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Echo Board Questions List

Question #1

The following M-mode is the result of which of the following?


A. Bicuspid aortic valve

B. Aortic stenosis

C. Aortic Regurgitation

D. Mechanical Aortic Valve

E. Left ventricular assist device

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Answer #1

The correct answer is E, left ventricular assist device. The M-mode through the aortic valve reveals that the aortic valve remains closed throughout the cardiac cycle, i.e. there is no ejection though the aorta. This can only take place in the presence of cardiopulmonary bypass or a left ventricular assist device, which totally unload the left ventricle. A bicuspid aortic valve would show opening of the aortic valve with an asymmetric coaptation point. Aortic stenosis would cause thickened and calcified aortic valve leaflets with decreased excursion. Aortic regurgitation is difficult to diagnose on M-mode of the aortic valve but one can see a causal vegetation and possibly prolapse of one of the leaflets. A mechanical valve has stereotypic appearance with echo-reflective leaflets and abrupt opening/closing.

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Question #2

Which of the following is associated with the condition show in the video below?


A. primum ASD

B. secundum ASD

C. Dilated cardiomyopathy

D. rheumatic heart disease


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Answer #2

The correct answer is A: primum ASD. The video shows a cleft mitral valve. The anterior leaflet in the picture actually as two separate components. A cleft mitral valve is a congenital disorder that is part of the complex of an atrioventricular canal defect which also involves a septum primum ASD. None of the other conditions are associated with a cleft mitral valve.

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Question #3

A 65 year old woman is post-op day two after aortic valve replacement for aortic stenosis. A preoperative cardiac catheterization showed a severely elevated LVEDP and she has been treated with IV diuretics. Over the course of several hours, she has progressive hypotension, and urine output decreases. An echocardiogram is obtained and the following representative M-mode image is shown. What is the appropriate next step in management?


A. IV dobutamine

B. IV furosemide and metolazone

C. Return to the OR for exploration

D. Transesophageal echocardiogram

E. IV Fluid Bolus



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Answer #3

The correct answer is E, IV fluid bolus. The M-mode reveals severe systolic anterior motion of the mitral valve causing LV outflow tract obstruction. This is not a primary hypertrophic cardiomyopathy per se, but is a common scenario in patients post-op from cardiac surgery who have some degree of LVH and hyperdynamic LV function on inotropes post-op. IV fluids will increase LV preload, increase LV cavity size and decrease the degree of obstruction. IV dobutamine would make the situation worse by increasing LV contractility and lowering systemic afterload. Similarly, IV diuretics would worsen preload and could increase the degree of obstruction. There is no indication from the M-mode of a significant pericardial effusion such that a transesophageal echocardiogram or return to the OR is warranted.

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Question #4

Which of the following is associated with the M-mode profile illustrated in the figure below?


A. Mitral stenosis

B. Aortic stenosis

C. Left ventricular outflow tract obstruction

D. Aortic regurgitation

E. Mitral valve vegetation

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Answer #4

The correct answer is D, Aortic regurgitation. The M-mode illustrates fluttering or vibration of the mitral valve leaflets. This occurs in diastole when the jet of aortic regurgitation hits the anterior leaflet of the mitral valve. Note that fluttering of the mitral leaflets is not correlated with severity of aortic regurgitation. However, early MV closure is suggestive of severe aortic regurgitation. Mitral stenosis is accompanied by left atrial enlargement, thickened mitral valve leaflets and a reduced E-F slope. Left ventricular outflow tract obstruction would have mid systolic closure of the aortic valve due to obstruction in the LVOT. A mitral valve vegetation would be a mobile mass on the mitral leaflets and may appear in the mitral valve orifice, moving in random fashion.

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Question #5

The following spectral Doppler profile was obtained in a patient with dyspnea. Identify the structure through which the Doppler flow profile was obtained and the associated pathophysiology


A. Mitral valve. Mitral stenosis and mitral regurgitation.

B. Aortic valve. Aortic stenosis and aortic regurgitation.

C. Tricuspid Valve. Tricuspid stenosis and tricuspid regurgitation

D. Pulmonic Valve. Pulmonic stenosis and pulmonic regurgitation.

E. Mixed aortic stenosis and mitral regurgitation..

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Answer #5

The correct answer is D, pulmonic valve, pulmonic stenosis and pulmonic regurgitation. The spectral Doppler profile demonstrates high velocity flow away from the probe in systole and lower velocity flow towards the probe in diastole. The systolic flow is not holosystolic but rather is a later peaking ejection jet, suggestive of aortic stenosis or pulmonic stenosis. Thus choices A, C and E are incorrect as a regurgitant atrioventricular valve typically has a holosystolic jet on spectral Doppler and does not peak in mid or late systole. We are then left to differentiate between aortic stenosis/regurgitation and pulmonic stenosis/regurgitation. The key here lies in the diastolic flow. The 3.5 m/s jet in systole could signify moderate aortic stenosis or severe pulmonic stenosis. However, the velocity at end diastole is only 1.5 m/s equating to a pressure gradient of 9 mm Hg between the PA/RV or AO/LV at end diastole. Unless there is severe AI, this gradient is too low to be between the aorta and LV, otherwise aortic diastolic pressure would be similar to LVEDP which is unlikely. Thus, the correct answer is pulmonic stenosis/regurgitation.

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Question #6

Which of the following is true regarding the lesion shown in the TEE image below?


A. The lesion is usually associated with severe aortic regurgitation

B. The lesion is most commonly seen on the mitral or aortic valve

C. The lesion almost always requires surgical therapy

D. The lesion is the most common primary cardiac tumor

E. The lesion is can be effectively treated with anticoagulation

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A6

The correct answer is B, the lesion is most commonly seen on the mitral or aortic valve. The lesion shown in the TEE aortic long axis image has the classic appearance of a papillary fibroelastoma. Papillary fibroelastomas are the second most common primary cardiac tumor, the most common being myxoma. They are the most common tumors seen on cardiac valves. There are seen much more frequently on left sided valves. Papillary fibroelastomas are generally not associated with severe valvular regurgitation. Many are small and discovered incidentally. Not all will require surgery. Though some have suggested anticoagulation in patients with suspected papillary fibroelastomas to prevent thrombus formation and embolism, the only effective therapy for large lesions is surgical resection

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Q7

Which of the following is illustrated in the M-mode figure below?


A. Tricuspid regurgitation

B. Ebstein's anomaly

C. Pulmonary hypertension

D. Pulmonic stenosis

E. Right bundle branch block

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A7

The correct answer is C, pulmonary hypertension. The M-mode illustrated is through the pulmonic valve and reveals notching of the pulmonic valve leaflet, with a characteristic flying W sign. Also note the absence of an 'A dip in the pulmonic valve tracing. This differentiates the M-mode from pulmonic stenosis in which there is an exaggerated 'A dip. The M-mode is through the pulmonic valve and as such, cannot reveal tricuspid regurgitation or Ebstein's abnormality. There is no characteristic finding on pulmonic valve M-mode in right bundle branch block


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Q8

Which structure is the arrow pointing to in the following picture?

[insert coronary artery picture]

A. The coronary sinus

B. The left anterior descending artery

C. The left circumflex artery

D. The right coronary artery

E. Patent ductus arteriosus

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A8

The answer is C: The left circumflex artery. In this view the left circumflex artery follows this course. The diagram below shows the expected position of the coronary arteries in both the TTE and TEE view. The short axis images are the best views in which to see the coronary arteries

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Q9

Which of the following is suggested by the following M mode?

[Insert color M mode AI]

A. Mitral regurgitation

B. Aortic insufficiency

C. Bicuspid Aortic valve

D. Aortic stenosis

E. Mitral stenosis

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A9

The correct answer is B: aortic insufficiency.

The picture shows a color M mode through the aortic valve in someone with aortic insufficiency. Color M mode is a good modality to assess for timing of regurgitant jets in this view, especially in those with fast heart rates. Here we see an aortic insufficiency jet in diastole. The width of the jet suggests the AI is mild [or moderate]. The mitral valve is not seen in this view and there is nothing to suggest aortic stenosis or a bicuspid aortic valve. There is a nice square box during systole without hindrance to the opening of the valve and the valve coaps in the center of the aortic root plane, which you may not see with a bicuspid valve.

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A10

The answer is D. D. A higher index means better function


The myocardial performance index is calculated as follows:

MPI = ICT + IVRT/SEP. A lower index therefore means better function. The calculation is independent of geometry and combined measures of both systolic and diastolic (relaxation time) function. It can be used to assess both right and left sided function.

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Q10

Which of the following is not true of the myocardial performance index as calculated by echocardiography?


A. It is independent of ventricular shape

B. Can be used for both right and left ventricular assessment

C. It is a combined measure of both systolic and diastolic function

D. A higher index means better function

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Q11

The following CW doppler across the mitral valve was obtained in someone complaining of significant dyspnea. What is the approximate Dp/Dt based on the information given?


A. 1200

B. 1000

C. 800

D. 1500

E. 500

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A11

To calculate the DP/DT using the MR tracing, take the pressure at 3m/s and 1m/s (so 36mmHg-4mmHd) and divide by the time it takes to go across this interval. Normal dp/dt is >1200, borderline is 1000 mmHg to 1200 and abnormal is less than 1000. do 36-4 x 1000/delta t in ms. the 1000 converts to sec.

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Q12

Which of the following physical signs is mostly likely to be seen in someone with the following M mode?


A. S3

B. Opening snap

C. Harsh systolic murmur that increased with valsalva

D. pericardial knock

E. mid systolic click

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A12

The correct answer is B. 


This individual has a classic M mode for mitral stenosis, and the most likely clinical finding in this case would be an opening snap. Note on the M mode how the mitral valve fails to open fully in diastole. Compare this to a normally opening mitral valve [insert M mode]. An S3 would be heard in someone with decompensated systolic heart failure and the M mode might show a dilated venticle with large E point septal separation. A murmur that increased with valsalva would been seen in someone with HCM where there might also be SAM. A pericardial knock may be seen in someone with pericarditis which is not diagnosed by M mode although one may be able to see signs of a pericardial effision. A mid systolic click might be heard in someone with MVP which is readily seen by M mode

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Q13

A 60 year old man with ischemic cardiomyopathy on a good medical regimen for several months is being considered for a primary prevention ICD. EF is calculated using Simpsons rule method however in the 2 chamber view a diastole frame is used for measurements before true end diastole is reached. What will this do to the calculated EF?

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A13

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