CHAPTER 7

7

Questions

121. Bicuspid aortic valve may be associated with:

A. Coronary anomalies

B. Coarctation of the aorta

C. Atrial septal defect

D. None of the above

122. A dilated coronary sinus could be seen in all of the following conditions except:

A. Right atrial hypertension

B. Persistent left superior vena cava

C. Coronary A–V fistula

D. Unroofed coronary sinus

E. Azygos continuity of inferior vena cava

123. Atrial septal defect (ASD) of sinus venosus type is most commonly associated

with:

A. Anomalous drainage of right upper pulmonary vein into the right atrium

B. Anomalous drainage of left upper pulmonary vein into the right atrium

C. Persistent left upper superior vena cava

D. Coronary artery anomalies

124. Ostium primum ASD is most commonly associated with:

A. Cleft in anterior mitral leaflet

B. Cleft in septal leaflet of the tricuspid valve

C. Patent ductus arteriosus

D. Aortic stenosis

125. Dilatation of the pulmonary artery is seen in all of the following conditions except:

A. Atrial septal defect

B. Valvular pulmonary stenosis

C. Infundibular pulmonary stenosis

D. Pulmonary hypertension

Echocardiography Board Review: 500 Multiple Choice Questions with Discussion, Second Edition.Ramdas G. Pai and Padmini Varadarajan.© 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

41

42 Echocardiography Board Review

126. Risk of aortic dissection is increased in the following conditions except:

A. Marfan’s syndrome

B. Bicuspid aortic valve

C. Pregnancy

D. Mitral stenosis

127. A 52-year-old patient with a 31mm St. Jude mitral valve has severe shortness of

breath. Left ventricular function and aortic valve are normal. The disk motion

of the prosthetic valve is normal. Analysis of transmitral flow with continuous

waveDoppler revealed an E-wave velocity of 2.6m/s, A-wave velocity of 0.6m/s,

E-wave pressure half-time of 40ms, diastolic mean gradient of 6mmHg at a heart

rate of 60/min, and isovolumic relaxation time (IVRT) of 30ms. This patient is

likely to have:

A. Mitral regurgitation

B. Pannus growth into the prosthetic valve

C. Prosthetic valve thrombosis

D. Normal prosthetic valve function

128. In a person with suspected paravalvular (mechanical) mitral regurgitation, the

following transducer position has the best chance of revealing the mitral regur-

gitation jet:

A. A.Parasternal long axis view

B. Apical four-chamber

C. Apical two-chamber

D. Apical long axis

129. A patient with a bileaflet mechanical aortic valve has shortness of breath on exer-

tion. An echocardiogram revealed normal left ventricular systolic function and

mitral valve function. The left ventricular outflow tract (LVOT) dimension was

2.2 cm, LVOT (V1) velocity was 1.5m/s, and aortic transvalvular velocity (V2) was

4.5m/s, with no aortic regurgitation.Measurements obtained 2 years earlier when

the patient was asymptomatic were LVOT diameter 2.2 cm, V1 0.9m/s, and V2

2.7m/s. Likely cause of this patient’s shortness of breath is:

A. Prosthetic valve stenosis

B. Patient–prosthesis mismatch

C. High cardiac output state, patient may be anemic

D. None of the above

130. A patient with a mechanical prosthetic mitral valve has gastrointestinal bleed-

ing and the following measurements were obtained: diastolic mean gradient

11mmHg, peak gradient 16mmHg, pressure half-time 65ms, heart rate 114/min.

This increased gradient is likely to be:

A. Likely normal

B. Likely abnormal

C. Cannot comment

131. The following measurements were obtained in a patient with mitral regurgita-

tion: proximal isovelocity surface area (PISA) radius 1 cm at a Nyquist limit of

50 cm/s, peak mitral regurgitation velocity 5m/s, and mitral regurgitation signal

time velocity integral 100 cm. The regurgitant volume is:

A. 63 cc/beat

B. 31 cc/beat

C. 63 cc/s

D. 63%

Chapter 7 43

132. Distribution of leaflet thickening and calcification in rheumatic mitral stenosis is:

A. More at the tip

B. More at the base

C. Uniform throughout the leaflets

133. Leaflet calcification in degenerative mitral stenosis is:

A. More at the tip

B. More at the base

C. Uniform throughout the leaflets

134. The predominant mechanism of chronic ischemic mitral regurgitation is:

A. Restriction of mitral leaflet closure

B. Papillary muscle dysfunction

C. Ruptured chordae tendinae

D. Ruptured papillary muscle

135. In a person with chronic ischemic mitral regurgitation (MR) due to old inferior

myocardial infarction (MI) and an ejection fraction of 50%, the location of the MR

jet would be:

A. Medial commissure

B. Lateral commissure

C. Central

136. In the above patient, the jet direction would be:

A. Posterior

B. Anterior

C. Central

137. In a patient with old anteroseptal MI with an ejection fraction of 28%, an ischemic

MR jet is likely to be:

A. Central

B. Lateral wall hugging

C. Medial wall hugging

138. Mitral regurgitation in aortic stenosis is related to which of these factors:

A. Degree of mitral annular calcification

B. Severity of aortic stenosis

C. An increase in LV end systolic dimension

D. Degree of aortic leaflet calcification

139. Left atrial myxoma may be differentiated from a left atrial thrombus by all of the

following characteristics except:

A. Enhancement with transpulmonary contrast agent

B. Presence of blood vessels on color flow imaging

C. Attachment to the atrial septum

D. Similar mass in the left ventricle (LV) with normal LV function.

140. The most common location of a left atrial thrombus is:

A. Left atrial appendage

B. Body

C. Atrial septum

D. Atrial roof

44 Echocardiography Board Review

Answers for chapter 7

121. Answer: B.Bicuspid valve is associated with coarctation of the aorta. Biscuspid aortic valve

occurs in 1–2% of the population. In these people, aortic coarctation is rare, but

25% of patients with coarctation have a bicuspid aortic valve.

122. Answer: E.Coronary sinus can be dilated due to increased pressure or flow. There is an

increased flow in the coronary sinus in the left superior vena cava, which

drains into the coronary sinus, coronary A–V fistula due to increased shunt,

and unroofed coronary sinus due to increased flow from the left atrium (LA) to

coronary sinus. Right atrial hypertension causes increased pressure, which will

lead to dilated coronary sinus.

123. Answer: A.ASDof sinus venosus type ismost commonly associatedwith anomalous drainage

of the right upper pulmonary vein into the right atrium.

124. Answer: A.Ostium primum ASD is most commonly associated with a cleft anterior mitral

leaflet. This is a form of endocardial cushion defect or partial AV canal defect.

125. Answer: C.Infundibular pulmonary stenosis is not associated with dilatation of the pul-

monary artery. Poststenotic dilatation is seen only in valvular pulmonary stenosis

and not in subvalvular pulmonary stenosis. In ASD the pulmonary artery dilates

due to increased flow and pulmonary hypertension dilatation is due to increased

pressure. Idiopathic dilatation of the pulmonary artery can also occur. Marfan

syndrome is a cause of pulmonary artery dilatation as well.

126. Answer: D.All conditions except mitral stenosis have weakened media predisposing to dis-

section. Hypertension can also increase the risk for dissection. There is aortopathy

inMarfan syndrome and bicuspid aortic valve. Progesterone in pregnancy loosens

connective tissue and may result in aortic as well as coronary dissection.

127. Answer: A.Normal IVRT is 70–100ms, and pressure half-time is 65–80ms for a pros-

thetic mitral valve. With a normal cardiac output, the mean gradient would be

3–4mmHg at a heart rate of 60/min. Shortened IVRT, short pressure half-time,

and high E/A ratio indicate high LA pressure. A stenotic prosthetic valve would

have caused increase in pressure half-time and an increase in mean gradient far

more than 6mmHg at a heart rate of 60/min. A mildly increased gradient despite

a shortened pressure half-time indicates increased transvalvular flow suggestive

of mitral regurgitation, which may be difficult to visualize from a transthoracic

echo. Hence, a transesophageal echocardiogram (TEE) would be warranted. High

LA pressure without an increase in flow would result in shortened IVRT and

pressure half-time without an increase in the gradient. A good example of this is

superadded restrictive cardiomyopathy.

128. Answer: A.Shadowing in the left atrium is least with a parasternal long axis view; however,

TEE is the best technique to evaluate for paravalvular mitral leaks.

Chapter 7 45

129. Answer: C.An unchanged V1/V2 ratio compared to prior echo confirms the absence of

prosthetic valve stenosis. An elevated V1 indicates elevated cardiac output and

the transvalvular gradient is flow dependent. Anemia is a common problem

secondary to blood loss due to anticoagulation and less commonly due to

mechanical hemolysis. Patient prosthesis mismatch occurs when the valve is too

small for the cardiac output needs of the patient. The effective aortic orifice area in

this patient is about 1.3 cm2. There is no change in the intrinsic valvular function

in this patient.

130. Answer: A.The measurements are normal. Pressure half-time of 65ms indicates normal valve

function. Mean gradient is appropriately increased due to tachycardia (which

shortens the diastolic filling period), anemia, and possibly high cardiac output.

Prosthetic valves are intrinsically mildly stenotic.

131. Answer: A.Effective regurgitant orifice area is given by the formula 2𝜋r2 ×Nyquist limit/MR

velocity, that is, 2 × 3.14 × 1 × 1 × 50/500 cm/s = 0.628 cm2. Regurgitant volume is

effective regurgitant orifice area (in cm2) × TVI (in cm). In this patient, it is 0.628 ×100 = 62.8 cc. This is per beat and not per second.

132. Answer: A.

133. Answer: B.Calcification extends from the annulus, that is, in a centripetal fashion compared

to rheumatic, which is centrifugal.

134. Answer: A.Restriction, tethering, and tenting refer to the phenomenon of incomplete systolic

closure due to apical traction on themitral leaflets due to outward displacement of

the papillary muscles. This causes tenting of the leaflets, and the coaptation point

is displaced apically. This is not due to contractile failure of the papillary mus-

cles (papillary muscle dysfunction). Papillary muscle rupture causes acute MR,

leading to pulmonary edema and hemodynamic compromise. Tenting is far more

common than papillary muscle rupture.

135. Answer: A.Owing to displacement of the posteromedial papillary muscle, there is tethering

of medial portions of both leaflet (P3 and A3) segments causing a medial commis-

sural jet. When the left ventricle (LV) is uniformly dilated, the jet could be central

in origin.

136. Answer: B.As there is greater tenting of P3 than A3, the jet is directed posteriorly. There may

also be some tenting of P2.

137. Answer: A.In an anterior MI, there is generally remodeling of the noninfarcted segments as

well, causing dilatation of the whole LV cavity. This is reflected by a low ejection

fraction. This causes displacement of both papillarymuscles and tenting of all seg-

ments of both leaflets, giving rise to central MR, although exceptions may occur.

MR in dilated cardiomyopathy occurs because of a similar mechanism.

46 Echocardiography Board Review

138. Answer: C.The mechanism of MR is functional and is related to LV dilation and leaflet tether-

ing. Aortic leaflet calcification, mitral annular calcification, and severity of aortic

stenosis contribute very little in the genesis of MR. A higher driving pressure in

more severe degrees of aortic stenosismay increase the regurgitant volume and the

jet area but will not cause MR in the absence of a defect in the mitral coaptation

mechanism.

139. Answer: C.Myxomas are vascular; blood vessels may be seen on color flow imaging and

enhanced mildly with transpulmonary contrast agent. Although left atrial throm-

bus is most commonly seen in the appendage, it may be attached to the atrial

septum or may traverse through a patent foramen ovale from the right side (para-

doxical embolism). The presence of a mass in the LV in the face of normal LV

function makes a thrombus unlikely and points to a familial myxoma syndrome

(Carney’s syndrome).

140. Answer: A.This generally occurs in the presence of atrial fibrillation or flutter. The probability

is increased by the presence of mitral stenosis, heart failure, low ejection fraction,

large left atrium, and left atrial spontaneous echo contrast.