Perrino Mcqs, Ch1-23

Front 1

Which of the following affects a sound wave’s propagation velocity? a. Signal frequency b. Signal amplitude c. Tissue density d. Transducer size

Back 1

c

Front 2

Sound waves propagate in all of the following except:a. Vacuumb. Bloodc. Boned. St. Jude mitral valve

Back 2

a

Front 3

The speed of sound in soft tissue is approximately:a. 1,500 cm/s b. 1,500 m/s c. 1,500 km/h d. 1,500 mph

Back 3

b

Front 4

High frequency sound waves are advantageous in cardiac imaging because they provide: a. Better penetration through fatty tissue b. Better amplitude in the far fieldc. Smaller transducer faced. Better focus

Back 4

d

Front 5

The signal amplitude is related to the:a. Square root of the intensityb. Intensity squaredc. Intensity divided by sector width d. Intensity times sector width

Back 5

a

Front 6

The sharply demarcated border between the ascending aortic walls and aortic blood in the ME AV LAX view:a. Results from specular reflectionsb. Results from scattering reflectionsc. Depends on the Nyquist limitd. Is not affected by reflection coefficient

Back 6

a

Front 7

Factors in loss of ultrasound signal amplitude include:a. Dispersion and reflection coefficientb. Absorption and sector widthc. Frequency and pulse repetition frequency d. Distance and gain settings

Back 7

a

Front 8

Which of the following is false regarding piezoelectric crystals?a. They transmit ultrasoundb. They convert an AC electrical signal to ultrasound c. They receive the reflected sound signalsd. They are controlled by gain settings

Back 8

d

Front 9

The length of the near field is:a. Increased with large transducers and large wavelength b. Increased with large transducers and high frequency c. Increased with small transducers and large wavelength d. Increased with small transducers and low frequency

Back 9

b

Front 10

Typical cross-sectional beam dimensions at a distance of 10 cm from the transducer equal:a. 1 mm2 b. 5 mm2 c. 15 mm2 d. 50 mm2

Back 10

b

Front 11

Side lobe artifacts:a. Can be mitigated by increasing gain settingsb. Can be mitigated by increasing transducer output c. Do not occur in single crystal transducersd. Are limited to the near field

Back 11

c

Front 12

The transducer is most commonly operating in transmit mode.a. True b. False

Back 12

b

Front 13

Reject circuits are best employed to:a. Reduce white outb. Reduce background speckle c. Protect against electrical injury d. Reduce side lobe artifacts

Back 13

b

Front 14

Round trip travel time (time from emission to return of reflected signals) in a TEE cardiac examination:a. Varies significantly based on tissues encountered b. Is impacted by sector widthc. Equals 13 μs/cmd. Is highest with high frequency signals

Back 14

c

Front 15

The round trip travel time for a 10 MHz signal reflected from a target 20 cm from the transducer is:a. 3,080 μs b. 3,080 ms c. 260 μs d. 2,600 ms

Back 15

c

Front 16

M-mode has higher temporal resolution than 2D ultrasound because:a. M-mode employs higher frequency signalsb. 2D employs sector displayc. Effective depth of M-mode is one-half that of 2D d. 2D employs B-mode

Back 16

b

Front 17

Phased array:a. Is a passing fadb. Is critical to M-mode displayc. Is an advancement over B-moded. Features electronic control over the activation of individual transducer elements

Back 17

d

Front 18

Frame rate is related to the pulse repetition frequency.a. True b. False

Back 18

a

Front 19

A freeze frame’s image quality is directly impacted by all of the following except:a. Pulse lengthb. Scan line densityc. Frame rated. Amplitude of returning signals

Back 19

c

Front 20

Dynamic motion appearance will be negatively impacted by:a. Increase in sector widthb. Decrease in signal frequency c. Decrease in depth settingd. Decrease in scan line density

Back 20

a

Front 21

Using the described standard nomenclature, which of the following commands will move the center of the imaging sector toward the patient’s left?

a. Anteflex–retroflex b. Forward rotation c. Turningd. Backward rotation

Back 21

c

outlines the standard terminology for probe manipulation. Turning the probe in a leftward or counterclockwise direction will place more left-sided structures in the center of the imaging sector. Rotation refers to the angle of the imaging plane.

Front 22

If the imaging plane is set at 45 degrees, the viewed cross section will run from:

a. Left shoulder to right hip b. Right shoulder to left hip c. Left side to right sided. Right side to left side

Back 22

a. Using the right hand analogy described in the text and Figures 2.2 and 2.3, at 45 degrees, right hand is rotated 45 degrees clockwise so that the right thumb is toward the left shoulder and the right little finger is toward the right hip. This is the approximate orientation of the probe when viewing the ME AV SAX.

Front 23

Which of the following structures cannot be seen at the apex of the imaging sector during a TEE examination?a. Aortab. Left atriumc. Left ventricled. Right ventriclee. None of the above

Back 23

e. Although the majority of views with have the aorta, left atrium, or left ventricle at the apex of the imaging sector. In the TG RV inflow view the right ventricle is seen at the apex of the imaging sector.

Front 24

Which view is necessary to identify the specific cusp pathology of the aortic valve?

a. ME AV short axisb. ME AV long axisc. ME ascending aortic short axis d. ME ascending aortic long axis

Back 24

a. Although the cusps of the AV can be seen in the ME AV LAX, it is difficult, if not impossible, to truly identify the near-field cusp as left or noncoronary cusp. The only view where all the three cusps can be clearly seen and identified is the ME AV SAX. The valve cusps should not be visible in either of the ascending aortic views.

Front 25

Measuring the AV annulus size is most easily done in which imaging view?a. ME AV short axisb. ME AV long axisc. ME ascending aortic short axis d. ME ascending aortic long axis

Back 25

b. The AV annulus is best seen in the ME AV LAX view. It is important to get the largest diameter when making the measure; otherwise the plan is off the midline and not the true diameter. In the ME AV SAX it is difficult to determine the correct level to make the measurement. The ME ascending aortic views image the aorta above the level of the annulus.

Front 26

The tip of a correctly positioned intra-aortic balloon pump should be visible in which of the following views?a. ME descending aortic long axis b. UE aortic arch short axisc. UE aortic arch long axisd. UE ascending aorta short axis

Back 26

a. The tip of a correctly placed intra-aortic balloon pump should be in the proximal descending aortic distal to the takeoff of the great vessels. This area of the aorta is only seen in the ME descending aortic short- and long-axis views.

Front 27

7 Which views are helpful in placing and/or determining the position of a pulmonary artery catheter?

a. ME bicavalb. ME RV inflow–outflowc. ME ascending aortic short axis d. ME ascending aortic long axis e. All of the above

Back 27

e. All of the views can be helpful with the placement of a pulmonary artery catheter. The ME bicaval view can be used to steer the catheter into the tricuspid valve (seen at approximately 7 o’clock). This view is especially useful when refloating a PA catheter following CPB. The RV inflow–outflow view and the ascending aortic short axis can confirm that the catheter has passed into the main pulmonary artery. The ascending aortic long- and short-axis views can identify if the catheter is in the right pulmonary artery.

Front 28

Which of the following views is not useful for accessing pathology of the tricuspid valve?a. ME RV inflow–outflow b. TG RV inflowc. ME four-chamberd. ME two-chamber

Back 28

d. All the listed views except the ME two-chamber provide views of the tricuspid valve. The RV inflow– outflow and the ME two-chamber views are most commonly used to evaluate the tricuspid valve, especially with color flow Doppler. The ME two-chamber view allows evaluation of the mitral valve not the tricuspid.

Front 29

When standard orientation and terminology is used, at 180 degrees, the image seen on the right side of the display is:a. On the patient’s left b. On the patient’s right c. Cephaladd. Caudad

Back 29

b. At 0 degrees, left-sided structures are visible on the right, and right-sided structures are visible on the left side of the imaging display. At 180 degrees, the imaging plane has rotated a full 180 degrees and the image is reversed so that right-sided structures are now visible on the right side of the screen.

Front 30

Diagnostic uses of the TG basal short-axis view include:a. Assessment of mitral valve pathologyb. Assessment of papillary muscle functionc. Assessment of apical LV regional wall motion d. Assessment of mid LV regional wall motion

Back 30

a. The TG basal SAX allows for assessment of mitral valve and LV basal segment regional function. The papillary muscles, mid, and apical LV segments should not be seen in the TG basal SAX view.

Front 31

When measuring thickness of the anterior wall of the left ventricle, which view will give you the best resolution?a. TG Mid SAXb. ME four-chamber c. ME two-chamber d. TG RV inflow

Back 31

a. The ME four-chamber view looks at the septal and lateral walls of the left ventricle. The TG RV inflow view does not look at any of the left ventricle. As discussed in the Physics and Doppler Chapter, axial resolution is far superior to lateral resolution. Even though the anterior wall of the left ventricle is seen in the TG mid-SAX and in the ME two-chamber views, whenever possible, measurements should be performed in an axial direction as in the TG mid-SAX view and not a lateral direction as in the ME two- chamber view.

Front 32

Diagnostic uses of the UE aortic arch long axis include all of the following EXCEPT:a. Evaluation for aortic atherosclerosisb. Evaluation for aortic dissectionc. Inspection of aortic cannulation sightd. Evaluation of intra-aortic balloon pump placement

Back 32

d. The UE aortic arch LAX view looks at the distal ascending aorta and aortic arch. Aortic athero- sclerosis and dissection pathology may be seen in this view. Depending on the surgical technique, the aortic cannulation site may be seen in this view. The tip of an intra-aortic balloon pump should be seen in the proximal portion of the descending aorta and is not visible in the UE aortic arch LAX view.

Front 33

The origin of the pulmonary veins may be seen in all of the views EXCEPT:a. ME midshort axis b. ME AV short axis c. ME two-chamber d. ME bicaval

Back 33

a. Pulmonary veins are seen emptying into the left atrium so any view of the left atrium may reveal the pulmonary veins. The pulmonary veins are most commonly seen in modifications of the ME bicaval and two-chamber views. The left atrium is seen in the ME AV short axis and can potentially show the left sided pulmonary veins. The term ME midshort axis is not commonly used nomenclature for a standard view. This will be discussed in depth in the subsequent chapters.

Front 34

14 The large and small knobs on the TEE probe control are:a. Anteflexion/retroflexion and left/right flexion b. Anteflexion/retroflexion and image rotation c. Left/right flexion and image rotationd. Image rotation and probe depth

Back 34

a. As described in Figure 2.1, the large knob controls ante- and retroflexion. The small knob controls left–right flexion. A button controls image rotation. Advancing or withdrawing the probe controls probe depth.

Front 35

Which of the following views is useful for placement of femoral cannula prior to the initiation of CPB?a. ME bicavalb. ME four-chamber c. ME two-chamber d. TG midshort axis

Back 35

a. The femoral cannula will not be visible in the femoral artery. However, TEE is especially useful for placement of the venous cannula. The cannula is advanced up the IVC through the right atrium and into the proximal SVC. Using the ME bicaval view, the cannula can be precisely placed in the correct position.

Front 36

Which of the following views is useful for the evaluation of pulmonary pathology in an adult patient with a prior tetralogy of Fallot repair?a. ME RV inflow–outflowb. UE aortic arch short axisc. TG RV inflowd. a and b

Back 36

d. Both the ME RV inflow–outflow and the UE aortic arch SAX views allow inspection of the pulmonary valve. The ME RV inflow–outflow view allows for inspection of the RV outflow tract and the UE aortic arch SAX view provides the proper angle for spectral Doppler interrogation of the outflow tract and the pulmonic valve.

Front 37

Increasing the near-field time gain compensation may be necessary when evaluating all of the following EXCEPT:a. Aortab. Left atrium c. Left ventricle d. Mitral valve

Back 37

d. Depending on the view obtained, the aorta, the left atrium, and the left ventricle may be seen at the apex of the imaging sector and hence in the near field. By increasing the near-field gain, pathology present near the apex may be better defined. Evaluation of the mitral valve is not as dependent on near- field gain changes.

Front 38

Thrombus in the left atrial appendage is best seen in which view?a. ME bicavalb. ME two-chamber c. TG two-chamber d. ME four-chamber

Back 38

b. The left atrial appendage is best viewed in the ME two-chamber view. The ME bicaval, four-chamber,and the TG two-chamber views show portions of the left atrium but not the appendage.

Front 39

Which of the following views are not useful for spectral Doppler interrogation of the aortic valve?a. ME AV long axis b. TG long axisc. Deep TG long axis

Back 39

a. As discussed in the Physics Chapter, spectral Doppler (both PW and CW) measures flow in an axial direction from the probe head. In the TG LAX and deep TG LAX aortic flow is aligned in an axial direction. In the ME AV LAX, flow is perpendicular to the axial direction and spectral Doppler is not useful.

Front 40

Left ventricular papillary muscles are visible in each of the following views EXCEPT:a. TG basal short axis b. TG midshort axis c. TG two-chamber d. ME four-chamber

Back 40

a. Papillary muscles should not be visible in the TG basal SAX. This view is at the level of the chordae tendineae/mitral valve and above the papillary muscles.

Front 41

Left ventricular ejection fraction can be calculated from which of the following parameters?a. Ventricular volumes b. Ventricular areasc. Ventricular diameters d. All of the above

Back 41

d

Front 42

The area-length (“bullet”) formula for calculating LV volumes is most useful in which of the following echocardiographic techniques?

a. Transthoracicb. Epiaorticc. Transesophageal d. Epicardial

Back 42

c

Front 43

The normal values for posterior wall thickness and septal wall thickness in a healthy male subject are respectively:a. 7 to 12 mm and 7 to 12 mmb. 7 to 12 mm and 6 to 10 mmc. 6 to 10 mm and 7 to 12 mmd. 6 to 10 mm and 6 to 10 mm

Back 43

d

Front 44

Endocardial fractional shortening is calculated from end systolic and end diastolic measurements of:a. Inferior wallb. Anterior wallc. Minor internal diameter d. Major internal diameter

Back 44

c

Front 45

Endocardial fractional shortening is measured from:a. Endocardial border to endocardial border b. Endocardial border to epicardial border c. Leading edge to trailing edged. Trailing edge to trailing edge

Back 45

a

Front 46

A calculated endocardial fractional shortening of 48% in a healthy woman is:a. Normalb. Below normal c. Above normal d. Very abnormal

Back 46

c

Front 47

The diameter used for the cubed formula can be the:a. Minor axis in the midesophageal long-axis viewb. Major axis in the midesophageal two-chamber view c. Minor axis in the midesophageal four-chamber view d. Major axis in the transesophageal short-axis view

Back 47

c

Front 48

Normal values for myocardial velocities measured in a healthy young adult male at the mitral annulus in the septal wall by transesophageal echocardiography are approximately:a. 3 cm/s b. 5 cm/s c. −3 cm/s d. −5 cm/s

Back 48

d

Front 49

Myocardial velocities as measured by tissue Doppler imaging may be affected by:a. Mitral annular calcification b. Tetheringc. Angle of incidenced. All of the above

Back 49

d

Front 50

With respect to color coding and strain, an akinetic segment is coded as:a. Blue b. Green c. Yellow d. Red

Back 50

b

Front 51

Using transesophageal echocardiography, the rate of left ventricular pressure rise (dP/dT) may be calculated from a:a. Continuous wave Doppler profile of aortic stenosis b. Pulse wave Doppler profile of aortic insufficiency c. Pulse wave Doppler profile of left ventricular inflow d. Continuous wave Doppler of mitral insufficiency

Back 51

d

Front 52

To perform dP/dT, the time interval between which of the following velocities is measured?a. 0 and 4 cm/sb. 1 and 3 m/sc. 0 and 4 m/sd. 1 and 3 cm/s

Back 52

b

Front 53

Normal values of dP/dT are:a. <500 mm Hg/sb. 500–1,000 mm Hg/s c. >1,000 mm Hg/s d. >2,000 mm Hg/s

Back 53

c

Front 54

Match the following echocardiography modalities (a, b) to the correct method of measurement (i, ii).a. M-Modeb. B-Modec. Leading edge to leading edge d. Trailing edge to leading edge

Back 54

(a) i, (b) ii

Front 55

With regard to systolic velocities measured by tissue Doppler imaging (TDI), which of the following statements is correct in a healthy individual with normal systolic function and no regional wall abnormalities?a. Septal annular < lateral annularb. Septal annular < septal mid ventricularc. Septal annular > anterior annulard. Septal annular (female) > septal annular (male)

Back 55

a

Front 56

Myocardial velocities as measured by tissue Doppler imaging (TDI) are:a. Gender independentb. Inversely related to mortalityc. Age dependentd. Same value if measured by TEE or TTE

Back 56

c

Front 57

For a given myocardial segment, color tissue Doppler measures:a. Peak instantaneous myocardial velocities b. Mean myocardial velocitiesc. Modal myocardial velocitiesd. Absolute myocardial velocities

Back 57

b

Front 58

During the early stages of primary restrictive cardiomyopathy the ventricles typically:a. Are dilatedb. Have severely depressed systolic function c. Have normal wall thicknessd. Have increased mass

Back 58

c

Front 59

During end stage restrictive cardiomyopathy secondary to amyloid there is typically:a. Stage 1 diastolic dysfunctionb. Normal systolic functionc. Biatrial enlargementd. Significant variation of mitral E wave during respiration

Back 59

c

Front 60

The most reliable echocardiographic modality for distinguishing primary hypertrophic cardiomyopathy from left ventricular hypertrophy in an athlete is:a. Continuous wave Doppler of the left ventricular outflow tract b. Color flow Doppler of the mitral valvec. Tissue Doppler imaging of the left ventricled. B-mode imaging of the left ventricle

Back 60

c

Front 61

Which statement regarding coronary topographic anatomy is true?a. The left main coronary artery runs in the atrioventricular sulcus between the pulmonary trunk and the left atrial appendageb. In the midesophageal short-axis view of the aortic valve, the right coronary ostium is seen in the middle of the right coronary cusp at the 9-o’clock positionc. The marginal branches of the left circumflex coronary artery supply the interventricular septumd. The coronary sinus runs along the anterior atrioventricular groove and drains into the right atrium

Back 61

a

Front 62

Which statement regarding coronary blood supply is true?a. The inferolateral segments of the LV are always supplied by the right coronary arteryb. The anterolateral segments of the LV are always supplied by the left circumflex coronary arteryc. The anterior segments of the LV are always supplied by the left anterior descending coronary artery d. The anteroseptal wall of the RV is always supplied by the right coronary artery

Back 62

c

Front 63

Acute occlusion of the left circumflex coronary artery does not cause dysfunction of the:a. Inferolateral segments of the LV b. Anteroseptal segments of the LV c. Anterolateral segments of the LV d. Apicolateral segment of the LV

Back 63

b

Front 64

Studies in humans have shown that:a. Akinesia and dyskinesia are always indicative of ischemiab. The basal septum does not thicken as much as the other parts of left ventricular walls c. New dyskinesia is associated with a worse outcome than new severe hypokinesiad. Echocardiography of acutely infarcted myocardium looks similar to scar tissue

Back 64

b

Front 65

Echocardiographic detection of myocardial ischemia may be complicated by all the following factors EXCEPT:a. Translational and rotational movements of the heartb. Ventricular pacingc. Incorrect alignment of the imaging plane with the axis of the ventricled. The physiologic variability in myocardial perfusion of some segments depending on the type of coronary distribution

Back 65

d

Front 66

Normal systolic contraction can be diagnosed if:a. Thickening of the myocardium is 20% or moreb. Radial shortening is more than 30%c. Rotation and translation of the heart can be excluded d. All of the above apply

Back 66

b

Front 67

Which statement is correct regarding echocardiographic findings during acute ischemia?a. The degree of ischemic mitral regurgitation is typically independent of changes in preload and afterloadb. Coronary air embolism after open heart surgery most frequently causes systolic wall contraction abnormalities of the anterior wallc. Acute akinesia indicates myocardial ischemia, acute dyskinesia myocardial infarctiond. None of the above

Back 67

d

Front 68

All of the following statements are true regarding myocardial perfusion EXCEPT:a. Maintained contraction of the RVOT may be present despite ostial occlusion of the right coronary arteryb. Parts of the RV anterior wall may receive blood supply from the left anterior descending coronary arteryc. The moderator band artery originates from the right coronary artery and may provide collateral blood supply in case of occlusion of the left circumflex coronary arteryd. There are no established rules for detailed analysis of regional contraction of the right ventricle

Back 68

c

Front 69

Which of the following statements regarding complications of ischemia is true?a. Acute myocardial ischemia and acute myocardial infarction cannot be differentiated by echocardiographyb. Ischemic rupture in the septum causes a ventricular septal defect with an interventricular left to right shuntc. A pseudoaneurysm has the same pathology as a ventricular septal defectd. All of the above apply

Back 69

d

Front 70

Regarding complications of ischemia all statements are true EXCEPT:a. Papillary muscle rupture is more likely in the posteromedial than the anterolateral papillary muscle b. Patients with papillary muscle rupture typically have a severely hypodynamic left ventriclec. Complete rupture of a papillary muscle affects both leaflets of the mitral valved. Ventricular septal defects develop most frequently after inferior myocardial infarction

Back 70

b

Front 71

Regarding variations in coronary anatomy it is true that:a. With a left dominant blood supply, the interventricular septum is perfused only by the left coronary arteryb. About 80% of individuals have a balanced coronary distribution typec. The posterolateral branch originates from the RCA in the balanced distribution typed. The posterior descending artery originates from the RCA in about 50% of individuals

Back 71

a

Front 72

Which of the following is not a complication of myocardial infarction?a. Pericardial tamponade b. Papillary muscle rupture c. Membranous ventricular septal defect d. Ventricular thrombus

Back 72

c

Front 73

TEE is useful in off-pump coronary artery bypass (OPCAB) for:a. Evaluating the adequacy of the coronary anastomosisb. Evaluating the ability of the patient to tolerate vessel occlusionc. Evaluating the hemodynamic consequences of cardiac displacement d. All of the above

Back 73

d

Front 74

The most sensitive TEE indicator of myocardial ischemia is:a. A reduction of systolic wall thickeningb. The presence of systolic wall thinningc. A reduction in endocardial excursiond. The presence of compensatory hyperkinesis

Back 74

a

Front 75

All of the following statements are true regarding digital cine loops EXCEPT:a. Electrocardiography (ECG) monitoring from the echocardiographic machine should be standard practiceb. The cine loop captures off the P wavec. In the absence of an ECG tracing, a capture of 1 second or more is requiredd. Ventricular systole is more difficult to determine with paced rhythms

Back 75

b

Front 76

All 17 segments of the LV model adopted by the ASE/SCA can be visualized by the combination of:

a. The ME four-chamber and LAX views and the TG mid-SAX view b. The TG mid-SAX, two-chamber, and LAX viewsc. The ME four-chamber, two-chamber, and LAX viewsd. The TG basal SAX, mid-SAX, and apical SAX views

Back 76

c

Front 77

All of the following “tricks” are helpful in attempting to visualize the LV apex EXCEPT:a. Probe retroflexion at the level of the TG SAX viewb. Optimizing far field gain and time gain compensation settingsc. Moving the focal zone over the apexd. Maximally increasing the frequency of the transducer in the ME four-chamber view

Back 77

d

Front 78

The TG mid-SAX view is commonly used for monitoring during CABG surgery because:a. Changes in intracavitary volume are easily determinedb. Territories of all three main coronary arteries perfusing the LV are visualizedc. The papillary muscles serve as a useful reference point to ensure that the same territory is being evaluatedd. All of the above

Back 78

d

Front 79

Which of the following may be associated with wall contraction abnormalities?a. Ventricular pacingb. Hypovolemiac. Hypertrophic cardiomyopathy d. All of the above

Back 79

d

Front 80

Chronic ischemic mitral regurgitation is postulated to occur through all of the following mechanisms EXCEPT:a. Ventricular dilatation with incomplete leaflet coaptationb. Papillary muscle rupturec. Ischemic dysfunction of one or both papillary musclesd. Hypokinesis of the ventricular segment underlying a normal papillary muscle

Back 80

b

Front 81

Which of the following statements about Doppler echocardiography is true?a. The received Doppler signal is stronger than the 2D signalb. Christian Doppler was a Swedish echocardiographerc. Doppler velocity measurements are based on the change in the signal’s frequency d. Doppler velocity measurements are based on reflections from plasma

Back 81

c

Front 82

In clinical practice the Doppler frequency shift is:a. Typically 2.5 to 7.5 MHzb. Less than 1 MHzc. Not relevant to the Nyquist limitd. Negative for flow directed perpendicular to the ultrasound beam

Back 82

b

Front 83

The Doppler frequency shift is affected by all of the following except:a. Transmitted frequencyb. Blood velocityc. Incident angle of the ultrasound beam d. Distance of the target from the transducer

Back 83

d

Front 84

Fast Fourier analysis is applied to:a. Pulse wave but not continuous wave Doppler signalsb. Identify the Doppler frequency shiftc. Identify the component frequencies of the Doppler frequency shift d. Extract noise from weaker Doppler signals

Back 84

c

Front 85

All the following statements are true of pulsed wave Doppler except:a. Requires two separate crystalsb. Is useful to identify blood flow in a particular areac. Has a limited maximum velocity that can be measured d. Is the basis for color flow Doppler

Back 85

a

Front 86

Techniques useful to correct an alias signal include all the following except:a. Adjust baselineb. Position transducer closer to target c. Increase transmitted frequencyd. Use high–frequency-pulsed Doppler

Back 86

c

Front 87

The Nyquist limit is directly related to:a. Blood flow velocity b. Pressure gradient c. Pulse repetition frequency d. Red cell mass

Back 87

c

Front 88

Which of the following statements about color flow Doppler is true?a. It is susceptible to aliasingb. It is a good choice for measuring high blood velocities c. It is based on continuous wave technologyd. It provides nonquantitative information

Back 88

a

Front 89

Demodulation:a. Filters out noise in the Doppler signalb. Identifies the Doppler shiftc. Is not necessary for color flow Dopplerd. Is not necessary for continuous wave Doppler

Back 89

b

Front 90

A spectral display with sharp, dense edges:a. Is diagnostic of stenotic lesionsb. Suggests echoes from a strong reflector such as a near-by calcified valve c. Assures that the beam is parallel to blood flowd. Suggests proper interrogation of blood flow

Back 90

d

Front 91

Increasing distance will increase the Nyquist limita. True b. False

Back 91

b

Front 92

Which of the following is likely in the case of a double envelope spectral signal obtained from the TG LAX view with peak velocities of 115 cm/s?a. Severe aortic stenosis is presentb. Fractional area change of 55%c. Biscuspid aortic valvular disease is present d. Subaortic stenosis is present

Back 92

b

Front 93

To increase accuracy in velocity measurements of subpulmonic artery blood flow in a patient with pulmonic stenosis from the UE aortic arch SAX view?a. The selected sample volume should have a length greater than 10 mmb. Range resolution should be adjusted to highc. Continuous wave Doppler should be employedd. The imaging array should be adjusted to 0 degrees to obtain the UE aortic arch LAX view

Back 93

a

Front 94

In obtaining blood velocity measurements of the right ventricular outflow tract using PW Doppler the angle of incidence is 70 degrees. The resulting measurement:a. Will display blood flow in the opposite direction of true blood flow b. Will underestimate blood flow by approximately 70%c. Will underestimate blood flow by approximately 30%d. Will be more accurate using the color flow Doppler setting

Back 94

b

Front 95

All the following are true concerning color flow Doppler except:

a. High velocity flow away from the transducer can appear dark red b. Color flow Doppler displays B-mode acquired imagesc. Color flow Doppler uses pulse wave technologyd. Turbulent flow is displayed as bands of red, yellow, and blue

Back 95

d

Front 96

As per the Doppler equation, the difference between the reflected and received frequency is inversely related to the cosine of the angle of incidence between the ultrasound beam and blood flow.a. True b. False

Back 96

b

Front 97

Time gating:a. Filters out low-frequency signalsb. Filters out high-frequency signalsc. Requires a fixed speed of soundd. Selects a defined distance from the transducer face

Back 97

d

Front 98

Compared to pulsed wave Doppler, continuous wave Doppler can more accurately measure high blood flow velocities because:a. It uses two transducers rather than one b. It uses M-mode technologyc. It time gates the signald. It uses high signal frequency

Back 98

a

Front 99

The color flow map is set at ±32 cm/s. Blood flow traveling away from the transducer at 77 cm/s will appear:a. Greenb. Bluec. Redd. As banded colors

Back 99

b

Front 100

The color flow map is set at ±32 cm/s. Blood traveling perpendicular to the probe at 77 cm/s will appear as:a. Green b. Blue c. Red d. Black

Back 100

d

Front 101

Which one of the following patterns of left ventricular diastolic dysfunction occurs most commonly in the early stages of infiltrative disorders?a. Restrictiveb. Pseudonormal c. Constrictived. Poor relaxation

Back 101

d. Changes in LV relaxation and compliance contribute to the spectrum of Doppler LV filling patterns that are observed with progressive diastolic dysfunction. The initial abnormality of diastolic filling in most disorders of cardiac physiology is impaired myocardial relaxation exceeding that expected with aging alone. Impaired LV relaxation occurs with myocardial ischemia/infarction, LV hypertrophy, hypertrophic cardiomyopathy, and in the early stages of infiltrative disorders (12).

Front 102

During spontaneous inspiration, patients with pericardial tamponade will most likely demonstrate which one of the following changes in the peak E-wave velocity of the transtricuspid and transmitral Doppler flow profiles?Peak E-wave velocity Transtricuspid Transmitral

a. IncreaseDecrease

b. DecreaseDecrease

c. DecreaseIncrease

d. IncreaseIncrease

Back 102

a. The diagnosis of pericardial tamponade includes identification of significant respiratory variation in atrial and ventricular Doppler inflow profiles. Normally during spontaneous respiration, intrathoracic pressures are transmitted equally to the pericardial space and intracardiac chambers. The transmission of intrathoracic pressure, however, is shielded by significant pericardial effusions. Consequently, LA and LV filling pressure gradients are decreased during spontaneous inspiration, resulting in diminished pulmonary venous forward diastolic velocities, delayed MV opening, prolonged IVRT, and decreased mitral E-wave velocity (23,48). Reciprocal changes occur in the transtricuspid valve velocities.

Front 103

In comparison to the restrictive pattern of left ventricular diastolic dysfunction, the impaired relaxation pattern is characterized by which of the following changes in the transmitral Doppler flow velocity isovolumic relaxation and E-wave deceleration times?Transmitral Doppler flow velocityIsovolumic relaxation time E-wave deceleration time

a. IncreaseIncrease

b. IncreaseDecrease

c. DecreaseIncrease

d. DecreaseDecrease

Back 103

a. The TMDF profile associated with impaired relaxation is typically characterized by a prolonged IVRT and a decreased initial TMPG (Fig. 7.4) (13). Consequently, the peak E-wave velocity decreases relative to the peak A-wave velocity when LV relaxation is impaired (E/A < 1), since the MV tends to open before relaxation is complete. In addition, the duration of LV relaxation is prolonged resulting in a prolonged DT (5) since the LA–LV pressure gradient takes longer to equilibrate.

Front 104

An increased pulmonary AR-wave/mitral A-wave duration ratio is consistent with which one of the following conditions?a. Increased left atrial complianceb. Decreased left atrial pressurec. Increased left ventricular end-diastolic pressure d. Decreased pulmonary venous compliance

Back 104

c. The normal PVAR (≈90 to 115 milliseconds) duration is the same or less than the transmitral A-wave duration (≈120 to 140 milliseconds) (11). In general, LA contraction should result in a greater net forward blood volume and flow toward a normal, compliant LV compared with any retrograde flow back toward the PV. A PVAR velocity that exceeds the mitral A-wave by >35 cm/s or PVAR duration >30 milliseconds longer than the transmitral A-wave duration usually indicates an age-independent elevation in LVEDP

Front 105

A pulmonary venous Doppler flow velocity profile with a biphasic systolic component, has an initial antegrade velocity (PVS1) that is most related to which one of the following cardiac cycle components?a. Left atrial relaxationb. Left ventricular contraction c. Left atrial contractiond. Left ventricular compliance

Back 105

a. A typical pulmonary venous Doppler flow (PVDF) profile consists of an antegrade systolic velocity which may appear monophasic, or biphasic especially in the presence of low LAP probably owing to temporal dissociation of atrial relaxation and mitral annular motion (Fig. 7.5) (16). The first systolic component, PVS1, is dependent upon LA relaxation and the subsequent decrease in pressure. The later peaking PVS2, reflects right ventricular (RV) stroke volume, LA compliance, the effects of early ventricular systole on LAP, and any concomitant MR.

Front 106

A pulmonary venous Doppler flow velocity profile with a biphasic systolic component, has a later peaking systolic antegrade velocity (PVS2) that is most related to which of the following cardiac cycle components?a. Right ventricular stroke volume b. Left atrial compliancec. Left ventricular contractiond. Concomitant mitral regurgitation e. All of the above

Back 106

e. A typical pulmonary venous Doppler flow (PVDF) profile consists of an antegrade systolic velocity which may appear monophasic, or biphasic especially in the presence of low LAP probably owing to temporal dissociation of atrial relaxation and mitral annular motion (Fig. 7.5) (16). The first systolic component, PVS1, is dependent upon LA relaxation and the subsequent decrease in pressure. The later peaking PVS2, reflects right ventricular (RV) stroke volume, LA compliance, the effects of early ventricular systole on LAP, and any concomitant MR.

Front 107

n comparison to normal adult values, the restrictive pattern of left ventricular diastolic function exhibits which one of the following sets of relative changes in Doppler echocardiographic velocities?

Pulmonary vein S/D ratio Mitral annular DTI Transmitral color M-mode Velocity ratio Peak E velocity (E′) Propagation velocity (Vp)

a. IncreasedIncreasedDecreased

b. DecreasedDecreasedDecreased

c. IncreasedIncreasedIncreased

d. DecreasedDecreasedIncreased

Back 107

b

Front 108

Which one of the following Doppler echocardiographic measurements is the best predictor ofincreased left ventricular filling pressure in patients with atrial fibrillation?a. Increased PVAR/MVA duration ratiob. Decreased pulmonary venous diastolic flowc. Increased transmitral peak E-wave velocityd. Decreased transmitral E-wave deceleration time

Back 108

d. In patients with atrial fibrillation (AF), the transmitral and PVAR-waves are absent and the E-wave peak velocity and DT vary with the length of the cardiac cycle. AF may also be associated with a loss of PVS1, and a decreased PVS2 relative to the dominant PVD (23). Peak acceleration rate of the E-wave velocity (24), transmitral E-wave DT shortening, and the duration and initial deceleration slope time of PVD may still correlate with increased LV filling pressure in the presence of AF (23).

Front 109

The use of a nitroglycerin will convert a pseudonormalized left ventricular inflow pattern to which one of the following transmitral Doppler flow velocity patterns?a. Normalb. Restrictivec. Poor relaxation d. Constrictive

Back 109

c. The intermediate, pseudonormalized stage of diastolic dysfunction is therefore characterized by normal values for peak E-wave and A-wave velocities, IVRT, and DT. Reducing preload by utilizing reverse Trendelenburg positioning, partial cardiopulmonary bypass (CPB), a Valsalva maneuver (14), or by administering nitroglycerin may also reveal underlying impaired LV relaxation in a patient with pseudonormalized transmitral inflow (15).

Front 110

The transmitral color M-mode propagation velocity (Vp) is most likely to increase during which one of the following conditions?a. Administration of milrinoneb. Reverse Trendelenburg positioning c. Administration of nitroglycerind. Valsalva maneuver

Back 110

a. In contrast to standard Doppler filling indices, Vp is relatively independent of preload, yet responds to changes in lusitropic conditions (32) and systolic performance (33). Consequently, while TMDF and PVDF tend to show a parabolic distribution from normal through progressive. Furthermore, altering preload by utilizing various techniques (partial CPB, inferior vena cava occlusion, intravenous nitroglycerin, amyl nitrate inhalation, Valsalva maneuver, Trendelenburg positioning, leg lifting) is associated with changes in transmitral peak E-wave velocity, E/A-wave velocity, and E-wave deceleration, but has little affect on Vp (33–35).

Front 111

In comparison to other conventional Doppler echocardiographic measures of diastolic function, which of the following is most unique for strain imaging?a. Angle dependenceb. Independent of rotational and translational movement of the heart c. Uses measures of tissue velocityd. Can also be used to evaluate systolic function

Back 111

b. Both strain rate (SR) and strain (S) imaging are angle dependent. However, they are generally used in long-axis views to measure longitudinal shortening (systolic function) or lengthening (diastolic function) of the LV along the ultrasound beam. Consequently, unlike Doppler tissue imaging (DTI), both S and SR are relatively independent of translational or rotational movement. Thus strain imaging may have additional advantages over conventional echocardiography techniques for evaluating diastolic function in the perioperative period.

Front 112

Which one of the following echocardiographic measurements made during spontaneous inspiration is most consistent with a diagnosis of decreased right ventricular compliance and increased filling pressures?

a. Prolonged transtricuspid E-wave deceleration time b. Diastolic predominance of hepatic vein flowc. Diminished hepatic AR-wave velocity time integral d. >50% inspiratory collapse of the IVC

Back 112

b. Diastolic RV dysfunction can manifest with the same relative changes in transtricuspid peak E- and A- wave velocities, E/A-wave ratios, and DT that occur with TMDF profiles associated with alterations in LV relaxation and compliance (43,44). The ratio of the total hepatic reverse flow integral to total forward flow integral (TVIA + TVIV/TVIS + TVID) increases with either RV diastolic dysfunction or significant TR, but appears to be more affected by the former (45). In addition, a marked shortening of the transtricuspid DT and diastolic predominance of HV flow with prominent V- and A-wave reversals during spontaneous inspiration, indicates significant decreases in RV compliance and increased diastolic filling pressures (Fig. 7.11C) (10).

Front 113

Approximately what percentage of patients with congestive heart failure have diastolic dysfunction and normal ejection fractions?a. 10% b. 30% c. 50% d. 70% e. 90%

Back 113

c. Congestive heart failure (CHF) is the most common diagnosis amongst inpatients in the United States and accounts for 720,000 hospital admissions annually (54). Nearly half of the patients with CHF have diastolic dysfunction and normal ejection fraction (55). Diastolic dysfunction increases with age, especially amongst elderly patients with hypertensive heart disease (55).

Front 114

Preoperative diastolic dysfunction has been reported in approximately what percentage of cardiac surgical patients?a. <10%b. 10% to 30% c. 30% to 60% d. 70% to 90% e. >90%

Back 114

c. Preoperative diastolic dysfunction has also been reported in 30% to 60% of cardiac surgical patients and independently associated with difficult weaning from cardiopulmonary bypass (CPB), more frequent inotropic support, and increased morbidity.

Front 115

Which of the following echocardiographic measures is the best surrogate of left ventricular end-diastolic pressure?a. Propagation velocity (Vp)b. Deceleration time (DT)c. Pulmonary venous systolic flow velocity (PVS)d. Isovolumic relaxation time (IVRT)e. Ratio of early transmitral Doppler flow velocity to early mitral annular Doppler tissue velocity (E/e′)

Back 115

e. While more complex algorithms for evaluating diastolic dysfunction may be considered impractical to obtain in the perioperative period, simpler echocardiographic measures of diastolic dysfunction including the tissue Doppler-derived surrogate for LV diastolic pressure E/e′, have also been shown to be prognostic of adverse postoperative outcomes after cardiac surgery (60,61).

Front 116

In comparison to normal adult values, patients with hypertension, normal systolic function, and impaired diastolic function are more likely to demonstrate which one of the following sets of relative changes?Peak diastolic strain rate (SR) Propagation velocity (Vp)a. Increased Reducedb. Reduced Increasedc. Increased Increasedd. Reduced Reduced

Back 116

d. Diastolic deformation of the LV can also be analyzed with strain imaging and Vp to describe both early and late filling. Pixel velocity values obtained by color DTI can be processed to velocity gradients as a measure of longitudinal strain rate with a technique termed strain rate imaging (SRI), which can show the spatial–temporal relations of the diastolic phases. The phases of early and late filling can be seen to consist of a stretch wave in the myocardium, propagating from the base to the apex (Vp). Diastolic function is characterized by both peak strain rate and propagation velocity of this wave (41) (Fig. 7.10). In a series of 26 patients with hypertension, normal systolic function, and impaired diastolic function, Stoylen et al. (41) demonstrated that both the peak diastolic SR and Vp are reduced.

Front 117

Perioperative diastolic dysfunction in cardiac surgical patients is associated with which of the following adverse events?a. Difficulty weaning from cardiopulmonary bypass b. More frequent inotrope supportc. Mortalityd. All of the above

Back 117

d. Preoperative diastolic dysfunction has also been reported in 30% to 70% of cardiac surgical patients and independently associated with difficult weaning from cardiopulmonary bypass (CPB), more frequent inotropic support, and increased morbidity (3,37). Merello et al. (59) evaluated diastolic dysfunction in 191 CABG patients. Mortality and complications through 30 days postoperatively were compared with that predicted by the EuroSCORE and Parsonnet score. Increasing degrees of diastolic dysfunction correlated well with survival. However, mortality was not predicted by either the EuroSCORE or Parsonnet score suggesting the potential values adding a measure of diastolic dysfunction to these widely used risk stratification schemes (59).

Front 118

Which of the following echocardiographic measures of diastolic function is least sensitive to changes in loading conditions?a. Early mitral annular Doppler tissueb. Late transmitral Doppler flow velocityc. Diastolic pulmonary venous Doppler flow velocity d. Transmitral deceleration time

Back 118

a. The concordance between mitral annular motion assessed by DTI and mitral inflow velocities, however, is disrupted with progressive diastolic dysfunction when poor relaxation coexists with an elevated filling pressure. In patients with elevated LVEDP who present with a pseudonormal (27) or restrictive transmitral Doppler inflow velocity profile (28), E′ remains reduced suggesting relative preload independence. In fact, E′ has actually been shown to be the best discriminator between normal and pseudonormal patients when compared to any single or combined index of TMDF or PVDF profiles (25).

Front 119

Left atrial contraction usually contributes what percentage of left ventricular filling in normal patients?a. <20%b. 20% to 40% c. 40% to 60% d. >60%

Back 119

a. The LA contribution to LV diastolic filling is usually <20% in young healthy patients, yet may approach 50% in patients with decreased LV filling associated with early diastolic dysfunction.

Front 120

Which of the following echocardiographic measures of diastolic function are observed in patients with a pseudonormal pattern?a. Increased early transmitral Doppler flow velocity (E)b. Decreased late transmitral Doppler flow velocity (A)c. Increased early mitral annular Doppler tissue velocityd. Decreased systolic pulmonary venous Doppler flow velocity e. Decreased diastolic pulmonary venous Doppler flow velocity

Back 120

d

Front 121

Which of the following types of mitral regurgitation is typically not associated with a “structural” defect of the mitral leaflets?a. Type 1b. Type 2c. Type 3ad. Type 3be. None of the above

Back 121

d

Front 122

Which of the following statements is false regarding the mitral annulus?a. It is saddle shapedb. Its diameter decreases in systolec. In disease states, it tends to dilate, but maintains its saddle shape d. When dilated, it may contribute to mitral regurgitatione. None of the above statements is false

Back 122

c

Front 123

In the Carpentier nomenclature, which mitral valve segment coapts with P3?a. A1b. A2c. A3d. None of the above

Back 123

c

Front 124

Assuming all measurements are taken appropriately, which of the following signs could beseenwith severe mitral regurgitation?a. Forward systolic pulmonary venous flow b. Vena contracta of 3 mmc. Regurgitant volume 15 mLd. Jet area/left atrial area 20%e. None of the above

Back 124

a

Front 125

A TEE report states that “the mechanism of MR is type 2, with a central MR jet.” What conclusion will you draw from this report?a. This is expected: The MR jet in type 2 disease is usually central b. This is impossible: The TEE report must be wrongc. This is expected, but only in cases of A2 prolapsed. This could happen if there is bileaflet prolapsee. None of the above

Back 125

d

Front 126

Which of the following statements is false about the vena contracta?

a. It represents the narrowest point of the MR jet b. It should be measured in the ME-commissural viewc. A diameter of 7 mm or more is associated with severe MRd. Like all other color Doppler measurements, it may be affected by gain and Nyquist limit e. None of the above

Back 126

b

Front 127

Which of the following echocardiographic signs is typically not associated with severe MR?a. A large mitral coaptation defect on 2D echob. A wall-hugging MR jetc. A vena contracta of 8 mmd. A large color Doppler MR jet, which fills two-thirds of the left atrial area e. All the above signs are associated with severe MR

Back 127

e

Front 128

A patient is stable in the coronary care unit, after a late-presentation inferior ST elevation myocardial infarct. Suddenly, he becomes severely dyspneic and requires intubation. On auscultation, you hear a new loud holosystolic murmur. In this clinical context, what is the most likely diagnosis and what do you expect to find on echocardiography?a. Acute severe type 3b (functional) MR from tethering of the mitral valve b. Severe RV dilatation from acute pulmonary embolismc. Severe type 2 MR from a ruptured posterior papillary muscled. Acute endocarditis with a torn anterior mitral leaflete. None of the above is very likely

Back 128

c

Front 129

Pick the best answer among the following choices: Mitral annular dilatation typically occurs in which of the following situations?a. Chronic type 1 MR b. Chronic type 2 MRc. Chronic type 3b MRd. It can occur in any of the above situations e. None of the above is true

Back 129

d

Front 130

A patient presents to your operating room for mitral valve repair. The preoperative evaluation showed severe (4+) MR. After induction of anesthesia, your examination demonstrates only mild MR. Your course of action would include which of the following?a. Obtain a second opinion from a colleagueb. Administer vasopressors (e.g., phenylephrine, ephedrine, or norepinephrine) to raise the bloodpressurec. Perform a comprehensive mitral valve examination to determine the anatomy and pathophysiology of the MRd. Review the preoperative images and contact the cardiologist, if possiblee. All of the above are appropriate actions

Back 130

e

Front 131

During coronary artery bypass surgery, you perform a comprehensive TEE examination after induction of anesthesia, and you find trace (1+) MR. Half an hour later, (without any change to the settings on the echo machine) you repeat the mitral valve images and you find moderate to severe (3+) central MR! All of the following factors could conceivably contribute this sudden increase in MR, EXCEPT:a. An acute ischemic eventb. The surgeon opened the pericardiumc. The patient received a large fluid bolusd. Surgical stimulation has caused a rise in blood pressure e. None of the above

Back 131

e

Front 132

Which of the following mechanisms are believed to play a role in functional mitral regurgitation (type 3b)?a. Posterior and apical papillary muscle displacement b. Mitral annular dilatationc. Tethering of the mitral valve leafletsd. All of the above factorse. None of the above factors

Back 132

d

Front 133

Which of the following statements about 3D TEE of the mitral valve is TRUE?a. 3D technology has only been available since 2008b. 3D is not associated with any significant artifactsc. 3D technology often makes up for poor 2D images quality d. 3D technology eliminated the problem of low frame rates e. None of the above statements is true

Back 133

e

Front 134

Which of the following 3D modalities allows simultaneous visualization of multiple orthogonal 2D-echo planes?a. 3D full-volume viewb. Multiplane reconstruction (MPR) c. 3D zoomd. Live 3De. None of the above

Back 134

b

Front 135

Which of the following statements are true, concerning 3D echo of the mitral valve?

a. The images must be processed off-line and cannot be used in the operating room b. It eliminates the need for novice echocardiographers to understand 2D imagesc. It allows imaging of the ventricular surface of the mitral valved. It does not lend itself to quantitative measurements of the mitral valvee. None of the above

Back 135

c

Front 136

Which of the following statements is false, regarding the currently available quantitative 3D mitral valve analysis software packages?a. It can be used in the operating roomb. It provides a detailed structural analysis of the mitral valve c. It usually will not show mitral annular calcificationd. It has many research applicationse. All the above statements are true

Back 136

a

Front 137

Which of the following conditions is most likely to be associated with functional (type 3b) MR?a. Alcoholic cardiomyopathyb. Myxomatous mitral valve diseasec. Rheumatic mitral valve diseased. Acute bacterial mitral valve endocarditis e. Fibroelastic mitral valve disease

Back 137

a

Front 138

f a patient ruptures his/her posteromedial papillary muscle, all of the following mitral segments (Carpentier nomenclature) are likely to be affected, EXCEPT:a. A2 b. P2 c. A3 d. P1 e. P3

Back 138

d

Front 139

Which of the following is not an example of type 2 mitral valve disease?a. Restricted P2 segmentb. Prolapsed A3/P3 segments c. Flail P2 segmentd. Billowing A2 segmente. None of the above

Back 139

a

Front 140

All of the following factors have an impact on the surgeon’s ability to repair the mitral valve, EXCEPT:a. The location of the pathologyb. The severity of the MRc. The mechanism of the MRd. The degree of mitral annular calcification e. The surgeon’s experience

Back 140

b

Front 141

Which among the following statements is correct concerning mitral valve anatomy?a. The anterior mitral leaflet base-to-margin dimension is longer than that of the posterior mitral leaflet, yet the two leaflets are nearly identical in overall surface area.b. A normal mitral valve area is 4 to 6 cm2.c. The anterior mitral leaflet has an attachment of approximately one-third of the circumference of themitral annulus.d. All of the above are correct.

Back 141

d

Front 142

The “Hockey stick” deformity of the anterior mitral leaflet is reflective of which of the following findings in rheumatic mitral disease?a. Concomitant severe mitral regurgitation b. Severe aortic insufficiencyc. Restriction to mitral valve diastolic flow d. Pulmonary hypertension

Back 142

c

Front 143

Two-dimensional features of long-standing mitral stenosis include:a. Left atrial enlargementb. Presence of spontaneous echo contrast in the left atrium c. Thickened and relatively immobile mitral valve leafletsd. All of the above

Back 143

d

Front 144

Severe mitral stenosis would be most consistent with which of the following pressure half-time measurements?a. 60 millisecondsb. 120 milliseconds c. 180 milliseconds d. >300 milliseconds

Back 144

d

Front 145

Which among the following statements is correct concerning the use of mean pressure gradient to assess severity of mitral valve stenosis?a. Presence of severe mitral regurgitation can lead to an overestimation of mitral stenosis when using mean pressure gradient estimates due to an increase forward flow across the mitral valve.b. Mean pressure gradients across the mitral valve are independent of degree of forward flow.c. Pulmonary hypertension can lead to an underestimation of degree of mitral stenosis when using themean pressure gradient estimates.d. None of the above statements are correct.

Back 145

a

Front 146

Which among the following may introduce error to mitral valve area measurements when using planimetry to calculate mitral valve area?a. Instrumentation factors such as gain settings set too high or too low b. Inadequate imaging plane orientationc. Postmitral valvuloplastyd. All of the above

Back 146

d

Front 147

A mitral valve pressure half-time of 280 milliseconds from a Doppler spectral profile would yield a calculated mitral valve area of:a. 1.5 cm2 b. 2 cm2c. 0.78 cm2 d. 1.2 cm2

Back 147

c

Front 148

8 Which among the following mean pressure gradient parameters are most consistent with severe mitral stenosis?a. 3 mm Hgb. 5 to 6 mm Hgc. >12 mm Hgd. 8 mm Hg

Back 148

c

Front 149

When using the pressure half-time to calculate mitral valve area, which among the following statements can lead to the introduction of measurement errors?a. Patients with mild aortic insufficiencyb. Moderate pulmonary hypertensionc. Severe aortic insufficiencyd. Mild left ventricular compliance changes

Back 149

c

Front 150

The continuity equation can be used to calculate mitral valve area. Which among the following statements is true?a. Concomitant regurgitation of the mitral valve or reference valve may introduce error b. Presence of pulmonary hypertension will limit accuracyc. Continuity equation is not theoretically independent of left ventricular compliance d. Presence of shunt flow will not interfere with the accuracy

Back 150

a

Front 151

One of the benefits to the use of the PISA method to calculate mitral valve area is:a. Presence of mitral regurgitation invalidates the PISA method in the calculation of mitral valve areab. Aortic insufficiency introduces inaccuracies when using PISA method to calculate mitral valve areac. PISA method accuracy is not influenced by concomitant mitral or aortic regurgitationd. PISA method is not as quantitative a method to calculate mitral valve area when compared to the use of planimetry.

Back 151

c

Front 152

PISA is most useful in the following circumstances:a. When there are technical limitations to the use of planimetryb. When continuity equation cannot be used due to lack of reference valve forward flow c. When pressure half-time is affected by hemodynamic changesd. All of the above

Back 152

d

Front 153

Use of PISA for mitral valve area calculation requires the addition of which of the following in order to improve accuracy?a. Exclusion of peak flow rateb. Introduction of an angle correction factor: α/180 degrees c. Consideration of concomitant mitral regurgitationd. A correction factor for presence of diastolic dysfunction

Back 153

b

Front 154

Which among the following statements regarding the newly proposed real-time three- dimensional score system for rheumatic mitral stenosis differentiates it from the Wilkins criteria?

a. Does not include a measure of extent of subvalvular involvement

b. Provides a more detailed assessment of leaflet involvement by subdividing each leaflet into three

c. Excludes extent of leaflet calcification

d. Does not include extent of leaflet thickening

Back 154

b

Front 155

Given a deceleration time of 800 milliseconds from a Doppler spectral profile, the calculated mitral valve area would be:a. <1.0 cm2 b. 1.5 cm2 c. 2.8 cm2 d. 2.0 cm2

Back 155

b

Front 156

Which among the following statements concerning the echocardiographic finding of spontaneous echo contrast is correct?a. It is indicative of a high-flow stateb. May represent a warning sign for increased patient risk for thrombosis c. Is present in the left atrium in patients with severe mitral regurgitation d. Is less common in patients with atrial fibrillation

Back 156

b

Front 157

Long-standing mitral stenosis with chronic elevation in left atrial pressure can result in:a. Structural alterations in the pulmonary vasculature b. Right-sided heart failurec. Pulmonary hypertensiond. All of the above

Back 157

d

Front 158

Which among the following mitral valve area measurements is most consistent with severe mitral valve stenosis?a. 2 cm2b. <1 cm2c. 1.5 cm2d. 1.5 to 1.8 cm2

Back 158

b

Front 159

Pathologic features of rheumatic mitral stenosis include which among the following?a. Leaflet thickeningb. Calcium depositionc. Restricted leaflet mobility d. All of the above

Back 159

d

Front 160

Which among the following conditions can lead to the development of mitral stenosis?a. Rheumatic heart diseaseb. Parachute mitral valve deformity c. Cor triatriatumd. All of the above

Back 160

d

Front 161

Which of the following is true?a. Chronic severe mitral regurgitation is a contraindication for surgery and should be treated medicallyb. Mitral regurgitation secondary to dilative cardiomyopathy is typically a functional rather thanstructural pathologyc. Patient outcome after mitral valve repair is independent of surgical skill leveld. Successful repair should lead to restriction of the range of mitral valve leaflet motion

Back 161

d

Front 162

Secondary cardiac pathophysiology associated with mitral regurgitation includes all of the following, EXCEPT:a. Left ventricular dilatationb. Left atrial dilatationc. Lipomatous hypertrophy of the interatrial septum d. Eccentric cardiac hypertrophy

Back 162

c

Front 163

Regarding mitral valve anatomy, the following are true EXCEPT:a. The anterior mitral leaflet is divided anatomically into three segments by the presence of two indentationsb. The surface area of the posterior mitral leaflet is less than that of the anterior mitral leafletc. Primary chordae tendineae attach to the free edge of the mitral leafletsd. The mitral valve has two commissures, one anterolateral commissure and one posteromedial commissure

Back 163

a

Front 164

Regarding mitral valve anatomy, the following are true EXCEPT:a. The mitral annulus normally has a saddle-shaped profileb. When the mitral annulus dilates, it does so in a predominantly anterior to posterior direction c. The length of the posterior leaflet is greater than the length of the anterior leafletd. The papillary muscles are each connected to both mitral leaflets by chordae tendineae

Back 164

c

Front 165

All of the following are true regarding the assessment of the severity of mitral regurgitation EXCEPT:a. In patients under general anesthesia, the severity of mitral regurgitation is usually overestimatedb. The Nyquist limit for color flow Doppler assessment of the regurgitant jet should be set between 50and 60 cm/sc. Systolic flow reversal in a pulmonary vein indicates severe mitral regurgitationd. Regurgitant jet vena contracta is best measured in the midesophageal four-chamber and long-axis views

Back 165

a

Front 166

All of the following are true regarding the functional classification for mitral regurgitation EXCEPT:

a. In type IIIb regurgitation leaflet restriction is limited to systoleb. Cleft defect of a mitral leaflet is an example of a type I pathology c. Type II regurgitation results from excessive leaflet motiond. Chordal rupture typically results in type III regurgitation

Back 166

d

Front 167

When assessing the severity of mitral regurgitation, which of the following is true:a. Vena contracta of the regurgitant jet should be measured at the narrowest part of the jet, just proximal to the regurgitant orificeb. For multiple regurgitant jets, the sum of the individual vena contractae represents the true severity of the regurgitationc. When using the PISA method to quantify the severity of mitral regurgitation, the Nyquist limit should be set between 50 and 60 cm/sd. Regurgitant jet area is not recommended for assessment of mitral regurgitation severity

Back 167

c

Front 168

Regarding the circumflex artery, the following are true EXCEPT:a. The artery can be visualized using TEE whilst the patient is on bypass, unless the aorta is cross- clampedb. Increasing the Nyquist limit for color flow Doppler will improve the sensitivity for detection of flow within the vesselc. The incidence of circumflex artery occlusion occurring following mitral valve surgery is approximately 1% to 2%d. Decreasing gain improves visualization of the vessel

Back 168

b

Front 169

Which of the following scenarios is most compatible with successful mitral repair:a. The mitral annulus is calcifiedb. The dysfunction is localized prolapse (e.g., P2 segment) c. The dysfunction is classified as type IIIa d. The mitral annulus is severely dilated

Back 169

b

Front 170

Factors which help to predict the likelihood of postoperative systolic anterior motion (SAM) of the anterior mitral leaflet occurring after mitral valve repair include the following, EXCEPT:a. Decreased distance from the septum to mitral leaflet coaptation point (C-sept) b. An absolute height of the posterior leaflet of more than 1.5 cmc. A ratio of anterior leaflet height to posterior leaflet height of <1.4d. Presence of mitral annular calcification

Back 170

d

Front 171

Regarding the management of postrepair SAM, which of the following is true?a. Presence of postoperative SAM almost always requires a return to bypass and further surgical correctionb. Increasing heart rate and decreasing afterload will reduce the severity of the SAMc. Epinephrine is the drug of choice in the management of postoperative SAMd. Left ventricular outflow tract obstruction is usually also evident in patients with SAM

Back 171

d

Front 172

Regarding the assessment of immediate postrepair mitral stenosis, which of the following methods is most helpful if available?a. Pressure half-time of mitral inflowb. Pulse wave Doppler assessment of the mean gradient across the mitral valvec. Continuous wave Doppler assessment of the peak gradient across the mitral valve d. Planimetry of the mitral valve opening area

Back 172

d

Front 173

The A2/P2 segments of the mitral valve can usually be seen in the following TEE views, EXCEPT:a. Midesophageal two-chamber b. Transgastric basal short-axis c. Midesophageal four-chamber d. Midesophageal long-axis

Back 173

a

Front 174

The following statements regarding the Alfieri stitch repair technique are true EXCEPT:a. It involves suturing A2 and P2 segments togetherb. It leads to the creation of a triple orifice valvec. The effective opening area of the valve is equal to the sum of the individual orifice areas d. Mitral stenosis is a recognized potential complication

Back 174

b

Front 175

Regarding excessive leaflet motion, which of the following is true?a. Billowing always progresses to prolapse and then to flailb. Billowing leaflets always result in a regurgitant jetc. The regurgitant jet flows over the nonaffected segment in patients with type II dysfunction d. Chordal rupture always results in flail leaflet

Back 175

c

Front 176

New regional left ventricular wall motion abnormalities in the inferolateral or anterolateral segments occurring postbypass for mitral valve repair should prompt particular concern about:a. Iatrogenic circumflex coronary artery damage b. Coronary artery air embolusc. Myocardial stunning d. Hyperkalemia

Back 176

a

Front 177

Which of the following is not a benefit of mitral valve repair versus replacement?a. Preservation of left ventricular function b. Fewer thromboembolic eventsc. Better early and late survival ratesd. Shorter operative time

Back 177

d

Front 178

Fundamental goals of mitral valve repair do not include:a. Restoration of full leaflet motionb. Decreasing the size of the mitral valve orifice with an annuloplasty ring c. Stabilization and remodeling of the mitral valve annulusd. Creation of a large coaptation area

Back 178

b

Front 179

Common techniques for repair of mitral valves include the following EXCEPT:a. Chordal transferb. Implantation of an annuloplasty ring c. Isolated chordal released. Implantation of synthetic chordae

Back 179

c

Front 180

Regarding TEE for mitral valve repair, all of the following are true EXCEPT:a. TEE is a level I indication for mitral valve repairb. A problem-focused TEE should be used preoperatively rather than a comprehensive exam c. TEE evaluation of the mitral valve is generally superior to transthoracic echocardiography d. If TEE is contraindicated in a particular patient, epicardiac echocardiography can be used

Back 180

b

Front 181

Which of the following factors can affect the degree of AR during an operative examination?a. Administration of vasopressors b. Presence of volatile anesthetics c. Patient’s volume statusd. All of the above

Back 181

d

Front 182

Which TEE view is most helpful in evaluating the aortic valve in a patient with a St. Jude mitral valve?a. ME four-chamber viewb. ME aortic valve long-axis view c. ME aortic valve short-axis view d. TG long-axis view

Back 182

d

Front 183

Which view allows for optimal Doppler beam alignment in a patient with AR?a. ME four-chamber viewb. ME aortic valve long-axis view c. ME aortic valve short-axis view d. TG short-axis viewe. Deep TG long-axis view

Back 183

e

Front 184

When the ratio of the AR jet height to the LVOT diameter is used to quantify the degree of AR, the following is true

a. One must optimize the color gain settingb. The ME aortic valve long-axis view is preferredc. The ratio for AR with a grade of 4 + is more than 65%d. All of the above

Back 184

d

Front 185

When the pressure half-time method is used to quantify the severity of AR, which of the following will NOT artificially worsen the apparent severity of the AR?a. Congestive heart failureb. Restrictive physiologyc. Diastolic dysfunctiond. Acute myocardial infarction e. Acute hemorrhage

Back 185

e

Front 186

Obtaining diastolic aortic flow reversal in a patient with AR with TEE is difficult. The following statements regarding techniques are true EXCEPT:a. The upper esophageal aortic arch long-axis view is usefulb. Obtaining accurate flow velocities is essentialc. Holodiastolic flow in the distal aorta indicates severe ARd. AR end-diastolic velocity profiles in the descending aorta correlate better with AR severity than those in the ascending aorta

Back 186

b

Front 187

Which statement about continuous wave Doppler analysis of AR is true?a. Parallel alignment with the regurgitant jet is essential b. The deep TG long-axis and TG long-axis views are preferredc. ME views are seldom adequate because of poor beam alignment d. A smooth waveform with an intact envelope is necessarye. All of the above

Back 187

e

Front 188

Which principle is not important in an evaluation of the slope of AR jet decay with Doppler?a. Pulsed wave Doppler is preferred because of “cleaner” envelopesb. The velocity of the regurgitant jet is directly proportional to the pressure gradient between the aortaand the LV in diastolec. A severe regurgitant lesion will equalize the pressure gradient between the aorta and the LV more quicklyd. The velocity of the AR jet diminishes more quickly as the severity of AR increases

Back 188

a

Front 189

Which of the following observations is useful to remember in an attempt to optimize the Doppler beam alignment in a patient with AR?a. The velocity should be high (4 to 5 m/s)b. AR has a loud and pure audio tone as the jet is enteredc. The intensity (darkness) of the spectral Doppler signal is proportional to the severity of the leak d. Patients with significant AR frequently have LVOT systolic velocities greater than 1.5 m/se. All of the above

Back 189

e

Front 190

All of the following indicate severe AR EXCEPT:a. Pressure half-time of less than 500 millisecondsb. Ratio of height of the AR jet in the LVOT to the diameter of the LVOT above 65% c. Ratio of area of AR jet in LVOT to area of LVOT above 60% d. Diastolic flow reversal in the descending aorta

For the following questions match each question with the appropriate item(s) from the followingchoices:a. Midesophageal long-axis view b. Midesophageal short-axis view c. Transgastric long-axis viewd. Deep transgastric view

Back 190

a

Front 191

All of the following indicate severe AR EXCEPT: a. Pressure half-time of less than 500 milliseconds b. Ratio of height of the AR jet in the LVOT to the diameter of the LVOT above 65% c. Ratio of area of AR jet in LVOT to area of LVOT above 60% d. Diastolic flow reversal in the descending aorta

For the following questions match each question with the appropriate item(s) from the following choices: a. Midesophageal long-axis view b. Midesophageal short-axis view c. Transgastric long-axis view d. Deep transgastric view

The mechanism and etiology of aortic insufficiency is best assessed by which view(s)?

Back 191

a, b

Front 192

All of the following indicate severe AR EXCEPT: a. Pressure half-time of less than 500 milliseconds b. Ratio of height of the AR jet in the LVOT to the diameter of the LVOT above 65% c. Ratio of area of AR jet in LVOT to area of LVOT above 60% d. Diastolic flow reversal in the descending aorta For the following questions match each question with the appropriate item(s) from the following choices: a. Midesophageal long-axis view b. Midesophageal short-axis view c. Transgastric long-axis view d. Deep transgastric view

The most clinically accurate assessment of the severity of aortic regurgitation by color Doppler utilizes which view(s)?

Back 192

a, b

Front 193

All of the following indicate severe AR EXCEPT: a. Pressure half-time of less than 500 milliseconds b. Ratio of height of the AR jet in the LVOT to the diameter of the LVOT above 65% c. Ratio of area of AR jet in LVOT to area of LVOT above 60% d. Diastolic flow reversal in the descending aorta For the following questions match each question with the appropriate item(s) from the following choices: a. Midesophageal long-axis view b. Midesophageal short-axis view c. Transgastric long-axis view d. Deep transgastric view

The optimal alignment for determining the rate of decline of the diastolic gradient across the aortic valve utilizes which view(s)?

Back 193

c, d

Front 194

All of the following indicate severe AR EXCEPT: a. Pressure half-time of less than 500 milliseconds b. Ratio of height of the AR jet in the LVOT to the diameter of the LVOT above 65% c. Ratio of area of AR jet in LVOT to area of LVOT above 60% d. Diastolic flow reversal in the descending aorta For the following questions match each question with the appropriate item(s) from the following choices: a. Midesophageal long-axis view b. Midesophageal short-axis view c. Transgastric long-axis view d. Deep transgastric view

The least accurate color flow Doppler view for assessment of the severity of regurgitation is which view?

Back 194

d

Front 195

Three-dimensional imaging of an eccentric jet in the LV outflow tract:

a. May allow alignment with the vena contracta in three planes, increasing accuracy of its measurement

b. Is readily obtained in all patients because of the large number of elements available in a 3D TEE probe (approximately 3,000)

c. May be difficult to obtain because of the relative depth of aortic valve from the probe tip

d. Is not effected by aortic valve calcification

e. All of the above

f. a and c

g. b and d

Back 195

f

Front 196

The superior insertion point of the commissures of the aortic leaflets is approximately at:a. The level of the sinotubular junctionb. The level of the aortic annulusc. The sinuses of Valsalvad. The level of the takeoff of the right and left coronary arteries

Back 196

a

Front 197

Which of the following Type(s) of aortic regurgitation are most likely to require aortic valve replacement?a. Type Ib. Type IIc. Type IIId. All of the above

Back 197

c

Front 198

The peripheral blood pressure in a patient with aortic regurgitation is 175/75 mm Hg. The peak velocity at the onset of an appropriately interrogated regurgitant jet is approximately:a. 2 m/s b. 3 m/s c. 4 m/s d. 5 m/s

Back 198

c

Front 199

Following aortic valve repair for regurgitation, the following risk factors predict a high recurrence rate for significant AR EXCEPT:a. High level of coaptation relative to the annulus b. Coaptation length <4 mmc. Restrictive leaflet motiond. Residual AR postrepair

Back 199

a

Front 200

3D TEE for AR is most useful for calculation of the following:a. Regurgitant volumeb. Effective regurgitant orifice areac. Vena contractad. Not useful secondary to anterior location of AV

Back 200

c

Front 201

Use of the Gorlin equation in the catheterization suite has all of the following limitations EXCEPT:a. In patients with aortic insufficiency, the aortic valve area may be falsely elevatedb. The cardiac output (CO) of multiple beats must be averaged for patients in atrial fibrillation c. The peak-to-peak gradient is requiredd. The systolic ejection period must be calculatede. The gradient across a stenotic aortic valve varies directly with cardiac output

Back 201

c

Gorlin equation:

VA = CO / HR x systolic ejection period x 44.3 x sq root mean grad

Front 202

The following statements regarding the usefulness of planimetry in the evaluation of AS are true EXCEPT:a. The midesophageal (ME) aortic valve short-axis view is preferredb. The results of planimetry correlate extremely well with catheterization-derived determinations of theaortic valve areac. An adequate planimetry-derived determination of the aortic valve area depends on an adequate COd. Significant valvular calcification decreases the accuracy of planimetry-derived determinations of areae. Three-dimensional planimetry facilitates obtaining the true minimal cross-sectional valve area by orienting this in a third dimension

Back 202

c

Front 203

All of the following statements regarding continuous wave Doppler evaluation of the aortic valve are true EXCEPT:a. The preferred view is the deep transgastric (TG) long-axis view because of the parallel alignment of the Doppler beam with flowb. The deep TG long-axis view offers a correlation of more than 0.9 with transthoracic echocardiography (TTE)-derived aortic valve flow velocitiesc. If a mitral prosthetic valve is present, the TG long-axis view at 120 degrees can be used to obtain aortic valve flow velocitiesd. Accurate flow velocities can be obtained with the ME views by electronically steering (angle correcting) the resulting signal to the jet direction as visualized on the 2D color Doppler image

Back 203

d

Front 204

A patient is determined to have the following Doppler parameters: Left ventricular outflow tract (LVOT) velocity, 1.7 m/s; aortic valve velocity, 4.6 m/s. The pressure gradient across the aortic valve is:a. 84.64 mm Hg b. 73 mm Hgc. 33.64 mm Hg d. 11.56 mm Hg

Back 204

b

Front 205

In regard to pressure gradients in the left ventricular (LV) and aortic valve, the following is/are true:a. The Doppler-derived mean transvalvular gradient approximates the catheterization-derived mean transvalvular gradientb. The peak-to-peak catheter gradient is usually the highest gradient recordedc. The Doppler-derived maximal instantaneous gradient is comparable with the peak-to-peakcatheterization gradientd. All of the above

Back 205

a

Front 206

A patient has an LV ejection fraction of 10%. Which measurement is preferred in determining the severity of the AS?a. Peak aortic valve flow velocityb. Aortic valve area response to dobutamine-mediated increase in cardiac output c. Aortic valve mean gradientd. Planimetered aortic valve areae. LVOT time–velocity integral (TVI)/aortic valve TVI ratio

Back 206

b

Front 207

Preoperative evaluation of a patient undergoing valve replacement for critical aortic stenosis shows that the basal interventricular septum has hypertrophied into the left ventricular outflow tract (“sigmoid septum”). When coming off bypass after valve replacement the patient is hypotensive. The appropriate intervention is:a. Administer pressors with positive inotropy to maintain adequate peripheral perfusion pressureb. Administer pressors and volume load because the hypertrophied left ventricle requires a high fillingpressure due to its lack of compliancec. Reassess the status of the left ventricle to determine if subaortic obstructive physiology has developed postoperatively (systolic anterior motion of the mitral valve or “SAM”)d. Volume load, withdraw pressors and consider adding beta blockers

Back 207

c

Front 208

Which of the following parameters does not impact on the measured aortic valve area?a. Arterial blood pressureb. Diameter of the sinotubular junction c. Left ventricular systolic functiond. Mitral regurgitation

Back 208

d

Front 209

Which of the following may be associated with a low transvalvular gradient in the presence of

a. Dilated cardiomyopathyb. Nonobstructive hypertrophic cardiomyopathyc. Normal ejection fraction in a small noncompliant LV d. All of the abovee. None of the above

Back 209

d

Front 210

In the presence of aortic stenosis with subaortic obstruction due to hypertrophic cardiomyopathy the best method for assessing aortic valve area is:a. Continuity equation using the peak velocity in the LV outflow tract above the area of obstruction b. Planimetry of the aortic valve orificec. Dimensionless indexd. Continuity equation using the peak velocity in LV just below the area of subaortic obstruction

Back 210

b

Front 211

When the continuity equation is used, which of the following statements regarding measurement of the LVOT is true?a. The diameter is measured 1 cm proximal to the aortic valveb. Inner to inner edge, parallel and adjacent to the aortic valve at its leaflet insertions, or at the site ofvelocity measurement.c. The diameter is measured at the leaflet tipsd. The chance of introducing error into this measurement is small

Back 211

b

Front 212

A patient is found to have aortic stenosis. What maneuvers will increase the gradient across the aortic valve?a. Exercise b. Aortic insufficiencyc. Acute myocardial infarction d. Both a and be. All the above

Back 212

d

Front 213

All of the following have been shown to be associated with decrease in myocardial perfusion reserve EXCEPT:a. Aortic valve pressure gradients b. LV mass indexc. Male sexd. LV filling pressuree. Myocardial fibrosis

Back 213

c

Front 214

Of the choices given below, which one correlates most with a decrease in myocardial perfusion reserve?a. Aortic valve pressure gradients b. LV mass indexc. Male sexd. LV filling pressuree. Myocardial fibrosis

Back 214

a

Front 215

Treatment for SAM can include which of the following?a. MV replacementb. Volume expansionc. Reduction of intraoperative inotropes d. Beta blockade e. All of the above

Back 215

e

Front 216

A patient is determined to have the following Doppler parameter: Aortic valve velocity, 5 m/s. The mean pressure gradient across the aortic valve is:a. 30 b. 50 c. 60 d. 100

Back 216

c

Front 217

3D TEE of the aortic valve is not limited by:a. High temporal resolution b. Thin AV leafletsc. Anterior locationd. Low frame rates

Back 217

a

Front 218

A 40-year-old man develops syncope while playing golf. Despite poor TTE 2D imaging, the patient’s aortic valve mean gradient is 40 mm Hg. What is the most common cause of his aortic stenosis?a. Bicuspid aortic valveb. Calcific aortic stenosis c. Rheumatic heart disease d. Marfan’s syndrome

Back 218

a

Front 219

A patient with a heart rate of 80 bpm, CO of 2 L/min, AV peak gradient of 30 mm Hg, and 20% LVEF, undergoes dobutamine stress testing. His results are in the following table.

Which example is consistent with severe aortic stenosis?Choice Heart rate Cardiac output (L/min) AV peak gradient (mm Hg) Aortic valve area (cm3)

a.802301b.1002301c.1003.5501d.1003.5501.4e.1002301.4

Back 219

c

Front 220

A patient with a heart rate of 80 bpm, CO of 2 L/min, AV peak gradient of 30 mm Hg, and 20% LVEF, undergoes dobutamine stress testing. His results are in the following table. Which example is consistent with primary myocardial disease?dChoice Heart rate Cardiac output (L/min) AV peak gradient (mm Hg) Aortic valve area (cm3)

a.802301

b.1002301

c.1003.5501

d.1003.5501.4

e.1002301.4

Back 220

d

Front 221

A 62-year-old male underwent aortic valve replacement for aortic stenosis with a bioprosthetic valve prosthesis. Continuous wave Doppler echocardiography measured a peak velocity of 231 cm/s and a mean velocity of 141 cm/s across the prosthetic valve. Pulsed wave Doppler echocardiography measured a peak velocity of 154 cm/s and a mean velocity of 86 cm/s in the left ventricular outflow tract. The most accurate peak pressure gradient across the bioprosthetic aortic valve is:

a. 30 mm Hg b. 21 mm Hg c. 12 mm Hg d. 10 e. 4 mm Hgmm Hg

Back 221

c. The simplified Bernoulli equation, ΔP = 4 × V22, is often used to estimate the transvalvular pressure gradient across a prosthetic aortic valve. When the proximal flow velocity in the left ventricular outflow tract is close to or exceeds 1.5 m/s, the nonsimplified Bernoulli equation, ΔP = 4 × (V22 − V12) provides a more accurate estimate of the transvalvular pressure gradient across the prosthetic valve in the aortic position. Using the nonsimplified Bernoulli equation, ΔP = 4 × (2.312 − 1.542) = 11.9 mm Hg.

Front 222

An 82-year-old female who was 5′2′′ and 148 lbs with a body surface area (BSA) of 1.68 m2 underwent aortic valve replacement with a 19-mm bioprosthetic valve. Echocardiographic measurements after prosthetic valve implantation yielded a left ventricular outflow tract (LVOT) diameter of 1.8 cm, a velocity–time integral of 30 cm in the left ventricular outflow tract (VTILVOT), and a velocity–time integral (VTIAoV) of 60 cm across the prosthetic aortic valve. These findings are consistent with:

a. No prosthetic–patient mismatchingb. Mild prosthetic–patient mismatchingc. Moderate prosthetic–patient mismatchingd. Severe prosthetic–patient mismatchinge. Cannot determine the severity of prosthetic–patient mismatching based on the information

Back 222

c. Moderate prosthetic–patient mismatching. The estimated orifice area (EOA) of the prosthetic valve is calculated by EOA = LVOTarea × (VTILVOT/VTIAoV). The LVOT area is determined by the formula, LVOTarea = π × (LVOTdiameter/2)2. The EOA indexed to body surface area, EOAi = EOA/BSA. In the above case, the calculated EOAi for the patient is (π × [LVOTdiameter/2]2 × [30 cm/60 cm])/1.68 = 0.76 cm2/m2. An EOAi ≤ 0.65 cm2/m2 is consistent with severe prosthetic–patient mismatch, EOAi > 0.65 cm2/m2 and ≤0.85 cm2/m2 is consistent with moderate prosthetic–patient mismatch, and EOAi > 0.85 cm2/m2 is consistent with no or mild prosthetic–patient mismatch.

Front 223

A 74-year-old male underwent aortic valve replacement for aortic stenosis. Intraoperative TEE examination after implantation of the prosthetic aortic valve revealed paravalvular regurgitation. The best echocardiographic method to grade the severity of prosthetic regurgitation is performed by:a. Measuring the width of the regurgitant jet with Doppler color flow imagingb. Estimating the density of the regurgitant jet using continuous wave Dopplerc. Detecting the presence of proximal flow acceleration at the site of regurgitation d. Calculating the regurgitant volumee. Combining qualitative and quantitative echocardiographic parameters of regurgitation

Back 223

e. Combining qualitative and quantitative echocardiographic parameters of regurgitation in an integrative approach is typically necessary to provide an estimate of the severity of prosthetic regurgitation because grading the severity of prosthetic aortic regurgitation is more difficult than grading native aortic regurgitation. Standard echocardiographic parameters to grade the severity of native aortic valve regurgitation do not always provide an accurate assessment of the severity of prosthetic aortic regurgitation.

Front 224

A 70-year-old female underwent TEE examination to assess the function of a mechanical bileaflet mechanical prosthetic valve implanted in the mitral position for mitral stenosis 15 years ago. Continuous wave Doppler echocardiography measured a peak velocity across the prosthetic valve of 1.5 m/s, a mean gradient across the valve of 4 mm Hg, and a pressure half- time of 110 milliseconds. These findings are consistent with:a. A normally functioning prosthetic valve in the mitral positionb. Possible stenosis of the prosthetic valvec. Significant stenosis of the prosthetic valved. Significant stenosis of the prosthetic valve if the cardiac output is normal e. Echocardiography cannot be used to diagnosis prosthetic mitral stenosis

Back 224

a. A normally functioning prosthetic valve in the mitral position has a peak velocity <1.9 m/s, mean gradient ≤5 mm Hg, and pressure half-time of <130 milliseconds. A peak velocity 2.5 m/s, mean gradient >10 mm Hg, and pressure half-time >200 milliseconds suggest significant prosthetic mitral stenosis.

Front 225

A 56-year-old male with a height of 5′10′′, weight of 180 lbs, and body surface area of 2 m2, and a left ventricular ejection fraction of 60% is scheduled for aortic valve replacement for calcific aortic stenosis. Intraoperative TEE demonstrated a native aortic valve annulus of 19.5 mm in diameter. To avoid severe patient–prosthetic mismatching, the following needs to be performed:a. Aortic root enlargementb. Avoid using a mechanical prosthetic valve c. Aortic root replacement d. Myomectomye. Select a prosthetic valve with an estimated orifice area greater than 1.3 cm2

Back 225

e. A prosthetic valve with an estimated orifice area (EOA) greater than 1.3 cm2 would yield an indexed estimated orifice area (EOAi = EOA/BSA) of >0.65 cm2/m2. An EOAi greater than 0.65 cm2/m2 would avoid severe prosthetic–patient mismatch. Severe prosthetic–patient mismatch is defined as an EOAi ≤ 0.65 cm2/m2.

Front 226

A 50-year-old male with bicuspid aortic valve, aortic regurgitation, and a dilated ascending aorta underwent a composite aortic root replacement, ascending aorta, and partial aortic arch graft with a mechanical valved conduit. A leak at the proximal aortic valve annular suture line would:a. Have no clinical consequencesb. Cause paravalvular regurgitation that can be detected by TEE c. Cause nonpathologic transvalvular regurgitationd. Cause cardiac tamponadee. Lead to an aortic pseudoaneurysm

Back 226

d. Leakage at the proximal anastomotic suture line would cause cardiac tamponade in the acute setting because blood would extravasate into the pericardial space. Paravalvular regurgitation is not possible with composite aortic root replacement because the prosthetic valve is fused to the vascular graft used to replace the aortic root and ascending aorta. A delayed dehiscence of the proximal aortic suture line would lead to an aortic pseudoaneurysm.

Front 227

The best TEE view to assess the individual motion of the occluders of a mechanical bileaflet prosthetic valve implanted in the aortic position is the:a. TEE midesophageal aortic valve short-axis viewb. TEE midesophageal aortic valve long-axis viewc. TEE midesophageal right ventricular inflow–outflow viewd. TEE transgastric long-axis viewe. TEE cannot be used to assess the individual motion of occluders of a mechanical prosthetic valve implanted in the aortic position

Back 227

d. The TEE transgastric long-axis view provides an image of the prosthetic valve in the aortic position in the far field where the motion of both occluders can often be imaged. The individual motion of each occluder of a mechanical bileaflet prosthesis in the aortic position cannot be reliably determined from the midesophageal imaging planes because of acoustic shadowing caused by the annular stent or the occluders.

Front 228

The best TEE view to assess the individual motion of the occluders of a mechanical bileaflet prosthetic valve implanted in the mitral position is the:a. TEE midesophageal four-chamber viewb. TEE midesophageal aortic valve short-axis view c. TEE transgastric long-axis viewd. TEE transgastric two-chamber viewe. TEE deep transgastric long-axis view

Back 228

a. The TEE midesophageal view provides an image plane through the prosthetic valve in the mitral position where the motion of both occluders can usually be discerned without interference from acoustic shadowing. Depending on the orientation of the hinge points of the prosthetic valve at the time of implantation, adjusting the TEE multiplane angle from the midesophageal window to provide a cross section perpendicular to the motion of the occluders permits the motion of both occluders to be imaged simultaneously.

Front 229

An 85-year-old female who had a caged-disc prosthetic valve implanted in the mitral position for mitral stenosis presents with congestive heart failure. TEE was ordered to assess the function of the prosthetic valve. The following can be most accurately determined from the TEE examination:a. Prosthetic–patient mismatchingb. The severity of prosthetic valve stenosisc. The severity of paravalvular regurgitationd. The left ventricular end-diastolic pressuree. The estimated orifice area of the prosthetic valve

Back 229

c. The severity of paravalvular regurgitation, if present can be detected and estimated by the TEE examination. The TEE examination cannot accurately estimate the transvalvular pressure gradient or effective orifice area for a caged-disc prosthetic valve because blood flow through the orifice is not central.

Front 230

A 48-year-old female who underwent Tetralogy of Fallot repair as a child had a pulmonic valve replacement with a bioprosthetic valve for severe pulmonic regurgitation. TEE examination can be used to estimate the pulmonary artery pressure in the presence of mild physiologic transvalvular regurgitation through the bioprosthetic valve in the pulmonic position using the following imaging plane:a. TEE midesophageal aortic valve short-axis viewb. TEE midesophageal right ventricular inflow–outflow viewc. TEE transgastric right ventricular inflow viewd. TEE upper esophageal aortic arch short-axis viewe. There is no TEE imaging plane that can be used to measure the velocity of blood flow across a prosthetic valve in the pulmonic position

Back 230

d. The TEE upper esophageal aortic arch short-axis view provides a cross section through the pulmonic valve and pulmonary artery in long axis that permits blood flow velocity across the pulmonic valve to be measured using continuous wave Doppler. The mean pulmonary artery pressure and pulmonary artery diastolic pressure can be estimated from the velocity profile of the transvalvular regurgitant jet.

Front 231

The TEE midesophageal aortic valve short-axis view (see image below) indicates that the patient has the following type of prosthetic valve in the aortic position:a. Mechanical bileaflet prosthesisb. Tilting disc mechanical prosthesis c. Caged-ball mechanical prosthesis d. Stentless porcine bioprosthesise. Pericardial bioprosthesis

Back 231

e. The prosthetic valve type must be a pericardial bioprosthetic valve because the bioprosthetic valve leaflets constructed from pericardium are mounted onto stents or struts that can be imaged within the aortic root in the TEE midesophageal aortic valve short-axis imaging plane. Stents or struts are absent in porcine stentless bioprosthetic valves that are constructed from the porcine aortic root and reinforced by a fabric cuff. Mechanical prosthetic valves can be identified by the acoustic shadowing produced by the pyrolytic carbon valve occluders.

Front 232

The continuous wave Doppler spectral display of blood flow velocity through the mitral valve indicates that the patient had what type of prosthetic valve implanted in the mitral position (see image below)?a. Bileaflet mechanical prosthetic valve b. Porcine bioprosthetic valvec. Bovine pericardial prosthetic valve d. Prosthetic mitral annular ringe. Did not have a prosthetic valve implanted in the mitral position

Back 232

a. Bileaflet mechanical prosthetic valves produce characteristic specular acoustic artifacts in the spectral display of flow through the valve upon leaflet opening and closure. The native mitral valve, bioprosthetic valves in the mitral position, or mitral valve after repair with a prosthetic annular ring do not produce specular acoustic artifacts in the spectral display that mark the opening and closure of the valve leaflets.

Front 233

The following prosthetic valve is no longer available for clinical use:a. Caged-ball valveb. Porcine bioprosthetic valvec. Bovine pericardial bioprosthetic valve d. Human aortic allografte. Mechanical bileaflet prosthetic valve

Back 233

a. Although the caged-ball valve was the first prosthetic heart valve to be successfully implanted, it is no longer manufactured for clinical implantation. The present generation of prosthetic valves has a more favorable hemodynamic performance in relation to their annular diameter as compared to the first generation caged-ball prosthetic valves.

Front 234

TEE examination is requested to evaluate a patient with a bioprosthetic valve in the mitral position who presents with fever. The following echocardiographic findings are consistent with prosthetic valve endocarditis:a. Paravalvular regurgitation b. Vegetation on the prosthetic valve leaflet c. Transvalvular regurgitationd. Rocking motion of the valve stente. All of the above

Back 234

e. Paravalvular regurgitation, vegetation, transvalvular regurgitation, and motion or “rocking” of the prosthetic valve stent indicating annular dehiscence can all be signs of prosthetic endocarditis on the echocardiographic examination.

Front 235

Which of the following sites of regurgitant flow across a prosthetic valve detected by color Doppler flow imaging immediately after valve implantation are most likely considered pathologic?a. At the hinge points in mechanical bileaflet prosthetic valvesb. At the central commissure of bovine pericardial bioprosthetic valves c. At the site of a suture through the sewing ringd. Between the native annulus and the sewing ringe. All regurgitation after valve implantation is considered pathologic

Back 235

d. Regurgitation occurring at a site between the native valve annulus and the sewing ring is defined a paravalvular regurgitation and is always considered pathologic. Physiologic, nonpathologic regurgitation can be detected by Color Doppler flow imaging at the coaptation of the leaflets, the hinge points, through cloth-covered regions of the valve stent, and even through suture holes in the sewing ring of prosthetic valves immediately after implantation.

Front 236

Echocardiographic findings that indicate structural valvular degeneration of a bioprosthetic valve are:a. Leaflet prolapseb. Leaflet calcificationc. Leaflet perforationd. Restricted leaflet opening e. All of the above

Back 236

e. Leaflet prolapse, calcification, perforation, and restriction are all signs of structural valvular degeneration that eventually affect bioprosthetic valves.

Front 237

Pannus ingrowth impairing the function of a bileaflet mechanical prosthetic valve implanted in the aortic position would most likely produce the following pathologic echocardiographic finding:a. Mass on the prosthetic valveb. Disappearance of the normal transvalvular regurgitant jets at the hinge points c. A Doppler velocity index less than 0.25d. Abnormal motion of the valve stente. Paravalvular regurgitation

Back 237

c. A Doppler velocity index (DVI) less than 0.25 indicates prosthetic valve stenosis. Pannus ingrowth is the most common cause of stenosis in a patient with a mechanical prosthetic valve. Pannus is difficult to image even with TEE and must be diagnosed based on indirect evidence of the effect of pannus causing valve stenosis, pannus impeding the range of motion of the occluders, or transvalvular regurgitation from pannus impairing leaflet closure.

Front 238

Accurate application of the Doppler velocity index to quantify the severity of the prosthetic valve stenosis in a patient with a bioprosthetic valve in the aortic position requires:a. Measurement of blood flow velocity in the left ventricular outflow tract b. Calculation of the cardiac outputc. Knowledge of the prosthetic valve sized. Estimation of the cross-sectional area of the left ventricular outflow tract e. Normal sinus rhythm

Back 238

a. The Doppler velocity index (DVI) is a ratio of the blood flow velocity in the left ventricular outflow tract, proximal to the prosthetic valve to the transvalvular blood flow velocity across the prosthetic valve. The DVI provides a measure of the prosthetic valve orifice area relative to the cross-sectional area of the left ventricular outflow tract. Using the DVI to quantify the severity of prosthetic aortic valve stenosis is independent of the area of the left ventricular outflow tract, cardiac rhythm, or cardiac output.

Front 239

A 52-year-old male who had a mitral valve replacement 5 years ago for rheumatic mitral stenosis presents with fever and leukocytosis. Blood cultures had no bacterial growth. The most sensitive and specific test to evaluate this patient for prosthetic endocarditis is:

a. Transthoracic echocardiographyb. Transesophageal echocardiography c. Fluoroscopyd. Cine computed tomographye. Cardiac catheterization

Back 239

b. Transesophageal echocardiography (TEE) has a high sensitivity (86% to 94%) and specificity (88% to 100%) for detecting vegetations, paravalvular regurgitation, or abscess associated with prosthetic endocarditis. TEE is superior to transthoracic echocardiography (TTE) for diagnosis of prosthetic endocarditis.

Front 240

TEE midesophageal four-chamber view with Doppler color flow imaging in systole from a 56- year-old patient with a normally functioning prosthetic valve in the mitral position (see image below). The TEE examination indicates that the prosthetic valve is a:a. Starr–Edwards caged-ball prosthesis b. Bjork–Shiley tilting disk prosthesisc. Medtronic Hall tilting disk prosthesis d. St. Jude Medical bileaflet prosthesis e. Sorin Mitroflow prosthesis

Back 240

c. The Medtronic Hall mechanical tilting disk valve has a central orifice through which a large central regurgitant washing jet arises when the valve is in the closed position in systole. A Starr–Edwards (caged-ball valve) has no washing jet. The Bjork–Shiley (single tilting disk) valve has two laterally directed regurgitant jets that originate from the site where the occluder contacts the annular stent, but no central jet. A St. Jude Medical bileaflet mechanical valve has regurgitant washing jets that originate from the hinge points of the occluder or from the site where the occluder contacts the annular stent, but never produces a large central regurgitant jet. The Sorin Mitroflow valve is a pericardial bioprosthetic valve which is approved in the United States for implantation only in the aortic position. Only a mechanical prosthetic valve produces the degree of acoustic shadowing and comet tail artifact seen on the far side of the prosthetic valve in the TEE image above.

Front 241

Regarding insertion of a TEE probe:a. Bacteremia is common with TEE insertionb. Arrhythmias are uncommon following TEE insertionc. A hiatus hernia is an absolute contraindicationd. Odynophagia is uncommon following TEE insertione. Recurrent laryngeal palsy is a complication of TEE insertion

Back 241

e. Compression of the recurrent laryngeal nerve can occur between the TEE probe and an endotra cheal tube when in situ for prolonged periods. Midesophageal views can be safely obtained in patients with a hiatus hernia.

Front 242

In 3D TEE:a. Stitching artifacts are seen frequently in live 3Db. 3D is less reliant on endocardial border tracking than 2Dc. Spatial resolution is lower but temporal resolution is higher than 2D d. 3D is more resistant to artifacts produced by atrial fibrillation

Back 242

b. Stitching artifacts occur with full-volume acquisition

Front 243

In 3D echo:a. The paramagnetic image on the report page reflects the time taken to relaxb. The LV dyssynchrony index is the standard deviation of regional contraction timesc. The LV dyssynchrony index may be useful for placing the right ventricular lead in resynchronization therapyd. Segmental analysis is useful in assessing diastolic dysfunction

Back 243

b

Front 244

Concerning right ventricular function:a. Right ventricular failure occurs in <1% of patients post-CABGb. Left ventricular dysfunction occurs because of ventricular interdependencec. The right cardiac vein is well protected with retrograde cardioplegiad. E/A waves of the tricuspid valve are a good marker of ventricular systolic dysfunction

Back 244

b

Front 245

In off-pump coronary revascularization:a. The transgastric view is the best to detect wall motion abnormalitiesb. Infusion of normal saline can assist in TEE viewsc. Mitral valve regurgitation can develop with application of the octopusd. Mitral valve regurgitation is a contraindication to off-pump coronary surgery

Back 245

c. Transgastric views are often lost. The development of mitral regurgitation may result in conversion to on-pump but is not a contraindication

Front 246

In using TEE to assess cannulation:a. The presence of a Eustachian valve is a contraindication to retrograde cardioplegiab. The right main bronchus results in poor views of the ascending aortac. Dissection of the ascending aorta from the retrograde cardioplegia cannula is usually seen in the ME LAX 135-degree viewd. The bicaval view is the best view for assessing atrial septal transverse by the long venous wire

Back 246

d

Front 247

Which is true?a. Rapid hemodynamic deterioration during endoscopic vein harvesting (EVH) should be assessed by the bicaval viewb. The subclavian vein can be seen by rotating left after obtaining the SAX view of the ascending aorta at 90 degreesc. In port access surgery aortic stenosis is a contraindicationd. Plaques in the descending aorta are usually 1 to 2 grades worse than in the ascending aorta

Back 247

a

Front 248

In a VAD placement which of the following is not a contraindication requiring intervention:a. Intraventricular thrombus b. Ventricular septal defect c. Aortic regurgitationd. Mitral regurgitation

Back 248

d

Front 249

In assessment of LVADs:a. Intraventricular shift to the left can decrease right ventricular functionb. Intraventricular shift to the left can aid filling of the LVADc. Fractional shortening of the basal segments >20% is a predictor of right ventricular failure d. Assessment for a PFO should only be made early in the insertion process

Back 249

a

Front 250

In a patient with a LVAD:a. The afterload is reduced to the left ventricleb. Turbulence in the inflow cannula detected by PW can be an indication of malfunctionc. The aortic valve may open intermittently with pulsatile devicesd. An increase in proximal flow velocity compared to distal can indicate valvular incompetence

Back 250

d

Turbulence in the inflow cannula is detected by CFD

Front 251

Which of the following is true?

a. In LVADs increasing the preload can precipitate RV failureb. Echo is useful in weaning from V-V ECMOc. Inflow to the ECMO cannula should be positioned just above the tricuspid valve d. LVOTVTI <10 cm support weaning from V-A ECMO

Back 251

a. RV failure occurs in 30% of LVAD patients. It is usually temporary in nature

Front 252

With TEE, coronary artery blood flow:a. Can be accurately quantified with pulsed wave Dopplerb. Can usually be visualized in the atrioventricular groovec. Can be seen in 80% of the right and 50% of the left coronary ostiad. Cannot be demonstrated in the distribution areas of all three arteries while using one view

Back 252

b

Front 253

Dyskinesis with myocardial thickening may occur when there is:a. Ventricular epicardial pacingb. Electrolyte disturbancesc. Epinephrine infusion during separation from bypass d. Decreased volume loading

Back 253

a

Front 254

The intraoperative discovery of a small secundum ASD or patent foramen ovale:a. Is very rareb. Can most reliably be quantified with pulsed wave Dopplerc. Can most reliably be assessed with color flow Doppler and agitated saline contrast injection in the transgastric short-axis viewd. May affect the postoperative management and outcome of any cardiac patient

Back 254

d

Front 255

In case of the unexpected intraoperative discovery of moderate aortic stenosis during a CABG procedure:a. The patient should be woken up and consented for a combined surgical procedure before progressingb. A subsequent AVR after the CABG has a higher mortality than a single combined procedurec. The progression of stenosis is 0.3 cm2/y and should not change the surgical approachd. An intra-aortic balloon pump should be inserted to assist coronary perfusion after bypass

Back 255

b

Front 256

In case of the unexpected intraoperative discovery of moderate functional mitral regurgitation during a CABG procedure:a. A more reliable quantification of regurgitation severity should be made by increasing contractility with a positive inotropic agentb. A more reliable quantification of regurgitation severity should be made by increasing preload and afterload with a vasopressorc. The MV should be left untouched when severity is less than grade 3d. Revascularization of the ischemic papillary muscle usually decreases the MR severity

Back 256

b

Front 257

During intraoperative visualization of RWMAs:a. An akinetic region is the result of myocardial infarction and reflects nonviable myocardium b. A hypokinetic region is the result of myocardial infarction and reflects nonviable myocardium c. Ventricular rotation and twist during systole complicates quantificationd. Most WMAs benefit from coronary revascularization

Back 257

c

Front 258

During a CABG procedure acute right ventricular dysfunction:a. Should be minimized by providing retrograde cardioplegia via the coronary sinus b. Is caused by a poor coronary anatomizes to the right coronary arteryc. May be caused by air embolism down the right coronary arteryd. Should be accurately quantified with myocardial deformation techniques

Back 258

c

Front 259

During OPCAB surgery, is most useful to access RWMAs during grafting of which coronary artery?a. Right coronary arteryb. Circumflex coronary arteryc. Left anterior descending coronary artery d. All the above

Back 259

c

Front 260

Acute septal hypokinesis immediately after separation from CPB:a. Requires immediate revision of the internal mammary artery graft anastomosis b. Will require inotropic support to improve ejection fractionc. May be due to right ventricular pacingd. Is relatively common and may resolve spontaneously after 15 minutes

Back 260

d

Front 261

The current delivery system for transcather valve is:

a. Ascendra delivery system with a 33-Fr sheath b. Ascendra delivery system with a 34-Fr sheath c. NovaFlex delivery system with an 18-Fr sheath d. NovaFlex delivery system with a 17-Fr sheath

Back 261

c

Front 262

Cohort B in the PARTNER Trial for aortic valve replacement demonstrated:a. Inoperable patients requiring medical therapy have better outcomeb. Surgical AVR has better outcomec. Transapical AVR has beneficial effects compared to surgical AVRd. The benefits of transfemoral AVR outweighs the risk when compared to conservative treatment

Back 262

d

Front 263

The present role of real-time 3D echo for TAVI is:a. To detect the extent and severity of any paravalvular leaks b. For proper valve placementc. For proper guidewire placementd. To assist balloon valvuloplasty

Back 263

a

Front 264

The best view for valve assessment postdeployment is:a. ME AV LAX viewb. TG AV LAX viewc. Biplane mode showing ME AV SAX and ME LAX views d. Deep TG view

Back 264

c

Front 265

The SAPIEN valve (Edwards Lifesciences, Inc., Irvine, CA) has 3 sizes:a. 23, 25, and 27 mm b. 21, 23, and 25 mm c. 23, 25, and 27 mm d. 23, 26, and 29 mm

Back 265

d

Front 266

The CoreValve (Medtronic, Inc., Minneapolis, MN) has 3 sizes:a. 26, 29, and 31 mm b. 26, 28, and 30 mm c. 25, 27, and 29 mm d. 23, 26, and 29 mm

Back 266

a

Front 267

The CoreValve (Medtronic, Inc., Minneapolis, MN) can be used for valve implantation via the:a. Both the antegrade and retrograde approach b. Retrograde approach onlyc. Antegrade approach onlyd. None of the above

Back 267

b

Front 268

The SAPIEN valve (Edwards Lifesciences, Inc., Irvine, CA) can be used for valve implantation via the:a. Antegrade approach onlyb. Retrograde approach onlyc. Both antegrade and retrograde approach d. None of the above

Back 268

c

Front 269

Cohort A from the PARTNER aortic valve replacement trial suggests that:a. Surgical AVR is better than TAVIb. TAVI is an acceptable alternative to high-risk patients who are operable c. TAVI is not feasible for patients who can be surgically operated d. TAVI has proven to be much better than surgical AVR

Back 269

b

Front 270

The present indications for TAVI in 2013 include:a. Any aged high-risk patientb. Selected high-risk patients above 80 years of age c. Selected high-risk patients above 40 years of age d. Young patients with high-risk for cardiac surgery

Back 270

b

Front 271

Intraoperative occlusion of the coronary ostium during valve implantation is best detected by:a. 2D echocardiographyb. Fluoroscopic imagingc. Real-time 3D echocardiographyd. Intraoperative rotational multislice computer tomography

Back 271

b

Front 272

Annulus measurements before valve implantation have the best correlation between:a. 3D echocardiography and 2D echocardiography b. 3D echocardiography and fluoroscopyc. 3D echocardiography and computer tomography d. 2D echocardiography and fluoroscopy

Back 272

c

Front 273

If aortic regurgitation persists after valve implantation then the following may be tried to reduce the degree of aortic regurgitation:http://anesthesiology.lwwhealthlibrary.com.ezproxy.anzca.edu.au/content.aspx?sectionid=52366614&bookid=888 Page 19 of 22Health Library | Content 2016-05-09, 10:54 AMa. Deployment of a second valveb. Surgical AVRc. Balloon valvuloplasty followed by a valve in valve procedured. Once deployed no maneuver can decrease the level of regurgitation

Back 273

c

Front 274

Compared to surgical AVR the TAVI tends to have:a. Higher postoperative gradientsb. Lower postoperative gradientsc. Similar gradientsd. Similar gradients to mechanical valves

Back 274

b

Front 275

Asymmetric calcification of the native valve may lead to:a. Device migration b. Paravalvular leak c. Transvalvular leak d. All of the above

Back 275

d

Front 276

Present indications for TAVI exclude:a. Octogenariansb. Patients above the age of 60 years and above with symptomatic AS c. Old patients with high-risk comorbidities with symptomatic ASd. Old patients with AS whom surgery has been denied

Back 276

b

Front 277

Complications during TAVI may include:a. Aortic dissection and coronary artery occlusionb. Rupture of aortic annulus and pericardial tamponade c. Rupture of apex of left ventricled. All of the above

Back 277

d

Front 278

Modern iterations of the valve and delivery system aim toward:a. Miniaturization of delivery systemb. Valve which can be repositioned and retrievable c. To decrease paravalvular leakd. All of the above

Back 278

d

Front 279

The TEE findings of regional wall motion abnormality post-TAVI may be secondary to:a. Aortic dissectionb. Valve migrationc. Coronary occlusiond. Patient prosthetic mismatch

Back 279

c

Front 280

During implantation of a CoreValve with the nitinol stent in ME AV LAX view the valve should be positioned:a. Above the annulus extending into the ventricleb. Below and within the calcified annulusc. More than halfway between the annulus and left ventricular outflow tract d. None of the above

Back 280

b

Front 281

TEE can reliably image which of the following zones of the aorta?a. Zone 2b. Zone 3c. Zone 4d. All of the above

Back 281

a. Zones 3 and 4 cannot be reliably imaged due to bronchial interposition

Front 282

What is the hallmark finding of an acute aortic dissection on TEE?a. Severe aortic regurgitationb. A large pericardial effusionc. An intimal flapd. Regional wall motion abnormalities of the left ventricle

Back 282

c. An intimal flap is seen due to the separation of that layer from the medial or adventitial layer of the aorta. Aortic regurgitation, effusions, and regional wall motion abnormalities are often seen in association with aortic dissections, but do not make the diagnosis.

Front 283

The aortic arch is typically seen in long axis at an omniplane angle of ______ and short axis at an omniplane angle of ______ when using TEE.

a. 120 degrees, 30 degreesb. 0 degrees, 90 degreesc. 90 degrees, 0 degreesd. The aortic arch is not visible using TEE

Back 283

b. Unlike the ascending or descending aorta, the aortic arch is typically seen in long axis around 0 degrees and short axis at 90 degrees due to its horizontal nature.

Front 284

Which of the following aortic pathologies are generally NOT taken to the operating room emergently?a. Asymptomatic DeBakey Type III aortic dissectionb. Stanford Type B dissection with evidence of ischemic bowel c. DeBakey Type I aortic dissectiond. All of the above require immediate surgical intervention

Back 284

a. DeBakey Type III, also called Stanford Type B, dissections only involve the descending aorta. They are generally medically managed initially, unless there are signs of visceral malperfusion, such as bowel ischemia.

Front 285

All of the following are typical of the false lumen of an aortic dissection EXCEPT:a. Color flow Doppler demonstrates flow into it at the tear site b. It expands during systolec. It is often the larger of the two lumensd. It may contain spontaneous echo contrast

Back 285

b. The TRUE lumen typically expands during systole. Statements A, C, and D are correct regarding the false lumen.

Front 286

Acute aortic syndromes encompass all of the following entities EXCEPT:a. Acute aortic dissectionb. Penetrating atherosclerotic ulcer c. Ascending aortic aneurysm d. Intramural hematoma

Back 286

c. Ascending aortic aneurysms typically develop over a long time period and are not considered an acute aortic syndrome.

Front 287

In the image shown, what is the yellow arrow pointing to?a. The distal end of an elephant trunk graft b. A dissection flapc. An aortic cannulad. A pulmonary artery catheter

Back 287

a. The arrow is pointing to the distal end of an elephant trunk graft. It can be identified as a graft material versus a cannula by the serrated appearance.

Front 288

Which of the following is a characteristic of a Type A intramural hematoma?a. The underlying etiology is a tear in the intimal layer of the aortab. There is thickening of the medial layer of at least 15 mmc. There is protrusion above the intimal layer into the lumen of the aorta d. Left untreated, it may progress to aortic rupture

Back 288

d. Intramural hematomas (IMHs) are part of the acute aortic syndromes, with Type A considered a surgical emergency because they can progress to flap formation or frank aortic rupture. The etiology is thought to be rupture of the vasa vasorum in the medial layer as opposed to a tear in the intimal layer. Medial thickening of 7 mm or more is consistent with ascending IMHs. Atherosclerotic plaques, not IMHs, typically protrude into the lumen of the aorta above the intimal layer.

Front 289

.

Back 289

.

Front 290

All of the following are characteristic of an acute aortic dissection flap EXCEPT:a. Irregularly shapedb. Highly mobilec. Indistinct bordersd. Contained within the lumen of the aorta

Back 290

c. A dissection flap can usually be distinguished from artifact by its rapid, oscillatory movements within the lumen of the aorta. Objects with indistinct borders that cross anatomical boundaries (i.e., seen outside of the aorta) are typically artifacts.

Front 291

In a patient undergoing elective aortic valve replacement, poststenotic dilation of what size should warrant consideration of surgical treatment?a. 4 cm b. 4.5 cm c. 5 cm d. 5.5 cm

Back 291

b. According to 2010 guidelines on thoracic aortic disease, patients undergoing cardiac surgery with dilation of the ascending aorta measuring 4.5 cm or greater should be considered for concomitant aortic repair. It is important to note, however, that exactly what type of surgical intervention (i.e., replacement vs. plication vs. external wrapping) is not addressed.

Front 292

.

Back 292

.

Front 293

What is the major disadvantage of using a phased-array transducer for epiaortic scanning?a. All walls of the aorta cannot typically be imaged at once.b. The frequency is usually too low for detailed imaging.c. The probe requires a “stand-off” to prevent near-field clutter. d. They must be autoclaved to maintain sterility.

Back 293

c. Unlike a linear (i.e., vascular) probe, a phased-array transducer can typically visualize all walls of the aorta at once. However, a phased-array probe cannot be placed directly on the aorta. Both types of probes are available in high frequencies (>7 MHz) and can be placed in sterile sheaths for use on the surgical field.

Front 294

What type of thoracoabdominal aneurysm involves the greatest length of the descending aorta?a. Crawford Type I b. Crawford Type II c. Crawford Type III d. Crawford Type IV

Back 294

b. The Crawford system of thoracoabdominal aneurysm (TAA) classification was developed in order to help standardize the reporting of the extent of the aneurysm. Type I TAAs involve most of the descending thoracic aorta, but typically terminate prior to the renal arteries in the abdomen. Type II TAAs have the greatest extent, involving all of the thoracic descending aorta and reach below the renal arteries, often into the inguinal area. Type III TAAs involve the distal half or less of the descending thoracic aorta, and Type IV TAAs may only involve the upper abdominal aorta.

Front 295

What is the pathology shown in the image below?a. Acute aortic dissectionb. Reverberation artifactc. Intramural hematomad. Severe atherosclerotic disease

Back 295

c. This is a Type A intramural hematoma, as evidenced by the medial thickening of 10 mm. No dissection flap is present. Atherosclerotic disease would typically protrude irregularly into the lumen of the aorta and be seen as intimal thickening. Seen in more than one view, this is not an artifact.

Front 296

What is the pathology shown in the image below?a. Grade 3 atherosclerosis of the ascending aorta b. Acute aortic dissectionc. Grade 3 atherosclerosis of the descending aorta d. Penetrating atherosclerotic ulcer

Back 296

a. This is an epiaortic scan (note lack of an omniplane angle) showing the midascending aorta in short axis, making C incorrect. Thickening of >3 mm is present, making this a grade 3 plaque. The intimal layer is intact in this patient, whereas a penetrating atherosclerotic plaque would disrupt it and erode into the media. The white line in the center of the aorta is an artifact, likely caused by either the catheter in the right PA or in the superior vena cava.

Front 297

Assuming no chronic dissection or connective tissue disorders are present, at what diameter is it recommended to surgically address the descending aorta in an asymptomatic patient?a. ≥4.5 cm b. ≥5 cm c. ≥5.5 cm d. ≥6 cm

Back 297

d. Since the risk of rupture increases dramatically at 7 cm in the descending aorta, it is recommended that asymptomatic patients undergo stent or open repair at diameters ≥6 cm. The cutoff for ascending aortic repair is 5.5 cm, and 4.5 cm if the patient is already undergoing cardiac surgery.

Front 298

The size of a “normal” aorta depends upon:a. Weightb. Heightc. Aged. All of the above

Back 298

d. The size of a patient’s aorta most closely correlates with age and body surface area, which is dependent upon height and weight.

Front 299

What is the next appropriate step in management of the patient seen in the image below?a. Obtain angiography, including cardiac catheterization b. Attempt placement of a percutaneous aortic valvec. Obtain an MRI to rule out artifactd. Proceed directly to the operating room

Back 299

d. This patient should go directly to the operating rooms since the TEE images clearly show a dissection flap. Other imaging tests are not necessary. Although some aortic regurgitation is present, a new aortic valve alone will not appropriately treat this condition.

Front 300

According to the Katz grading system, an atherosclerotic plaque with any type of mobile component to it would be graded:a. Grade M b. Grade V c. Type A d. Type IV

Back 300

b. Any plaque with a mobile component would be a Grade V lesion on the Katz grading system. There is no grade M. Type A is the Stanford classification of acute aortic dissection. Type IV refers to the Crawford classification system of thoracoabdominal aneurysms.

Front 301

A 75-year-old woman arrives in the ICU from the emergency room with the diagnosis of urosepsis. She is intubated and mechanically ventilated. BP is 90/55, HR is 110. Bedside echo shows normal valves, no effusions, and a left ventricular internal dimension (LVID) at end- diastole of 3.5 cm and LVID at end-systole of 0.5 cm. Which of the following interventions is the most appropriate next step?a. One liter normal saline bolus b. Dobutamine infusionc. Norepinephrine infusiond. Heparin infusion

Back 301

a. Her ventricular dimensions are small, and fractional shortening is elevated (3.5 − 0.5/3.5 × 100 = 85.7%). This is most consistent with hypovolemia.

Front 302

A 75-year-old woman arrives in the ICU from the emergency room with the diagnosis of urosepsis. She is intubated and mechanically ventilated. BP is 90/55, HR is 110. Bedside echo shows normal valves, no effusions, and a left ventricular internal dimension (LVID) at end- diastole of 6 cm and LVID at end-systole of 4 cm. Which of the following interventions is the most appropriate next step?a. One liter normal saline bolus b. Dobutamine infusionc. Norepinephrine infusion

Back 302

c. Her LV dimensions are all in the upper limit of normal and her fractional shortening is normal (6 − 4/6 ×100 = 33.33%). This is most consistent with vasodilatory shock due to urosepsis.

Front 303

A 75-year-old woman arrives in the ICU from the emergency room with the diagnosis of urosepsis. She is intubated and mechanically ventilated. BP is 90/55, HR is 110. Bedside echo shows normal valves, no effusions, and a left ventricular internal dimension (LVID) at end- diastole of 8 cm and LVID at end-systole of 7 cm. Which of the following interventions is the most appropriate next step?a. One liter normal saline bolus b. Dobutamine infusionc. Norepinephrine infusiond. Heparin infusion

Back 303

b. Her LV dimensions show an enlarged LV, and her fractional shortening is decreased (8 − 7/8 × 100 = 12.5%). This is most consistent with myocardial dysfunction.

Front 304

A 75-year-old woman arrives in the ICU from the emergency room with the diagnosis of urosepsis. She is intubated and mechanically ventilated. BP is 105/55, HR is 90, and ScvO2 is 75%. Bedside echo shows moderate tricuspid regurgitation, no effusions, and RV area > LV area in the four-chamber view. Which of the following interventions is the most appropriate next step?a. One liter normal saline bolus b. Dobutamine infusionc. Norepinephrine infusiond. Heparin infusion

Back 304

d. She has dilated RV with TR, this is most consistent with an acute pulmonary embolus.

Front 305

A 75-year-old woman arrives in the ICU from the emergency room with the diagnosis of urosepsis. She is spontaneously breathing. BP is 90/55, HR is 110. Bedside echo shows normal valves, no effusions, and a left ventricular internal dimension (LVID) at end-diastole of 6 cm and LVID at end-systole of 4 cm. In addition, her IVC diameter is 1 cm at end expiration and 0.3 cm at end inspiration. Which of the following interventions is the most appropriate next step?

a. One liter normal saline bolus b. Dobutamine infusionc. Norepinephrine infusiond. Heparin infusion

Back 305

a. Although her LV size and fractional shortening are normal, she has a small IVC with marked collapse on inspiration. This implies fluid responsiveness and a bolus should be given then the measurements should be repeated.

Front 306

A 60-year-old man with normal LV function is in the ICU for 4 hours following CABG. His chest tube output per hour for the last 4 hours has been 400, then 300, then 300, then 10. He is now requiring increasing norepinephrine to maintain his blood pressure. He remains intubated, but is breathing spontaneously. Bedside TTE shows the following:No effusionsLeft ventricular internal dimension (LVID) at end-diastole is 6 cm LVID end-systole is 4 cmIVC diameter at end expiration is 2 cmIVC diameter and end inspiration is 1 cmWhich of the following is the most appropriate next step?

a. One liter normal saline bolusb. Dobutamine infusionc. Increase norepinephrine infusion d. Re-exploration

Back 306

d. TTE cannot rule out postoperative tamponade, because postop tamponade can be localized—as opposed to the usual medical tamponade. TEE showed an isolated clot posterior to the left atrium that was impairing LV filling.

Front 307

A 60-year-old man with normal LV function is in the ICU for 4 hours following CABG. His chest tube output per hour for the last 4 hours has been 400, then 300, then 300, then 10. He is now requiring increasing norepinephrine to maintain his blood pressure. He remains intubated, but is breathing spontaneously. Bedside TTE shows the following:No effusionsLeft ventricular internal dimension (LVID) at end-diastole is 6 cm LVID end-systole is 4 cmIVC diameter at end expiration is 2 cmIVC diameter and end inspiration is 1 cmDyskinetic anterior wall of LVWhich of the following is the most appropriate next step?a. One liter normal saline bolusb. Dobutamine infusionc. Increase norepinephrine infusion d. Re-exploration

Back 307

d. A new regional wall motion abnormality may mean the bypass graft to the LAD is down. This requires urgent intervention—either in the operating room or cath lab.

Front 308

Which of the following echo findings is most consistent with acute right heart failure following a massive PE?a. Severe pulmonic insufficiencyb. RV free wall thickness >1 cmc. Left ventricular end diastolic diameter of 8 cm d. RV area > LV area

Back 308

d. The normal response to acute RV failure is dilation, that can also result in TR.

Front 309

A 56-year-old man is in the ICU intubated and mechanically ventilated 2 hours after an LVAD was placed. His SaO2 is 88% on a F1O2 of 1. His CXR is unremarkable. Which of the following TEE views would be most helpful in determining the cause of his hypoxia?a. Midesophageal four-chamber b. RV outflowc. Transgastric short axisd. Bicaval

Back 309

d. With a normal CXR, a right to left shunt needs to be ruled out. The bicaval view is the best view to rule out an ASD/PFO.

Front 310

When performing a focused transthoracic echo examination during advanced cardiac life support, which of the following is the preferred single view?a. Subcostal four-chamber b. Parasternal long axisc. Parasternal short axis d. Apical four-chamber

Back 310

a. In supine patients undergoing CPR this is often the easiest and fastest four-chamber view to obtain

Front 311

What is the best time to obtain a transthoracic echo image during ACLS for ventricularfibrillation?a. Before CPR startsb. As soon as the echo machine arrives c. Immediately following defibrillation d. After 2 minutes of CPR

Back 311

d. The key is to minimize interruptions of CPR, so the best time to perform a limited echo is after shock and 2 minutes of CPR during the rhythm and pulse check.

Front 312

Focused TTE during ACLS shows the following:Limited wall motion. No pulse. Regular rhythm. This is most consistent with which of the following conditions:

a. Pseudo PEAb. True PEAc. Hypovolemiad. Cardiac standstill

Back 312

a. Patients with wall motion on echo, but no pulse may have a better outcome. This finding would support continuation of ACLS.

Front 313

Focused TTE during ACLS shows the following:No wall motion No pulse Regular rhythmThis is most consistent with which of the following conditions:a. Pseudo PEAb. True PEAc. Hypovolemiad. Cardiac standstill

Back 313

b. This describes true PEA. True PEA has a worse prognosis than pseudo PEA.

Front 314

A 42-year-old woman with a history of long standing hypertension is in the ICU following CABG. Her CVP is 18 mm Hg and her CI is 1.5 L/min/m2. HR is 90, BP is 90/60. Bedside echo shows the following: Left ventricular internal diameter (LVID) at end-diastole 4 cm LVID end-systole 1 cmLV septal thickness at end-diastole 1.8 cmWhich of the following is the most appropriate next step?

a. One liter normal saline b. Norepinephrine infusion c. Vasopressin infusiond. Dobutamine infusion

Back 314

a. Her ventricle is small, and fractional shortening is normal (4 − 1/4 × 100 = 75%), but she has severe LV hypertrophy, which makes CVP very unreliable as a marker of fluid responsiveness.

Front 315

A 42-year-old woman with a history of long standing hypertension is in the ICU following CABG. Her CVP is 18 mm Hg and her CI is 1.5 L/min/m2. HR is 90, BP is 90/60. Bedside echo shows the following:Left ventricular internal diameter (LVID) at end-diastole 4 cm LVID end-systole 1 cmLV septal thickness at end-diastole 1.8 cmSevere MRWhich of the following is the most appropriate next step?a. One liter normal saline b. Norepinephrine infusion c. Vasopressin infusiond. Dobutamine infusion

Back 315

a. She most likely has severe MR due to systolic anterior motion of the MR. This process is worsened by hypovolemia, small LV size, and increased contractility. The first step would be to optimize LV volume and size.

Front 316

Which of the following findings is most consistent with the diagnosis of severe aortic stenosis (AS)?a. Aortic jet velocity is 5 m/sb. Mean gradient is 20 mm Hgc. Valve area is 1.2 cm2d. A “late peaking” velocity curve

Back 316

a. Severe AS is defined by:Jet velocity >4 m/sMean gradient >40 to 50 mm HgValve area <1 cm2The shape of the curves do not correspond with severity.

Front 317

Which of the following findings is most consistent with severe mitral stenosis (MS)?a. Mean gradient is 12 mm Hgb. Valve area is 1.5 cm2c. PA systolic pressure is 35 mm Hgd. Pressure half-time is 200 milliseconds

Back 317

a. Severe MS is defined by:

Mean gradient >10 mm Hg

Valve area <1 cm2

PA systolic pressure >50 mm Hg

Pressure half-time >220 milliseconds

Front 318

Which of the following findings is most consistent with severe aortic regurgitation (AR)?a. Jet width/LVDT is 70%b. Vena contraction is 0.3 cmc. Pressure half-time is 500 milliseconds d. Regurgitant orifice area 0.1 cm2

Back 318

a. Severe AR is defined by:

Jet width/LVDT of >65%

Vena contraction of >0.6 cm

Pressure half-time of <200 milliseconds

Regurgitant orifice area of >0.3 cm2

Front 319

Which of the following findings is most consistent with severe central mitral regurgitation (MR)?a. Jet area (percent of LA) 50%b. Vena contraction is 0.3 cmc. Regurgitation volume is 30 mL d. Regurgitant orifice area is 2 cm2

Back 319

a. Severe MR is defined by:

Jet area (percent of LA) of >40%

Vena contraction of >0.7 cm

Regurgitation volume of >60 mL

Front 320

A 65-year-old man in shock undergoes bedside echo. He is found to have severe mitral regurgitation (MR). Which of the following additional findings is most consistent with acute severe MR?a. Left ventricular internal diameter at end-diastole of 5 cm b. Depressed LV functionc. Left atrial diameter of 6 cmd. Mitral valve annulus of 3.5 cm

Back 320

a. Acute MR (endocarditis, papillary/chordal rupture) is associated with normal LV size and function, normal LA size, and normal annulus. Chronic MR (myxomatous, annular dilation) is associated with LV and LA dilation. LV function may be normal or depressed.

Front 321

Most frequently performed surgical procedure in the adult patient with congenital heart disease:a. Pulmonary (pulmonic) valve replacement b. Placement of ventricular assist devicec. Arterial switch operationd. Closure of ventricular septal defecte. Heart transplantation

Back 321

a. The most frequently performed surgical procedures in adults with congenital heart disease include pulmonary valve replacement, closure of secundum atrial septal defect, aortic valve replacement, and right ventricle to pulmonary artery conduit placement.

Front 322

Anomalous pulmonary venous drainage is most frequently seen in association with:a. Secundum atrial septal defectb. Primum atrial septal defectc. Sinus venosus atrial septal defectd. Patent foramen ovalee. The type of atrial septal defect seen in an atrioventricular canal defect

Back 322

c. Among atrial septal defects, those involving the sinus venosus region are most commonly associated with anomalous pulmonary venous drainage.

Front 323

Lesion least likely to be associated with a ventricular septal defect:a. Right ventricular outflow tract obstruction b. Tetralogy of Fallotc. Bicuspid aortic valved. Partial anomalous pulmonary venous return e. Coarctation of the aorta

Back 323

d. Congenital lesions associated with a ventricular septal defect include a bicuspid aortic valve, aortic coarctation, and right ventricular outflow tract obstruction. One of the components of the “tetrad” in tetralogy of Fallot is a conoventricular septal defect.

Front 324

Regarding a bicuspid aortic valve all the following are true EXCEPT for:a. It represents the most common form of congenital heart diseaseb. It displays a “fish-mouth” appearance in the midesophageal aortic short-axis view c. It is found in a significant number of patients with coarctationd. It may be associated with aortic root dilatione. It invariably results in severe aortic stenosis

Back 324

e. A bicuspid aortic valve represents the most common form of congenital pathology. The characteristic feature on echocardiography is a “fish-mouth” appearance of the valve in systole. Some patients can develop aortic stenosis, aortic regurgitation, and/or aortic root dilation.

Front 325

The presence of a persistent left superior vena cava should be suspected if the TEE displays:a. Dilated left atriumb. Enlarged coronary sinusc. An interatrial shunt by injection of agitated saline into a right arm vein d. Ebstein anomalye. Pulmonary (pulmonic) stenosis

Back 325

b. A persistent left superior vena cava is associated with an enlarged coronary sinus. The presence of this systemic venous connection is confirmed by the appearance of right atrial contrast upon injection of agitated saline into a left arm or left neck vein. This is characterized by contrast draining across the coronary sinus into the right atrium.

Front 326

Optimal TEE view to assess the anterosuperior rim of a secundum atrial septal defect during device closure:a. Midesophageal four-chamber viewb. Midesophageal two-chamber viewc. Midesophageal aortic valve short-axis view d. Midesophageal aortic valve long-axis view e. Midesophageal bicaval view

Back 326

c. The anterosuperior rim of an atrial septal defect is best imaged in the midesophageal aortic valve short-axis view and represents the distance between the aortic ring and the defect. The lack of this rim does not necessarily preclude device deployment.

Front 327

Type of ventricular septal defect most amenable to percutaneous device closure due to its anatomic characteristics:a. Perimembranous defect b. Muscular defectc. Supracristal defectd. Inlet defecte. Conal

Back 327

b. Muscular ventricular septal defects may be suitable for percutaneous device closure due to their favorable location as they are relatively distant from the aortic and atrioventricular valves. These defects oftentimes are difficult to identify by the surgeon due to their location in the trabecular portion of the ventricular septum.

Front 328

Type of ventricular septal defect seen in association with complete atrioventricular canal (atrioventricular septal defect):a. Perimembranous defect b. Muscular defectc. Supracristal defectd. Subarterial defecte. Inlet defect

Back 328

e. Inlet defects are located in close proximity to the atrioventricular valves in the posterior or inlet portion of ventricular septum. A common atrioventricular valve annulus and associated primum atrial septal defect are also part of a complete atrioventricular canal defect.

Front 329

A peak velocity of 4 m/s across a ventricular septal defect given optimal Doppler alignment, a systemic blood pressure of 100/56 mm Hg, and no right ventricular outflow tract obstruction, would predict a systolic pulmonary artery pressure of:a. Suprasystemic levelsb. Systemic levelsc. A fourth of the systemic pressure d. 36 mm Hge. 46 mm Hg

Back 329

d. The right ventricular (or pulmonary artery) systolic pressure can be estimated using the formula: RV systolic pressure = Systolic blood pressure − 4(VVSD)2. In this case, RV systolic pressure = 100 − 4(4)2 or would be equal to 36 mm Hg.

Front 330

In which aortic valve intervention is it particularly important to evaluate the pulmonary (pulmonic) valve?a. Aortic balloon valvuloplasty b. Aortic valve replacementc. Ross procedured. Subaortic resectione. Aortic valvotomy

Back 330

c. During a Ross procedure a pulmonary autograft is harvested and used to replace the aortic root. An assessment of the pulmonic valve in terms of patency/competency is thus essential before this intervention is undertaken. The right ventricular outflow tract is reconstructed using a homograft or alternate material.

Front 331

Pulmonary (pulmonic) stenosis is considered moderate if:a. Estimated gradient across the valve exceeds >64 mm Hgb. Right ventricular pressure is suprasystemicc. The patient presents with chest pain symptomsd. Doppler-derived peak instantaneous transvalvar gradient is between 36 and 64 mm Hg e. There is an associated atrial septal defect

Back 331

d. Severity grading systems for pulmonary (pulmonic) stenosis rely on Doppler-derived peak instantaneous transvalvar gradients. Moderate stenosis is characterized by a gradient of 36 to 64 mm Hg. Symptoms associated with moderate obstruction include dyspnea and fatigue. Systemic and suprasystemic right ventricular pressures imply severe disease.

Front 332

In a patient with tetralogy of Fallot, TEE imaging in the midesophageal short-axis view is useful to detect which potentially associated lesion:a. Coronary artery anomaliesb. Systemic venous anomaliesc. Right aortic archd. Left ventricular outflow tract obstructione. Persistent left superior vena cava to the coronary sinus

Back 332

a. Associated lesions in tetralogy of Fallot include anomalies of the systemic veins, aortic arch, and coronary arteries. The midesophageal aortic valve short-axis view facilitates the assessment of anomalous origin of the coronary arteries in tetralogy of Fallot.

Front 333

In tetralogy of Fallot, placement of an extensive transannular patch during the definitive repair invariably results in:a. Residual right ventricular outflow tract obstruction b. Free pulmonary regurgitationc. Cyanosisd. Syncopee. Branch pulmonary artery stenosis

Back 333

b. Extensive patching across the pulmonary (pulmonic) valve, also referred to as transannular patching in patients with tetralogy of Fallot, results in free pulmonary regurgitation. In addition to this indication, other causes of surgical reintervention include right ventricular outflow tract obstruction, aneurysmal dilation of the right ventricular outflow, and significant residual intracardiac shunts.

Front 334

14 Long-term problems associated with an atrial switch procedure (Mustard or Senning operation) for D-transposition of the great arteries include all of the following EXCEPT for:a. Baffle stenoses b. Right ventricular dilationc. Right ventricular systolic dysfunctiond. Tricuspid regurgitatione. Supravalvar pulmonary (pulmonic) stenosis

Back 334

e. Long-term problems in patients with D-transposition of the great arteries depend on the type of initial repair. Patients who underwent an atrial switch procedure (Mustard or Senning operation), which leaves the morphologic right ventricle (RV) supporting the systemic circulation, have a high likelihood of developing RV failure and tricuspid regurgitation over time. Conversely, patients who undergo an arterial switch operation have significantly less morbidity in the current surgical era.

Front 335

Regarding congenitally corrected transposition and features that facilitate echocardiographic diagnosis, which of the following is correct:a. A ventricular septal defect is rarely seenb. The spatial orientation of the great arteries is abnormalc. The systemic ventricle is the left ventricled. The tricuspid valve insertion in the septum is more superior than that of the mitral valve e. Mitral regurgitation is a frequent finding

Back 335

b. Atrioventricular valves are associated with their corresponding ventricle. A septophilic tricuspid valve will identify a right ventricle and a septophobic valve a left ventricle. In corrected transposition the discordant atrioventricular connection implies that the right ventricle functions as the systemic chamber. This defect is frequently associated with a ventricular septal defect, obstruction to pulmonary blood flow, and left atrioventricular (tricuspid) valve dysplasia (Ebstein-like malformation). There is abnormal spatial orientation of the great arteries relative to that present in the normal heart.

Front 336

he apical displacement index used as a criterion for the diagnosis of Ebstein anomaly is defined as:a. >8 mm/m2 body surface area b. <8 mm/m2 body surface area c. =8 mm/m2 body surface area d. 12 mm/m2 body surface area e. None of the above

Back 336

a. An apical displacement index that exceeds 8 mm/m2 relative to the mitral hinge point on the ventricular septum is consistent with the diagnosis of Ebstein anomaly.

Front 337

Regarding univentricular palliation during the Fontan procedure which statement is true?a. There is mixing of the oxygenated and deoxygenated blood with an average systemic arterial oxygen saturation of ~80%b. The pulmonary and systemic circulations are separatedc. The physiology varies depending on whether the single ventricle has a left or right ventricularmorphologyd. An arterial shunt is necessary to maintain pulmonary blood flowe. Increases in the pulmonary artery pressures have no effect on Fontan physiology

Back 337

b. The separation of the pulmonary and systemic circulations in patients with single ventricle physiology is achieved with the Fontan procedure, which directs blood from the inferior vena cava into the pulmonary artery without intervening pumping chamber.

Front 338

The origin of the coronary arteries from the sinuses of Valsalva is best interrogated in the:a. Deep transgastric viewsb. Midesophageal short-axis view during systole c. Midesophageal short-axis view during diastole d. Midesophageal four-chamber during diastole e. Midesophageal long-axis view during systole

Back 338

c. The coronary arteries are best visualized in the midesophageal aortic short- and long-axis views. Most of the coronary perfusion occurs during diastole; thus, in that portion of the cardiac cycle, the vessels are easier to be identified.

Front 339

Regarding congenital coronary artery anomalies the following are true EXCEPT for:a. May be seen in association with congenital heart disease b. May present as an incidental findingc. Always present as a manifestation of ischemia d. Upon diagnosis surgical intervention may or may not be indicatede. Should be evaluated by two-dimensional echocardiography as well as color Doppler imaging

Back 339

c. Congenital coronary artery anomalies can be seen as isolated lesions or within the context of congenital or acquired heart disease. They can be recognized as an incidental finding, present with nonspecific symptoms, or manifest as myocardial ischemia.

Front 340

Regarding the use of TEE in the catheterization laboratory in congenital heart disease:a. It can be used as a diagnostic tool prior to the procedure b. It serves to monitor interventional proceduresc. It can detect procedural complications earlyd. It can limit radiation exposuree. All the statements are correct

Back 340

e. All the statements are correct. The use of TEE in the cardiac catheterization laboratory to acquire detailed anatomic and hemodynamic data before and during interventions has been well documented. TEE provides for real-time evaluation of catheter placement across valves and vessels and immediate assessment of interventional procedures. It is also valuable in monitoring for catheter-induced complications, such as cardiac tamponade. This modality also limits radiation exposure by complementing the information obtained by fluoroscopy and angiography.

Front 341

The Coumadin ridge is the tissue fold between left atrial appendage and left upper pulmonary vein that can often be mistaken for a thrombus or a small tumor.

T or F

Back 341

True

Front 342

The Chiari network is a remnant of fetal circulation which appears as a mobile density in the left atrium and can be confused with a left atrial mass.

T or F

Back 342

F

Front 343

Lipomatous hypertrophy of the intra-atrial septum is commonly seen in older women and usually has a benign clinical course.

T or F

Back 343

T

Front 344

Myxoma is a highly vascular tumor that will appear highly enhanced after administration of echo contrast.

T or F

Back 344

F

Front 345

Benign stromal tumors with low vascularity appear as filling defects on contrast echocardiography.

T or F

Back 345

T

Front 346

Renal cell carcinoma is commonly associated with transit of tumor fragments through the IVC to the right heart.

T or F

Back 346

T

Front 347

Decreased blood flow velocity (<40 cm/s) in the left atrial appendage is associated with an increased risk of thromboembolic events.

T or F

Back 347

T

Front 348

The presence of a PFO in an otherwise healthy patient is a strong predictor of stroke.

T or F

Back 348

F

Front 349

Increased gain setting on echo machines can mimic spontaneous echo contrast.

T or F

Back 349

T

Front 350

In endocarditis, the vegetation size is not a predictor of embolic events.

T or F

Back 350

F

Front 351

All of the following statements regarding an intracardiac thrombus are true EXCEPT:a. A left ventricular apical thrombus is almost always associated with apical wall motion abnormality b. The left ventricular apex is best seen from a transgastric TEE viewc. A thrombus will appear as a filling defect with administration of echo contrastd. Size and mobility are predictors of systemic embolization

Back 351

b

Front 352

All of the following statements are true EXCEPT:a. Primary cardiac tumors are very rare and comprise a minority of all cardiac neoplasmsb. Metastatic tumors involve the heart or pericardium through local invasion or hematogenous spread c. Locally invading tumors are often seen as a mass invading the chambers or pericardiumd. Echocardiography is an effective technique in identifying the tissue origin of cardiac masses

Back 352

d

Front 353

All of the following statements are true EXCEPT:a. A myxoma is the most common primary cardiac tumor in adultsb. Cardiac myxomas are pedunculated masses that commonly arise from the atrioventricular valves c. A myxoma is a slow-growing tumor and can remain asymptomatic for a long period of time d. A myxoma can grow in size and occupy a significant portion of the cardiac chambers

Back 353

b

Front 354

All of the following statements are true EXCEPT:a. Fibroelastomas are small mobile tumors that appear as a small (0.5 to 2 cm) pedunculated echo density on valvular structuresb. Fibroelastomas are often associated with valvular calcificationsc. Fibroblastomas have high potential for embolizationd. In contrast to vegetations, fibroelastomas are not associated with significant valvular regurgitations

Back 354

b

Front 355

All of the following statements are true EXCEPT:a. Rhabdomyomas are the most common primary cardiac tumor in childrenb. Rhabdomyomas are almost always associated with tuberous sclerosisc. Rhabdomyomas are single tumors that usually originate from the atrial myocardiumd. Asymptomatic rhabdomyomas are usually followed over time, as some of these tumors can spontaneously resolve

Back 355

c

Front 356

All of the following statements are true EXCEPT:a. Fibromas are the second most common benign cardiac tumor in childrenb. Fibromas usually originate from the intra-atrial septumc. Singularity is a key factor in differentiating fibromas from rhabdomyomasd. The presence of central calcification adds in differentiating fibromas from rhabdomyomas

Back 356

b

Front 357

All of the following statements are true EXCEPT: a. Intracardiac thrombi are associated with stasis of bloodb. Thrombus can be formed on intracardiac devices such as pacemaker wiresc. Thrombus in the ventricles is almost always associated with underlying wall motion abnormality d. Thrombus size is not a predictor of systemic embolization

Back 357

d

Front 358

All of the following statements are true EXCEPT:a. Spontaneous echo contrast (SEC) or smoke is an echogenic swirling pattern of blood flow in the left atriumb. The presence of SEC in the left atrium or LAA is associated with increased risk of thromboembolismc. The presence of SEC in the left atrium appendage is associated with increased risk ofthromboembolismd. Spontaneous echo contrast is only seen in atrial fibrillation

Back 358

d

Front 359

All of the following statements are true EXCEPT:a. Lambl’s excrescences are commonly seen on commissural edges of the valve leaflets b. Larger Lambl’s excrescences are often confused with valvular vegetationsc. Similar to vegetations, Lambl’s excrescences are associated with valvular regurgitations d. Lambl’s excrescences are not associated with embolic events

Back 359

c

Front 360

All of the following statements are true EXCEPT:a. Fibroblastomas have high potential for embolizationb. Emboli are from tumor fragments or associated thrombic. Tumor size is not a predictor of embolizationd. Valvular fibroelastomas are frequently confused with vegetations given the size, location, and potential for embolization

Back 360

c

Front 361

Real-time 3D TEE acquires raw data by:a. Volume scanningb. Sector scanningc. Off-line reconstruction d. Planar scanning

Back 361

a. Acquisition of raw 3D data involves volume scanning with online processing. Planar or sector scanning is used for 2D imaging and may be processed off-line to create 3D images.

Front 362

An RT 3D echo probe comprises a:

a. Linear phased array of 250 crystalsb. Fully sampled matrix array of 2,500 crystalsc. Nonlinear phased array of 250 crystalsd. Partly sampled matrix array probe of 1,100 crystals

Back 362

b. Current technology uses a fully sampled matrix array probe which comprises 2,500 crystals all of which can be fully activated or sampled.

Front 363

Which is not a step in creating a 3D image?a. Segmentation b. Renderingc. Conversiond. Interpretation

Back 363

d. Processing of raw 3D data includes the initial steps of segmentation, conversion, and interpolation followed by rendering to display the 3D dataset.

Front 364

Which form of rendering allows a virtual dissection of a structure?a. Wireframe b. Sectorc. Surface d. Volume

Back 364

d. Volume rendering includes all the data points and recreates the inner details of a structure. Surface and wireframe rendering show only the outer parts of structures.

Front 365

Which 3D mode has the largest sized 3D dataset?a. 3D liveb. 3D zoomc. 3D full volumed. 3D color Doppler

Back 365

c. 3D full volume dataset is the largest. The other modes can be adjusted but are limited in width and depth.

Front 366

Which 3D mode has the lowest frame rate?a. 3D liveb. 3D zoomc. 3D full volumed. 3D color Doppler

Back 366

b. 3D zoom has good spatial resolution but often has a low frame rate of <10 Hz. 3D color Doppler also may have a low frame rate but gating and the small sector size improves the frame rate to over 10 Hz.

Front 367

Postprocessing to optimize a 3D image does not include adjusting:a. Gainb. Colorc. Brightness d. Smoothing

Back 367

b. All the others can be adjusted on all 3D datasets

Front 368

Which is not an artifact in 3D images?a. Overgain b. Dropout c. Stitchd. Inversion

Back 368

b. All the others can appear in 3D datasets. Stitch artifacts occur in full volume acquisitions between adjacent segments.

Front 369

Structures are most difficult to image using 3D if they are:a. In the near field b. Thickenedc. Heavily calcified d. Mobile

Back 369

c. Like in 2D imaging, heavily calcified structures create dropout in the far field from shadowing making it difficult to image them completely.

Front 370

3D color Doppler is least affected by:a. Sector sizeb. Stitch artifacts c. Frame rated. Nyquist limit

Back 370

d. The Nyquist limit is set in the 2D image prior to the 3D color Doppler FV acquisition and cannot be adjusted in the 3D dataset.

Front 371

Which 3D mode is best to obtain an en face view of the entire mitral valve?a. 3D liveb. 3D zoomc. 3D full volumed. 3D color Doppler

Back 371

b. The Zoom mode is the easiest and most reliable to show the entire MV in a single display. Full Volume can achieve an en face view but is often subject to stitch artifacts making interpretation difficult.

Front 372

Which structure should be included to help orientate the mitral valve in 3D space?a. Tricuspid valveb. Aortic valvec. Pulmonic valved. Left upper pulmonary vein

Back 372

b. The aortic valve is easily incorporated into 3D MV datasets and helps orientate the MV with the AV

Front 373

Angled views to assess mitral valve prolapse does not include the:a. Left ventricular view b. Posteromedial view c. Scallop viewd. Anterolateral view

Back 373

a. All the angled views are displayed from the left atrium, not the LV, and orientated to emphasize different regions of the MV.

Front 374

Mitral valve area in mitral stenosis is most accurately assessed using 3D echocardiography by:a. Direct planimetry in real timeb. Creation of 3D modelc. Off-line measurement using multiplanar reconstruction d. Superimposing a 3D grid

Back 374

c. Off-line processing using analytical software that aligns planes through the narrowest orifice allows accurate planimetry of the MV orifice. It is considered the gold standard for assessing MV area in mitral stenosis. Creation of an MV model can assess other dimensions of the MV.

Front 375

3D assessment of global left ventricular function using a surface-rendered model does not overcome the limitation of:a. Poor endocardial definition b. Ventricular sizec. Ventricular shaped. Wall motion abnormalities

Back 375

a. Assessment of LV function using analytical software to create the surface-rendered model requires good endocardial definition to semiautomatically trace the endocardial border. Poor endocardial definition makes assessment difficult.

Front 376

3D TTE assessment of LV global function is not comparable to: a. 2D TTEb. Computed tomography (CT)c. Magnetic resonance imaging (MRI) d. 3D TEE

Back 376

d. There have been no studies to date that have looked at the reliability of assessing LV global function using 3D TEE.

Front 377

Assessment of LV regional wall motion abnormalities using 3D TEE involves:a. Measuring wall thickeningb. Measuring wall motionc. Assessing segmental timing d. Measuring segmental volume

Back 377

d. Individual LV segmental volumes are graphed against time to show wall motion abnormalities. Unlike 2D imaging, wall motion thickening and motion are not directly assessed. Timing of wall motion abnormalities is an important determinant of ventricular dyssynchrony.

Front 378

During assessment of aortic root dissection 3D TEE poorly interrogates:a. Flap location and movement b. Aortic insufficiency severity c. Aortic arch involvementd. Coronary blood flow

Back 378

c. Like 2D imaging the aortic arch may be obscured by the trachea (blind spot), so obtaining good- quality arch images may be difficult.

Front 379

During transcatheter aortic valve implantation procedures, 3D TEE is least useful to:a. Measure aortic valve diameter b. Position valvec. Assess paravalvular leak d. Assess valve function

Back 379

a. Shadowing in calcific aortic stenosis makes the aortic annulus difficult to measure in both 2D and 3Dimages. This cannot be overcome even by exporting 3D datasets to analytical software.

Front 380

Real-time 3D TEE assessment of masses cannot be easily used to determine:a. Locationb. Sizec. Attachmentd. Functional effect

Back 380

b. A current limitation of RT 3D echocardiography is the inability to perform even simple area or length measurements without exporting the 3D dataset to analytical software. The other answers are easily obtained using 3D TEE.

Front 381

What is the most common type of imaging artifact?a. Acoustic shadowingb. Reverberationc. Suboptimal image quality d. Mirroring

Back 381

c

Front 382

2 Which of the following assumptions of the US imaging system can be disrupted when artifacts occur?

a. The echoes travel in straight lines from the transducerb. The echoes come back to the transducer after a single reflectionc. The time that the US wave employs to return to the transducer provides the distance between the transducer and the reflective structured. All of the above

Back 382

d

Front 383

Acoustic shadowing can result from:a. High attenuation b. Refractionc. Enhancementd. None of the above

Back 383

a

Front 384

Acoustic shadowing will produce a dark area:a. Proximal to the strong reflector b. Distal to the strong reflectorc. Left of the strong reflectord. Right of the strong reflector

Back 384

b

Front 385

Axial resolution artifacts occur when:a. Two objects lying perpendicular to the main US beam are displayed as a single structure b. Two objects lying parallel to the main US beam are displayed as a single structurec. The US system employs longer spatial pulse lengthd. The US system employs shorter pulse duration

Back 385

b

Front 386

In most imaging systems, axial resolution is at least:a. Equal to lateral resolutionb. Twice the lateral resolutionc. Ten times the lateral resolution d. Half of the lateral resolution

Back 386

b

Front 387

The diameter of the US main beam impacts:a. Temporal resolutionb. The number of scan lines c. Axial resolutiond. Lateral resolution

Back 387

d

Front 388

The artifacts correlated to the lateral resolution are:a. A double image of the object of interestb. A single image of two objects orientated perpendicular to the main beam c. Multiple equidistance bright signalsd. None of the above

Back 388

b

Front 389

Range ambiguity depends on the failure of which of the following fundamental assumptions?

a. The time that a single reflection employs to return back to the transducer only depends on the distance between the reflector and the transducer itself

b. The echoes detected by the system are those generated by the most recent pulse emitted by the transducer

c. a and b

d. All the echoes are generated by the US main beam

Back 389

c

Front 390

Aliasing artifacts are typical of:a. 2D USb. Color Doppler and pulsed Doppler c. Continuous wave Dopplerd. None of the above

Back 390

b

Front 391

Which of the following factors is not related to aliasing in spectral Doppler imaging?a. Pulse repetition frequency b. Nyquist limitc. “Wraparound”d. Lateral resolution

Back 391

d

Front 392

The crista terminalis is located in the:a. Right atrium b. Left atriumc. Right ventricle d. Left ventricle

Back 392

a

Front 393

The moderator band is located in the:a. Right atrium b. Left atrium c. Right ventricle d. Left ventricle

Back 393

c

Front 394

The Eustachian valve is located in the:a. Right atrium b. Right ventricle c. Left atriumd. Left ventricle

Back 394

a

Front 395

The Coumadin ridge is located in the:a. Right atrium b. Right ventricle c. Left atriumd. Left ventricle

Back 395

c

Front 396

Which of the following statements is NOT true of a lipomatous atrial septum?a. It has a dumbbell shapeb. The fatty infiltration is echo-dense c. The fossa ovalis is thickenedd. The fossa ovalis is spared

Back 396

c

Front 397

In an interrogation of flow with spectral Doppler, a nonparallel beam angle will:a. Overestimate the true velocity b. Underestimate the true velocityc. Correctly measure the velocityd. Spectral Doppler does not measure velocities

Back 397

b

Front 398

Side lobe artifacts:a. Are true structures outside the path of the main beamb. Are true structures in the path of the main beamc. Are incorrectly displayed in the two-dimensional sectord. a and c

Back 398

d

Front 399

Reverberation artifacts will not produce:a. Multiple linear densitiesb. Dual structures in an axial orientationc. Dual structures in a left–right orientationd. A duplication that is the same size as the original

Back 399

c

Front 400

The comet tails are an atypical examples of:a. Reverberation b. Ringdownc. Multipathd. Mirroring

Back 400

a

Front 401

Smoothing of a two-dimensional image is referred to as:a. Rejectb. Compression c. Dynamic range d. Variance

Back 401

b

Front 402

Time gain compensation allows the echocardiographer to overcome:a. Attenuationb. Low frame ratec. Poor lateral resolution d. Image artifacts

Back 402

a

Front 403

ncreasing the size of the color flow Doppler sector will:a. Decrease axial resolutionb. Improve temporal resolution c. Decrease temporal resolution d. None of the above

Back 403

c

Front 404

Increasing the dynamic range results in:a. An increase in the number of shades of gray between black and white b. An increase in the shades of gray at each end of the spectrumc. An elimination of a greater number of low-intensity signalsd. An elimination of a greater number of high-intensity signals

Back 404

a

Front 405

Higher frequency ultrasound beams have all of the following properties EXCEPT:a. Improved resolution in the near field b. Less penetrationc. Subject to greater attenuationd. Improved lateral resolution

Back 405

d

Front 406

Focusing an ultrasound beam on an object results in:a. Improved lateral resolution in the far field b. Increased frame ratec. Improved axial resolution in the near field d. Improved lateral resolution in the near field

Back 406

d

Front 407

Techniques to improve image quality include:a. Using lower frequencies when visualizing structures in the far fieldb. Adjust the depth so as not to include structures beyond the structure of interest c. Adjust the color flow Doppler sector to include only the region of interestd. All of the above

Back 407

d

Front 408

As the number of velocities in a color sector increase, the ______ is said to increasea. Dynamic rangeb. Variancec. Nyquist limitd. None of the above

Back 408

b

Front 409

The amplitude of the transmitted ultrasound signal is controlled by:a. The transmit powerb. Adjusting the gainc. Adjusting the time gain compensation d. All of the above

Back 409

a

Front 410

Decreasing the depth of the image results in:a. A lower frame rateb. Lower temporal resolutionc. A higher pulse repetition frequency d. Lower axial resolution

Back 410

c

Front 411

By lowering the Nyquist limit:

a. Lower velocity blood will be displayed

b. A jet will appear smaller

c. Pulse repetition frequency will increase

d. All of the above

Back 411

a

Front 412

To optimize color gain settings:a. The gain should be increased until color pixels appear within the tissuesb. Settings should be changed to the echocardiographer’s preferencec. The gain should be increased until color pixels appear within the tissues and then reduced slightly d. None of the above

Back 412

c

Front 413

Postprocessing controls include:a. Doppler gainb. Brightnessc. Contrastd. All of the above

Back 413

d

Front 414

The filtering of low-intensity signals is performed with which control:a. Rejectb. Compression c. Dynamic range d. Persistence

Back 414

a

Front 415

To optimize image quality of the aortic valve in the deep transgastric view, one could:a. Increase the frequencyb. Adjust the focus to the level of the aortic valve c. Increase the transmit powerd. Set the time gain compensation higher in the near field

Back 415

b

Front 416

To optimize the image quality of the mitral valve in the mitral commissural view, one could:a. Increase the sector sizeb. Increase the frequencyc. Increase the gaind. Increase the image depth to encompass the entire left ventricle

Back 416

b

Front 417

When applying color flow to the aortic valve in the midesophageal aortic valve long-axis view, the temporal resolution will be increased by:a. Increasing the area which color is displayedb. Decreasing the image depthc. Adjust the Nyquist limit so aliasing does not occur d. All of the above

Back 417

b

Front 418

High gain settings result in:a. Increased lateral resolutionb. Increased temporal resolution c. Decreased temporal resolution d. The image appearing brighter

Back 418

d

Front 419

Frame rate is affected by:

a. Sector sizeb. Image depthc. Color sector size d. All of the above

Back 419

d

Front 420

Excessive reject may result in the inability to image:a. An intracardiac thrombusb. Valvular motionc. Turbulent blood flow across a stenotic aortic valve d. Lower flow velocities in the pulmonary veins

Back 420

a