ACS

Question 1

Which valvular abnormality must be corrected prior to LVAD implantation?

Answer 1

The one lesion that must ALWAYS be corrected for LVAD is Severe Aortic REgurgitation. In an LVAD, blood is pumped from the apex to the aorta. I. severe AI, blood immediately leaks back into the LV creating a closed loop where the LVAD pumps in circles leading to no forward cardiac output.

Question 2

What is MPI ( Myocardial Performance Index) and what is the formula to assess LV Function?

Answer 2

he MPI, also known as Tei index or the index of myocardial performance (IMP), is a Doppler-derived index used to assess global ventricular function. Systolic dysfunction results in a prolongation of the pre-ejection isovolumic contraction time (IVCT) and a shortening of the ejection time (ET), while both systolic and diastolic dysfunction cause abnormal myocardial relaxation, which prolongs the IVRT. This index is derived from the sum of the isovolumic times divided by the ejection time (Figure 11-2). In this example, the MPI is greater than 0.4, which is abnormal.

MPI= IVCT + IVRT / ET

Anything above .4 is abnormal

Question 3

A 68-year-old male patient is admitted to the hospital for shortness of breath and peripheral edema. The echocardiogram showed moderate mitral regurgitation (MR). The blood pressure was 120/65mm Hg, the peak MR velocity measured 5.2m/s, and the time duration between the peak MR velocity at 1m/s and at 3m/s was measured at 0.032 s. Based on these measurements, what is the dP/dt?

Answer 3

The dP/dt refers to the change in pressure (dP) over the change in time (dt) during the isovolumic contraction phase of the cardiac cycle. This is measured from the MR continuous-wave Doppler trace as the time difference (Δt) between the MR velocity at 1m/s and the MR velocity at 3m/s. Using the simplified Bernoulli equation, the pressure difference between 1m/s and 3m/s is 32mm Hg:

4v2

(4) * 1(v) squared = 4mmhG

(4) * 3(v) squared = 36mmhG

36 - 4 = a difference of 32mmhG for PRESSURE change

dP/dT = 32 (difference in pressure) / .032s (difference in time)

=1000

Question 4

How do you calculate cardiac index?

Answer 4

CO/BMI=CI

CO= SV * HR

Question 5

What is fractional shortening and how do we calculate it?

Answer 5

FS= ((LVEDDiameter − LVESDiameter)÷LVEDD)×100

Done in PLAX

FS is the percentage of change in left ventricular (LV) cavity dimension with systole. It is typically calculated from 2D or M-mode linear LV measurements acquired from the parasternal long-axis or parasternal short-axis views at end-diastole and end-systole. These measurements are obtained just distal to the mitral leaflet tips and perpendicular to the long axis of the left ventricle. It is current practice to measure the LV dimensions at the blood-tissue interfaces from the basal septum to the basal inferolateral wall. It is important to obtain good-quality, non-foreshortened images and accurate measurements to calculate FS. A normal FS is 27% to 45%. FS evaluates only basal contractility and therefore is not a reliable method for the evaluation of LV function in the setting of regional wall motion abnormalities.

Question 6

What is the difference between Axial, Temporal and Lateral Resolution?

Answer 6

In the context of ultrasound imaging, axial resolution refers to the ability to distinguish between two objects that are close together in the direction parallel to the ultrasound beam, while lateral resolution refers to the ability to distinguish between two objects that are close together in the direction perpendicular to the beam. Temporal resolution, on the other hand, relates to the ability to accurately track the movement of objects over time.

Question 7

How does the inspiration affect pre-load?

Answer 7

Intrathoracic pressure decreases during inspiration and abdominal pressure increases, which pushes blood toward the right atrium. The skeletal muscle pump affects preload in the following way: muscles in the legs squeeze the deep veins pushing blood back toward the heart.

Question 8

What is the equation for LV MPI Myoardial Performance Index??

Answer 8

(IVCT + IVRT) / ET

But the easiest way to measure in doppler is to measure the whoele thing (mitral valve closure to mv opening which is :

IVCT+ET+IVRT/ET

In order to seperate its:

IVCT+IVRT+ET - ET/ET

Question 9

Does an E/A ratio ALAWAYS indicate severe diastolic dysfunction? If not, why?

Answer 9

No
An E/A ratio >2 suggests a restrictive filling pattern, characteristic of severely reduced left ventricular (LV) compliance and significantly elevated left atrial pressure. This is usually seen in advanced stages of diastolic dysfunction.

Real Severe DD is often associated with other abnormal findings like a short E wave deceleration time (<150 ms) and an elevated E/e’ ratio.

Young, healthy individuals or athletes can have an E/A ratio >2. In these cases, it’s not due to diastolic dysfunction but rather reflects supernormal diastolic function and highly elastic hearts.

Question 10

A 68-year-old male patient is admitted to the hospital for shortness of breath and peripheral edema. The echocardiogram showed moderate mitral regurgitation (MR). The blood pressure was 120/65mm Hg, the peak MR velocity measured 5.2m/s, and the time duration between the peak MR velocity at 1m/s and at 3m/s was measured at 0.032 s. Based on these measurements, what is the dP/dt?

Answer 10

pressure difference / time
1 m/s = 4v2

4 x 1(2) = 4

3 m/s = 4v2

4 x 3(2) = 4 x 9 = 36

the difference between 36 and 4
(36-4) = 32

32/.032 =1000

Question 11

What normal anatomical structure in the left atrial appendage (LAA), as seen in Figure 35-3, could be mistakenly diagnosed as a left atrial appendage thrombus or mass?

Answer 11

pectinate

Question 12

What is an aortic annular abscess and when do we see it?

Answer 12

Aortic annular abscess is a very serious complication of aortic valve endocarditis. It is more commonly associated with prosthetic aortic valves than native aortic valves. It can present in a range of severities from inflammation and swelling of the annular tissue to paravalvular abscess formation encapsulated in the aortic annulus. Severe cases may result in a fistulous communication into the abscess and can result in a left-to-right shunt through the abscess into the right heart structures. As the aortic annulus and proximal ventricular septum become swollen and infected, the atrioventricular node may be affected, resulting in a prolonged PR interval and possibly higher degrees of heart block. Once the diagnosis of aortic abscess is confirmed, urgent surgery is required. Antibiotics alone will fail to control the infection. Surgery involves debridement of the infected tissue and replacement of the aortic valve.

Question 13

What is one way to treat pericarditis?

Answer 13

Prednisone, a type of corticosteroid, can be used to treat pericarditis. Corticosteroids like prednisone are strong anti-inflammatory medications. They work by suppressing the inflammatory response and reducing the symptoms of pericarditis.
However, prednisone is not typically the first-line treatment for acute pericarditis. Nonsteroidal anti-inflammatory drugs (NSAIDs) like aspirin or ibuprofen, often combined with colchicine, are generally recommended first.

Question 14

In a patient that does not have a measurable tricuspid regurgitation jet, which of the following would suggest elevated pulmonary pressures?

Answer 14

decreased pulmonary valve acceleration time.
A PV acceleration time of less than 105 is associated with elevated pulmonary pressures.

Question 15

What is the difference between LV filling pressures and end diastolic pressure?

Answer 15

While the terms “left ventricular (LV) filling pressures” and “left ventricular end-diastolic pressure (LVEDP)” are sometimes used interchangeably, they represent distinct hemodynamic concepts. LVEDP reflects the pressure in the left ventricle at the end of diastole, just before contraction, and is a key indicator of ventricular compliance and preload. Left ventricular filling pressures, on the other hand, is a broader term encompassing pressures throughout the diastolic filling period, including the mean left atrial pressure (LAP), which is often a better indicator of pulmonary congestion

Question 16

What are the key signs of heart block on ECG?

Answer 16

PROLONGED PR INTERVAL
Key signs of heart block on an ECG (electrocardiogram) include prolonged PR intervals (first-degree), dropped QRS complexes (second-degree), and complete dissociation between P waves and QRS complexes (third-degree). These abnormalities indicate issues with the heart’s electrical conduction system, potentially affecting heart rate and rhythm.

Question 17

What echocardiographic findings do we look for in a patient with Systemic Lupus Erythematosus (SLE)?

Answer 17

PERICARIDAL EFFUSION
This is the most common cardiac manifestation, observed in a significant percentage of SLE patients.

Libman-Sacks Endocarditis: This specific form of valvular involvement, characterized by non-bacterial vegetations on the valves, is more prevalent in patients with active SLE and antiphospholipid antibodies.

Question 18

What pathology represents the blue berry on top phenomenom?

Answer 18

Apical Hypertrophic Cardiomyopathy

Question 19

What is the formula for GLS?

Answer 19

End Diastolic Length - End Systolic Lenght/ End Diastolic Length

Question 20

What do we look for on Dobutamine SE for LFLG AS?

Answer 20

Flow reserve: This refers to the ability of the heart to increase its stroke volume (the amount of blood pumped with each beat) during dobutamine infusion.

Presence of flow reserve: An increase in stroke volume of greater than or equal to 20% compared to baseline suggests the presence of flow reserve.

Absence of flow reserve: No significant increase in stroke volume or flow rate during dobutamine infusion suggests a lack of flow reserve.

1.Changes in valve parameters: Dobutamine infusion can help differentiate true severe AS from pseudo-severe AS.

2.True-severe AS: Characterized by a significant increase in the mean gradient (often ≥40 mmHg) with only minor changes in the AVA (remaining <1.0 cm² or ≤0.6 cm²/m² for indexed AVA) as flow increases.

3Pseudo-severe AS: Characterized by a substantial increase in AVA (usually >1.0-1.2 cm²) with only minor changes in the gradient (<40 mmHg) as flow increases. This indicates that the valve opening was initially restricted due to low flow, but not due to a fixed severe narrowing.

4.Projected AVA (AVAproj): This parameter can be calculated when there is an incomplete normalization of flow or persistent discordance in AVA and gradient findings at the end of DSE.

Question 21

What is the TricValve and what is its main purpose?

Answer 21

Bicaval stenting of the IVC/SCV in cases of severe TR and TV treatment doesnt work(TriClip or Repair). Its purpose is sustained hemodynamic improvement from the reduction of IVC and SVC backflow

Question 22

What are the cut offs for bioprostetic Tricuspid valve?

Answer 22

Blauwet et al. demonstrated that a

peak tricuspid E velocity >2.1 m/sec,

DVI >3.3 and

PHT >230msec

Mean > 6mmHg

were predictive of abnormal TPV function in tricuspid valve bioprostheses.

2 The same group has also proposed the use of the TVI ratio for the evaluation of mechanical tricuspid valve prostheses. A peak tricuspid E velocity <1.9 m/sec, TVITPV/TVILVOT<2.0 and PHT<130 msec was found to be predictive of normal mechanical TPV function.3

Question 22

What is DVI formula for all prostetic valves?

Answer 22

Easiest way to remember:
DVI:

DVI=Pros AV: VTI LVOT/VTI AV
All other Prostetic valves have the Valve VTI on top compared to the LVOT VTI on bottom

TV: LVOT VTI/TV VTI
MV: LVOT VTI/MV VTI

Rvol=
MV:
MV SV -LVOT SV

AV: for AI
LVOT SV - MV SV

RVOL / Regurg VTI. = EROA

RVOL / valve SV = RF%

EOA = LVOT SV/ VTI across all other valves

Question 23

What is the formula for EOA on any prostetic valve?

Answer 23

EOA = LVOT SV / VTI across the prosthetic valve

Question 24

Aortic valvular gradients are best obtained using transesophageal echocardiography (TEE) in which view?

Answer 24

Deep transgastric view at 0° with anteflexion

Question 25

When performing high-level disinfection of a transesophageal transducer, enzymatic cleaning is performed to?

Answer 25

Remove inorganic and organic debris that can otherwise remain on the probe’s surface and defeat the efficacy of the disinfection

Question 26

A patient with an acute inferior myocardial infarct has now developed fulminant pulmonary edema. What is the most likely complication of the infarct that caused the edema? a.Aortic dissection b.Left ventricular apical thrombus c.Papillary muscle rupture d.Ventricular septal rupture

Answer 26

C. Infarction of the left ventricular (LV) inferior wall can lead to posteromedial papillary muscle rupture. The posteromedial papillary muscle has a single supply of blood from the posterior descending artery of the right coronary artery or dominant left circumflex artery. If this blood supply is occluded for any significant period and infarction occurs, a complication can be the rupture of the papillary muscle head (Video 34-6A). This can lead to acute severe mitral regurgitation and the development of pulmonary edema (Video 34-6B). Papillary muscle rupture of the anterolateral papillary muscle is rarely seen as this papillary muscle has a dual blood supply from the left anterior descending and left circumflex coronary arteries.

Question 27

Transmitral pulsed-wave (PW) Doppler is performed on a patient with acute severe mitral regurgitation (MR) who remains in sinus rhythm. Which feature of the PW Doppler waveform is expected? L-wave E/A reversal A-wave greater than 1.2 m/s E-wave velocity greater than 1.2 m/s

Answer 27

E-wave velocity greater than 1.2 m/s In severe MR without stenosis, the mitral E velocity is higher than the velocity during atrial contraction (A velocity) and is usually greater than 1.2 m/sec. A mitral inflow pattern with an A-wave dominance virtually excludes severe MR".3) In addition, the European Association of Echocardiography suggests that "In the absence of mitral stenosis, a peak E wave velocity > 1.5 m/sec suggests severe MR. Conversely, a dominant A wave virtually excludes severe MR".4)

Question 28

peripartum vs postpartum cardiomyopathy?

Answer 28

Peripartum cardiomyopathy (PPCM) and postpartum cardiomyopathy are essentially the same condition: a rare form of heart failure that occurs during the end of pregnancy or in the months following childbirth. The term "peripartum" refers to the period surrounding birth, including pregnancy and the postpartum period, while "postpartum" specifically refers to the period after delivery. Thus, postpartum cardiomyopathy is a subset of peripartum cardiomyopathy.

Question 30

What does a Q wave on an ecg represent on a YOUNG patient ?

Answer 30

HOCM Would be indicative of an old MI if patient was older

Question 31

What do we look for on an echo for a patient with CKD and/or undergoing dialysis?

Answer 31

LVH Diastolic and Systolic Dysfunction AOV/MV calcification

Question 32

When evaluating diastolic function, the Valsalva maneuver may be used to decrease preload and distinguish normal from pseudonormal filling. What change in the E/A ratio with Valsalva is highly specific for increased filling pressures?

Answer 32

50%

Question 33

Myocardial strain is calculated as the: a)change in length of a myocardial segment / original length of the segment x 100. b)change in length of a myocardial segment - original length of the segment x 100. c)change in length of a myocardial segment z original length of the segment x 100. d)change in length of a myocardial segment + original length of the segment x 100.

Answer 33

b)change in length of a myocardial segment - original length of the segment x 100.

Question 34

Which of the following items pose the highest risk during pregnancy? Choose three that apply. mitral valve prolapse severe aortic stenosis mechanical heart valve pulmonary hypertension repaired cyanotic heart disease

Answer 34

severe aortic stenosis mechanical heart valve pulmonary hypertension

Question 35

How do you get E/e' average?

Answer 35

Mitral E velocity = 86 Medial e' = 6.92 Lateral e' = 7 Average e' ( 6.92 + 7 )/2 = 7 E/e = 86/7 = 12 ( <14)

Question 36

What is the effective regurgitant orifice area in a patient with moderate mitral regurgitation? 0.56 cm2 0.41 cm2 0.21 cm2 0.16 cm2

Answer 36

.21cm2

Question 37

A 56-year-old patient presents with dyspnea on exertion and a history of hypertension, diabetes and smoking. Which might be an expected finding? tricuspid stenosis pulmonary atresia diastolic dysfunction mitral valve prolapse without MR

Answer 37

diastolic dysfunction

Question 38

On the ECG , what do we call when we see P wave morphology or p waves of different shapes??

Answer 38

WAP Wandering Atrial Pacemaker

Question 39

How do we diagnose LAE on ECG?

Answer 39

When the P wave looks like a bundle branch block on lead II

Question 40

What is the difference between temporal and axial resolution?

Answer 40

Temporal Resolution What it is: Ability to capture rapid movement accurately (how well you see motion). How it's improved: Higher Frame Rate (Hz) by decreasing imaging depth, fewer scan lines, or smaller sector angle. Analogy: Like the frames per second (FPS) in a video, showing smooth motion. Key Trade-off Improving one often hurts the other. For example, using high frequency for better axial resolution reduces penetration and can lower temporal resolution (frame rate), while capturing deeper structures slows down the frame rate, worsening temporal resolution. Axial Resolution (Spatial) What it is: Ability to tell two objects apart when they are one above the other (along the beam path). How it's improved: Higher frequency (shorter wavelength) and shorter spatial pulse length (fewer cycles in a pulse). Analogy: Like the pixel density in a photo, showing fine detail in depth.

Question 41

How do you measure Fractional Shortening using a LV Diameter of 4.0 cm and a LV systolic diameter of 2.9cm?

Answer 41

LVED-LVSD/ LVED 4-2.9 =1.1 1.1 / 4 = .275 or 28%

Question 42

What is a diastolic shudder?

Answer 42

Official term for "septal bounce" which is specifically seen in constrictive pericarditis.

Question 43

Which spectral doppler measurement can be best compared to cardiac catheterization when determining the severity of aortic stenosis?

Answer 43

Aortic Mean Pressure Gradient

Question 44

When the LVOT peak velocity is over 1, what does that mean for an AoV vMax of 4.2 m/s and a mean over 40mmHg?

Answer 44

The peak and mean will be over estimated. LVOT peak should always be less than 1

Question 45

When LVOT VMax is above 1, how do you correct peak and mean AoV pressure gradients?

Answer 45

Use the expanded Bernouli equation: Subtraction Aov Peak Gradient - LVOT Peak Gradient Aov Mean Gradient - LVOT Mean Gradient

Question 46

What are the PHT, Doppler E velocity and mean gradients cutoffs for Prosthetic Tricuspid Valve Stenosis?

Answer 46

A narrowed inflow color map is a helpful corroborative . Obstruction is also suggested on CW Doppler by an E velocity > 1.7 m/s, mean gradient > 6 mm Hg, or pressure half-time > 230 (Figure 16). Indirect, nonspecific signs are an enlarged right atrium and engorged inferior vena cava.

Question 47

When is LVEDP considered to be abnormal?

Answer 47

LVEDP is considered to be abnormal when it is greater than 15mmHG. The 15mmHg is derived from the E/e ratio.

Question 48

How do you calculate E/e prime?

Answer 48

1.Measure the E wave (Mitral Inflow Velocity): Use pulsed-wave Doppler on an echocardiogram to find the peak velocity of blood flowing into the left ventricle during early diastole (filling). 2.Measure the e' wave (Mitral Annular Velocity): Use tissue Doppler imaging (TDI) to measure the velocity of the mitral valve annulus moving inward during early diastole at both the septum (medial) and the side (lateral). 3.Calculate the Mean e' (e' mean): Average the septal and lateral e' velocities. Compute the Ratio: Divide the E wave velocity by the mean e' velocity: E/e' = E / (e' septal + e' lateral) / 2. What it Means (Clinical Interpretation) Normal: E/e' < 8 suggests normal filling pressures. Elevated: E/e' ≥ 15 often indicates elevated left ventricular filling pressures, suggesting diastolic dysfunction (impaired relaxation). Uses in Cardiology Assessing heart failure with preserved ejection fraction (HFpEF). Estimating left ventricular end-diastolic pressure (LVEDP).

Question 49

What is Pulmonary capillary wedge pressure and how do we measure it?

Answer 49

PCWP is the same as LAP. It is determined via Right Heart Cath where a catheter is placed in the one of the PA branches

Question 50

Why is the E/e ratio important and what does it actually measure?

Answer 50

The peak mitral E-wave velocity divided by the average of the medial and lateral tissue doppler e' velocity (E/e) has been validated as a reliable index for the estimation of mean LAP. LV Filling Pressures (LVFP): The primary goal is to estimate these pressures non-invasively. PCWP: Because PCWP approximates LV diastolic pressure, the E/e′ ratio is often used to predict elevated PCWP. LVEDP: It also correlates moderately with Left Ventricular End-Diastolic Pressure, though the correlation is not perfect

Question 51

What is the biggest difference between restrictive and constrictive physiology out side of just respiratory variation?

Answer 51

A mitral septal E greater than has been shown to be highly accurate in determining constrictive physiology. Restriction is associated with elevated E/A ratio , short decel time and decreased mitral tissue dopplers Constriction is associated with annulus reversus and septal bounce.

Question 52

How is Pulmonary Vein Flow important in Constriction and Restrictive physiology?

Answer 52

The hemodynamic characteristics of constriction show markedly elevated atrial and ventricular pressures and an early diastolic “dip-and-plateau” pattern (42). The respiratory variation of the Doppler flow velocities has been reported in the differentiation between constriction and restriction (7,43,44). In restrictive cardiomyopathy, PVF shows blunting of the S2 velocity and decreased S2/D ratio throughout the respiratory cycle (Fig. 3A). In contrast, marked respiratory change in PVF was observed in constrictive pericarditis (Fig. 3B). The S2 and D velocities increased, especially the D velocity, during expiration, and decreased during inspiration. This is explained by incomplete transmission of the inspiratory fall of intrathoracic pressure to the LA (44). Those changes were more prominent compared with changes in mitral inflow velocities (44). The combination of the S2/D ratio >0.65 in inspiration and a respiratory variation of D velocity >40% correctly classified 86% of patients with constrictive pericarditis (43). Similar respiratory variation can also be observed even in patients with constrictive pericarditis and atrial fibrillation (AF) regardless of the irregular cycle lengths (45)(Fig. 3C).

Question 53

What is Pulmonary Vein AR and what is it indicative of?

Answer 53

Pulmonary vein (PV) atrial reversal (AR) velocity and duration are crucial Doppler echocardiography measures for assessing left atrial pressure (LAP) and left ventricular (LV) diastolic function, Increased AR velocity (typically > 35 cm/s) and a prolonged AR duration (especially when significantly longer than the transmitral A-wave duration, often > 30ms difference) indicating elevated LV filling pressures and diastolic dysfunction, helping diagnose conditions like heart failure

Question 54

Why is there an increase in Pulmonary Vein AR (Atrial Reversal) velocity in the setting of impaired LV relaxation?

Answer 54

Impaired left ventricular (LV) relaxation causes slower early filling, leading to higher left atrial (LA) pressure and volume, which, during atrial contraction (Ar wave), pushes more blood backward into the pulmonary veins, increasing the peak Ar velocity and duration, creating a prominent "V" wave or atrial reversal. This backward flow helps the stiff LV fill, reflecting increased LA pressure and LA compensation for poor LV relaxation, often seen as a hallmark of diastolic dysfunction.

Question 55

Why is there a shortened Pulmonic valve acceleration time in the setting of a PE?

Answer 55

This measurement is a key component of the echocardiographic "60/60 sign," which indicates acute pulmonary hypertension. The mechanism is driven by the following factors: Increased Afterload and Resistance: The blood clot mechanically obstructs pulmonary arteries, causing a rapid rise in resistance to blood flow. Rapid Peak Velocity: Because the pulmonary artery is suddenly obstructed and stiffer, the blood ejected by the right ventricle reaches its peak velocity much faster than normal (normal PAT is >100-120 msec). Early Systolic Notching: The increased pressure and resistance cause reflected waves from the pulmonary vasculature to return early, appearing as a notch in the Doppler waveform during the first half of systole. RV Strain: The right ventricle cannot immediately adapt to this high pressure, leading to "right heart strain," where the ventricle struggles to push blood against the obstruction.

Question 56

What is the E/e cut off for estimation of LV filling pressures in patients with atrial fibrillation?

Answer 56

A septal E/e greater than 11 coorelates well with elevated pulmonary capillary wedge pressures

Question 57

When should diastolic stress testing be ordered?

Answer 57

Diastolic stress testing should be indicated in patients with Grade 1 (mild) diastolic dysfunction

Question 58

What does it mean when you have an LVOT velocity greater than 1.2 in aortic stenosis?

Answer 58

Aortic Stenosis Assessment: If a patient has aortic stenosis, an LVOT velocity > 1.2 m/s (specifically, if VTI is elevated) means that the standard continuity equation for calculating the aortic valve area (AVA) must be corrected to prevent underestimation of the severity

Question 59

How do you correct under estimating the AVA when you have an LVOT velocity above 1.2 m/s?

Answer 59

Simple subtraction: LVOT Mean/Peak - AoV Mean/Peak

Question 60

Which doppler signal is longer, the MR signal or the Aortic Stenosis signal?

Answer 60

The Mitral regurgitation signal is longer because it incorporates both IVCT and IVRT.

Question 61

What occurs when blood rushes back towards a small opening? (PISA)

Answer 61

It forms concentric hemispheric shells of increasing velocity.

Question 62

How do get the SV indexed of a patient who has a BMI of 1.83 and a LVOT SV of 54?

Answer 62

54/1.83=29.5

Question 63

How is the AT/ET ratio useful in determining AS severity in LFLG AS?

Answer 63

. It helps identify severe AS by integrating the structural valve limitation (AT) with the overall systolic function (ET) Based on the 2024 American Society of Echocardiography (ASE) guidelines for the evaluation of prosthetic heart valves, the acceleration time/ejection time (AT/ET) ratio is a key parameter used to identify prosthetic valve obstruction. Abnormal Threshold: A ratio of >0.37 is generally considered abnormal for prosthetic aortic valves. Significance: An AT/ET ratio >0.37 has been reported to have high sensitivity (96%) and specificity (82%) for identifying prosthetic valve stenosis. have shown that an AT/ET ratio >0.34 is a strong argument for severe AS.4

Question 64

How do you calculate the AT/ET ratio ? What is the cuttoff for severe AS in regards to AT/ET ratio?

Answer 64

AT/ET Ratio : Acceleration time / Ejection time Although no single cutoff for AT has emerged, an AT/ET ratio >0.34 has been associated with severe AS.

Question 65

What is the cuttoff for severe AS with Acceleration time? And why does a longer AT indicate severe AS?

Answer 65

An AT greater than 100 indicates severe AS A longer acceleration time (AT) indicates severe aortic stenosis because the severely narrowed valve restricts blood flow, forcing the left ventricle to take longer to generate the pressure needed to achieve maximum ejection velocity, resulting in a delayed, late-peaking, and rounded jet. This delayed, or "tardus-parvus" flow, signifies severe obstruction.

Question 66

What is another factor to look at as evidence of Hemodynamic compromise other than hypotension?

Answer 66

Dilated Right atrium

Question 67

What is Loeffler's endocarditis (LE) and how is characterized on echo?

Answer 67

Apical Obliteration: The most characteristic finding is a dense apical mass or fibrosis, often leading to obliterating the left ventricle (LV) or right ventricle (RV) apex. Loeffler's endocarditis (LE) is a restrictive cardiomyopathy characterized by eosinophilic infiltration leading to endomyocardial fibrosis. Key echocardiography (echo) findings include apical thrombus, endomyocardial thickening, ventricular restriction, and mitral valve regurgitation. It is often diagnosed in the thrombotic phase when apical shadowing or obliteration is present.

Question 68

What coronaries feed the 1. Mid and Basal Inferior Lateral wall. 2 Mid and Basla Anterior Lateral Wall.

Answer 68

1. Mid and Basal Inferior Lateral wall = RCA or CX Inferior = RCA Lateral = CX Inferior Lat = RCA + CX 2. Mid and Basal Anterior Lateral wall = LAD or CX Anterior = LAD Lat = CX Anterior Lat = LAD or CX Apex is ALWAYS LAD (excluding 2 chamber where there is NO LATERAL SEGMENTS ) Lateral ALWAYS = CX Apical Anterior Lat = LAD or CX Apical Inferior Lat= LAD or CX

Question 69

An aortic stenosis murmur is typically best heard at: 1. Apex or 5th intercostal space 2.Left 2nd intercostal space 3.Left 4th Intercostal space 4. Right 2nd intercostal space

Answer 69

4. The aortic stenosis murmur is typically a harsh, crescendo-decrescendo systolic ejection murmur heard loudest at the right upper sternal border (second intercostal space), often referred to as the aortic area.

Question 70

What is the most common finding in a patient with Williams Syndrome?

Answer 70

Supravalvular aortic stenosis (SVAS) is a, or in some cases the, primary, cardiovascular complication in Williams syndrome (WS), affecting roughly 45% to 75% of patients. It is a narrowing of the aorta just above the aortic valve caused by elastin gene deficiency, often requiring surgical intervention in 20-30% of cases.

Question 71

What are the severities for RVol for both MR AND AI?

Answer 71

Less than 30 - Mild Greater than 60 - Severe

Question 72

What do you do to the MI when you see swirling in the apex?

Answer 72

MI is set to high. Reduce the MI to reduce the swirling

Question 73

What is the main characteristic seen in Arrythmogenic Righ Ventricular Displasia?

Answer 73

Epsilon Wave on ECG.

Question 74

What is the Venturi effect and when do we see it?

Answer 74

SAM. The Venturi effect occurs as a decrease in pressure when blood travels quickly through a narrowing at a high velocity. This creates a suction effect which pulls the AMVL up towards the LVOT.

Question 75

How do you differ LVOT and MR doppler signals?

Answer 75

MR is holosystolic. It includes both isovolumic periods.

Question 76

What is the formula for MVA via continuity? (Which is the same formula as AVA via continuity; just swap out AoV VTI for MV VTI)

Answer 76

LVOT SV/ MV VTI

Question 77

What does DP/DT actually determine?

Answer 77

The time it takes to generate 32mmHg of pressure during the isovolumic phase. With normal LV function, the ventricle is able to generate 32mmg of pressure during the isovolumic phase very rapidly while in the setting of LV systolic dysfunction, there is a prolongation of the DP/DT and/or prolngation of IVCT.

Question 78

What physiological event occurs when you valsalva?

Answer 78

The goal is to reduce LV volume (decrease preload) as well as decrease resistance to LV flow ( decrease afterload) in order to increase the force of LV contraction.

Question 79

How do you determine Dp/DT?

Answer 79

The DP/DT is performed by measuring the time interval between two arbitrary points on the MR velocity spectrum. (Usually between1 and 3m/s). Using the simplified Bernoulli equation, the velocity at these points can be converted to pressure and , hence, the pressure difference between these points can be determined. For example, the pressure difference between 1 m/s and 3m/s: 1 m/s (4)v2 1x1 = 1 x4 = 4 3 m/s. (4)v2 3x3 = 9 x 4 = 36 36-4 = 32mmHg dp/dt = 32 / (the time interval between 1m/s and 3m/s)

Question 80

What are the cutoffs for MPI for both conventional and TDI?

Answer 80

Conventional - Normal is less than or equal to .4 TDI- Less than or equal to .55

Question 81

What is the best way to remember Carpentier's Functional Classification of Mitral Regurgitation (Secondary)

Answer 81

Type 1 - Normal Leaflet Motion - prolapse - leaflet perforation - Cleft valve Type 2 - Increased Leaflet Motion - Flail - Chordal/Pap elongation or rupture Type 3 - Restricted Leaflet Motion - Leaflet tethering - Leaflet thickening -Papillary muscle displacement

Question 82

Deep ECG T wave inversion indicates which cardiomyopathy?

Answer 82

Apical hypertrophic CMY or ischemia

Question 83

Which condition causes inflammation of the endocardium that results in a thick endocardial layer that thrombus then forms on top of?

Answer 83

Hypereosinophilic syndrome (Loefflers endocarditis)

Question 84

Is Hypereosinophilic Syndrome considered a restrictive cardiomyopthy? And what type of cardiopmyopathy is it?

Answer 84

Yes, HES is considered a restrictive CMY. The type: Endomyocardial

Question 85

What should MI be set at for evaluation on non-compaction with an ultrasound enhancing agent?

Answer 85

HIGH MI >3

Question 86

Low voltage ECG, and LVH on echo but not on ECG suggests which condition?

Answer 86

Amyloid. Electrical signal is dampened by amyloid infiltration. Additionaly, the voltage does NOT match the wall thickness

Question 87

What is RIMP? Whats the formula & the normal values?

Answer 87

RIMP = right ventricular index of myocardial performance; tells us the relationship between ejection and non ejection time of the heart RIMP = (TVCOt-ETpv)/ETpv where TVCOt = TV close to open time Normal RIMP <0.4

Question 88

What affect does valsalva have on preload & afterload?

Answer 88

the Valsalva maneuver decreases preload and decreases afterload; this increases the force of contraction. it will increase HOCM gradients.

Question 89

Whats the equation to calculate a HOCM gradient if given an MR peak velocity of 8.14? Blood pressure is 145/93.

Answer 89

After one correctly identifies that the CW Doppler signal in this case is the MR signal, the LV-LA gradient is calculated to be 265 mm Hg (4V2). LV-LA gradient = 265 The left ventricular systolic pressure (LVSP) is then estimated by the formula LV-LA gradient + estimated LA pressure (assumed to be 10-15 mm Hg), which calculates to 275 mm Hg (265 + 10 mm Hg). LVSP = 275 The LVOT gradient is then estimated by the formula: LVSP – systolic BP, which reveals the correct answer choice of 130 mm Hg (275 – 145 mm Hg).

Question 90

Whats the guideline for diagnosis LV mechanical dysnchrony? Which cardiomyopathy presents with this? Whats the treatment?

Answer 90

LV dysnchrony can be measured with M mode thru the PSAX and the time between the septal systolic peak to lateral wall systolic peak can be measured. Can also be measured as time to peak velocity in the RVOT compared to the LVOT >130 msec = LV dysynchrony occurs with DCM Treatment = Biventricular pacemaker (CRT)

Question 91

Decreased E to F slope, and diastolic dysfunction with a high E/e' is seen with which cardiomyopathy?

Answer 91

HCM

Question 92

Normal Heart Transplant Echo findings?

Answer 92

-tachycardia (nerve endings are cut with donation procedure, this eliminates the parasympathetic response that lowers heart rate) -bi atrial enlargement & suture lines -decreased RV function (RV is more prone to trauma from transplant procedure)

Question 92

Echo criteria for diagnosis on noncompaction

Answer 92

echo criteria is to measure the noncompacted/compacted myocardium at end systole, >2 = noncompaction

Question 93

Most common benign adult tumor? Malignant adult tumor?

Answer 93

Benign = myxoma Malignant = angiosarcoma

Question 94

Where is angiosarcoma most commonly seen in the heart?

Answer 94

Rigth side of heart

Question 95

What is Virchow's Triad and what does it incicate?

Answer 95

Virchow's Triad = blood stasis, vessel wall injury, hypercoagulability -tells us that thrombus formation is likely *think V = DVT

Question 96

Which tumors, benign or malignant, are more likely to be mobile?

Answer 96

Benign tumors are more freely mobile (think pedunculated myxoma), malignant tumors are fixed to adjacent structures (think pericardial tumor)

Question 97

What type of LV thrombus has the highest risk of embolization?

Answer 97

pedunculated & mobile. Laminated thrombus is a low risk for embolization

Question 98

Systemic lupus is an autoimmune disease where non bacterial endocarditis can occur. What is this called?

Answer 98

Libman Sack endocarditis. Blood cultures will be negative since this is a nonbacterial thrombotic endocarditis

Question 99

3 main contraindications for stress testing?

Answer 99

1 - unstable acute coronary syndrome, current or very recent MI (48 hours) 2 - cardiac arrhythmias (v tach, 3rd degree heart block) 3 - severe hypertension (SBP >180 at rest)

Question 100

What diastolic parameter post exercise suggests ischemia?

Answer 100

E/e' >16

Question 101

List the ischemic cascade

Answer 101

Perfusion abnormality, abnormal relaxation (diastolic dysfunction), systolic dysfunction (RWMA), ECG changes, Symptoms (Angina)

Question 102

Which part of the cardiac cycle will be prolonged with systolic dysfunction?

Answer 102

IVCT. both systolic & diastolic dysfunction will result in prolonged IVRT

Question 103

How do you calculate dP/dT? Whats the normal value?

Answer 103

Find the change in pressure between MR @ 1 sec and MR @ 3 seconds (use 4v2, 1 sec = 4 mmHg, 3 sec = 36, find the difference = 32 mmHg), divide this change in pressure over the time given to you to find the dP/dT -normal >1200 mmHg/sec

Question 104

Where in the LV is free wall rupture most common? How quickly is this most often seen post MI?

Answer 104

the lateral wall is the most common location of free wall rupture; typically occurs between 5 days and 2 weeks post MI

Question 105

Which papillary muscle is most likely to rupture? Which coronary artery & wall causes this?

Answer 105

the Posteromedial papillary muscle is most likely to rupture because the underlying wall its attached to is supplied by a single coronary artery; Occurs with inferior MI, RCA stenosis

Question 106

A new holosystolic murmur is heard, Spectral doppler of MR demonstrates low velocity flow and a "V cut off sign" meaning there is marked elevation in LA pressure. What do you suspect?

Answer 106

Papillary muscle rupture

Question 107

True or False: with an RV MI the RV apex still functions normally.

Answer 107

True. the apex of the RV (and LV) is supplied by the LAD; so even with RCA occlusion and RV MI the apex is typically normal or hyperdynamic

Question 108

which coronary artery lies in the AV groove between the LA & LV?

Answer 108

circumflex

Question 109

what does 'pleuritic chest pain' mean and what condition does it indicate?

Answer 109

means chest pain with inspiration. Indicates pericarditis (or pulmonary embolism) -cases with non-pleuritic chest pain are more likely MI

Question 110

Where is a ventricular septal rupture most likely to occur with an anterior MI? With an inferior MI?

Answer 110

Anterior MI = Apical septal rupture Inferior MI = Basal septal rupture

Question 111

What are some stress echo endpoints?

Answer 111

Achieving >90% or 85% target heart rate -severe symptoms (angina, near syncope) -significant hyper or hypotension (SBP drop of 10 mmHg) -significant ECG changes (ST changes >2 mm -ventricular arrhythmias (Vtach, SVT)

Question 112

Leads & MI location: Leads II, III & AVF= Leads I & AVL = Leads V1-V6 =

Answer 112

Leads II, III & AVF= inferior wall = RCA Leads I & AVL = lateral wall = circumflex Leads V1-V6 = anterior wall = LAD

Question 113

What are the minimum target heart rates for exercise and dobutamine stress tests? What does it do to the stress test if these minimum heart rates arent achieved?

Answer 113

exercise = 80% MPHR (220-age x.8) dob = 85% MPHR (220-agex.85) - not achieving the minimum target heart rate reduces the sensitivity of the test for detecting ischemia

Question 114

What conditions can cause a false positive stress echo result? False negative?

Answer 114

False + = LBBB, interpreter bias, hypertensive response False - = circumflex disease, failure to achieve max (or minimum) heart rates/work load for test

Question 115

What echo parameter tells you that there's elevated filling pressures with exercise?

Answer 115

E/e' ratio -with abnormal myocardium with exercise, E goes up but e' stays the same so the E/e' ratio increases indicated elevated filling pressures (diastolic dysfunction)

Question 116

Whats the cut off for severe MS with exercise & dobutamine? Which measurement do we use to assess MS with stress?

Answer 116

MG >15 mmHg with exercise, >18 mmHg with Dob PASP >60 mmHg -only look at mean gradient. Not quantified with MVA or PHT with stress

Question 117

Why do we not do stress testing for to look for worsening AI?

Answer 117

with exercise diastole shortens, which is when AI occurs so AI will actually look less severe with exercise -we can do stress testing in patients with severe AI to reveal symptoms if they are reporting they are asymptomatic, or in patients who are symptomatic but AI is not severe to look for other causes of symptoms (diastolic dysfunction, PHTN, dynamic MR)

Question 118

Which type of stress test is best for evaluating each parameter (exec or dob) 1. Diastology 2.MR with symptoms 3. LFLG AS 4. inotropic reserve in DCM 5. LVOT obstruction with HCM

Answer 118

1. Diastology: Exec 2.MR with symptoms: Exec 3. LFLG AS: Dob 4. inotropic reserve in DCM: Dob 5. LVOT obstruction with HCM: Exec

Question 119

whats value for TR vmax indicates a diagnosis of stress induced PHTN?

Answer 119

TR Vmax >3.1 m/sec = exercise PHTN

Question 120

What LVOT gradient with obstruction that indicates intervention? -what patient position can increase this gradient? -when doing a stress test for LVOT obstruction should these patients hold their beta blocker?

Answer 120

LVOT gradient > or equal to 50 mmHg. If a patient has a resting gradient of 50, you should not have them valsalva as this is the threshold for severe, symtomatic obstruction. -standing position after exercise can decrease preload & create a higher gradient -do not stop beta blockers on these patients for stress testing

Question 121

What is contractile reserve? How do we evaluate it and what does it tell us? What affect does CR have on the patients perioperative mortality rate?

Answer 121

contractile reserve is the difference between the myocardial contractility at rest compared to stress. CR tells us the max amount that cardiac output can increase. We evaluate CR with dobutamine stress test and measure stroke volume increase. -Normal SV increase with stress is > 20% -the lower the CR, the higher the patient's mortality rate

Question 122

What is the most common factor to differenciate HCM from Athletes Heart?

Answer 122

HCM will have low annular tissue dopplers and exibit diastolic dysfunction. Athletes will have normal or super normal diastolic dysfunction with preserved mitral annular tissue doppler.

Question 122

What is commonly noted in patients with Apical HCM?

Answer 122

Pouching which is why there is a lobster claw effect

Question 122

What is post prandial exacerbation and how does it effect HOCM patients?

Answer 122

The postprandial (post-meal) effect in Hypertrophic Cardiomyopathy (HOCM) occurs because eating triggers vasodilation (widening of blood vessels) in the digestive system, which lowers blood pressure (afterload) and increases heart rate, leading to a significant increase in left ventricular outflow tract (LVOT) obstruction and symptomatic worsenings

Question 123

What is a large atrial reversal in the Pulmonary veins indicative of?

Answer 123

Increased LV end diastolic pressures or increased LVEDP

Question 124

What is an absolute contraindication for TEE

Answer 124

Esophageal diverticulum

Question 125

Are Myxomas typically attatched by a stalk to the intratrial septum? yes or no?

Answer 125

yes. The most common benign tumor of the heart. Surgery is the preferred method of treatment

Question 126

What angle is for bi-com in TEE? What leaflets do you see?

Answer 126

60 degrees left to right= P3 - A2 - P1

Question 127

What degree do we use to visualize the apical 4 chamber in TEE?

Answer 127

0 degress

Question 128

How do you adjust from 0 to 180 degrees on TEE probe?

Answer 128

Side buttons

Question 129

In a TEE, which coronary cusp is seen adjacent to the IAS?

Answer 129

Non coronary cusp The right cc is adjecent to the RVOT The left cc is adjacent to the LA

Question 130

What condition presents with: -EF <40% -RWMA that doesnt go with coronary territories -lateral wall akinesis = "smile" strain pattern

Answer 130

sarcoid

Question 131

What are these myocardial responses to dobutamine? 1. Monophasic 2. Nonphasic 3. Biphasic 4. Ischemic

Answer 131

1. Monophasic: normal response to Dob; LV contractility increases and LV cavity size decreases 2. Nonphasic: no change in LV contractility with Dob; indicates scarred non-viable myocardium 3. Biphasic: increased contractility at low dose, then decreases at peak dose; indicates viable myocardium that will benefit from reperfusion 4. Ischemic: decrease in LV Fx with Dob

Question 132

What does it mean about the RCA if the RV appears to have normal contractility by there is RWMA in the inferior wall of the LV and basal inferoseptum?

Answer 132

The RV branch comes off the RVA first so the blockage must be mid RCA and thats why its only causes ischemia to the LV wall segments fed by the RCA

Question 133

What is the MVA cutoff which makes a mitral valve amendable for MTEER procedure?

Answer 133

Greater than 4

Question 134

What is the most ideal placement for mitral clip?

Answer 134

A2/P2

Question 135

How do you measure post TAVR LVOT? Inner to inner or outer to outer?

Answer 135

outer to outer

Question 136

Which imaging modality offers the largest and most reproducible left ventricular volumes?

Answer 136

CMR

Question 137

Can a stroke indication be a trigger for stress induced cmy? y or no?

Answer 137

Yes. Central nervous system (CNS) disorders like stroke are well-recognized triggers for stress-induced cardiomyopathy (Takotsubo syndrome), often termed "neurogenic stunned myocardium" when caused by brain injury. Takotsubo is one of the cardiac abnormalities most frequently induced by CNS disorders. Appropriate management of TTS from CNS disorders is essential to improve the outcome of affected patients.

Question 138

What is the formula for GLS?

Answer 138

End systolic length - End Diastolic Length / End diastolic length x 100

Question 139

What is highly considered the gold standard for assessing EROA?

Answer 139

CMR It is considered a gold standard for quantifying valvular regurgitation (MR/AR) severity by measuring flow and, and it is particularly useful for assessing left ventricular remodeling. Cardiovascular Magnetic Resonance (CMR) is an accepted, accurate, and highly reproducible choice to assess Effective Regurgitant Orifice Area (EROA) and Regurgitant Volume ( ), especially when echocardiography is inconclusive

Question 140

What is the difference between MTEER and Alfieri stitch?

Answer 140

The Alfieri stitch (surgical edge-to-edge repair) and Transcatheter Edge-to-Edge Repair (M-TEER, e.g., MitraClip) both treat mitral regurgitation by creating a double-orifice valve, but differ significantly in invasiveness and patient selection. The Alfieri stitch is an open-heart technique, while TEER is a less invasive, percutaneous procedure often used for higher-risk patients.

Question 141

is persistent left svc indicative of an asd?

Answer 141

Yes, a Persistent Left Superior Vena Cava (PLSVC) is often associated with congenital heart diseases, including atrial septal defects (ASDs), particularly the sinus venosus type. While PLSVC is often benign, it is frequently found alongside cardiac anomalies like ASDs, ventricular septal defects (VSDs), or coarctation of the aorta.

Question 142

What is metabolic syndrome?

Answer 142

Metabolic syndrome is a group of conditions that increase the risk of heart disease, stroke and type 2 diabetes. a cluster of conditions—specifically high blood pressure, high blood sugar, excess waist fat, high triglycerides, and low HDL cholesterol—that occur together, significantly increasing the risk of type 2 diabetes, heart disease, and stroke. It is closely linked to insulin resistance and obesity

Question 143

A qp/qs of less than 1 indicates which direction of the shunt?

Answer 143

right to left Greater than 1 is left to right

Question 144

What is more likely to cause Dyspnea or shortness of breath? Severe MR or TR?

Answer 144

Severe mitral regurgitation (MR) is generally a more direct and common cause of severe dyspnea (shortness of breath) than severe tricuspid regurgitation (TR) because it directly causes blood to back up into the pulmonary veins and lungs. While both can cause breathlessness, the pathophysiology differs: Phoenix Heart Phoenix Heart +4 Severe Mitral Regurgitation (MR): Leads to left atrial enlargement and increased pressure, which causes pulmonary venous congestion (fluid in the lungs). This presents with progressive or acute dyspnea, particularly with exertion or when lying flat (orthopnea). Severe Tricuspid Regurgitation (TR): Primarily causes right-sided heart failure symptoms, such as abdominal swelling, ankle edema, and neck vein distension. While it causes exertional fatigue and some dyspnea due to reduced cardiac output, it does not cause pulmonary congestion in the same way as left-sided failures

Question 145

Which mitral valve leaflets are visualized in the long axis tte or tee?

Answer 145

A2 P2

Question 146

What mitral valve leaflets are viewed in the bi com view TEE?

Answer 146

P1 - A2 - P3

Question 147

How can you use M mode to assess for acute pericarditis?

Answer 147

Use of M-mode to identify temporal changes in septum and ventricular filling: M-mode is essential to identify the "septal bounce" or abnormal septal motion in early diastole, which is a key indicator of ventricular interdependence and pericardial constriction.

Question 148

Which prosthetic valve frequently uses CT imaging prior to the procedure?

Answer 148

TAVR