which of the following is critical for a proper acquisition of complete cardiac cycles in digital imaging
a high quality EKG signal
a patient presents with a clinical history of stable angina.what medication is most likely to be listed in her chart that is related to this clinical history
nitroglycerin
a three lead EKG is used for resting echocardiography where are the electrods placed
under the right and left clavicle at the mid-clavicular line and on the lower left abdomen within the rib cage frame
the American heart association recommends that a rescuer try to perform at least_______________compressions per minute on a child or infant
100
when transporting a patient in a wheelchair with an IV bag
you should always transport the IV bag above the level of the patient’s heart
which of the following describes the best patient position for obtaining the Supraternal notch view
suspine with neck extended
which of the following describes the correct method of needle insertion for an intravenous catheter prior to a dobutamine stress echo
position the needle as parallel to the skin as possible when puncturing vein
a patient is referred for an echo due to a history of osler Weber rendu syndrome which of the following exams would best evaluate the cardiovascular abnormalities related to this syndrome.
saline contrast echo
if there is a weak signal and significant fluctuation in the vertical position of the EKG tracing across the screen
the skin contact with the electroids is poor
which of the following is not the proper procedure for disinfection of instruments between patients
all needles used in. cardiocentesis procedures should be sent out for sterilization after each use
an EKG performed during an echocardiogram requires the use of three leads which of the following is not a standard location for lead placement
right leg
which of the following patients would need a guardian to sign an informed consent form for a pericardiocentesis
a patient with Alzheimer’s disease
which of the following can increase the risk of a vasovagal response to contrast injection
drink a caffeinated drink the day of the exam
which of the following describes the proper explanation of a 2d echo exam to a female patient
you will tell her that the exam uses ultrasound waves that are not harmful to look at the size and function of the heart at rest
preparing for a microbubble contrast echo to evaluate the left ventricle requires all of the following except
explain to the patient that the contrast is sailing based and presents no risk of allergic reaction
for the best results when performing a dedicated CW Doppler evaluation of the aortic valve with the probe located along the right sternal order the patient should be placed in the
right lateral decubitus position
which of the following statements is false regarding requirement preparation for beginning and ultrasound exam
always place the cord around your neck or shoulder to avoid dragging the cord across open stores wounds or ulcers during the exam
which of the following task is not normally performed prior to the start of the echo exam
offer treatment options
what patient parameters are required to calculate the body surface area
height and centimeters in weight in kilograms
the universal precautions standards were created by which of the following organizations
Center of disease control
a patient presents for an echo and the order does not list an indication for the exam you review the chart for the patient history to locate an appropriate indication for the echo which of the following is an appropriate indication to perform an echo
lab work that demonstrates the presence of staphylococcus aureus
which of the following items should be available in the echo room for a patient who is suffering from anaphylactic response caused by a contrast injection
hydrocortisone
transesophageal transducers are considered __________devices that should be disinfected using____________
semi-critical high level disinfectant
the American heart association recommends compressions and breaths are used in single rescuer or daughter CPR
30/2
a patient presents for an echo following a recent cardiac MRI that demonstrates egg shell calcification of the pericardium what cardiac abnormality will most likely be identified on the echo
constructive pericarditis
why would a cardiologist request a t e e exam on a patient before performing a synchronized cardiovision for chronic atrial fibrillation
to roll out thrombus formation in the left atrium and appendage
which of the following is not a required part of an informed consent form
percentage of patients that have experienced complications after the same procedure at the facility
if you set the game to the lowest level and slowly increase it until an echo is identified on the image what are you evaluating on the ultrasound system
minimum sensitivity
which of the following statements is true regarding damage to the matching layer of the transducer
it causes an increased risk of electrical shock to the patient
you are performing a resting echo with contrast for wall motion evaluation just after the injection of microbubble contrast the patient complains of feeling short of breath and their face appears to be flushed the heart rate on the EKG is 117 BPM which of the following correctly describes their symptoms
the patient is most likely experiencing an anaphylactic reaction to the contrast
which of the following describes an important reason to verify the US examination that is ordered is the exam that should really be performed
when the suspected diagnosis is not able to be evaluated by the exam that is ordered
which of the following is an inappropriate reason to contact the physician to request cancellation of a treadmill stress test for a patient
patient has unstable angina
which of the following is an absolute contraindiction for a stress echo
more than one of the above
which of the following describes the expacted procedure to verify you have the proper patient for the requested exam
use the patient’s wristband provided by the hospital to verify the patient’s name and medical record number
what type of precautions is required for patient that had a renal transplant yesterday
protective environment precautions
if a patient takes a beta blocker the morning of their stress echo
the exam should be rescheduled
which of the following correctly describes the best patient position for performing a transesophageal echo
left lateral decubitus with head elevated about 30°
if a patient has a pacemaker in the left chest where is the electrode for the left arm placed for a three lead EKG
three to five inches below the pacemaker
a 76-year-old female with diabetes htn and COPD is sent to the vascular lab for a 6-month follow-up on a aortic stenosis what is the best patient position to use for the exam
left lateral decube or suspine with the head elevated and neck extended
which of the following is the responsibility of the sonographer before the transthoracic echo exam begins
calculate the body surface area
according to American heart association guidelines where do you place your hands to perform abdominal thrust on a conscious female who is 36 weeks pregnant and is choking
chest thrust are performed instead of abdominal thrust
all of the following tasks are normally performed prior to the start of the echo exam except
obtain information on treatment options
which of the following best describes the primary reason why the te probe are soaked in a disinfectant for a specific amount of time
soaking the probe too long in a disinfectant solution can damage the bonding effect of the glue used to assemble the probes
you are reviewing prior reports for today’s exams and note that one of the patients just had a echo for months ago when the patient arrives he states that he has no new symptoms but was told to come for a follow-up exam by his referring doctor the only finding on the prior exam was aortic insufficiency with a pressure have time of 230 milliseconds which of the following should you do next
review the diastolic LV size on the last study to compare to today’s measurement
when placing the electrodes on a patient for a 12-lead EKG for a stress echo the electrodes for V1 and V2 are placed
at the fourth intercostal space on either side of the sternum
what is benzoin tincture used for
to aid an electrode adhesion for EKG
a patient presents for an echo and the order does not list an indication for the exam you review the patient history in the chart to locate an appropriate indication for the echo which of the following is an appropriate indication to perform an echo
history of chemotherapy for liver carcinoma
which of the following information should be never be entered into the ultrasound system as identifying information
social security number
when using an automated external defibrillator on a patient in ventricular fibrillation the protocol by the American heart association is
to deliver a single shock and reassess the patient
which lab values are most important for the physician to review prior to scheduling a pericardiocenthesis
PT and INR
which of the following transducers can be used to safely scan the patient
betadine and filtration of the matching layer
when placing the electrodes on a patient for a 12-lead EKG for two a stress echo the electrode for a left leg is placed
at the interior electric line between the last rib and the illiac crest
which of the following describes how to obtain the diastolic systemic blood pressure
record the pressure level at the last sound heard before the pulsation disappear
which of the following is a responsibility of the sonographer assisting with a pericardiocentesis
instruct the patient breathing techniques necessary during the procedure
infection control procedures and precautions utilized for all patients are collectively referred
standard precautions
which of the following is not an expected symptom of a vasovagal response
tachycardia
a patient presents for an echocardiogram that is 63 and 320 lbs which transducer would be the best transducer to use to perform the echo
2MHz
you notice the cord of the echo transducer is slightly separated from the back of the probe which of the following describes the appropriate action to take next
place a service call for the probe and reschedule all appointments until it is repaired
you arrive at the hospital to start your shift at 7:00 a.m. and there are numerous orders for patients exams there is a stat echo in the ER due to chest trauma is that echo in ICU for severe pulmonary htn pre ventilator assessment an echo ordered on the third floor for suspected CHF and t e e for pre-op for a mitral valve replacement at 10:00 a.m. which of the following lists the proper order to perform these exams based on exam indication in physician requests
chest trauma severe pulmonary HTN TEE for pre-op suspected CHF
which of the following drugs should be immediately available in case of an anaphylactic reaction when performing a contrast echo
epinephrine
a patient presents for suspected loeffler endocarditis which of the following related information should you look for in the charts that would support the diagnosis
eosinophil level on complete blood count
which of the following is a common symptom of anaphylactic reaction to contrast media
dyspnea
patience having a t e e or stress echo
should be NPO 4 to 6 hours prior to the exam
the ultrasound system relies on the ____________for accurate recording of the motion clips on an echo
our wave and t-wave on the EKG
which of the following must be reviewed on a prior echo when following the progression of aortic stenosis
the window used to obtain the highest aortic velocity
what type of precautions is required for a patient with MRSA
contact precautions
why can’t tea eat pros be thermally sterilized
if the probe is heated above the curry temperature the piezoelectric properties will be lost
which of the following statements is correct regarding inspecting a TEE probe for a potential electrical hazard
normal use of disinfecting agents can lead to damage of the coding which will cause a risk of electrical hazard
which of the following patients would benefit the most from a te exam
St Jude ave with suspected stenosis
which of the following lab tests should be performed regularly for a patient with a star Edwards valve
prothrombin time
if a patient experiences significant left-sided trepapnea how will this change how you perform the echo exam
the patient will need to be scanned in the spine or semi-erect position
when placing the electrodes on a patient for a 12-lead EKG for to a stress echo the electrode for left arm is placed
2 cm below the left clavicle
which of the following is true regarding hand washing recommendations in the standard precautions guidelines
hands should be always be washed before and after assisting with any type of interconventional procedure
which of the following would be a contradiction for using only amyl nitrate to evaluate MVP
severe Arctic stenosis
which of the following items is not part of a standard patient history required prior to an echocardiogram
electroencephalogram report
Mitral Valve prolapse and Aortic dilation
Which abnormalities commonly go with Marfan’s?
Ischemic Heart Disease
Papillary muscle dysfunction usually results from
3 mm
In order to record the veg of endocarditis by echo, it must be
4
How many veins connect the pulmonary vascular bed with the LA?
infiltrative
Which cardiomyopathy is associated with amyloidosis?
Diastolic
Which m-mode finding is considered to be a specific indicator of a fenestrated AV?
VSD
Pulmonic stenosis in uncommon as an isolated defect and is usually accompanied with a
Positioning the tdx in too high an intercostal space
false overriding of the aorta may be produced on the m-mode echo by
rheumatic mitral stenosis
A fib is most common with what valvular disease
bovine, equine, or porcine valve
Example of a bioprosthetic
pericardial effusion may not be present
When a patient has a clinical diagnosis of pericarditis
less than 0.06 seconds after MV closure
TV closure usually occurs
coronary artery aneurysm
Kawasaki’s disease may lead to
pulsed doppler
which echo technique is best for the detection of MR
fossa ovalis region of the atrial septum
atrial myxomas are usually attached to the
apical 5 and apical long axis view
which 2d views are best for direct imaging of a discrete subaortic membrane
constrictive pericarditis
premature opening of the pulmonary valve may be seen in
low CO
an underestimation of AS may occur because of
pressure half-time
Estimation of MV area from doppler is calculated by the
apical 4
What is the standard view for contrast study with an ASD?
Aortic Insufficiency
The doppler jet of MS obtained at the apex is sometimes confused with
be higher following long R-R intervals
For patients with AS and A fib, peak systolic aortic velocity will
reversal in color
Aliasing on color flow doppler is shown by a
aortic insuffiency
Premature MV closure on mmode is a sign of high LV diastolic pressure in
MV prolapse
Midsystolic clicks and or late systolic murmurs are most characteristic of
ASD and bicuspid AV
The two most frequently encountered congenital heart lesions in adults are
an infected MV
On m-mose a flail MV may have a similar appearance to
Aneurysm formation
One of the most common complications of a myocardial infarction is
damped
in pericardial effusion the motion of the pericardium may be
TV
On 2D Echo, a cleft MV may be confused with an anatomic
subcostal 4 chamber
In which view is the ultrasound beam most perpendicular to the IAS
be continuous wave
To determine peak AS velocity the tdx should be
LA enlargement and signs of pulmonary hypertension
secondary findings in mitral stenosis
LVH
patients with longstanding AS will have
left ventricular dimension changes
Patients with AI may have serial echos for
abnormal wall motion
A left ventricular thrombus is usually in an area of
myocardial infarction
Rupture of the IVS is most commonly a complication of
T wave
Ventricular repolarization
Tricuspid regurgitation
A common cause for right ventricular volume overload
Aortic insufficiency
Premature closure of the MV can be seen in patients with
Calcified mitral annulus
Most common cause of MR in elderly patients
Mitral stenosis
LV mass (weight) remains normal in chronic
narfans
What syndromes fit with AI, Aortic dilation, dissection?
check LV size
Why follow chronic AI?
post valvuloplasty
When is mitral pressure half-time NOT accurate?
Right ventricular systolic pressure
Given TR and RA pressure, what can you calculate?
severe MR
If a pt has a dilated LV and thin septum what might be going on with this patient?
pulmonary venous flow
What is the best way to determine severity of Mitral regurgitation?
Carcinoid
Which cardiac pathology affects valves?
causing restrictive diastolic filling
Cardiac tamponade is rapid filling fluid
AI
Peripheral contrast is NOT useful in
because of the coronary arteries
Why are the RCC, LCC, and NCC called what they are?
atrioventricular sulcus
Where does the left anterior descending artery originate?
Tricuspid Regurgitation
A systolic rumble could be
sit them up
if you are doing an echo on a supine patient who becomes SOB
pulmonic
Which valve is least likely to be affected by rheumatic disease?
Valvular areas
Gorlin Formula in cath lab is used to calculate
gender
MV inflow velocity should not be affected by
apical infarction
With what disease should you not rely on mmode for quantifying LVEF?
AI
patients with ankylosing spondylitis may develop
high MI
What can cause contrast to disipate too quickly?
40 cc
Normally how much pericardial fluid is present?
hypovolemia (pulmonary hypertension, caridac tamponade, TS all do)
All of the following may result in JVD except
Right ventricular increase
If a patient has Cor Pulmonale which of the following conditions are most likely to exist?
pleural effusion (pericardial effusion, AS, hypertrophic can)
An enlarged heart on xray could be all of the following except?
4th
Which embryonic arch develops into the trasverse arch?
fusiform
If you have a uniformly dilated Aortic root the term
apical infarction
The primary cause for papillary muscle dysfunction is
MV close
Which valve event starts isovolumic contraction?
AV closure
Which valve event starts isovolumic relaxation?
AV open
Which valve event ends isovolumic contraction?
MV open
Which valve event ends isovolumic relaxation?
retrograde
Systolic reversal of flow is called
Eustachian
What is the valve of the IVC?
R to L
Which shunt causes cyanosis in newborns?
tricuspid
Which valve is most likely to have regurgitation?
Trabiculation
What is not a normal type of mass in the heart
irregularly
Vegetations are usually shaped
upstream
Vegetations are usually attached
pericardium and epicardium
Most nonprimary cardiac tumors involve the
Blood stasis
Main cause of thrombus formation in the LV
TTE
Which modality is best for identifying LV thrombus
True
Contrast may help with the diagnosis of an apical thrombus
low LVEF
What does not cause LA thrombus
TEE
Best modality to diagnose LA thrombus
True
Pulsus Paradoxus is an inspiratory decline of >10mmHg in systemic blood pressure
0.5-2.0 cm
Moderate effusion
Systole
Increased intrapericardial pressure results in collapse of RA free wall
subcostal
Best view to image pericardial effusion
With inspiration, RV filling velocities are _ while LV filling velocities are _
true
Pericardial effusion is recognized as an echolucent space around the heart
Severity of tamponade is detrmined by
chaotic
Vegetations have a _ movement
3/4
Almost _ of cardiac metastases are due to lung, breast, or hematologic malignancies
true
PE in a pt with known malignancy should alert the clinician of cardiac involvemtne
renal cell carcinoma
fingerlike projection protruding into RA from IVC
true
LV thrombus is uncommon if there is no wall abnormality
true
regurgitation is a common finding with veg and masses
lipoidoma
Involved superior and inferior fatty portions of IAS paraing fossa ovalis region
papillary fibroelastoma
Found more often on downstream side of valve
myxoma
Most often are single, protrude into LA from IAS
Angiosarcoma, Mesothelimas,
Malignant primary cardiac tumor
Myxoma
Causes a plop heard on auscultation
pericarditis
inflammation of pericardium
true
Left pleural effusion extends posterior to the descending aorta
Large E, small A
Constrictive pericarditis MV inflow doppler
RA
pericaridal effusions typically originate near the
25mm/sec
Sweep speed to evaluate for respiratory variation in effusion
true
Malignant primary cardiac tumors are rare
LV thrombus
strong predictor of subsequent embolic events
true
Prstheitc valves can be source of emnolic event
true
PFO is in 25-30% of people
1-2 beats
In a bubble study, bubbles should be present on the left side in
true
At least 2 injections should be performed with a bubble (one with valsalva, one without)
true
Pericardial adipose tissue can be mistaken for an effusion
Constrictive Pericarditis
Adherent, thickened, and fibrotic pericardium
true
Bioprosthtic valves are used for catheter implantation and are mounted on a compressible stent
False
Ball and Cage valves are still in use
Age and pannus growth
Mechanical valve stenosis or regurg is due to
true
Mechanical valves are prone to thrombus formation
PLAX
Standard __ plane provides optimal visualization of valve leaflet anatomy/movement with mechanical valves
midsystolic click and/or late systolic murmur
Clinically, prolapse of the MV is associated with
ischemic heart disease
papillary muscle dysfunction usually results from
3 mm
In order to see a veg it must be
akinetic
When a wall exhibits no motion it is called
Infiltrative
What cardiomyopathy is associated with amyloidosis?
VSD
Infundibular pulmonary stenosis is uncommon as an isolated lesion and usually goes with a
Ostium secundum
Most common type of ASD is
RCA
What coronary artery supplies the AV node and SA node?
Which Aortic leaflet is the superior one in the PSLA
Right Leaflet
Name the tricuspid leaflets
Posterior and Anterior
The coronary arteries come off of the..
Sinus of Valsalva
Name the vessels coming off the arch and the most proximal or distal.
Innominate (proximal), left carotid, and the left subclavian (distal)
What cardiac pathology is associated with bicuspid aortic valves?
Coarctation of the Aorta
Where do the most aortic Coarctation occur?
After the take-off of the left subclavian artery, or within the aortic isthmus
Where are the pulmonary veins loca? Which ones are seen in this view?
Rights and left superior (upper) pulmonary veins
Where is the coronary sinus located?
Posterior AV groove
To visualize the coronary sinus in the apical 4 chamber view you should tilt the transducer..
Posterior
During which phase do the coronaries fill?
early diastole
Where is the chiari network located?
RA
What portion of the pulmonary venous PW Doppler represents atrial systole?
A wave
Know frequency for TEE probes versus TTE
TTE probes are usually higher 5-7MGz, while TTE probes are 2-7MHz
At what temperature is it unsafe to use a TEE probe?
40-45C
Know TEE views by esophageal level (know mid esophageal- ME and transgastric) and degrees.
4ch- 0 degrees
2ch- 90 degrees
LAX- 120 degrees
Why is the SA node the primary pacemaker?
The SA node has the highest intrinsic rate of any cardiac tissue.
The save of contraction (depolarization) moves from the endocardium to the epicardium.
Inside to outside. Look at the purkinje fibers above.
What is the absolute refractory state?
That period when a muscle cell is not excitable- from phase 1 into phase 3; the ‘relative refractory period’ is during phase 3 and the muscle cell might contract if the stimulus is strong.
Know what P wave, P-R interval, T wave represents
P wave- atrial systole
P-R interval- includes P-R segment (from atrial to ventricular depolarization)
QRS complex- ventricular diastole (repolarization)
What is the normal duration for the QRS complex?
0.10 sec
Frank-Sterling Law
Increased volume= increased contractility
RUBBER BAND THEORY
Acute AI is hypercontractile because we shift up the Starling curve
Chronic AI is failure when we drop off the end
Does a PDA (patent ductus arteriosus) increase LV preload?
yes (when shunt L-R)
Echo finding for preload vs. afterload…
Preload= dilatation
Afterload= hypertrophy
Which study does not allows for the calculations of ejection fraction?
CXR
Does venous return increase or decrease with inspiration?
Increase
Mitral valve velocity during inspiration increases or decreases?
Increases
Hepatic venous flow reveral indicates _ TR.
Severe
Given a TR velocity of 4.0m/sec what is the RVSP?
70mmHg
A patient has a RVSP of 60mmHg. One year later the RVSP is 30mmHg. What happened to the pt?
Coanda effect?
Coanda Effect- Define.
Wall hugging effect
Pulmonary venous systolic flow reversal is..
Severe MR
Which of the following is used in echo to measure dP/dt?
Mitral regurgitation
dP/dt measurement of mitral regurgitation assesses what?
LV systolic dysfunction
__ is the rate of rise of LV pressure?
dP/dt
LAP=
systolic BP- MR gradient
Know pressure waveforms for MR (late systolic jump in LA pressure) pg. 97
…
Know about Marfan’s syndrome.. define
Congenital connective tissue disease causing aortic dilatation of MVP
In Marfan syndrome, why does aortic dissection and MVP occue?
Connective tissue disorder
Know Ehlers-Danlos. Another connecative tissue disorder
like Marfan’s pts, you look for MVP dilated Ao dissection
Severe Ao aneurysms are greater than:
5.0cm
Know libman-sachs=
Lupus and Marantic endocarditis
St. Jude is a __ valve
Bi-leaflet
Autografts
means using pts own tissue
Pannus
host tissue overgrowth
What are all the cardiomyopathies?
Dilated, hypertrophic, restrictive, ischemic
Which cardiomyopathy is autosomal dominant?
Hypertrophic
Apical Hypertrophic Cardiomyopathy (AHCM)
Normal etiology (genetic)
Typical spectral Doppler finding (flow acceleration in mid LV)
Ratio for assessing asymmetric hypertrophy.
1.3:1
LVOT obstruction cuases the aortic valve to…
close in mid systole
Pts with a history of IV drug abuse may present with…
Tricuspid endocarditis
The Venturi Effect can be associated with which cardiomyopathy?
Hypertrophic
Dos Inderal (beta blocker) increase SAM?
No, decreases HR reduces SAM with excercise
Chaga’s disease (Dilated CM)?
posterior and apical thinning septum usually normal
Know the echo signs of congestive cardiomyopathies:
-Multi chamber enlargement
-Globally impaired LV contractility
-B-Notch on MV M-Mode (increased LVEDP)
-Thrombus may be present
What type of CM might you see in a pt with AIDS?
Dilated CM
Know post-transplant 2-D appearance..
Double atria
Amyloid and sarcoid are what type of cardiac abnormalities?
Restrictive
Hemochromatosis is…
excess iron
“Ground glass” appearance is related to… (pg. 123)
infiltrative myocarditis
Amyloid LAX- PV inflow will have _ systolic velocity
Low
A restrictive CM has which of the following?
Decreased LV compliance
A typical ejection fraction in a dilated MC pt might be (for a HCM pt)
-15-25%
The majority of ventricular filling occurs during…
first third of diastole
If a pt has a normal MV inflow but Pulm veins showed a decreased S-wave and D-wave, consider that they might have a _ pattern.
pseudonormal
A pericardial effusion can often be seen in patients with…
Renal Failure
Pericardial Effusion Grading Criteria: Small? Med? Large?
Small: posterior fluid <1cm Med: anterior and posterior <1cm Large: surrounding the heart >1cm
Where does the oblique sinus of the pericardium lie?
Posterior to the LA in the PLAX view
Beck’s Triad? 3 options:
a. elevated venous pressure
b. Hypotension
c. Quiet Heart
The most sensitive way to diagnose cardiac tamponade is:
Respiratory variation
What cardiac condition would prevent diastolic right ventricular collapse?
Pulmonary Hypertension
Patients in tamponade cannot _
Lay flat
flow variation in tamponade can get a false positive if:
a. unstable sample volume
b. COPD
c. pleural effusion
What other pericardial abnormality also causes impaired ventriular filling?
Constrictive pericarditis
A huge, dilated PA, severe TR and RV enlargement best describes:
Pulmonary Hypertension
What is represented with a decreased “a” wave and a flying W?
Pulmonary hypertention by M-Mode
Decreased ‘a’ wave means..
PHTN
Your pt has PHTN with a dilated IVC (3cm) which collapsed 50% with sniff. Estimated the RA pressure:
15mmHg
What is the most common (mechanical) complication of an MI.
Aneurysm formation
Which occurs first in the setting of severe mitral regurgitation due to a flail leaflet?
Dilated RV
What type of MI causes a muscle rupture?
inferior MI
Definition of Ischemia
Lack of oxygen
The most common location for speudoaneurysm is..
Inferior basal- NOT apical
does the wall of a pseudoaneurysm contain endocardium?
No, it’s a rupture across both endo and myocardium
What information do you need pre-op in a patient with LV aneurysm?
Movement of other walls
Color Doppler in ischemic disease can be good for?
VSD
What do you look for in a pt with Kawasaki Disease?
Coronoary Artery Aneurysms
(R and L coronary artery aneurysms might be called “mickey mouse ears”)
Which of the following terms refers to a decrease in wall motion?
Hypokinesis
What is the IVS motion in a patient with LBBB?
Dyskinetic or paradoxical
From where do the coronaries originate?
In the L and R aortic sinus of Valsalva
What is meant by “right dominance”?
When the right coronary gives rise to the “posterior descending artery” (85% of the time)
Which coronaries supply the interatrial septum?
Right (also ususally supplies the SA and AV nodes)
Which coronary artery feeds the inferoseptal wall?
Right coronary artery
Which drug is used in Nuclear Stress Test?
Thallium
What would be a containdication to performing a stress test on an athlete with chest pain?
Unstable angina
Dobutamine provides all the following except responses EXCEPT increasing:
Myocardial perfusion
What is the most common type of ASD?
Secundum
Partial anomalous pulmonary venous return is seen in with what type of ASD?
Sinus Venosus
Which is the best view to diagnose a sinus venoses ASD?
Modified subcostal four chamber
Best view to demonstran an ASD?
Subcostal 4ch
If you see an anechoic dropout of the interatrial septum in the aprical 4ch view what should you do?
Look in the subcostal 4ch view
What is the standard echo view for contrast studies of an ASD?
Apical 4ch
How many beats to see contrast on the L side in a patient with an ASD? (with a pulmonary shunt)
1-2 beats for an ASD. 3-5 beats for a Pulm. shunt
Where should contrast be injected in order to diagnose a persistent left superior vena cava?
Left arm
Endocardial cushion defects (AV septal) are associated with:
Down syndrome or trisomy 21
Supracristal location is:
Subpulmonic region
Inlet location
subvalvular low near the mitral and tricuspid valves
Which is the most common type of VSD?
perimembraneous
Calculate the RVSP in a patient with 5m/sec VSD jet and BP of 130/80 (beware of distractors like RA pressure!)
VSD jet= 5m/sec
SBP= 130mmHg
What congenital abnormality has a displaced TV?
Ebstein’s anomaly
If a large PDA is not corrected what might develop?
Eisenmenger Syndrome
Patent Ductus Arteriosus:
Failure of the fetal ductus arteriosus (between the pulmonary artery and descending aorta) to close after birth.
Which is the following is NOT a TET defect?
a. Large
b. Pulmonic stenosis
c. RVH
d. ASD
ASD
Blood follows the path of less resistance. _ reverses the __.
Squatting, shunt
What part of the heart is most likely to be affected by cardiac contusion?
RV (most anterior)
What might be the first indication of metastatic cardiac disease?
Pericardial effusion
Which cardiac chamber is most likely involved with metastatic tumors?
RA
The most common benign tumor on the aortic valve is:
Papillary fibroelastoma
Myxoma
Benign tumor (most common in adults)
Where are most fibroelastoma found?
Heart valves, mostly mitral and aortic (frond-like)
__ is the most common benign tumor in children (slow growing)
Rhabdomyoma
Symptoms mimic mitral stenosis
Myxoma
LA Myxoma are usually attached where
interatrial septum
Which triculspid leaflets are seen?
Medial and anterior
Where is the LAA on TTE?
PSAX Ao valve level
What cardiac pathology is an associated with bicuspid aortic valve?
Coarctation of the aorta
In PLAX, which TV leaflets are seen? \n
Anterior and medial/ septal\nPosterior can only be seen in RVIT plax
The coronary Arteries come off the? \n
Sinuses of Valsalva
What is the structure under the arch? \n
Right Pulmonary Artery
The formula for calculating EF is: \n
EDV-ESV / EDV x 100
Stroke Volume \n
EDV-ESV
The LA dimension is measured on M=mode during? \n
End -systole
Where are the pulmonary veins located? \n
Can be seen in Apical 4 chamber w/inferior angulation.
How do you bring in the RVIT in PLAX? \n
Angle Medial and Inferior from Aortic Root. TV
How do you bring in the RVOT in PLAX? \n
Angle Lateral and Superior from Aortic root. PV
Where is the Chiari Network located? \n
RA
Where is the aortic isthmus located? \n
Area between the left subclavian and the ductus arteriosus(where most coarctations occur)Sinus of Valsalva is the most common area of dissections).
The __ is the most anterior chamber of the heart? \n
RV
Pulmonary artery is , \n
anterior, superior
The Eustachian valve is located in the? \n
IVC
Can you see the moderator band in the PLAX? \n
No- Moderator band is located in the RV
Where does the moderator band extend? \n
From the lower intraventricular septum to the anterior wall where it joins the papillary muscle.
Spontaneous chordal rupture more often occurs on which leaflet of the Mitral Valve? \n
Posterior \nAlso psterior medial papillary muscle \nSingle blood supply to posterior wall
The heart tube normally loops? \n
Anterior and to the right
Where is the coronary sinus located in relation to the descending aorta \n
The coronary sinus is located anterior to the descending aorta. If the coronary sinus is dilated, it can be mistaken for the descending aorta.
How would you angle to view the coronary sinus in the apical four chamber view? \n
From the apical four chamber you you would angle inferior in order to visualize the coronary sinus, which is located posterior to the mitral annulus.
Why is it important to know the location of the coronary sinus and the descending aorta? \n
Pericardial Effusions lie posterior to the coronary sinus and anterior to the descending aorta. \nPleural effusions lie posterior to the descending aorta.
What is another name for the RVOT? \n
Infundibulum
Where is the coronary sinus located in the parasternal long axis view? \n
The coronary sinus lies in the posterior AV groove. This groove is located between the LA and LV walls and lies posterior to be MV. In the parasternal long axis view, the coronary sinus can sometimes be seen as a small echo free circle.
What would cause the coronary sinus to become dilated? \n
The coronary sinus dialates due to increased pressure in the RA, increased flow to coronary sinus.
Describe the anatomy of the tricuspid valve, including the name and location if each leaflet. \n
Location is between the Right atria and right ventricle. It has three leaflets: anterior, posterior, and medial or (septal) leaflets. \nThe names reflect the anatomical relationship to the right ventricle. The medial leaflet is connected to the septal wall. It’s insertion is located closer to the cardiac apex than that of the anterior mitral valve leaflet.
Name and describe two main layers of the pericardium? \n
Often referred to as 2 main layers as visceral and parietal. This visceral layer lies directly upon external surface of the heart and is commonly referred as the epicardium. The parietal or fibrous pericardium is the thick outer sac. Pericardial cavity lies between the two layers.Anatomically 3 layers are: serous visceral, serous parietal, fibrous pericardium.
Name the three major coronary arteries. \n
The three major coronary arteries are the right, left ant descending (LAD), and the circumflex arteries
The heart tube loops at day ___ \n
The heart tube loops ANTERIORLY and RIGHTWARD at day 22
The AV canal is a large communication between the __ and \n
Primitive atria and primitive ventricle
The __ divides the AV canal into right and left AV orifices \n
Endocardial cushions
The ductus arteriosus closes after birth due to increased systemic pressure and becomes the _ \n
Ligamentum arteriosum
What are the two Right to Left shunts in the normal fetal circulation? \n
Foreman ovale\nDuctus arteriosus
Following electrical depolarization of the myocardial cell membrane, which ion rushes in first and which ion rushes in later?
Sodium is a rest \n\n* Calcium is 2nd and responsible for contraction
\nWhere is a subaortic membrane (DSS) located?
just below the Aortic Valve
Tricuspid Valve leaflets seen in the PSAX-Aortic valve
Medial (septal)\nAnterior
Name the cardiac walls supplied by each of the coronary arteries.
right coronary artery \na) inferior wall \nb) inferoseptal \nc) right ventricular apex \nd) right ventricular free wall. \n**RIGHT= inferior, septals, right
Left anterior descending artery – LAD
a) anterior wall \nb) anteroseptal \nc) left ventricular apex \n**LEFT = anterior, apical, left
Circumflex artery
a) anterior lateral wall \nb) inferolateral wall\nCIRC = laterals
What walls do the LAD supply?
Anterior IVS, Anterior Left Ventricle and Apex
What walls do the CX supply?
Anterolateral and inferolateral
\n\nWhat walls do the Posterior descending artery supply?
Inferior Left Ventricle, Inferior Right Ventricle and Inferior IVS
The LAD lies in the _ interventricular sulcus?
anterior
walls and coronary artery circulation on PLAX?.
- anterior RVOT – RCA\n2. anterior IVS – LAD\n3. inferolateral – CX/RCA
walls and coronary artery circulation on PSAX?
- anterior IVS – LAD\n2. anterior – LAD\n3. anterolateral – CX/LAD\n4. inferolateral – CX/RCA\n5. inferior – Posterior descending \n6. inferior IVS – Posterior descending /LAD
walls and coronary artery circulation A4?
- anterolateral – CX/LAD\n2. apex – LAD\n3. inferior IVS – LAD/RCA\n4. lateral Right Ventricle – RCA
walls and coronary artery circulation Apical 2 Ch?
- anterior – LAD\n2. apex – LAD\n3. inferior – Posterior descending artery (of the RCA)
The circumflex artery supplies?
anterolateral and inferolateral walls
The Posterior descending artery ( of the right coronary artery) supplies?
inferior Left Ventricle, inferior Right Ventricle and inferior IVS
The anterior septum and anterior wall of the Left Ventricle is supplied by the?
LAD
\n\nThe anterolateral, lateral and inferolateral walls of the Left Ventricle are supplied by the?
Circumflex
The inferior wall of the Left Ventricle and inferior septum are supplied by the?
Posterior descending artery
The cardiac apex is supplied by the?
LAD
Which coronary artery provides blood to the Right Ventricle?
RCA
Which coronary artery provides blood to the inferior septal walls in right dominant?
Posterior descending artery
Which walls of the left ventricle are seen in the parasternal and apical long axis views
The anterior septal and the inferolateral walls of the LV are seen in the parasternal apical long axis Views.
Which two aortic valve leaflets are seen in these views?
The right & non coronary leaflets are seen in these views. The right leaflet is on top (superior) and the non-coronary is on the bottom (inferior)
Where are the coronary arteries located on the surface of the heart?
The coronary arteries are located on the outer, epicardial surface of the heart as follows: \nthe right coronary artery (RCA) arises from the right aortic root sinus, follows the right atrioventricular junction, and to descends along the posterior interventricular groove. \nThe left anterior descending coronary artery (LAD) follows the Anterior interventricular groove. \nThe circumflex coronary artery’s or courses along the left AV junction.
Complications with MI?
- pericarditis/PE\n2. Dressler’s syndrome (PE post MI)\n3. Left Ventricle true aneurysm\n4. Left Ventricle false or pseudo aneurysm\n5. Left Ventricle thrombus\n6. Ventricular septal defect \n7. papillary muscle dysfunction\n8. Right Ventricle infarct
While scanning a 43 old man with history of an old myocardial infarction, you notice at the anterior cardiac wall is akinetic. Which coronary artery is most likely to have been involved in the infarction?
The left anterior descending (LAD) coronary artery, which supplies blood to the inferior cardiac wall, is most likely to have been involved. This artery also supplies the inferior portion of ventricular septum and the left ventricular apex. \n**LEFT = anterior, apical, left
In the apical 4 ch view of another patient, the distal ventricular septum and left ventricular apex are hypo-contractile. Which coronary artery is most likely to be diseased?
Again, the left Anterior descending (LAD) coronary artery is the most likely choice. Some patients with distal septal hypocontractility, the proximal portion of the septum moves normally because it is supplied by the RCA. \nNOTE: LEFT= left, ant, apicals
To visualize the inferior lateral wall the left ventricle, which 2D view would you use?
The anteriolateral wall of the left ventricle is best visualized in the apical four chamber view.( The lateral wall can also be seen in the short axis views, but the four chamber view is the best.)\nNOTE: 2 CH is anterior & inferior
The normal intracardiac pressure for the Right Atrium is?
5mmHG\nNOTE: RIGHT SIDED PULMONARY PRESSURES ARE LOWER THAN THE LEFT\n\nRight Atrium=5, Right Ventricle=25, PA=25 5-25-25\nLeft Atrium=10, Left Ventricle=120, Aorta =120. 10-130-120
The normal intracardiac pressure for the Right Ventricle is?
25/5mmHg
The normal intracardiac pressure for the PA is?
25/10mmHg
The normal intracardiac pressure for the Left Atrium is?
10mmHg
The normal intracardiac pressure for the Left Ventricle is?
120/10mmHg
The normal intracardiac pressure for the Aorta is?
120/80mmHg
Describe the normal mitral valve anatomy
The mitral valve is a bi-leaflet valve situated between the left atrium on the left ventricle. The valves anterior leaflet is relatively long, lies close to the aorta, and comprises one third of the valves circumference. The posterior leaflet is shorter and is usually divided into three sections (scallops). Both the anterior and the posterior leaflets are attached to the ventricular Papillary muscle by multiple cordae tendonae
Which aortic leaflet is the superior one in the parasternal long axis view?
Right leaflet (the posterior leaflet is the non coronary)
During which phase do the coronaries fill?
Early diastole
Inhalation of amyl nitrite causes?
Decreased after load\n-Vasodilator\n-BP drops\n-less blood comes back\n-HR increases\n\nDecreases vascular resistance. Increases forward flow murmurs decreases AR/MR ( retro flow murmurs)
When is Left Ventricle pressure the lowest?
Early diastole
Which type of mitral deformity occurs where there is only ONE PAPILLARY MUSCLE into which both chordae insert\nOR insertion of mitral chord into a single papillary muscle?
Parachute mitral valve\nNOTE: MOST COMMON FORM OF CONGENITAL MITRAL STENOSIS–it is a rare cause of mitral stenosis
Which is the most common chamber for a sinus of Valsalva aneurysm to rupture into?
Right Atrium \nNOTE: SINUS OF VALSALVA IS MOST COMMON AREA OF ANEURYSM IN MITRAL STENOSIS
Systolic flow reversal of bubbles in the IVC is indicated of Tricuspid Regurgitation or tamponade?
Tricuspid Regurgitation\n\nSevere grade TR\n\nRegurgitation is a preload= volume = Dilitation\nIt affects the chamber behind it. ( which is Left atria and the Ivc)
Which of the following is used in echo to measure dp/dt?
Mitral Regurgitation\n\nNOTE: \nThe rate (dP/dt max) of left ventricle (LV) pressure rise in early systole measures LV SYSTOLIC FUNCTION.
What is beck’s triad?
-elevated venous pressure\n-hypotension\n-quiet heart\nassociated with acute tamponade\n* IT IS THE CLINICAL DIAGNOSIS OF CARDIAC TAMPONADE\n\nBecks triad ( cardiac tamponade ) 3 Ds\nDistant heart sounds\nDistended jugular veins \nDecreased arterial pressure
A huge, dilated PA, severe Tricuspid Regurgitation and Right Ventricle enlargement best describes?
Pulmonary hypertension\n\nTricuspid reguritation. Is a preload, volume overload affects chambers ahead of it.
The size of aneurysms during systole:
Increase
What is the most common (mechanical) complication of an MI.
Aneurysm formation
Which of the following occurs first in the setting of severe mitral regurgitation due to a flail leaflet?
Dilated Right Ventricle\n\nFLAIL LEAFLET WILL CAUSE MITRAL REGURGITATION\n\nThis is a sudden onset (acute) and the heart does not have time to adjust yo the pressure difference.
What type of MI causes papillary muscle rupture?
inferior MI\n-Inferior pap muscle has a single blood supply (Medial papillary muscles receives dual blood supply and is less likely to rupture)\n\n* posterior papillary muscle single blood supply is most likely to rupture
From where do the coronaries originate?
In the LEFT and RIGHT aortic sinus of Valsalva
Which coronary supplies the Interatrial septum?
Right (also usually supplies the SA and AV nodes)
Which coronary artery feeds the inferoseptal wall?
Right coronary artery
What would be a contraindication to performing a stress test on an athlete with chest pain?
Unstable angina
Know that Atropine may be given at peak dose if the target heart rate is not reached.
Peak HR is 80%
Calculate the RVSP in a patient with 5m/sec VSD jet and BP of 130/80
RVSP=SBP-4(V)2 \n =130-4(5)2 \n =130-4(25)2\n =130-100\n =30 mm Hg
If your patient has a dilated Left Ventricle and thin septum what might be going on with this patient?
Severe mitral regurgitation.\n\nOn M mode anterior motion of the posterior leaflet
Which view shows the coronary sinus in long axis?
Apical 4 chamber with posterior angulation\nNOTE: PLSVC, CHF, PHTN = dialated CS
Where does the left anterior descending coronary artery originate?
anterior intraventricular sulcus
Are right-sided pressures elevated with a Valsalva maneuver?
During the strain phase=No \nDuring the release phase=Yes
Which clinical finding is associated with a friction rub?
pericardial effusion- \nconstrictive pericarditis (which leads to PE)- friction rub. \nConstrictive pericarditis impaired ventricular filling\nPericardial knock Similar in timing to a very loud S3. It’s caused by an abrupt cessation of early diastolic inflow.\n – respiratory variations of MV and TV
What does the sinus venous turn into?
Atrial connections (IVC, SVC, pulmonary veins, CS and part of the atria
In normal development which is the last to close?
patent foramen ovale \nFirst to close is. ASD
What is Qp/Qs?
Qp pulmonary circulatory flow\nQs = systemic circulatory flow\nASD surgery is mainly considered when the Qp/Qs exceed?\n1:5\nNormal ratio 1:1
What are the Qp/Qs for an ASD?
1 for left to right shunt \n< 1 for right to left shunt
In patients with A-fib which heart sound would be missing?
Fourth (occurs during atrial contraction)
How do you position a patient for using a Pedoff probe along the right sternal border?
right lateral decubitus
A 52 year old woman develops a murmur after a myocardial infarction. What is the most likely etiology?
ventricular septal defect
When Transporting a Patient with a Urinary Catheter the bag should always be ?
-Below the patients bladder
A 52 year old women developes a murmur after a myocardial infarction. What is the most likely etiology?
Ventricular septal defect VSD
Which of the following choices would not be used to correct for pulced wave doppler aliasing?
Use of higher frequency probe
How do you position a patient for using a Pedoff probe along the right sternal border?
Right lateral decubitus.
A patient with down syndrome is referred to your lab for an echo. Which of the following cardiac defects would you likely find?
Atrioventricular Canal defect.
During a pharmacological echo stress test using Dobutamine which drug is given if the patient dosnt reach target heart rate?
Atropine
How do you position a patient for a TEE exam?
Left lateral decubitus
If you measure the LVOT too big how will this affect your measurement for the aortic area?
Area is to large
A patient with AIDS ( acquired Immune Deficiency Syndrome) might present with what type of cardiomyopathy?
Dilated
A 3 year old patient comes to the lab with a systolic murmur. what is the most likely etiology?
Ventricular septal defect.
In a patient with COPD which frequency transducer would most likely result in the best images?
2.25MHz
Which is the best stress echo technique for revealing hibernating or stunned myocardium?
Dobutamine
You are in the emergency department and a patient presents with the signs and symptoms of aortic dissection. which modality would give you the most rapid diagnosis?
TEE
which is the proper term when the pulmonic valve is removed and put in place of the aortic valve in the same patient?
autograft
Know that pericarditis (pericardial Effusion) can present with positional chest pain.
Hurts more in certain positions or when changing positions.
what is the 1st structure seen when imaging from the suprasternal notch?
Aortic arch
which of the following drugs is used in Nuclear stress test?
Thallium
which of the following is the most important echo to do?
Murmur Post MI
At what time during fetal growth is the heart first fully developed?
40 days
on the 3oth day, the trunks normally divides. what anomaly occurs if the truncus does not divide?
Truncus ateriosus
The sinus venosus forms all of the following except:
Pulmonary arteries
The truncus ateriosus forms all of the following except:
Pulmonary veins
what are the two right to left saints in the normal fetal circulation?
Foramen oval and ductus arteriosus
which of the following left to right shunts is the last to close in the normal post partum period? when does it close ?
patent foramen ovale, closes at the end of the first week.
in the normal fetal circulation, which of the following has the least amount of blood flow?
pulmonary veins
all of the following hemodynamic events occur post delivery except:
Left atrial pressure decreases
The fetal ductus arteriosus closes soon after birth. what structure does it become?
ligamentum arteriosum
The ductus arteriosus connects the pulmonary artery and aorta in the fetus. at what site does the ductus attach to the aorta?
aortic isthmus
the following five structures are activated during a single cardiac cycle. Rank them in the normal order of activation.
SA node
AV node
Bundle of His
left bundle branch
purkinje fibers
which of the following structures is the primary pacemaker of the heart?
SA node
During the resting state, which of the following ions are pumped out of the cells of the myocardium?
Sodium
Following electrical depolarization of the myocardial cell membrane, which ion rushes in first, and which ion rushes in later?
sodium followed by calcium
which of the following helps slow heart muscle contraction?
potassium
in the cardiac cell action potential, what phases are included in the absolute refractory period?
phases 1 into phase 3
when contraction against which of the following pressures will the velocity of muscle cell contraction be more rapid?
75 mmHg
what happens to the beat following a premature ventricular depolarization ?
the beat is stronger than a typical beat
what is the Frank sterling Law?
the more the heart muscle is stretched, the more forcefully it contracts.
which of the following best describes preload?
LV filling
all of the following tend to increase preload except:
AS
what best describes afterload?
aortic pressure
all of the following tend to increase after load except?
MR
what is the predominant echo findings associated with increased after load?
LV hypertrophy
what is the predominant echo finding associated with increased preload?
LV Dilation
Afterload equals :
hypertrophy
Preload equals :
Dilation
a patients blood pressure is 120/80mmHg, stroke volume is 80mL,R-R interval is .86, heart rate is 70 beats/min, and age is 42 years. what is the patients cardiac output?
5.5L/min
Cardiac output=
heart rate x stroke volume
In the normal circulation, what is the value of the Qp/Qs ratio?
1
In a patient with a VSD, which of the following sites will provide a measure of pulmonic flow?
Mitral Valve
which of the following best describes a patient with sever MR?
RF=50%
Heart muscle beats automatically, without outside stimulation, the rate that the heart naturally contracts is called the inherent rate. which of the following terms has the same meaning as inherent?
intrinsic
At what time during fetal growth is the heart fully developed?
40 days
on the 30th day, the truncus normally divides. what anomaly occurs if the truncus does not divid ?
Truncus arteriosus
The Sinus venosus formal all of the following except
pulmonary arteries
The truncus arteriosus forms all of the following except
Pulmonary veins
What are the two right to left shunts in the normal fetal circulation?
Foramen ovale and ductus arteriosus
In the normal fetal circulation, which of the following has the least amount of blood flow?
Pulmonary veins
fetal ductus arterioles closes soon after birth. what structure does it become?
ligamantum arteriosum
which of the following is the primary pacemaker of the heart
SA node
All of the following are cardiac responses to increase sympathetic stimulation except:
Increased R-R interval
Stimulation of the vagus never will result in
Increased R-R interval
during the cardiac cycle, which valve event most closely follows the p-wave on the EKG?
TV closure
what hemodynamic event follows the p-wave on the EKG?
Atrial systole
What hemodynamic event follows the R-wave on the EKG?
isovolumic contraction
During the cardiac cycle, which valve event most closely follows the R-Wave on the EKG?
Pulmonic valve opening
During the cardiac cycle, which valve event most closely follows the T-wave on the EKG?
Aortic valve closure
What hemodynamic event follows the T-wave on the EKG?
isovolumic relaxation
Which TWO of the following pressures allows for the evaluation of AS?
LV pressure
Aortic pressure
Which TWO of the following allows for the evaluation of mitral stenosis?
LV pressure
LA pressure
Which TWO of the following pressures allows for the evaluation of pulmonic stenosis?
RV pressure
PA Pressure
Which TWO of the following pressures allows for the evaluation of tricuspid stenosis?
RA pressure
RV pressure
T or F: The hemodynamic evaluation of MR is performed during diastole
False
T or F: The hemodynamic evaluation of aortic stenosis is performed during diastole?
False
T or F: The hemodynamic evaluation of tricuspid stenosis is performed during diastole
True
T or F: The hemodynamic evaluation of pulmonic regurgitation is performed during diastole
True
Which of the following flow patterns is most likely to be longest?
Pulmonic insufficiency
What valve closures are associated with the first heart sound ?
Mitral & tricuspid
what valve even is associated with the second heart sound?
Aortic Closure
Which of the following grades represents a murmur that is most faint?
2 of 6
A thrill is most like associated with which of the following murmurs?
grade 5 to 6
T or F: A crescendo-decrescendo murmur is quite often associated with a stenosis
True
What is a typical or normal value for hematocrit?
40%
T or F: Mean right Atrial pressure is less than mean left atrial pressure
True
what is a typical value for mean left atrial pressure
10mmHg
what is a typical value for mean right atrial pressure?
5mmHg
What is the normal O2 saturation of the blood in the pulmonary artery?
75%
what is the normal O2 saturation of the blood in the pulmonary vein?
100%
where is the oxygen saturation of blood the lowest ?
Coronary sinus
T or F: the size of a color flow jet is always related to the volume of blood creating the jet.
False
During systole, the aortic and LV pressure are quite different. what is this fin find indication of?
Aortic stenosis
During diastole, the RA pressure is much higher then RV pressure, what does this indicate?
Tricuspid stenosis
Sinus bradycardia is defined as a heart rate less then 60bpm. How do the R-waves appear on the EKG?
more then 5 big boxes apart
Sinus tachycardia is defined as a HR more then 100bpm. How do the R-waves appear on the EKG?
Less then 3 big boxes apart.
A patient has an EKG with five premature ventricular contractions in succssion. what is this called?
ventricular tachycardia
Three vessels branch off of the aortic arch. Put them in order, closest to the aortic valve first.
Innominate
Left carotid
Left subclavian A
Most coarctations of the aorta occur after the take off of which of the following vessels?
Left Subclavian artery
what is the minimum length of time that echo records need to be kept ?
7 years
Normally, how much fluid is found in the pericardial sac?
40cc
Which is key EKG feature of Wenckebach
Progressive lengthening of the PR interval
What do the Coronary Arteries arise from?
Sinus of Valsalva
During which phase do the coronaries fill?
Early diastole
What Cardiac pathology is associated with bicuspid aortic valve ?
Coarctation of the aorta
which window do you use to look for the secondary finding in bicuspid valves?
suprasternal notch
where do most aortic carctations occur?
The aortic isthmus ( after the take off of the left subclavian artery)
From an apical 4ch view how do you rotate the transducer to obtain an A3?
counterclockwise 120 degrees
What two walls are you seeing of the LV in the apical 2 chamber view?
Inferior & Anterior
Where is the coronary Sinus located?
Posterior to the AV groove
To visualize the coronary sinus in the apical 4 chamber view you should tilt your transducer ….
posterior
which valve sits at the opening of the coronary sinus?
Thebesian
What portion of the pulmonary venous PW Doppler represents atrial systole?
A wave ( Atrial contraction)
At what temperature is it unsafe to use a TEE probe?
40-45 degrees C
AV Node
electrical impulses passes to prevent simultaneous contraction of the atrias and ventricles
Which has the fastest intrinsic rate?
SA node
What is the absolute refractory state?
That period when a muscle cell is not excitable- from phase I until into phase 3 the “relative refractory period” is during phase 3 and the muscle cell might contract if the stimulus is strong.
P wave
atrial systole
P-R interval
from atrial depolarization to ventricle depolarization
QRS complex
ventricular systole (depolarization)
T wave
ventricular diastole (repolarization)
what is the normal duration for the QRS complex
0.10 sec
Frank-Starling Law ( length- tension relationship)
The greater the load the greater the force of contraction.
Increase volume (preload)
Increase contractility
Increase myocardial fiber length (after load)
increase tension
Increased preload
Regurgitation
Preload =
Dilation
after load =
hypertrophy
EF= (normal >55%)
SV/EDV x 100
CO= (normal 4-6L/min)
SV x HR
How do you eliminate aliasing on PW spectral Doppler?
Switch to a lower frequency transducer
When does aliasing occur?
when nyquist limit is exceeded
The Nyqvist Limit=
1/2 of the PRF
How is VTI calculated ?
tracing the doppler spectral display
Normal VTI for MV and AOV
MV-12cm
AOV-20cm
What does VTIxCSA equal ?
Doppler stroke volume
Does venous return increase or decrease with inspiration?
increase
Inhalation of amyl nitrite causes?
Decreased after load
Mitral valve velocity during inspiration?
decreases
Cardiac cycle
Isovolumic contraction
ejection
isovolumic relaxation
rapid infow
diastasis
atrial systole
Isovolumic contraction
After R wave
isovolumic relaxation
After T wave
On the wiggers diagram when is the MV open
2-3
What is the duration of IVRT and IVCT
70msec
COCO
Close , open, close , open
when the Aortic valve is open:
the LV and aortic pressure are nearly identical
Pulmonary Hemodynamics
Low pressure
Low resistance
RV wall is thin
Low O2 content in the artery
Systemic Hemodynamics
High pressure
High resistance
LV wall is thick
High O2 content in the artery
blood components
54% is plasma
45% red blood cells (erythrocytes)
1% white blood cells (leukocytes)
What is the normal pressure in the pulmonary artery?
25/10
Normal pressure in the RA
5 mmHg (6mmHg)
Normal pressure in the LA
10mmHG
Where is the O2 saturation the lowest ?
coronary sinus
O2 saturation of the pulmonary veins
95%
O2 saturation of the pulmonary arteries
75%
Best cath technique for Left Ventricle function?
LV angiogram
What is PCW(pulmonary capillary wedge) measuring ?
LA pressure
SEP (systolic ejection period)
DFP(Diastolic filling period)
PCW ( from a Swan-Ganz catheter)
To determine AS where are 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 seperate sensors
High gain destroys:
resolution
low frequency
2.5MHz (better penetration)
high frequency
4.0MHz (Better resolution)
Fundamental Imagining
Transmit and receive at the same frequency
Harmonic imaging
Transmit at one frequency and receive at the second harmonic (twice the transmit freq)
Tissue harmonic imaging
result in thicker valve leaflets
Apical swirling of echo contrast for LVO is caused by
MI being too high or the amount of contrast injected is too low.
Attenuation of contrast
caused by the amount of contrast injected is to high or was injected to fast
A secondary finding in aortic stenosis is?
left ventricular hypertrophy
In Aortic stenosis is pulse pressure wide or narrow ?
Narrow ( pulse pressure is the difference between systolic and diastolic pressure-it is wide in AI and narrow in AS)
Aortic jet velocity
Mild: 2.6-2.9
Mod: 3.0-4.0
sever: >4.0
Aortic mean gradient
Mild: <20 Mod: 20-40 sever: >40
AVA
Mild:>1.5
Mod:1.0-1.5
sever: <1.0
The best view to diagnosis a bicuspid aortic valve is the parasternal:
Short Axis
What is a common symptom for aortic coarctation
Systemic hypertension
What is the best view for detection subvalvular membranes
A5 ( approximately 15% will grow back post surgical removal)
What is Takayasu arteritis?
-Also called aortic arch syndrome(occurs more in young women from asia)
-There is a fibrosis of the arch and descending Ao of unknown etiology.
Normal Aortic valve area
3-4 cm2
When does VTI Work better ?
In patients with poor LV function and when moderate to sever AI is present than peak velocities.
Using the continuity equation when would the severity of Aortic Stenosis be underestimated?
LVOT measured to large
When do you measure LVOT
Systole
Which pressure is obtained during Doppler?
Peak to Peak instantaneous ( for AS its the high gradient anytime during systole)
Know that echo gradients are usually higher than cath gradients.
Peak instantaneous versus peak to peak
Noonan Syndrome
classified as a cardiofacial syndrome with PS. HCM and ASD(30%)
Does PS cause Pulmonary hypertension?
Nope
Asked if unable to obtain PS gradient from the parasternal window where else can you go?
Subcostal short- axis
MS murmur=
low frequency “Diastolic Rumble” with an opening snap
Which cardiac valve is the second most common to be affected by rheumatic heart disease
AOV
Patients with mitral stenosis often develop:
atrial fibrillation
Patients with MS and A fib might:
Lose 50% of diastolic filling since they are very dependent on atrial contraction
Normal MV area
4-5cm2
With atrial fibrillation mitral stenosis velocity calculations are best performed:
averaged over 5-10 beats
In the PSAX view which method is used to asses the MV area
Pressure 1/2 time
Given a mitral pressure half-time of 400 m/sec what would the area be?
0.5cm2
how to calculate MVA
220/PHT
Carcinoid-vs-Rheumatic:
Carcinoid=fixed body of the leaflets
Rheumatic=tethered leaflet tips
Which anomaly goes with aortic dissection?
Marfan syndrome
classification for aortic regurgitation murmur
diastolic “blow”
What kind of murmur would you hear in a patient with a rupture of a sinus of Valsalva aneurysm?
continuous
What causes MV preclosure?
an elevated LVEDP (end diastolic pressure)
Mild aortic regurgitation has an _ spectral trace.
incomplete
How would you calculate pulmonary artery end diastolic pressure ?
Pulmonic insufficieny velocity
how to calculate PAEDP
PAEDP =RAP+EDP
IS systolic flow reversal of bubble in the IVC TR or Tamponade
TR
what is the most common valvular problem associated with carcinoid syndrome?
TR
What does central venous pressure refer to
IVC pressure close the RA
Hepatic venous flow reversal indicates_______ TR
sever
Given a TR velocity of 4.0m/sec what is the RVSP
70mmHg
RVSP=
TR gradient + RAP
RVSP=
4(v)2+ RAP
A vena contracta might be seen in wha type of cardiomyopathy?
Dilated
Coanda effect
happens with wall hugging jets. May underestimate jet size
If you suspect sever MR where els should you look?
Pulmonary vein (S, D, AR)
The greatest source of error in measuring PISA is with:
Radius of the flow convergence
What does PISA stand for
proximal isovelocity surface area
Which of the following is used in echo to measure dP/dt?
MR
dP/dt measurement of mitral regurgitation assesses what?
LV systolic function
normal LV dP/dt is
1200 mmHg/sec
Know pressure waveforms from MR
late systolic jump in LA pressure
Marfan’s Disease
congenital connective tissue disease causing aortic dilation and MVP
In Marfans syndrome why does aortic dissection and MVP occur?
decrease fibrillin
Ehlers-Danlos syndrome
Connective tissue disease, like in Marfan you look for MVP, Dilated AO, dissection
Sever aortic aneurysms are greater then:
5.0cm
Libman-Sachs: endocarditis
systemic lupus erythematosus
Marantic endocarditis
nonbacterial thrombotic endocarditis (NBTE), due to trauma. seen in patients with metastatic disease.
Patients with a history of IV drug abuse may present with:
Tricuspid endocarditis (vegetation’s)
Can you tell the difference between and old or new Vegetation?
Nope
In order to be seen by 2-D, vegetation’s need to be at least:
3mm
Ball and cage mechanical valves are made by?
Starr-Edwards
st. jude bi leaflet valve
Homografts or allograft
Same species
heterograft
different species
autograph
patients own tissue
what is the name of the dual valve surgery for congenital AS
Ross Procedure
Pannus=
Host tissue overgrowth
When will you see acoustical shadowing ?
MV prosthesis
Which cardiomyopathy is autosomal dominant?
hypertrophic
the ratio 1. 3: 1 is for assessing ?
asymmetric hypertrophy
LVOT obstruction causes the aortic valve to:
close in mid systole
MV inflow shows A wave greater then E wave
Abnormal relaxation
Does Inderal (beta blocker) increase SAM?
No, decreases heart rate reduces SAM with exercise
NOTE: SAM is increased with increase in HR. ( amyl nitrate and Valsalva will increase SAM ).
Global Longitudinal Strain in patients with HOCM is typically
-8 to -10%
Average GLS
-16to -19% or more
Chagas’ disease
Posterior and Apical thinning septum usually normal
Echo signs of congestive cardiomyopathy
-multichanber enlargement
globally impaired LV contractility
B-notvh on MV M-mode
What is the cause of B-notch
increased LVEDP
Post transplant 2-D appearance
double atria
What is the most common restrictive cardiomyopathy
Amyloidosis
Amyloid and sarcoid are what type of cardiac abnormalities?
restrictive
Hemochromatosis
excess iron deposits throughout the body
What does the term ” ground class appearance” refer to
infiltrative myocarditis
A restrictive cardiomyopathy has which of the following?
increased preload
what are the 4 types of cardiomyopathies
Normal
Dilated (congestive)
Hypertrophic
Restrictive
A typical ejection fraction in a dilated cardiomyopathy patient may be ?
30-40%
40-50%
The majority of ventricular filling occurs during:
in the first third of diastole
If a patient has a normal MV inflow but pulmonary veins show a decreased S wave and D wave you should consider:
they might have a pseudonormal pattern
diastolic phases
Isovolumic relaxation(closure of AOV to opening of MV) early filling
diastasis
atrial contraction
Normal doppler waveforms at the mitral annulus differs from the flow at the mitral leaflet tips.
E and A are reversed at these two sample sites
In Constrictive pericarditis does the E wave increase or decrease with inspiration?
decrease
How would you determine if a patient has constrictive versus restrictive disease?
TV inflow with respiration variation
Three layers of the pericardium
fibrous- thick outer sack
parietal- bound to fibrous pericardium smooth
visceral- bound to the epicardium
A pericardial effusion can often be seen in patients with
Renal failure
what is the murmur of a pericardial effusion
friction rub
Pericardial Effusion Grading Criterial:
Small: <1cm Med: Anterior and posterior 1-2cm Large: surrounding the heart >2cm
Identify the CS vs the descending Ao and its importance:
to differentiate bwetwwn pericardial and pleural effusion
Where does the oblique sinus lie
posterior to the LA in the PLAZ view- area between the two sets of palm. veins
What to do if tamponade is suspected?
immediate interpretation
Beck’s triad
Elevated venous pressure
hypotensive
quite heart
The most sensitive way to diagnosis cardiac tamponade is:
Respiratory variations
Cardiac tamponade Doppler
Flow will decrees across mitral and AOV and increase across tricuspid and pulmonic valves with inspiration
what cardiac conditions would prevent diastolic RV collapse?
Pulmonary hypertensive
What other pericardial abnormality also causes impaired ventricular filling?
Constrictive pericarditis
A huge, dilated PA, Severe TR and RV enlargement best describes?
Pulmonary Hypertension
Eisenmenger syndrome
Reversal of a long-standing left-to-right shunt from PHTN. Shunt is now right-to-left
what is represented with a decrease “a” wave and the flying W?
pulmonary hypertension by M-mode
given TR with 60mmHg gradient grade the severity of pulmonary hypertension
Sever
Pulmonary artery pressure
Normal: 18-40mmHg
Mild:40-54mmHg
Mod: 55-64mmHg
sever: >65mmHg
your patient has PHTN with dilated ivc (3cm) which collapsed 50% with sniff. Estimate the RA pressure:
8mmHg
The size of aneurysms during systole:
increase
What is the most common complication of MI
Aneurysm formation (8-15%)
What type of MI causes pap. muscle rupture?
Inferior MI
what occurs first in the setting of sever MR due to a flail leaflet?
Dilated RV
True Aneurysm (fusiform, saccular)
-wide base
-walls composed of myocardium
- low risk of free rupture
Pseudoaneurysm
-Narrow base
-Walls composed of thrombus and pericardium
-High risk of rupture
What is the most common location for pseudo aneurysms ?
inferior basal
Does the wall of a pseudoaneurysm contain endocardium?
no, its a rupture across both ends and myocardium
What information do you need to pre-op in a patient with a LV aneurysm?
Movement of other walls
Color Doppler in ischemic disease can be good for?
VSD, because you can use PW and CW Doppler for detecting Mitral Regurgitation
What is secondary to pap muscle dysfunction
MR
What do you look for in a patient with Kawasaki disease?
Coronary artery aneurysm
Decrease in wall motion
Hypokinesis
Akinesia wall motion
no motion
Dyskinesia
motion in opposite then normal direction
What is the IVS motion in a patient with LBBB
Dyskinetic or paradoxical
What does the LAD supply?
-anterior wall
-anteroseptal wall
-LV apex
what does the Left circumflex supply
-anterolateral wall
-inferolateral wall
What does the RCA supply?
-inferior wall
-inferoseptal wall
-RV apex
-RV free wall
From where do the coronaries originate?
In the LEFT and RIGHT aortic sinus of Valsalva
What is meant by “right dominance”
When the right coronary gives rise to the “posterior descending artery” (85% of the time)
which coronary supplies the interatrial septum
Right (also usually supplies the SA and AV nodes)
Which coronary artery supplies the inferoseptal wall?
RCA
Is a multivessel disease stress echo better then a nuclear stress echo ?
yes
What are the indications for a stress echo?
-chest pain
-severity of CAD
-guide post MI rehab
-evaluate cardiac arrhythmias
what would be a contraindication to preforming a stress echo on an athlete with chest pain?
unstable Angina
What is given if peak dose is given and still not at target heart rate?
Atropine
When the 2D image appears to have three atria. It might mean that the patient has a Cor Triatrium
a congenital malformation where there is a membrane above the level of the mitral valve. in sever cases these is supravalvular stenosis.
What is the most common type of ASD
Secundum ASD
Partial anomalous pulmonary venous return is seen with which type of ASD?
sinus venosus
which is the best view to diagnosis a sinus venous ASD?
modified subcostal four chamber
what is the best view to demonstrate an ASD
Subcostal 4 chamber
What is the standard echo view for contrast studies of an ASD
A4
How many beats to see contrast on the left side in a patient with an ASD?
<5 beats for an ASD (> 5 beats for pulm shunts)
Where should contrast be injected in order to diagnosis a persistent left superior vena cava?
Left Arm
endocardial cushion defect ( AV septal)
Down syndrome or trisomy 21
Which is the most common type of VSD
perimembranous
Supracristal location
high near the aortic and pulmonic valve
Inlet location
subvalvular low near the mitral and tricuspid valves
classic VSD murmur
Loud holosystolic murmur
What congenital abnormality has a displaced TV?
Ebstein’s
If a large PDA( patent ductus arterioles) is not corrected what might develop?
Eisenmengers syndrome
What is NOT a TET defect
ASD
Tetralogy of Fallot
-perimembranous VSD
-overriding Aorta
-Pulmonary stenosis
-RV hypertrophy
Should you use x-ray and off axis views for evaluation of myxomas
Yes
What part of the heart is most likely to be affected by cardiac contusion?
RV
What might be the 1st indication of metastatic cardiac disease?
pericardial effusion
which cardiac chamber is most likely involved with metastatic tumors?
RA
What is the most benign tumor on the aortic valve ?
pap fibrolastoma
Myxomas
benign muscle tumors
Where are myxomas mainly seen?
LA (75%)
LA myxomas are usually attached where?
interatrial septum