Ardms / Adult Echo / 3 / Valvular Stenosis

Front 1

What AS etiology is most common and starts as a bicuspid valve?

Back 1

Calcific/Degenerative

Front 2

What AS etiology is associated with mitral stenosis?

Back 2

Rheumatic

Front 3

What AS etiology affects only 1-2% of the population and is often simply a membrane?

Back 3

Congenital

Front 4

What are two AS etiologies unrelated to the native AV itself?

Back 4

Valvular Obstruction (Sub/Supra)
Prosthetic Valve Dysfunction

Front 5

A secondary finding in AS is?

A) LAE
B) LVE
C) LVH
D) AR

Back 5

C) LVH

Front 6

Why does AS lead to LVH?

Back 6

Systolic Pressure Overload (Increase in Afterload)

Front 7

An increase in LVEDP leads to an increase in what?

Back 7

LA Pressure

Front 8

Does ventricular dysfunction develop early or late in the course of AS?

Back 8

Ventricular Dysfunction develops LATE

Front 9

AS puts a patient at increased risk for what disease?

Back 9

Endocarditis

Front 10

How does aortic sclerosis differ from AS?

Back 10

Valvular thickening without a pressure gradient

Front 11

Name three physical signs of AS.

Back 11

Angina
Dyspnea
Syncope

Front 12

What kind of murmur is characteristic of AS? Located where?

Back 12

1) Harsh Systolic Ejection Murmur
2) Crescendo-Decrescendo
3) Right Upper Sternal Border

Front 13

When auscultating an AS patient, what will usually be missing?

Back 13

A2 (lack of valve movement)

Front 14

Name four physical signs of AS on 2D echocardiograms.

Back 14

1) Thickened AV leaflets
2) Decreased valve opening
3) Aortic dilatation
4) LVH

Front 15

Name the ranges for mild, moderate, and severe Aortic Jet Velocity (m/s)

Back 15

Aortic Jet Velocity
MILD: < 2.9 m/s
MOD: < 4.0 m/s
SEV: > 4.0 m/s

Front 16

Name the ranges for mild, moderate, and severe Aortic Mean Gradient (mmHg)

Back 16

Aortic Mean Gradient
MILD: < 20 mmHg
MOD: < 40 mmHg
SEV: > 40 mmHg

Front 17

Name the ranges for mild, moderate, and severe AVA (cm^2)

Back 17

AVA
MILD: > 1.5 cm^2
MOD: <= 1.5 cm^2
SEV: < 1.0 cm^2

Front 18

Name an M-Mode finding which would indicate a bicuspid AV.

Back 18

Eccentric Closure (diastolic closure line shifted anteriorly)

(NOTE: can be created artificially by being too low)

Front 19

How will bicuspid AV leaflets appear on M-mode?

Back 19

Thickened (may be mild)

Front 20

In the PLAX view, how may an AS patient with a bicuspid AV present?

Back 20

Systolic Doming (aka Tethering)

Front 21

In the PSAX view, how will an AS patient with a bicuspid AV present?

Back 21

Football-shaped oriface

Front 22

If an AS patient is found to have a bicuspid AV, what else must be checked for?

Back 22

Aortic Coarctation

Front 23

The best view to diagnose a bicuspid AV is:

A) PSAX diastole
B) PSAX systole
C) PLAX diastole
D) PLAX systole

Back 23

B) PSAX systole

Front 24

What is the normal velocity of the descending AO?

Back 24

1 m/s

Front 25

For a patient with AO coarctation, what pattern will be seen in the spectral doppler display (CW)?

Back 25

Diastolic Flow (aka Run-Off)

(right side of systolic U pattern will trail up to the next systolic U, since the flow takes time to pass through the narrowing)

Front 26

Which view is best for detecting subvalvular membranes?

Back 26

Apical 5

Front 27

In what anatomical location are most subvalvular membranes seen?

Back 27

LVOT, beneath the AV

Front 28

A subvalvular membrane can cause what two findings in 2D echo?

Back 28

1) LVH
2) Early systolic closure of AV leaflets

Front 29

Which is more common: subvalvular or supravalvular membranes?

Back 29

Subvalvular is more common
(Supravalvular is very rare)

Front 30

What is Takayasu's arteritis?

Back 30

Fibrosis of the aortic arch &amp; descending aorta (supravalvular). In advanced cases, multiple coarctations may occur.
- > young Asian &amp; African women
- aka Aortic Arch Syndrome

Front 31

Increased velocity and turbulance will occur where in relation to an obstruction?

A) Above
B) At the level of
C) Below

Back 31

B) At the level of

Front 32

Anytime an obstruction is discovered or suspected, a VTI should be performed in order to provide what two pieces of information?

Back 32

Peak Gradient
Mean Gradient

Front 33

LVOT velocity is 5 m/sec
BP = 110/84
What is this patient's peak LV pressure?

Back 33

210 mmHg

(Bernouli + sys BP)

Front 34

The theory behind the continuity equation is that the ___ & ___ of the LVOT will always equal that of the AV.

Back 34

Area & Flow Velocity

Front 35

Describe the Continuity Equation (using LVOT diameter & peak velocities).

Back 35

AVA = (A1 x Vlvot) / Vav

where A1 = (LVOT dia / 2)^2 x pi

Front 36

If peak LVOT velocity (PW) is 1 m/sec, LVOT diameter is 2 cm, and peak AV velocity (CW) is 3.5 m/sec, what is the AVA?

Back 36

0.9 cm^2

Front 37

Using the continuity equation, when would the severity of AS be underestimated?

A) LVOT measured too large
B) LVOT measured too small
C) Peak aortic velocity too high
D) Mean aortic velocity too high

Back 37

A) LVOT measured too large

Front 38

Describe the Continuity Equation (using LVOT diameter & VTI).

Back 38

AVA = (LVOT CSA x LVOT VTI) / AO VTI

LVOT CSA = (LVOT Dia^2) * 0.785

Front 39

If LVOT VTI is 24, LVT diameter is 2 cm, and AV VTI is 50, what is the AVA?

Back 39

1.51 cm^2

Front 40

If a patient has poor LV function or when mod/sev AI is present, which continuity equation works best:

A) Continuity Equation using peak velocities
B) Continuity Equation using VTI

Back 40

B) Continuity Equation using VTI

Front 41

Should LVOT diameter be measured in systole or diastole?

Back 41

Systole

Front 42

What anatomical locations should be used in measuring LVOT diameter?

Back 42

AV leaflet insertion points

Front 43

Which of the following correlate better?

A) Mean Gradient vs Cath Gradient
B) Peak vs Peak-to-Peak

Back 43

A) Mean Gradient vs Cath Gradient

Front 44

Which pressure is obtained during TTE/TEE doppler?

Back 44

Peak
(aka Peak Instantaneous)

Front 45

In a cath lab pressure tracing, what does it mean if the LV pressures & AO pressures track together (in unison)?

Back 45

No AS is present (unless LV/AO pressures are out of sync)

Front 46

When evaluating for AS, what is the first thing to look for?

Back 46

Decreased AVA
(AVA < 2.5 cm^2)

Front 47

When evaluating for AS, what is the second thing to look for (if valve areas are the same)?

Back 47

Increasing Peak Gradient (LVOT/AV)

Front 48

When evaluating for AS, what is the third thing to look for (if valve areas & peak gradients are the same)?

Back 48

Wall Thinkness (for LVH)

Front 49

What PS etiology is most common?

Back 49

Congenital

Front 50

What PS etiology is rare?

Back 50

Rheumatic

Front 51

Name four etiologies of PS, besides the most & least common (congenital & rheumatic, respectively)

Back 51

1) Carcinoid
2) Peripheral (Jxn of RPA/LPA)
3) Subvalvular (Infundibular)
4) Prosthetic Valve Dysfunction

Front 52

Which syndrome is classified as a cardiofacial syndrome with PS, HCM, and ASD (30%)?

Back 52

Noonan Syndrome

Front 53

PS will cause systolic (pressure or volume) overload which will lead to what?

Back 53

Pressure Overload
RVH

Front 54

What is often the cause of infundibular (subvalvular) PS?

Back 54

Regional Hypertrophy

Front 55

Name three congenital abnormalities that PS is commonly associated with.

Back 55

1) VSD
2) ASD
3) Tetralogy of Fallot

Front 56

How will PS typically affect RV and RA chamber sizes?

Back 56

RA will enlarge
RV will remain normal

Front 57

PS puts a patient at increased risk for what?

Back 57

Endocarditis

Front 58

What are two common physical symptoms experienced by patients with PS?

Back 58

1) Dyspnea upon exertion
2) Jugular Venous Pulsation (JVP)

Front 59

What is commonly found during ascultation in patients with PS?

Back 59

Systolic Ejection Murmer
(Left Upper Sternal Border)

Front 60

What is a common M-mode finding in patients with PS?

Back 60

Increased A wave

Front 61

In patients with severe PS, M-mode may show an increase in what of > 7mm?

Back 61

A dip

Front 62

Name three common 2D echo findings for patients with PS.

Back 62

1) Valvular thickening and systolic doming
2) RVH
3) Post-stenotic dilatation of the PA

Front 63

Name one 2D echo finding in patients with subvalvular (infundibular) PS.

Back 63

Narrowing of RVOT

Front 64

In the M-mode of the PV, what is the a-dip caused by?

Back 64

Atrial Contraction

Front 65

What happens to the a-dip (m-mode) with PS?

Back 65

A-dip becomes larger and exaggerated

Front 66

What happens to the a-dip (m-mode with pulmonary hypertension (PHTN)?

Back 66

A-dip disappears

Front 67

When using doppler in a stenotic area, will increased velocity & turbulance occur before, at, or after the obstruction?

Back 67

Increased velocity & turbulance will occur AT the obstruction

Front 68

Anytime PS is suspected, what measurements should be obtained? How & where?

Back 68

- Peak & Mean Gradients
- Tracing the doppler envelope
- PSAX/AV & PLAX/RVOT

Front 69

What is the normal pulmonary velocity?

Back 69

1 m/sec

Front 70

Does PS cause PHTN?

Back 70

No

Front 71

If unable to obtain PS gradient from the parasternal window, where else can you go?

Back 71

Subcostal SAX

Front 72

Name the peak velocity ranges (m/s) for mild, moderate, and severe PS

Back 72

PS: Peak Velocity (m/s)
MILD: < 3.0
MOD: < 4.0
SEV: > 4.0

Front 73

Name the peak gradient ranges (mmHg) for mild, moderate, and severe PS

Back 73

PS: Peak Gradient (mmHg)
MILD: < 36
MOD: < 64
SEV: > 64

Front 74

What is the most common etiology of MS?

Back 74

Rheumatic
(commissarial fusion)

Front 75

What is the rarest etiology of MS?

Back 75

Congenital
(parachute MV)

Front 76

What are two MS etiologies that are neither rare or common?

Back 76

Aquired MAC
Prosthetic Valve Dysfunction

Front 77

What is the cause of a parachute MV?

Back 77

Single Papillary Muscle (congenital)

Front 78

MS causes increased pressure and dilatation where?

Back 78

LA

Front 79

What effect can chronic MS have on the right side of the heart?

Back 79

PHTN (RV & RA enlargement)

Front 80

What effect does MS have on cardiac output?

Back 80

Decreased Cardiac Output

Front 81

Longstanding MS leads to all the following except:

A) CHF
B) PHTN
C) LV dilatation
D) LA dilatation

Back 81

C) LV dilatation

Front 82

45% of patients with this disease develop MS.

Back 82

Acute Rheumatic Fever

Front 83

What arrhythmia is common in patients with MS?

Back 83

Atrial Fibrillation

Front 84

What kind of murmur is present in patients with MS?

Back 84

Diastolic rumble with opening snap

Front 85

What are common physical symptoms of MS?

Back 85

CHF (dyspnea, fatigue, orthopnea, peripheral edema)
Hemoptysis (bloody sputum)

Front 86

Name four ways in which MV M-mode can identify MS.

Back 86

1) decreased E-F slope
2) anterior motion of posterior leaflet
3) reduced E wave amplitude
4) multiple echos

Front 87

Which of the following valves is least likely to be affected in rheumatic heart disease?

A) mitral
B) aortic
C) tricuspid
D) pulmonic

Back 87

D) pulmonic

Front 88

A "hockey-stick" presentation of the MV leaflet tips indicates what?

Back 88

Tethering
(associated w/ rheumatic MS)

Front 89

Thickened leaflets with decreased mobility describe what MV condition?

Back 89

MS

Front 90

Why can atrial fibrillation result from MS?

Back 90

LA dilatation causes stretched conduction tracts, which can trigger ectopic PMs

Front 91

Are MS patients with AFIB symptomatic? Why or why not?

Back 91

Symptomatic. MS patients are dependant on atrial contraction for their cardiac output, and AFIB will reduce diastolic filling by 50%

Front 92

To determine MS, name the ranges for mild, moderate, and severe MVA (cm^2)

Back 92

MS: MVA (cm^2)
MILD: > 1.5
MOD: < 1.5
SEV: < 1.0

Front 93

To support MS diagnosis, name the ranges for mild, moderate and severe Mean Gradient (mmHg)

Back 93

MS: Mean Gradient (mmHg)
MILD: < 5
MOD: < 10
SEV: > 10

Front 94

To support MS diagnosis, name the ranges for mild, moderate, and severe PA pressure (mmHg)

Back 94

MS: PA Pressure (mmHg)
MILD: < 30
MOD: < 50
SEV: > 50

Front 95

Name two additional measurements that should be taken when MS is suspected.

Back 95

1) Pressure Half Time
2) Mean Gradient

Front 96

With atrial fibrillation, MS velocity calculations are best performed:

A) averaged over 2 beats
B) averaged over 5-10 beats
C) averaged over 20 beats
D) unabled to measure in AFIB

Back 96

B) averaged over 5-10 beats

Front 97

Name two methods of calculating MVA in MS patients.

Back 97

1) Pressure Half-Time
2) Planimetry in PSAX

Front 98

What is pressure half-time?
For MS, which flow pattern is used to calculate it?

Back 98

- The time it takes for the pressure gradient to decrease by half.
- For MS, it is calculated from the diastolic mitral inflow deceleration slope

Front 99

How do you calculate MVA using pressure half-time?

Back 99

MVA (cm^2) = 220 / pressure half-time (msec)

Front 100

How do you calculate MVA using deceleration time?

Back 100

P1/2t = dt x 0.29
MVA (cm^2) = 220 / pressure half-time (msec)

OR

MVA (cm^2) = 759 / dt

Front 101

Given a mitral P1/2t of 400 msec, what would the area be?

A) 0.5 cm^2
B) 1.0 cm^2
C) 1.8 cm^2
D) 2.0 cm^2

Back 101

A) 0.5 cm^2

Front 102

Given a mitral deceleration time of 400 msec, what would the P1/2t be?

A) 50 ms
B) 116 ms
C) 220 ms
D) 600 ms

Back 102

B) 116 ms

Front 103

In a cath lab pressure tracing, what does it mean if the LA pressure tracks higher than the LV pressure in diastole?

Back 103

MS

Front 104

In a cath lab pressure tracing, what does it mean if the LV pressure tracks higher than the AO pressure in systole?

Back 104

AS

Front 105

What is the most common etiology of TS?

Back 105

Rheumatic

Front 106

What are the two rarest etiologies of TS?

Back 106

Congenital
Carcinoid

Front 107

What is another etiology of TS which is neither rare or common?

Back 107

Prosthetic Valve Dysfunction

Front 108

On 2D echo, how can you identify carcinoid vs rheumatic TS?

Back 108

Carcinoid = fixed leaflet bodies
Rheumatic = tethered leaflet tips

Front 109

Increased RA pressure causes what RA effect?

Back 109

RA dilatation

Front 110

Rheumatic TS is almost always associated with what?

Back 110

MS

Front 111

Increased serotonin production from a carcinoid tumor (intestinal tract or pancreas) can result in what?

Back 111

Carcinoid Heart Disease

Front 112

Serotonin deposits on the right heart endocardium causing TS/TR/PS/PR is called what?

Back 112

Carcinoid Heart Disease

Front 113

TS causes increased risk of what?

Back 113

Endocarditis