal athlete’s heart EXCEPT:

A. Concentric hypertrophy (< 17 mm)
B. Tissue Doppler E’ peak velocity > 8 cm/s
C. Left atrial dilatation
D. Normal E/A mitral ratio

Answer 5

C. It is difficult to differentiate an athlete’s heart from hypertrophic cardiomyopathy. Suggested abnormal findings include:

• Left ventricular dilatation (> 6 cm)
• Left ventricular wall thickness > 13 mm
• IS/LVPW ratio > 1.5
• Left atrial dilatation
• Abnormal transmitral flow velocity

Question 6

All of the following are expected echocardiographic/Doppler findings for atrial fibrillation EXCEPT:

A. Normal mitral valve E/A ratio
B. Biatrial dilatation
C. Reduced left atria appendage peak velocity
D. Pulmonary vein absent atrial reversal wave

Answer 6

A. Atrial fibrillation makes the evaluation of diastolic function difficult because of the absence of a mitral valve E/A ratio. Recommendations include examining the deceleration time (< 130 msec) and/or an E/E’ ratio of > 11 which suggests increased diastolic filling pressures.

The normal left atrial appendage peak velocity is 46 + 18 cm/s and is often reduced to 26 ‡ 19 cm/s in atrial fibrillation.

Question 7

Which of the following mitral valve PW Doppler parameters suggests increased left heart filling pressures in a patient with atrial fibrillation?

A. Decreased mitral valve E velocity
B. Reduced mitral valve deceleration time (< 130 msec)
C. Absent mitral valve A wave
D. Increased mitral valve A duration

Answer 7

B. A shortened mitral deceleration time < 130 msec averaged over five cardiac cycles, a consistent peak mitral E velocity of > 1.0 m/s and/or a mitral annulus tissue Doppler E/E’ ratio of > 11 suggests increased left heart filling pressures in a patient with atrial fibrillation.

Question 8

A left atrial volume is determined to be 44 ml/m^2. The left atrium is:

A. Normal
B. Enlarged
C. Hyperdynamic
D. Thrombosed

Answer 8

B. Historically left atrial linear dimension measured with M-mode or two-dimensional echocardiography has been the method for determining the presence of left atrial dilatation. Left atrial volume adjusted for body surface area is the current recommendation. The normal left atrial volume adjusted for body surface area for men and women is 22 + 6 ml/m^2

• Mild: 29 - 33 ml/m^2
• Moderate: 34 - 39 ml/m^2
• Severe: ≥ 40 ml/m^2

Question 9

A membrane is visualized in the left atrium and appears to be superior to the fossa ovalis. This finding suggests:

A. Mitral stenosis
B. Supravalvular mitral ring
C. Cor triatriatum
D. Tetralogy of Fallot

Answer 9

C. A membrane in the left atrium may obstruct left ventricular diastolic filling resulting in functional mitral stenosis. If the membrane insertion is located below the fossa ovalis then supravalvular mitral ring is present. If the insertion of the membrane is above the fossa ovalis cor triatriatum is present. The apical four-chamber view is the view of choice because the ultrasound beam is perpendicular to the membrane.

Question 10

A common echocardiographic finding in a cardiac surgery patient is:

A. Paradoxical interventricular septal motion
B. Pleural effusion
C. Valvular prolapse
D. Valvular stenosis

Answer 10

A. In addition, pericardial effusion is reported in 50 to 80% of all post-operative patients. This post-operative pericardial effusion may be loculated and can result in cardiac tamponade if it compresses the cardiac chamber it is located behind (regional cardiac tamponade).

Question 11

Which of the following is the most likely finding in Chagas disease?

A. Hypertrophic cardiomyopathy
B. Mitral stenosis
C. Dilated cardiomyopathy
D. Aortic stenosis

Answer 11

C. Chagas disease is the result of the invasion of a parasite into heart muscle. The echocardiographic/ Doppler findings for Chagas disease include dilated ventricles with thrombus and ventricular aneurysms with atrioventricular valve regurgitation.

Question 12

The expected echocardiographic/Doppler findings for cocaine ingestion include all of the following EXCEPT:

A. Acute myocardial infarction
B. Reduced global ventricular systolic function
C. Hypertrophic cardiomyopathy
D. Acute aortic dissection

Answer 12

C. Other findings include dilated cardiomyopathy, infective endocarditis and systemic hypertension.

Question 13

The echocardiographic/Doppler findings for cor pulmonale are very similar to:

A. Ischemic heart disease
B. Pulmonary hypertension
C. Hypertrophic cardiomyopathy
D. Hemochromatosis

Answer 13

B. Cor pulmonale is right heart failure due to intrinsic pulmonary disease and the echocardiographic/Doppler findings are similar to the ones present in patients with pulmonary hypertension.

Question 14

The echocardiographic/Doppler findings for diabetes include:

A. Dilated cardiomyopathy
B. Hypertrophic cardiomyopathy
C. Restrictive cardiomyopathy
D. Arrhythmogenic right ventricular cardiomyopathy

Answer 14

A. The ehocardiographic/Doppler findings for diabetes include diabetic (dilated) cardiomyopathy, left ventricular hypertrophy and abnormal diastolic function.

Question 15

In the parasternal short-axis of the mitral valve two separate mitral valve orifices are seen during ventricular diastole. This suggests:

A. Flail mitral valve
B. Cleft mitral valve
C. Mitral valve prolapse
D. Double orifice mitral valve

Answer 15

D. Double orifice mitral valve is associated with atrioventricular septal defects, ventricular septal defect, Ebstein’s anomaly, tetralogy of Fallot and coarctation of the aorta.

Question 16

A string-like structure is seen in the apex of the left ventricle. This finding may be called all of the following EXCEPT:

A. Moderator band
B. Ectopic chordae
C. False tendon
D. Chordal web

Answer 16

A. Ectopic chordae can be single or multiple in either the left ventricle or right ventricle and can be a source of a murmur, confused for a thrombus or a potential cause of catheter entrapment.

The moderator band is always in the right ventricle.

Question 17

All of the following are possible echocardiographic/Doppler findings for Ehlers-Danlos EXCEPT:

A. Ascending aortic aneurysm
B. Valvular prolapse
C. Mitral stenosis
D. Ventricular septal defect

Answer 17

C. Ehlers-Danlos is a connective tissue disorder associated with hypermobile joints. Additional cardiac findings include atrial septal defect, coarctation of the aorta, bicuspid aortic valve and dextrocardia.

Question 18

The expected echocardiographic finding for Fabry’s disease is mitral valve:

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

Answer 18

B. Fabry’s disease is a glycogen storage disease. Other cardiac findings include mitral regurgitation, increased left ventricular wall thickness and mass which may be progressive and reduced left ventricular global systolic function.

Question 19

The echocardiographic/Doppler findings for Friedreich ataxia include:

A. Left ventricular hypertrophy
B. Thickened mitral valve
C. Libman-Sacks endocarditis
D. Aortic stenosis

Answer 19

A. The classic finding for Friedreich’s ataxia is significant left ventricular hypertrophy which may resemble hypertrophic cardiomyopathy.

Question 20

The classic echocardiographic finding for Pompe’s disease is:

A. Aortic stenosis
B. Mitral stenosis
C. Left ventricular hypertrophy
D. Coarctation of the aorta

Answer 20

C. Pompe’s disease is a glycogen storage disease which may result in left ventricular hypertrophy, tumor-like appearance of the papillary muscles or poor global ventricular systolic function.

Question 21

The most common reason for congestive heart failure in the United States is:

A. Reduced global systolic function due to coronary artery disease
B. Diastolic dysfunction
C. Pressure overload (e.g., systemic hypertension)
D. Volume overload (e.g., significant mitral regurgitation)

Answer 21

A. The most common causes of systolic heart failure are coronary artery disease, dilated cardiomyopathy, systemic hypertension and valvular heart disease.

Question 22

The echocardiographic/Doppler findings for hyperthyroidism is:

A. Enhanced global left ventricular systolic function
B. Mitral stenosis
C. Aortic stenosis
D. Significant valvular regurgitation

Answer 22

A. Hyperthyroidism will usually result in an increase in left ventricular contractility resulting in a high-output state. Extreme hyperthyroidism may result in a reversible dilated cardiomyopathy.

Question 23

The echocardiographic/Doppler findings in hypothyroidism include:

A. Reduced global left ventricular systolic function
B. Pericardial effusion
C. Thickened mitral valve
D. Coarctation of the aorta

Answer 23

A. Other findings for hypothyroidism include left ventricular hypertrophy, abnormal myocardial texture, asymmetric hypertrophy of the interventricular septum, mitral valve prolapse and left ventricular diastolic dysfunction.

Question 24

All of the following are associated echocardiographic/Doppler finding for the Marfan syndrome EXCEPT:

A. Mitral stenosis
B. Aortic root dilatation
C. Aortic dissection
D. Valvular regurgitation

Answer 24

A. Marfan syndrome is a connective tissue disease and the cardiac malformation include aortic root dilatation, sinus of Valsalva aneurysm, multivalvular prolapse (mitral valve prolapse being most common), aortic dissection and valvular regurgitation (e.g., mitral regurgitation, aortic regurgitation).

Question 25

A membrane located at the level of the mitral valve annulus is mitral valve: A. Prolapse B. Flail C. Ring D. Annular calcification

Answer 25

C. A thin band of echoes located just above the mitral valve or within the funnel of the mitral valve leaflets is mitral valve stenosing ring.

Question 26

Rupture of the vasa vasorum into the media of the aortic wall may result in: A. Aortic aneurysm B. Supravalvular aortic stenosis C. Intramural hematoma D. Coarctation of the aorta

Answer 26

C. Intramural hematoma is considered a type of aortic dissection (a dissection without a tear). Transesophageal echocardiography may be the test of choice and will demonstrate thickening of the aortic wall with a preserved aortic lumen.

Question 27

The classic echocardiographic findings for Noonan syndrome is: A. Ventricular septal defect B. Dysplastic pulmonary valve C. Bicuspid aortic valve D. Dilated cardiomyopathy

Answer 27

B. The echocardiographic/Doppler findings for Noonan syndrome also include ventricular hypertrophy, secundum atrial septal defect, dilatation of the aorta and partial atrioventricular septal defect.

Question 28

Osler-Weber-Rendu disease is associated with pulmonary arteriovenous fistula. The preferred echocardiographic/Doppler technique to determine the presence of this finding is: A. M-mode B. Two-dimensional C. Color flow Doppler D. Agitated saline contrast

Answer 28

D. Agitated saline contrast appearing in the left atrium three or more cardiac cycles after injection suggests the presence of pulmonary arteriovenous fistula.

Question 29

All of the following are most likely to mimic the findings of mitral stenosis EXCEPT: A. Left atrial myxoma B. Cor triatriatum C. Parachute mitral valve D. Infective endocarditis

Answer 29

D. Infective endocarditis rarely results in valvular stenosis. Parachute mitral valve is a congenital abnormality in which there is only one papillary muscle in the left ventricle in which all the chordae tendineae attach.

Question 30

Penetrating aortic ulcer is considered to be: A. Congenital B. Idiopathic C. Aortic dissection D. Aortopulmonary window

Answer 30

C. Penetrating aortic ulcer is a type of aortic dissection where a penetrating ulcer burrows deeply through the intima into the aortic media resulting in aortic dissection and hematoma without an intimal flap or false lumen. Transesophageal echocardiography is the test of choice.

Question 31

A dilated coronary sinus is visualized in the parasternal long-axis. An agitated saline contrast study is performed and contrast is noted to appear in the coronary sinus before entering the right atrium. The diagnosis is most likely: A. Normal B. Persistent left superior vena cava C. Patent foramen ovale D. Inlet ventricular septal defect

Answer 31

B. It is important to inject the agitated saline into the left arm when evaluating for persistent left surperior vena cava. The suprasternal long-axis view with a leftward tilt with color flow Doppler on may demonstrate the persistent left superior vena cava.

Question 32

The echocardiographic/Doppler findings for pheochromocytoma include all of the following EXCEPT: A. Aortic aneurysm B. Segmental wall motion abnormalities C. Concentric left ventricular hypertrophy D. Acute myocarditis

Answer 32

A. Pheochromocytoma is a tumor located in the adrenal gland which may result in left ventricular hypertrophy, dilated cardiomyopathy, segmental wall motion abnormality and/or a tumor located in the atrioventricular groove.

Question 33

All of the following are associated findings for pulmonary embolism EXCEPT: A. Left ventricular hypertrophy B. D-shaped left ventricle C. Right ventricular dilatation D. Tricuspid regurgitation

Answer 33

A. Actual visualization of the thrombus is uncommon. Other findings for pulmonary embolism include reduced global and segmental right ventricular systolic function, pulmonary artery dilatation and pulmonary regurgitation. Tricuspid regurgitation allows calculation of the right ventricular systolic pressure and the systolic pulmonary artery pressure which will be increased in pulmonary embolism. Pulmonary pressures may return to normal within one month of treatment.

Question 34

Pulmonary vein stenosis may result in: A. Left atrial enlargement B. Left ventricular hypertrophy C. Pulmonary hypertension D. Mitral regurgitation

Answer 34

C. The etiology of pulmonary vein stenosis is usually congenital. Ablation therapy for atrial fibrillation has been associated with pulmonary vein stenosis. Findings include increased pulmonary vein peak systolic velocity (> 2 m/s), turbulent flow and evidence of pulmonary hypertension. Transesophageal echocardiography may provide better visualization of the pulmonary veins than transthoracic echocardiocardiography.

Question 35

A common two-dimensional echocardiographic finding in patients with chronic renal failure is: A. Pericardial effusion B. Pulmonary hypertension C. Aortic dissection D. Mitral valve prolapse

Answer 35

A. Additional findings in chronic renal failure include mitral annular calcification, functional mitral stenosis, aortic valve sclerosis/stenosis, left ventricular hypertrophy, ground-glass appearance of the myocardium, dilated cardiomyopathy, valvular regurgitation and diastolic dysfunction. Additional common etiologies for pericardial effusion include acute myocardial infarction, neoplasm, trauma, collagen vascular disease (e.g., lupus erythematosus) and viral and bacterial infections.

Question 36

The most common echocardiographic/Doppler finding for scleroderma is: A. Mitral stenosis B. Pericardial effusion C. Ebstein's anomaly D. Pulmonary stenosis

Answer 36

B. The most common finding for scleroderma is pericardial effusion. Other common findings for scleroderma include pulmonary hypertension, tricuspid regurgitation, ventricular fibrosis with reduced global ventricular systolic function and diastolic dysfunction.

Question 37

Tuberous sclerosis is associated with: A. Myxoma B. Angiosarcoma C. Rhabdomyoma D. Fibroma

Answer 37

C. Tuberous sclerosis is associated with mental retardation, seizures and adenoma sebaceum. Rhabdomyoma are commonly found in patients with tuberous sclerosis.

Question 38

The combination of left ventricular inflow tract obstruction and left ventricular outflow tract obstruction is called: A. Ebstein's anomaly B. Uhl's anomaly C. Shone's complex D. Takayasu's disease

Answer 38

C. The combination of supravalvular mitral valve ring, parachute mitral valve, discrete subaortic stenosis, bicuspid aortic valve and coarctation of the aorta is referred to as Shone's complex.

Question 39

Which of the following is strongly associated with syncope? A. Left ventricular outflow tract obstruction B. Perimembranous ventricular septal defect C. Carcinoid heart disease D. Rheumatic fever

Answer 39

A. Causes of syncope include left ventricular outflow tract obstruction (e.g., hypertrophic obstructive cardiomyopathy, aortic stenosis), mitral stenosis, mitral valve prolapse, pulmonary hypertension, pulmonary embolism, acute myocardial infarction, intracardiac mass, cardiac tamponade and aortic dissection.

Question 40

The most common echocardiographic/Doppler finding in systemic lupus erythematosus is: A. Aortic stenosis B. Coarctation of the aorta C. Left atrial myxoma D. Pericardial effusion

Answer 40

D. Other findings include myocarditis, Libman-Sacks endocarditis (most often involving the mitral valve) and mitral valve prolapse.

Question 41

An aortic arteritis associated with marked intimal proliferation and fibrous scarring is: A. Libman-Sacks B. Takayasu's disease C. Shone's complex D. Marfan's syndrome

Answer 41

B. Echocardiographic/Doppler findings for Takayasu's disease is dilatation of the aorta, increased echogenicity of the aorta and aortic regurgitation.

Question 42

All of the following are normal findings in cardiac transplantation patients EXCEPT: A. Reduced global ventricular systolic function B. Biatrial dilatation C. Mild tricuspid regurgitation D. Paradoxical interventricular septal motion

Answer 42

A. Due to the surgical procedure biatrial dilatation is a common finding in cardiac transplant patients.

Question 43

Turner syndrome is associated with: A. Mitral valve prolapse B. Aortic dissection C. Rhabdomyoma D. Coarctation of the aorta

Answer 43

D. Turner syndrome may also present with bicuspid aortic valve and hypoplastic left heart syndrome.

Question 44

Papillary muscle dysfunction usually results from: A. Dressler's syndrome B. Ischemic heart disease C. Infective endocarditis D. Rheumatic heart disease

Answer 44

B. Papillary muscle dysfunction is a generic term used to describe abnormalities associated with the papillary muscles which leads to mitral regurgitation. Causes of papillary muscle dysfunction include improper contraction of the papillary muscle associated with ischemia/infarction, rupture of the papillary muscle, left ventricular dilatation and fibrosis/calcification.

Question 45

In normal young patients most ventricular filling occurs during: A. Atrial systole B. Early ventricular diastole C. Diastasis D. During the PR interval

Answer 45

B. The normal pulsed-wave Doppler findings for a young patient include increased mitral valve E/A ratio, a deceleration time of < 220 msec, an isovolumic relaxation time of < 100 msec, a pulmonary vein S/D ratio of < 1 an a pulmonary vein atrial reversal of < 35 cm/s. Tissue Doppler of the mitral annulus should demonstrate E' peak velocity of > 10 cm/s and an E/E' ratio < 8. The left atrium and left ventricle should be normal.

Question 46

Which of the following is NOT associated with concentric left ventricular hypertrophy? A. Supravalvular aortic stenosis B. Aortic stenosis C. Discrete subaortic stenosis D. Cor pulmonale

Answer 46

D. Concentric left ventricular hypertrophy is defined as uniform increase in wall thickness with normal ventricular dimensions, increased relative wall thickness and increased ventricular mass. Eccentric hypertrophy is defined as increased ventricular dimensions, normal wall thickness, normal or low relative wall thickness and increased ventricular mass. This type of hypertrophy is associated with significant chronic mitral regurgitation and significant chronic aortic regurgitation.

Question 47

The principal echocardiographic feature of left bundle branch block is: A. Early systolic dip of the interventricular septum B. Hyperkinesis of the interventricular septum C. Hyperkinesis of the lateral wall of the left ventricle D. Posterior motion of the interventricular septum

Answer 47

A. The typical finding in a patient with left bundle branch block is an early systolic downward dip or beaking of the interventricular septum with paradoxical interventricular septal motion.

Question 48

Electrical pacing of the right ventricle mimics the electrocardiographic and echocardiography findings of: A. Complete atrioventricular block B. Left bundle branch block C. Right bundle branch block D. Wolff-Parkinson-White syndrome

Answer 48

B. With pacing of the right ventricle the characteristic early systolic dip of the interventricular septum with possible abnormal (systolic paradoxical interventricular septal motion is present. This is similar to the echocardiographic findings for left bundle branch block. Other causes of paradoxical interventricular septal motion include right ventricular volume overload and post-cardiac surgery.

Question 49

Two ventricular pacing wires are implanted with one placed in the right ventricle and one placed at the left ventricular free wall region via the coronary sinus. This is a description of (a): A. Holter monitor B. Cardiac resynchronization therapy C. Left ventricular assist device D. Conventional pacemaker therapy

Answer 49

B. Cardiac resynchronization therapy (CRT) is a proposed treatment option for left ventricular dyssynchrony with resultant congestive heart failure. Echocardiography may be useful in the patient selection, assessment of response and optimization.

Question 50

The motion of a congenitally stenotic aortic valve can be described as: A. Doming B. Hypokinetic C. Fluttering D. Flail

Answer 50

A. The doming of the aortic valve may best be visualized in the parasternal long-axis view.

Question 51

Dilated coronary sinus has been associated with all of the following EXCEPT: A. Coronary atrioventricular fistula with drainage into the coronary sinus B. Mitral regurgitation C. Persistent left superior vena cava D. Right atrial hypertension

Answer 51

B. Echocardiographic demonstration of a dilated coronary sinus been described in the following conditions: • Right atrial hypertension • Persistent left superior vena cava • Coronary arteriovenous fistula with drainage into the coronary sinus • Total anomalous pulmonary venous return with coronary sinus drainage Agitated saline contrast injection into the left arm may be used to prove the presence of persistent left superior vena cava with contrast appearing in the coronary sinus prior to entering the right atrium. This may best be seen in the parasternal long-axis view or apical four-chamber view.