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25 Cards in this Set

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A 32year old female presents with atypical chest pain. Her blood pressure is 112/50, height 6’ and weight 115lbs. an echo is performed which shows mitral valve prolapsed. What is the most likely diagnosis for this patient?

Which additional cardiac structures should be evaluated?
From the physical description of this patient and the finding on echo of mvp she may have marfans syndrome.

The aortic valve and aorta should be evaluated for the presence of valvular regurgitation, aortic dilatation and possible dissection.
A 39 year old male with no cardiac history enters the doctor’s office complaining of flu-like symptoms for one week. A previously undocumented systolic murmur is heard. An echo reveals abnormally thick anterior mitral leaflet and mild mitral regurgitation. What is the most likely cause of these echo findings?

What additional tests will be helpful in making the diagnosis for this patient?
With a new murmur and the echo finding of mitral valve thickening in a young person, the most likely diagnosis is MV endocarditis.

Blood cultures will be helpful in identifying the organism and a TEE will further assess the extent of mitral leaflet thickening.
A 55 year old female complains of increasing dyspnea on exertion for three months. Her physical examination reveals jugular venous distention, ascities, and a pericardial knock. What is the most likely clinical diagnosis?
This patient may well have constrictive pericarditis. The dyspnea, ascities and JVD could all result from a restriction to diastolic filling. A pericardial knock is a classic physical finding associated with constriction.
A 32 year old female complains of fatigue and her chest x-ray reveals cardiomegaly. An echo is ordered. Right atrial and ventricular enlargement appears on the echo. Additionally, there is flattening of the interventricular septum, m-mode findings of pulmonic valve mid-systolic closure and an absent A-wave. Identify the cardiac abnormality consistent with these findings.
These echo findings are consistent with pulmonary hypertension. A microcavitation study should be performed to rule out an atrial level shunt as the cause of this pulmonary hypertension.
A 22 year old male complains of chest pain following exercise. An echo displays concentric left ventricular hypertrophy (2.5cm) and a small LV cavity size. Systolic motion of the mitral leaflet (SAM) and pericardial effusion are not observed. What is the most likely diagnosis for this patient?

What additional noninvasive tests may help in diagnosing the patient?
The findings of concentric left ventricular hypertrophy and a small LV cavity size is diagnostic of hypertrophic cardiomyopathy.

In order to identify the presence or absence of an obstructive component, an amyl nitrate challenge should be performed while the left ventricular outflow tract is interrogated by CW Doppler.
A 38 year old man is sent to the echo lab for evaluation after complaining of severe dyspnea on exertion for two months. M-mode findings include a dilated left ventricle, increased EPSS, B-notch on the mitral valve and overall hypocontractile LV wall motion. What type of cardiac abnormality do these findings suggest?
The M-mode findings of a dilated LV, increased EPSS, B-notch on the MV and overall hypocontractile LV wall motion identify a patient with a dilated cardiomyopathy.
After a chest x-ray revealed cardiomegaly, a 58 year old female, with a primary complaint of increasing dyspnea on exertion, is sent for an echo. The echo demonstrates LV hypertrophy with a “bright” myocardial appearance, left atrial enlargement and a small pericardial effusion. What is this patients most likely diagnosis?
These findings are most consistent with a diagnosis of infiltrative (restrictive) cardiomyopathy.
A 56 year old female visits her doctor with the complaint of shortness of breath. Upon physical examination, a diastolic (rumbling) murmur is detected. The patient denies history of rheumatic fever. What three cardiac abnormalities might be present in this patient?
1. Mitral stenosis (or tricuspid stenosis). Even with no known history she may have had rheumatic fever as a child and now has rheumatic heart disease.
2. Left atrial myxomas mimic mitral stenosis with regard to both physical finding and symtoms.
3. Aortic regurgitation. If the aortic regurgitation jet hits the mitral valve anterior leaflet, the MV’s opening can be restricted. As a result, a “rumbling” diastolic murmur (Austin Flint), rather than the typical “blowing” diastolic murmur, will be heard.
A 31 year old male with a history of uncontrolled hypertension enters the ER with severe chest pain that he describes as “ripping”. What is a likely cardiac diagnosis for this patient?

Which noninvasive exam would be useful to confirm this diagnosis?
Although this patient may be experiencing a myocardial infarction, the history of uncontrolled hypertension and “ripping” chest pain also indicate the possibility of an aortic dissection.

TEE would be the next preferred noninvasive test as it is the fastest to perform and most sensitive method in diagnosing aortic dissections.
An 18 year old male complains of “palpitations”. His chest x-ray revealed cardiomegaly and as a result, an echo is ordered. The echo reveals right atrial and ventricular enlargement. The tricuspid valve appears abnormally displaced towards the apex. What is this patient’s most probable cardiac abnormality?

What additional test should be performed in the echo lab?
This patient probably has Ebstein’s Anomaly. Often patient’s with Ebstein’s are asymptomatic and this finding is a surprise when an echo is performed for something like evaluation a murmur.

A microcavitation (bubble) study should be performed to identify the presence of an associated atrial septal defect.
In the parasternal short-axis view, at the level of the MV and papillary muscle, how many segments is the LV divided into?

Name the ventricular segments seen in the parasternal short-axis view.
Six segments.

The ventricular segments are:
1. Inferolateral
2. Anterolateral
3. Anterior
4. Anteroseptum
5. Inferoseptum
6. Inferior
In the apical four-chamber view, which two walls of the left ventricle are seen?

In the apical two-chamber view, which two walls of the left ventricle are seen?
In the apical four-chamber view, the inferoseptal and anterolateral walls of the left ventricle are seen.

In the apical two-chamber view, the anterior and inferior walls of the left ventricle are seen.
Which walls of the left ventricle are seen in the parasternal and apical long-axis views?

Which two aortic valve leaflets are seen in these views?
The anteroseptal and inferolateral walls are seen.

The right and noncoronary leaflets are seen in these views.
Where is the coronary sinus located in the parasternal long-axis view?

Where is the coronary sinus located in relation to the descending aorta?

How would you angle to view the coronary sinus in the apical four-chamber view?
The coronary sinus lies in the posterior atrioventricular (AV) groove. This groove is located between the left atrial and the left ventricular walls and lies posterior to the mitral valve. In the parasternal long-axis view, the coronary sinus can sometimes be seen as a small echo-free circle.

The coronary sinus is located anterior to the descending aorta. If the coronary sinus is dilated, it may be mistaken for the descending aorta.

From the apical four-chamber view you would angle inferior in order to visualize the coronary sinus, which is located posterior to the mitral annulus.
Why is it important to know the location of the coronary sinus and the descending aorta?

What would cause the coronary sinus to become dilated?
The coronary sinus and the descending aorta are important landmarks that can help differentiate pericardial effusions and pleural effusions. Pericardial effusions lie posterior to the coronary sinus and anterior to the descending aorta. Pleural effusions lie posterior to the descending aorta.

The coronary sinus dilates due to increased pressure in the right atrium (as in severe tricuspid regurgitation) or increased flow into the coronary sinus as in some congenital malformations (as in persistent left superior vena cava).
Name the three major coronary arteries.

Where are the coronary arteries located on the surface of the heart?
The three major coronary arteries are the right, left anterior descending (LAD), and circumflex arteries. The latter two arteries branch from the left main coronary artery, which is not considered a major artery because it is very short.

The coronary arteries are located on the outer, epicardial surface of the heard as follows: the right coronary artery (RCA) arises from the right aortic-root sinus, follows the right atrioventricular junction, and descends along the posterior interventricular groove. The left anterior descending coronary artery (LAD) follows the anterior interventricular groove. The circumflex artery coronary artery courses along the left atrioventricular junction.
Name the cardiac walls supplied by each of the coronary arteries.
Normally, the major coronary arteries supply the cardiac walls as follows:

Right coronary artery
a) Inferior wall
b) Inferoseptal
c) Right ventricular apex
d) Right ventricular free wall

Left anterior descending artery
a) Anterior wall
b) Anteroseptal
c) Left ventricular apex

Circumflex artery
a) Anterolateral wall
b) Inferolateral wall
While scanning a 43 year old man with a history of myocardial infarction, you notice that the anterior cardiac wall is akinetic. Which coronary artery is the most likely to have been involved in the infarction?

In the apical four-chamber view of another patient, the distal ventricular septum and left ventricular apex are hypocontractile. Which coronary artery is most likely to be diseased?
The left anterior descending (LAD) coronary artery, which supplies blood to the anterior cardiac wall, is most likely to have been involved. This artery also supplies the anterior portion of the ventricular septum and the left ventricular apex.

Again, the left anterior descending (LAD) coronary artery is the most likely choice. In some patients with distal septal hypocontractility, the proximal portion of the septum moves normally because it is supplied by the right coronary artery.
What are the normal systolic and diastolic pressures in the four cardiac chambers and the great vessels?

When is the pressure in the left ventricle at its lowest?
Normal pressures are as follows:

Right atrial = 2 – 8 mmHg

Right ventricular diastolic = 2 – 8 mmHg

Right ventricular systolic = 15 – 30 mmHg

Systolic pulomonary artery = 15 – 30 mmHg

Mean pulmonary artery = 9 – 18 mmHg

Pulmonary end-diastolic = 4 – 12 mmHg

Left atrial = 2 – 12 mmHg

Left ventricular diastolic = 3 – 12 mmHg

Left ventricular systolic = 100 – 140 mmHg

Aortic = 120/80 mmHg

The left ventricle pressure is lowest in early diastole just after the mitral valve opens. After that the left ventricular pressure rises as the chamber fills in diastole.
What is the normal mean pulmonary artery wedge pressure?

How is the pulmonary artery wedge pressure determined?
The normal mean pulmonary wedge pressure is 10mmHg, which equals the left atrial pressure. The PA wedge pressure is NOT the same as the PA pressure.

A Swan-Ganz catheter is positioned in the PA, and a small balloon is inflated at the catheter’s tip. The balloon is then floated and wedged into a smaller pulmonary artery. A pressure reading is obtained distal to the balloon. The inflated balloon prevents the tip of the catheter from sensing the pulmonary pressure, and the left atrial pressure is recorded as it is reflected across the pulmonary bed.
To visualize the anterior wall of the left ventricle, which two-dimensional view would you use?

To visualize the anterolateral wall of the left ventricle, which two-dimensional view would you use?
The anterior and inferior walls of the left ventricle are best visualized in the apical two-chamber view.

The anterolateral wall of the left ventricle is best visualized in the apical four-chamber view.
On the electrocardiogram, at what point does the mitral valve normally close?

On the electrocardiogram, at what point does the aortic valve normally open?
The mitral valve normally closes appx. 60 milliseconds after the onset of the QRS complex, or about halfway through the QRS complex.

The aortic valve normally opens at the end of the QRS complex. This answer takes into account the delay between electrical and mechanical systole, as well as the isovolumic contraction time (between mitral closure and aortic opening).
What is the relationship between electrical and mechanical systole?

What is diastasis?
Mechanical systole follows electrical systole by appx. 12 milliseconds. This delay represents the time it takes for the electrical conductive impulse to spread and thereby cause myocardial contraction. The delay can best be appreciated during M-mode studies that examine the relationship between the electrocardiographic pattern and valvular motion.

Diastasis denotes the middle portion of diastole, which occurs between early, rapid filling of the ventricles and the start of atrial contraction. The duration of diastasis varies with the heart rate. Diastasis is quite long in patients with bradycardia and quite short in those with tachycardia.
How much of ventricular filling occurs during the passive phase of diastole?

Name the four phases of diastole.
At normal pressures, appx. 70% of ventricular filling occurs during the passive phase of diastole; atrial contraction accounts for the remaining 30% of ventricular filling. Of course, these percentages will change in patients with valvular abnormalities such as mitral stenosis or ventricular compliance problems such as hypertrophic cardiomyopathy.

The four phases of diastole are:

Isovolumic relaxation time (closure of AV to opening of the MV)

Early filling (passive)

Diastasis

Atrial contraction (active)
What causes side-lobe artifacts?

What is the best way to minimize side-lobe artifacts?
Side-lobe artifacts are caused by strong reflectors outside the main ultrasound beam. These off-axis targets create reflections from weaker extra ultrasound beams alongside the main beam.

The best way to minimize side-lobe artifacts is to decrease the overall gain, increase the reject level, or decrease the time gain compensation (TGC) in the area of the strong reflectors (such as the pericardium).