1. Adult Echocardiography Review
Harry H. Holdorf PhD, MPA, RDMS (Ab, OB, BR), RVT, LRT(AS)

2. Which valve separates the areas of greatest pressure differences?
Mitral valve

3. Know the anatomical locations of the following:
Superior Vena Cava
Aorta
Pulmonary Artery
Left Anterior Descending Coronary artery and vein
Great cardiac Vein
LAD lies in the anterior interventricular groove or SULCUS

4. Which aortic leaflet is the superior one in the parasternal long axis view?
Right leaflet is superior
Non-coronary is the posterior leaflet

5. From the left parasternal window, which of the following are you most likely to get accurate velocity measurements?
Pulmonary artery

6. Know the basic anatomy by other imaging techniques
MRI study showing the descending aorta (view mimics the LAX)

7. Name the tricuspid leaflets
Posterior and anterior

8. Know that the RV inflow tract view is the only standard view in which you see the posterior tricuspid leaflet
How to visualize the posterior leaflet of the tricuspid valve?
Also, in this view, red inflow at the image bottom would be…the IVC.

9. The inter-atrial septum connects to which aortic valve?
The non-coronary

10. The coronary arteries come off the?
Sinuses of Valsalva

11. It is important to visualize the origin of the coronary arteries because…
Patients, when exerting and dilating the great vessels, can suffer ischemia, angina, or sudden death
Anomalous coronaries

12. During which phase do the coronaries fill?
Early diastole

13. In the super-sternal arch view, what is the structure seen under the arch?
Right pulmonary artery

14. What cardiac pathology is associated with bicuspid aortic valves?
Coarctation of the aorta

15. Where do most aortic coarctations occur?
After the take-off of the left subclavian artery, or within the aortic isthmus.
(The beginning of the descending aorta)

16. On a apical four chamber view: Where are the pulmonary veins located
On a apical four chamber view: Where are the pulmonary veins located? Which ones are seen on this view?
Right and left upper (superior) pulmonary veins

17. Which other view would give you the same information as the parasternal LAX?
Apical LAX

18. Which standard 2D TTE view typically allows viewing of the Left atrial appendage?
Apical 2 chamber

19. Where is the coronary sinus located?
Posterior Atrial ventricular groove
Also, know that the “dot” on the coronary sinus LAX view that is to the right and posterior to the coronary sinus is the descending aorta

20. To visualize the coronary sinus in the apical 4 chamber view, you should tilt the transducer
Posterior

21. Which valve sits at the opening of the coronary sinus?
Thebesian

22. What portion of the pulmonary venous PW Doppler represents atrial systole?
A wave

23. At what temperature is it unsafe to use the TEE probe?
40-45C

24. Know where the LA appendage is by TEE.
To the left of the image, coming of the LA at 3 o’clock and turning down

25. Know the TEE views by esophageal level

26. Regarding cardiac physiology, which has the fastest intrinsic rate?
SA node

27. What is the absolute refractory state?
That period when a muscle cell is not excitable- from phase 1 until into phase 3
The relative refractory period is during phase 3 and the muscle cell might contract if the stimulus is strong

28. Know what P wave, P-R interval, and T wave represents
P wave = atrial systole
P-R interval = includes P-R segment from atrial ventricular depolarization
T wave = ventricular diastole (repolarization)

29. What is the normal duration for the QRS complex
0.10 sec to .12 sec

30. Electrocardiogram 1 small box = 0.04 seconds 1 big box = 0.2 seconds
5 big boxes = 1 second

31. Know Frank-Starling Law
Increased volume (preload) = increased contractility (to a physiologic limit)
Increased myocardial fiber length = increased tension (rubber band theory)

32. Chronic vs. Acute shift in the Frank – Starling graph
Acute AI is hyper contractile because we shift up the Starling curve
Chronic AI is failure when we drop off the end

33. Echo findings for preload vs. afterload
Preload = dilatation
Afterload = hypertrophy

34. Which study does not allow for the calculation of ejection fraction?
Chest x-ray

35. Calculate cardiac output (CO)
Co = SV (stroke volume) x HR (heart rate)
Normal is 4-8 L/min (5 Average)

36. How does switching to a lower frequency transducer affect aliasing?
Aliasing will occur at higher frequencies

37. What does VTI (Velocity time integral) x CSA (Cross sectional area) equal?
Doppler stroke volume

38. Does venous return increase or decrease with inspiration?

39. Inhalation of amyl nitrate causes:
Decreased afterload
Vaso dilator- drops BP
Tachycardia response- increased stroke volume- increase heart rate

40. Mitral valve velocity during inspiration:
Decreases

41. Know Wiggers Diagram Mitral closure Aortic opens Aortic closure
Mitral opens

42. Wiggers: Know isovolumetric timing with ECG:
After R wave – isovolumic contraction
After T wave – isovolumic relaxation
Know the duration of IVRT and IVCT
70 msec
On Wiggers, when is the mitral valve open?
4-1
The duration of isovolumetric relaxation time will be increased with
Bradycardia
Between which heart sounds will the murmur of aortic stenosis be heard?
S1-S2
During the cardiac cycle, this event NEVER happens:
Ao valve is open and mitral valve is open

43. Stuff you gotta know regarding the cardiac cycle
Normal arterial pressure is approx. 120/80. Thus, the aortic pressure lives high
Normal left atrial pressure is approx. 10 mmHg. Thus, the atrial pressure lives low
The left ventricular pressure bounces between aortic and atrial. High and Low
The valve that lives between the atrium and the left ventricle is the mitral valve. The mitral valve lives low.
When a normal valve is open, there is very little pressure difference between the chambers on either side of the valve.

44. What is the normal pressures in the pulmonary artery?
25/10

45. Where is the O2 saturation the lowest in the heart
Coronary sinus

46. O2 saturation…
Pulmonary veins = 95%
Pulmonary arteries = 75%

47. Best cath. Technique for LV function
LV angiogram

48. Know pressure waveforms for Aortic Stenosis Mitral Stenosis Mitral Regurgitation
See next three slides

52. What is PCW (Pulmonary Capillary Wedge) measuring?
Left atrial pressure

53. To determine AS, where are the catheters placed?
One in the LV and one in the Ao or one in the LV and pulled back across the AoV or one catheter with two separate sensors.

54. Technique
Tissue harmonic imaging results in thicker valve leaflets

55. A secondary finding in aortic stenosis is?
Left ventricular hypertrophy

56. In aortic stenosis, is pulse pressure wide or narrow?
Pulse pressure is the difference between systolic and diastolic pressures – it is wide in AI and narrow in AS

57. The best view to diagnosis a bicuspid aortic valve is the parasternal…
Short-axis systole

58. Systemic hypertension…
Is a common symptom of aortic Coarctation

59. What is Takayasu’s arteritis?
Also called aortic arch syndrome: occurs more in young women from Asia. There is fibrosis of the arch and descending Ao of unknown etiology. In advanced states, multiple coarctations may occur (look for supravalvular aortic stenosis)

60. The normal aortic valve areas is?
3-4 cm sq.

61. Patients BP = 110/84 Aortic velocity is 5 m/sec Peak LV pressure in this patient is?
210 mm Hg
Add the Ao gradient (100 mm Hg if the velocity is 5 m/sec) to the systolic BP.

62. Using the continuity equation, when would be severity of Aortic Stenosis be underestimated?
LVOT measured too large

63. Which pressure is obtained during Doppler?
Peak or peak instantaneous
For AS it is the highest gradient anytime during systole

64. Know that echo gradients are usually higher than catheter gradients
Peak instantaneous vs. peak-to-peak

65. Noonan Syndrome
Classified as a cardio-facial syndrome with Pulmonary Stenosis, Hypertrophy Cardiomyopathy, and Atrial Septal Defect (30%)

66. Pulmonary Stenosis…
Does NOT cause pulmonary hypertension

67. Asked if unable to obtain pulmonary stenosis gradient from the parasternal window, where else would you go?
Subcostal short-axis

68. The insertion of mitral chordae tendineae into a single papillary muscle is
Parachute mitral valve

69. Which cardiac valve is the second most common to be affected by rheumatic health disease?
Aortic

70. Longstanding Mitral Stenosis leads to all of the following :
Congestive heart failure Pulmonary hypertension Left atrial dilatation

71. Mitral stenosis = low frequency…
Diastolic Rumble
Opening SNAP

72. Rheumatic Mitral Stenosis…
“Hockey-Stick” presentation

73. With atrial fibrillation, mitral stenosis velocity calculations are best performed…
Averaged over 5-10 beats

74. Regarding Tricuspid Stenosis: Carcinoid vs. Rheumatic…
Carcinoid – fixed body of the leaflets
Rheumatic – tethered leaflet tips

75. Which anomaly goes with aortic dissection?
Marfan syndrome

76. If you have a uniformly dilated aortic root, which best describes this?
fusiform

77. Which is the most common chamber for a sinus of Valsalva aneurysm to rupture into?
Right atrium

78. What kind of murmur would you hear in a patient with a rupture of a sinus of Valsalva aneurysm?
Continuous

79. The classic aortic regurgitation murmur is …
Diastolic “blow”

80. Diastolic Mitral valve from aortic regurgitation is demonstrated by…
M-mode fluttering

81. What causes Mitral valve preclosure?
An elevated LVEDP
Left Ventricular End diastolic pressure

82. Know color Doppler M-mode of aortic insufficiency AKS Aortic Insufficiency

83. Know descending aorta diastolic flow reversal (AKA retrograde)

84. Mild aortic regurgitation
Has an incomplete spectral trace

85. How would you calculate pulmonary artery end diastolic pressure?
Pulmonic insufficiency velocity

86. Systolic flow reversal of bubbles in the IVC Tricuspid Regurgitation or Tamponade?

87. What is the most common valvular abnormality associated with carcinoid syndrome?
Tricuspid regurgitation

88. CVP (central Venous Pressure)
Refers to the IVC pressure close to the Right atrium

89. Hepatic venous flow reversal indicates
Severe tricuspid regurgitation

90. A patient has a right ventricular systolic pressure (RVSP) of 60 mm Hg
A patient has a right ventricular systolic pressure (RVSP) of 60 mm Hg. One year later RVSP is 30 mm Hg. What happened to this patient?
Dilated cardiomyopathy

91. A vena contracta (narrowest part of a color jet) might be seen in which type of cardiomyopathy?
Dilated

92. Coanda Effect Happens with wall hugging jets.
May underestimate jet size.

93. If you suspect severe Mitral regurgitation, where else should you look?
Pulmonary veins

94. The greatest source of error in measuring Proximal iso-velocity surface area (PISA) is with
Radius of the flow convergence

95. Which of the following is used in echo to measure dP/dt
Which of the following is used in echo to measure dP/dt? (the rate of rise of Left ventricular pressure)
Mitral regurgitation

96. dP/dt measurement of mitral regurgitation assesses what?
LV systolic function

97. Know pressure waveforms for Mitral regurgitation (late systolic jump in LA pressure

98. Mitral valve prolapse: Know about Marfan disease
Congenital connective tissue disease causing aortic dilatation and mitral valve prolapse (MVP)

99. In Marfan syndrome, why does aortic dissection and MVP occur?
Decreased fibrillin

100. Know Ehlers-Danlos Another connective tissue disease:
Like Marfan patients, you would look for MP, Dilated Ao, and dissection

101. Severe aortic aneurysms are greater than:
5.0 cm

102. MVP
Usually will be shown a 4-chamber image with obvious MVP

103. Regarding Endocarditis Libman-Sachs Marantic endocarditis
Libman-Sachs = endocarditis caused by lupus
Marantic = non-bacterial NBTE

104. Patients with a history of IV drug abuse may present with:
Tricuspid endocarditis

105. Can one tell old vs. new vegitations?

106. In order to be seen by 2-D, vegetations need to be at least
3 mm

107. Know what a ball and cage Mitral Valve looks like

108. Know that St. Jude is a bi-leaflet valve

109. Autographs…
Use patient’s own tissue

110. Regarding prostatic valves:
Acoustic shadowing with mitral valve prosthesis
Know echo appearance of common valves
Know the term Pannus = host tissue overgrowth

111. The normal pressure half-time for a mitral prosthetic valve is
< 170 msec

112. Cardiomyopathies: Which cardiomyopathy is autosomal dominant?
hypertrophic

113. HOCM
Hypertrophic obstructive cardiomyopathy

114. The ratio of assessing asymmetric hypertrophy:
1.3:1

115. The Venturi Effect
Law of conservation of energy means that when the velocity of fluid increased, the pressure decreases.

116. The Venturi Effect can be associated with which cardiomyopathy?
hypertrophic

117. LVOT obstruction causes the aortic valve to
Close in mid systole

118. Mitral inflow shows A wave greater than E
Some degree of diastolic dysfunction, abnormal relaxation

120. Does Inderal (beta Blocker) increase SAM? Systolic Anterior MotionNo
Decreases heart rate
Reduces SAM with exercise

121. A late peaking Doppler jet…
Goes along with:
HOCM: Hypertrophic Obstructive Cardiomyopathy
IHSS: Idiopathic hypertrophic Subaortic Stenosis

122. 61 year old male with IHSS and a resting gradient of 144 mm Hg.
Admitted to the hospital with chest pain.
Next day the resting gradient was 15 mm Hg.
What happened?
Left ventricular infarct

123. Strain: measures the deformation within the myocardium Global Longitudinal Strain in patients with HOCM is typically:
-10

124. Chagas’ disease Posterior and apical thinning of the myocardium
Septum is usually normal

125. Know the Echo signs of congestive cardiomyopathies

126. What is the cause of a B-notch
Increased LVEDP
Left Ventricular End Diastolic Pressure

127. Know post-transplant 2-D appearance Will have double atria

128. Amyloid and sarcoid are what type of cardiac abnormalities?
Infiltrative is via pathology and is the correct answer
Restrictive would be via physiology

129. Hemochromatosis
Excessive iron

130. Amyloidosis involves abnormal proteins.
Some may describe it as a translucent waxy protein build-up on the myofibrils

131. Ground glass appearance: Related to infiltrative myocarditis

132. A restrictive cardiomyopathy has:
Decreased Left Ventricular Compliance

133. A typical ejection fraction in a dilated cardiomyopathy patient might be? (for a HCM patient)
15-25% (pick the lowest range given)

134. The majority of ventricular filling occurs during:
First third of diastole

135. Know the following filling patterns:

136. If a patient has a normal Mitral valve inflow but the pulmonary veins showed a decreased S-Wave and D-Wave…
Consider that they might have a pseudonormal pattern

137. Diastolic Function values
In elderly patients (>60), the A wave is normally equal to or higher than the E-wave

138. Know how the normal Doppler waveform at the mitral annulus differs from flow at the mitral leaflet tips:
E and A are reversed at these two sample sites

139. How would you determine if a patient has constrictive versus restrictive disease?
Mitral valve inflow with respiratory variation with constrictive disease

140. In constrictive pericarditis, does the E wave increase or decrease with inspiration

141. Name the three layers of the pericardium
1. fibrous pericardium –thick outer sack
2. serous parietal-bound to fibrous pericardium smooth, wall of the cavity
3. serous visceral – bound to epicardium smooth, toward the organ
Pericardial fluid is found in between the two serous layers

142. A pericardial effusion can often be seen in patients with:
Renal failure

143. Know the classic M-mode pattern of a pericardial effusion M-mode echocardiogram showing moderate pericardial effusion present anteriorly(PE) and posteriorly(PPE). RVW=right ventricular wall

144. Know the anterior echo free space shown on a 2-D Parasternal LAX
Anterior echo-free space is probably an epi-cardial fat pad

145. Know what a large pericardial effusion looks like (>500 cc)

146. Pericardial Effusion Grading Criteria
Small = posterior fluid < 1 cm
Medium = Anterior & posterior < 1 cm
Large = Surrounding the heart > 1 cm
ALSO: measure spaces in Diastole

147. Identify the coronary sinus vs
Identify the coronary sinus vs. the descending Ao and it’s importance Pleural Effusion

148. Know where the oblique sinus of the pericardium lies:
Posterior to the LA in the PLAX view – area between the two sets of pulmonary veins

149. What to do if tamponade is suspected?
Immediate interpretation

150. Know Beck’s triad A. Elevated venous pressure B. Hypotension
C. Quiet heart
Elevation of venous veins (look at the Internal Jugular Vein in the neck)

151. The most sensitive way to diagnosis cardiac tamponade is:
RV diastolic collapse
RV systolic collapse
M-Mode of the LA wall motion
Respiratory variation

152. What cardiac condition would prevent diastolic right ventricular collapse?
Concentric LVH
High systemic hypertension
Pulmonary hypertension
Tricuspid regurgitation

153. Flow Variation in Tamponade Know how respiration affects the mitral and tricuspid flows in tamponade
Reversal of normal
In Tamponade what happens to hepatic diastolic and systolic flows during expiration?
What happens in a normal patient?

154. What other pericardial abnormality also causes impaired ventricular filling?
Constrictive pericarditis

155. A huge, dilated Pulmonary Artery, severe Tricuspid regurgitation, and Right Ventricular enlargement best describes…
Pulmonary hypertension

156. Know Eisenmenger Syndrome
Eisenmenger's syndrome is defined as obstructive pulmonary vascular disease that develops as a consequence of a large pre-existing left-to-right shunt causing pulmonary artery pressures to increase and approach systemic levels, such that the direction of blood flow then becomes bi- directional or right-to-left.

157. What is represented with a decreased “a” wave and a flying W
What is represented with a decreased “a” wave and a flying W? Pulmonary hypertension by M-mode

158. With small pulmonary emboli, the heart may be normal.
With large pulmonary emboli, the Right ventricle/right atria will dilate.
Pulmonary hypertension or Right ventricular systolic dysfunction may be present
SAX LV in PHTN stays flattened, while RV volume overload rounds some in systole.

159. Given tricuspid regurgitation with 60 mm Hg gradient, grade the severity of pulmonary hypertension
Severe

160. Pulmonary artery pressure
Normal = 18 – 30 mm Hg
Mild = mm Hg
Moderate = mm Hg
Severe = >70 mm Hg

161. Your patient has PHTN with a dilated IVC (3cm) which collapsed 50% with sniff. Estimate the RA pressure.
15 mm Hg
Hint: IVC= anything over 2 is dilated

162. The size of aneurysms during systole…
Increases

163. The most common (mechanical) complication of an MI…
Aneurysm formation

164. Dressler syndrome
Post MI Peri-Carditis

165. What type of MI causes papillary muscle rupture?
Inferior MI

166. Which of the following occurs first in the setting of severe mitral regurgitation due to a flail leaflet?
Dilated right ventricle

167. Know true vs. pseudo aneurysm
Wide base
Walls composed of myocardium
Low risk of free rupture
Pseudo
Narrow base
Walls composed of thrombus and pericardium
HIGH RISK OF FREE RUPTURE

168. The most common location for Pseudoaneurysm:
Inferior basal, NOT apical

169. Does the wall of a Pseudoaneurysm contain endocardium?No
It’s a rupture across both endo and myocardium

170. What information do you need pre-op in a patient with a LV aneurysm?
Movement of other walls

171. Color Doppler in ischemic disease can be good for?
Ventricular septal defect, because you can use PW & CW Doppler for detecting MR

172. What do you look for in a patient with Kawasaki disease?
Coronary artery aneurysms

173. What term refers to a decrease in wall motion?
hypokinesis

174. Akinesis Dyskinesis Akinesis = no motion and no thickening of walls
Dyskinesis = Left bundle block branch

175. What is the IVS motion in a patient with LBBB?
Dyskinetic or paradoxical

176. From where do the coronaries originate?
In the left and right aortic sinus of Valsalva

177. What is meant by “right Dominance”?
When the right coronary gives rise to the posterior descending artery (85% of the time).

178. Which coronary supplies the inter-atrial septum?
Right (also usually supplies the SA and AV nodes)

179. Which coronary artery feeds the infero-septal wall?
Right coronary artery

180. Know the indications for stress echo…
To aid in the diagnosis of chest pain
To determine the severity and prognosis of coronary artery disease
To guide post MI rehab
To evaluate cardiac arrhythmias
To screen high risk or asymptomatic patients with multiple risk factors

181. Know that in multi-vessel disease, stress echo is better than…
Nuclear stress scans
Single vessel disease: Nuclear medicine is better
Multiple vessel disease: Echo stress is better

182. Normal response to stress includes all of the following:
Hyper-dynamic walls
Systolic thickening
Decreased systolic cavity
Normal diastolic dimensions

183. What would be a contraindication to perform a stress test on an athlete with chest pain?
Unstable angina

184. Pharmacological Stress Echo:
Know that Atropine may be given at peak does if the target hart rate is not reached.

185. When the 2-D image appears to have three atria, it might mean that the patient has a Cor Triatium
This is a congenital malformation where there is a membrane above the level of the mitral valve. In severe cases, there is supravalvular stenosis.

186. What is the most common type of Atrial Septal Defect?
Secundum (70%)
mid-septal area

187. Partial anomalous pulmonary venous return is seen with what type of ASD?
Sinus venosus
Superior septal area- associated with anomalous pulmonary venous return (80%)

188. Which is the best view to diagnosis a sinus venosus ASD?
Modified subcostal four chamber view

189. Best view to demonstrate an ASD?
Subcostal 4-chamber

190. If you see anechoic dropout of the interatrial septum in the apical 4 chamber view, what should you do?
Look in the subcostal 4-chamber view

191. What is the standard echo view for contrast studies of an ASD?
Apical 4-chamber

192. How many beats to see contrast on the left side in a patient with an ASD? With a pulmonary shunt?
1-2 beats for an ASD
3-5 beats for pulmonary shunt

193. Persistent Left Vena Cava has a dilated coronary sinus
Most common venous malformation

194. Where should contrast be injected in order to diagnosis a persistent left superior vena cava?
Left arm

195. Know endo-cardiac cushion defect (AV septal)…
Are associated with Down Syndrome or trisomy 21

196. Which is the most common type of VSD?
Peri-membranous

197. Know Supra-cristal location
High near the aortic and pulmonary valves

198. Know inlet location
Subvalvular low near the mitral and tricuspid valves

199. The typical murmur of a ventricular septal defect.
It is usually best heard over the “tricuspid area”, or the lower left sternal border, with radiation to the right lower sternal border because this is the area which overlies the defect. It is characteristically a holosystolic murmur because the pressure difference between the ventricles is generated almost instantly at the onset of systole, with a left to right shunt continuing throughout ventricular contraction. If the defect persists without treatment, irreversible pulmonary hypertension may develop with reversal of the shunt into a right to left flow pattern (Eisenmenger syndrome). There is usually no diastolic component to the murmur, as the pressure between the ventricles during diastole is not sufficiently different to generate an audible flow.
     Because the flow pattern is usually left to right, the right ventricle suffers from volume overload and takes longer to eject the stroke volume. This causes a slight delay in the closing of the pulmonary valve, and a widely split S2 may result.

200. What congenital abnormality has a displaced Tricuspid Valve?
Ebstein’s

201. What is Wolff-Parkinson-White Syndrome?
Wolff–Parkinson–White syndrome (WPW) is one of several disorders of the conduction system of the heart that are commonly referred to as pre- excitation syndromes. WPW is caused by the presence of an abnormal accessory electrical conduction pathway between the atria and the ventricles. Electrical signals traveling down this abnormal pathway (known as the bundle of Kent) may stimulate the ventricles to contract prematurely, resulting in a unique type of supra-ventricular tachycardia referred to as an atrioventricular reciprocating tachycardia.

202. If a large PDA (patent ductus arteriosus) is not corrected, what might develop?
Eisenmenger Syndrome

203. All are Tetralogy of Fallot defects
Large VSD
Pulmonary stenosis
Right ventricular hypertrophy

204. Regarding missiles: For foreign bodies: use x-rays for reference.
Use off-axis views

205. What part of the heart is most likely to be affected by cardiac contusion
Right ventricle

206. Regarding Masses: What might be the 1st indication of metastatic cardiac disease?
Pericardial effusion

207. Which cardiac chamber is most likely involved with metastatic tumors?
Right atrium

208. The most common benign tumor on the aortic valve is:
Papillary fibroelastoma

209. Left atrial myxomas are usually located…
Interatrial septum