Heart Registry Exam Review: Key Questions and Answers

REGISTRY EXAM REVIEW QUESTIONS 1.Which is the most anterior chamber of the heart? - The right ventricle 2.What is the purpose of the pericardium? - The purpose of the pericardium is to prevent over distention of the heart, provide protection and hold the heart in the mediastinum 3.Name the two main layers of the pericardium. - The fibrous layer of the pericardium – which is the outermost layer - The serous pericardium – which is the inner layer of the pericardium. The serous layer can be broken up into two layers o The parietal layer of the serous pericardium o The visceral layer of the serous pericardium, also known as the epicardium. 4.Between which two layers of the pericardium does normal serous pericardial fluid lie? - Normal serous pericardial fluid is located between the parietal and visceral layers of the pericardium 5.Which chambers of the heart form its base? - The right and left atrium form the base of the heart 6.What are the three layers of the walls of the heart? - Endocardium o The endocardium is the intimal or epithelial layer. It is continuous with the intima of the vessels it connects to. The endocardium also lines the valves - Myocardium o The myocardium is the muscle layer. The cardiac muscle is very specialized and found only in the heart. - Epicardium o The epicardium is also known as the visceral layer of the serous pericardium. It’s composed of a single layer of mesothelial cells

7.Deoxygenated blood from the SVC, IVC, and coronary sinus empties into the ________. - Right atrium o The RA forms the right border of the heart. The SVC enters at the upper posterior border, the IVC enters into the lower posterior lateral border while the coronary sinus enters near the IVC. 8.A finger-like attachment to the LA contains pectinate muscles. The purpose of this structure is to increase the capacity in the atria, but is often where clots are formed, is known as the __________. - The left atrial appendage 9.Name the two atrioventricular valves and their purpose - Mitral and Tricuspid valves o The MV and TV allow blood to flow from the atria to the ventricles 10. Name the two semi-lunar valves and their positioning. - Aortic and pulmonic valves o Blood flows from the right ventricle through the aortic valve, and from the right ventricle through the pulmonic valve. 11. Where do the coronary arteries originate from? - From the right and left coronary cusps of the aortic valve, respectively. No coronary artery originates from the non-coronary cusp of the aortic valve. - The coronary cusps are located in the sinuses of Valsalva in the proximal region of the ascending aorta. 12. What are the 4 areas of the aorta? - Annulus - Sinus of Valsalva - Sinotubular Junction - Ascending aorta 13. What is the fold of tissue that guards the IVC? - The eustachian valve. In adults, the EV serves as a non-functioning valve of the IVC

14. What is the name of the portion of the right ventricle which contains the RVOT and the origin of the pulmonary trunk? - Infundibulum 15. Which supporting structure attaches the atrioventricular valves to the papillary muscles? - The chordae tendineae 16. A congenital abnormality in which there is absence of the pulmonary veins entering the left atrium is known as ________. - TAPVD or total anomalous pulmonary venous drainage. - The characteristic findings for this anomaly is the convergence of all pulmonary veins to form a venous sinus superior to the left atrium. - Other findings include enlargement of the right and left ventricles, right ventricular hypertrophy, and a patent foramen ovale or atrial septal defect. 17.The M-mode tracing displayed below indicates a wall motion abnormality involving the ________. - Interventricular septum 18. The muscle bundles that line the walls of the right and left ventricles are the ___. - Trabeculae carnae 19. What is the name of the small, fibrous nodule located at eh centre of each of the aortic valve cusps? - Arantius nodule - The arnatius nodules aid in the support of the cusps. 20. What is Chiari’s network? - A Chiari network is a congenital anomaly that exists due to a remnant of the right sinus venous valve that did not get absorbed properly after birth.

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- A Chiari network may be visualized in several locations in RA as a highly mobile, echogenic structure. 21. The mitral and tricuspid valves open during which part of the cardiac cycle on the ECG? a. R wave b. Q wave c. S wave d. T wave 22. Name the walls of the heart on the short axis view below. 1. Anteroseptum 2. Inferoseptum 3. Inferior 4. Inferolateral 5. Anterolateral 6. Anterior 23. What is the anatomy for #1 in the following CT image? A. LV papillary muscle B. LA C. Descending Aorta D. Moderator band

24. The naturally occurring shunt between the aorta and the pulmonary artery in fetal circulation is referred to as _________. - The ductus arteriosus - When closure occurs, it is called the ligamentum arteriosum. 25. What are the names of the pulmonic valve cusps? 1. Anterior cusp 2. Right cusp 3. Left cusp 26. What are the names of the tricuspid valve leaflets? - Anterior TV leaflet - Posterior TV leaflet - Septal TV leaflet 27. When performing an echocardiogram on a patient with a suspected cardiac tamponade, what important M-mode finding are we looking for to help confirm the diagnosis? - Right ventricular early diastolic collapse 28. Inflammation that affects the inner lining of the heart and the cardiac valves is known as _______. - Endocarditis 29. What portion of the heart is continuous with the interventricular septum? - The anterior aortic root wall 30. What portion of the heart is a continuation of the anterior mitral valve leaflet? - The posterior aortic root wall 31. What are the possible echocardiographic complications associated with a finding of mitral stenosis? 1. Atrial fibrillation (40-50% of patients with symptomatic mitral stenosis have atrial fibrillation). 2. Mitral regurgitation 3. Left atrial enlargement 4. Systemic emboli 5. Pulmonary hypertension

6. Endocarditis 7. Dilated right ventricle 8. Right ventricular hypertrophy 9. Tricuspid regurgitation 32. Which three vessels arise from the aortic arch? 1. Brachiocephalic trunk (innominate artery) 2. Left common carotid artery 3. Left subclavian artery 33. The “hockey stick” appearance is associated with what cardiac abnormality? - Mitral stenosis o “Hockey stick” appearance is also referred to as doming of the MV leaflets 34. Where is the aortic isthmus? - It is the area in the aorta just distal to the left subclavian artery in which the aortic arch and the descending aorta meet. 35. Which coronary artery supplies the majority of the blood flow to the inferior wall of the left ventricle? - The right coronary artery 36. The moderator band is a structure that is typically seen in the _______. - Right ventricle o Moderator band is a muscle that crosses from the lower interventricular septum to the anterior papillary muscle. 37. What is the volume or amount of blood in the left ventricle after passive and active filling from the atrium known as? A. Preload B. Afterload C. Isovolumic contraction D. Isovolumic relaxation 38. Barlow’s Syndrome is also commonly known as which mitral valve disease? - Mitral valve prolapse. - Alternative names are ballooning MV, billowing MV, and floppy MV

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39. What is the most common pathology seen on colour doppler associated with MVP? - Mitral regurgitation 40. If mitral valve prolapse is noted on the echocardiogram in a patient with a pericardial effusion, what should it be diagnosed as? - Pseudo prolapse o The MV can appear prolapsing if the patient has a moderate to large pericardial effusion. This SHOULD NOT be diagnosed as a true MVP unless other modalities of echo confirm the diagnosis. 41. What is one of the most common congenital cardiac abnormalities that affects the aortic valve? - Bicuspid aortic valve o A BAV may result in significant aortic stenosis or regurgitation in an infant or child, but typically does not cause problems until mid to late adulthood. A bicuspid aortic valve is the most common underlying cause of isolated calcific aortic stenosis. 42. The Valsalva maneuver is commonly used to provoke an abnormal response in patients with _________. 1. MVP o The Valsalva maneuver helps to augment or induce MVP 2. Hypertrophic obstructive cardiomyopathy o When Valsalva is performed on a patient with HOCM, the left ventricular outflow obstruction may increase due to the decreased venous return. 43. What is the most common benign cardiac tumour? - Myxoma o Account for approximately 50% of all benign primary cardiac tumours. Most commonly found in the left atrium attached to the left side of the interatrial septum.

44. Which 2D findings are most commonly seen in a patient with mitral regurgitation? - Left atrial enlargement, left ventricular hyperkinesis, and left ventricular dilation 45. A ruptured muscle usually results as a complication of what? - Myocardial infarction 46. What is the most common complication of a sinus of Valsalva aneurysm? - Rupture of the right coronary sinus into the right ventricle. 47. List the complications of a myocardial infarction. 1. Pericarditis/pericardial effusion (Dressler’s Syndrome) 2. True aneurysm 3. Pseudoaneurysm 4. Ventricular septal defect 5. Papillary muscle dysfunction 6. Right ventricular infarction 7. Cardiogenic shock 48. Transmural aneurysms associated with infarctions usually occur in which location of the ventricle? - Apical portion of the ventricle 49. Name the walls of the right and left ventricle that are seen in the apical four chamber view. 1. Right ventricular free wall 2. Basla and mid inferseptal walls 3. Apical septum 4. Basal and mid anteroseptal walls 5. Apical lateral wall 6. Apical cap 50. What is the difference between a true aneurysm and a pseudoaneurysm of the heart? - True aneurysm = weakening of the wall and a bulge occurs in the area of the weakened wall. Has a large neck leading into the aneurysm.

- Pseudoaneurysm = a rupture in the free wall where blood is trapped within the pericardial space. Narrow neck leading into the aneurysm. 51. When viewing a parasternal long axis view of the heart, what structure can be a helpful landmark to differentiate a pericardial effusion from pleural effusion? - Descending thoracic aorta o Fluid seen above the descending aorta is indicative of a pericardial effusion, whereas fluid seen below the descending aorta is indicative of a pleural effusion 52. What other anomaly often coexists with a bicuspid aortic valve? - Coarctation of the aorta o Most common site for coarctation of the aorta is just distal to the subclavian artery origin. 53. Name the walls of the ventricle identified on the apical two chamber view of the heart. 1. Apex 2. Inferior wall 3. Anterior wall 54. The “flying W’ or “absent a wave” on the M-mode tracing of the pulmonic valve may be an indication of what? - Pulmonary hypertension o Caused by mid systolic notching of the pulmonic valve. 55. Name the four characteristics associated with Tetralogy of Fallot. 1. Large perimembranous VSD 2. Overriding aorta 3. Right ventricular hypertrophy 4. Pulmonic stenosis (usually infundibular or sub-valvular, but may be valvular or supravalvular) 56. What does the following M-Mode demonstrate? A. Mitral regurgitation B. Mitral valve prolapse C. Mitral stenosis D. Normal mitral valve motion

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57. Which method is the most accurate for calculating ejection fraction? - The modified Simpson’s Biplane Method 58. What is the most common type of atrial septal defect? - Ostium secundum 59. An increased “a” wave on the pulmonic valve M-mode usually indicated which pathology? - Pulmonary stenosis. Values typically over 7mm. 60. Which of the following is a cause of an increased E point septal separation (EPSS)? 1. Aortic stenosis 2. Hypertrophic cardiomyopathy 3. Mitral stenosis 4. Mitral regurgitation - When a patient has MS, the E wave decreases, therefore the distance between the E wave and the septal wall will increase. This is also seen in patients with LV dilation, systolic dysfunction and aortic regurgitation. 61. The most common cause of a metastatic cardiac tumour of the heart is caused from __________. - Melanoma 62. Cortriatriatum is a congenital defect that is characterized by ___________. - A fibromuscular membrane that separates one of the atrium. - If the membrane is present in the RA it is called cortriatriatum dextrum. - If the membrane is present in the left it is called cortriatriatum sinistrum. 63. All are typical M-mode findings in a patient with a hypertrophic obstructive cardiomyopathy except? 1. Increased E-F slope 2. Systolic anterior motion of the MV 3. Asymmetrical septal hypertrophy 4. Mid-systolic closure of the aortic valve

64. A VTI defines: A. Peak velocity B. Sum of velocities C. Stenosis D. Regurgitation 65. Which is not an M-Mode finding in a patient with A dilated cardiomyopathy? A. “Double Diamond” appearance of the M-mode on the mitral valve B. An increase in the E point septal separation (EPSS) C. Immobile aortic root walls due to low cardiac output D. An increase in the “a” wave of the mitral valve 66. What 2D views may be used to evaluate for patent ductus arteriosus? 1. Parasternal short axis view at the level of the aortic valve 2. Suprasternal view 3. Left parasternal long axis view performed higher than usual 67. The cardiac veins drain into the __________? - Coronary sinus 68. All of the following are findings in Ebstein’s anomaly except: 1. Apical displacement of one or more tricuspid valve leaflet(s) 2. Tricuspid regurgitation 3. Right ventricular hypertrophy 4. Right atrial enlargement 69. Which is NOT a common finding in a patient with cardiac tamponade? 1. “Swinging heart” 2. Right ventricular systolic collapse 3. Right atrial collapse 4. 25% difference with respiration between the “e” waves of the tricuspid valve 70. Mitral valve prolapse may be provoked by the use of __________? 1. Amyl nitrite 2. Valsalva maneuver 3. Positional changes by the patient

71. Which of the following statements is NOT true regarding mechanical prosthetic valves? A. A small amount of regurgitation is normal B. Normal flow velocities are usually higher than those of native valves C. Normal flow velocities are usually lower than those of native valves D. Normal flow velocities in prosthetic valves varies depending on the type of the valve. 72. What are the four types of ventricular septal defects? - Perimembranous (membranous) - Trabecular (muscular) - Inlet (AV canal defects. AVSD’s) - Outlet (supracristal, subpulmonary) 73. The “ground glass” appearance is associated with which type of cardiomyopathy? - Hypertrophic cardiomyopathy o The increased echogenicity of the interventricular septum is a result of the disarray of the myofibers in the interventricular septum 74. On the M-mode tracing of the mitral valve, a prolapse is considered when one or both leaflets are displaced _________ beyond the mitral annular plane? - >/= 2mm 75. Severe mitral stenosis is considered when the mitral valve area is? - < 1.0cm 2 76. Fine diastolic fluttering of the AMVL on the M-mode is a finding of which aortic valve pathology? - Aortic regurgitation 77. What is the normal range for percent fractional shortening? - 25% to 44% 78. How is the peak systolic pressure gradient of a ventricular septal defect calculated between the right and left ventricles? - By applying the modified Bernoulli equation to the peak velocity to the blood flow found across the septal defect.

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- Modified Bernoulli equation: P = 4V 2 - High pressure gradients can mean a small hole whereas lower pressure gradients can mean a larger hole 79. Reversal of a congenital shunt from left-to-right to right-to-left that is secondary to irreversible elevation of pulmonary vascular resistance and severe pulmonary hypertension is known as ___________. - Eisenmenger’s syndrome 80. The left ventricular outflow tract ends at the level of the ___________. - Aortic annulus 81. How can you distinguish endocarditis from aortic stenosis on an M-mode image? - Aortic stenosis will have calcifications and a reduced systolic opening, where as a patient with endocarditis will have normal systolic opening, with calcifications only seen during diastole, or aortic closure. 82. Which chamber would have a higher pressure in patients with AS: A. Aortic B. Left ventricle C. Right ventricle D. Right atrium 83. In which disease process is it necessary to use a dedicated CW probe in your study? - Aortic stenosis 84. A “B bump” on the m-mode tracing of the mitral valve be an indication of _____? - Elevated left ventricular end-diastolic pressure 85. The most common form of cyanotic heart disease is ________? - Tetralogy of Fallot 86. The most common primary, malignant, cardiac tumour are _________. - Various types of sarcomas. - Sarcomas account for approximately 20% of primary cardiac tumours 87. The severity of aortic stenosis may be underestimate when using a pressure gradient on patients who have ___________. - Low cardiac output

88. What conditions may result in the reduction of left ventricular wall contraction? 1. Cardiomyopathy 2. Coronary artery disease 3. Congestive heart failure 89. What is the most common complication associated with bioprosthetic valves? - Calcification/degeneration of the valve 90. What is the most common cause of mitral stenosis? - Rheumatic heart disease 91. Which sinus is most often affected in a patient with a sinus of Valsalva aneurysm? - Right sinus 92. What characteristics of 2D echocardiography demonstrate a left ventricular overload (LVVO) pattern? - Left ventricular dilation with hyperkinesis of the LV 93. Possible complications of chronic mitral regurgitation include __________. 1. Congestive heart failure 2. Increased left atrial volume load 3. Increased left ventricle volume load 4. Atrial fibrillation 5. Pulmonary hypertension 6. Possible left atrial thrombus 7. Possible emboli 94. An outward motion or bulging of a wall segment in systole, usually associated with a thin, scarred myocardium best describes ___________. - Dyskinesis 95. An absent motion of the heart wall is known as __________. - Akinesis 96. Which valvular disease will present with a left ventricular volume overload (LVVO) pattern? - Mitral regurgitation, mitral valve prolapse, and aortic regurgitation

97. What structure is considered to be the pacemaker of the heart? - SA node o Located in the upper portion of the right atrium 98. What is the most common cause for vegetations that are located on the right sided heart valves? - Intravenous drug use/abuse 99. Constrictive pericarditis is difficult to differentiate from this disease state? - Restrictive cardiomyopathy - Changes in flow parameters across the mitral and tricuspid valves with inspiration and expiration may help in the differential diagnosis. 100. Gradual close of the aortic valve on the M-mode is associated with which type of cardiomyopathy? - Dilated cardiomyopathy. 101. Define pressure half-time. - The time it takes for the pressure to drop half its original value. 102. What are some of the factors that may influence the pressure half-time measurement? 1. Stroke volume 2. Left ventricle diastolic compliance 3. Tachycardia 4. Severe aortic regurgitation 5. Immediate post mitral valve balloon valvuloplasty 103. What percentage of the normal ventricular filling is contributed by atrial contraction? - 30% - The first 70% of ventricular filling is due to passive filling 104. What is the MVA in a patient with a pressure half-time of 160msec? - 1.4cm 2 - MVA = 220/160 = 1.37cm 2 – indicates moderate mitral stenosis 105. What is the most common cause of aortic stenosis? - Calcification. The second most common cause is congenital.

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106. An eccentric line of closure seen on the m-mode of the aortic valve indicates _________. - Bicuspid aortic valve 107. What is the most common complication of a bicuspid aortic valve? - Aortic stenosis - Aortic regurgitation is the second most common complication. 108. A peak instantaneous pressure gradient of 32mmHg across the aortic valve is consistent with which pathology? - Mild aortic stenosis 109. What three echo characteristics are seen in a patient with a complete endocardial cushion defect? 1. Ostium primum atrial septal defect 2. Inlet ventricular defect 3. Common AV valve 110. What phases of the cardiac cycles are listed on the Wigger’s diagram in labels in labels 1-11? 1. Aortic valve opening 2. Mitral valve closure 3. Mitral valve opening 4. Isovolumic contraction 5. Isovolumic relaxation 6. Aortic valve closure 7. LV pressure waveform 8. LA pressure waveform 9. Aortic pressure waveform 10. Ventricular systole 11. Ventricular diastole 111. When aliasing of the pulsed wave Doppler occurs, what steps can be taken to correct this? 1. Move to shallower image 2. Shift baseline

3. Increase velocity scale 4. Switch to continuous wave Doppler 112. What is the purpose of the time gain compensation (TGC)? A. Increase gray scale B. Adjust for attenuation C. Increase frame rate D. Increase cycles per second - When properly adjusted, all images of similar reflectors located at different depths will appear identical. Higher frequency sound waves will require more TGC because of increased attenuation. 113. The reject control helps to ___________. - Eliminate smaller amplitude voltage pulses which in turn helps to reduce the low-level noise. 114. The ECG trigger device is used to __________. - Obtain images or information at a particular point during the cardiac cycle. 115. What direction does the tip of the mitral valve leaflet point when the point when the leaflet is flail? - Towards the left atrium 116. What four pharmacological agents can be used with a stress echocardiogram? - Dobutamine, dipyridamole, adenosine, and atropine 117. What control function can be changed to help eliminate low-level signals from the valves or wall motion when performing a Doppler exam? - Wall filter 118. When using pulsed wave Doppler, what does the sample gate or sample volume provide? 1. Discrimination of Doppler signals from different depths 2. Detects flow from within defined area 119. What is the formula for wall motion score index (WMSI)? - WMSI = Sum of the wall motion score/number of segments visualised

120. This type of cardiomyopathy is characterized by left ventricular hypertrophy in the absence of another cause. - Hypertrophic cardiomyopathy 121. What views can be used to interrogate the tricuspid valve with Doppler - RVIT - PSSAX level of AoV - Apical 4 chamber - Subcostal 4 chamber 122. What echo views can be used to obtain an accurate aortic valve peak velocity? - Right parasternal (CW pedof probe) - Apical 5 chamber - Apical 3 chamber - Suprasternal notch 123. What causes the Doppler signal to alias? - The Doppler signal aliases when flow velocities exceed the Nyquist limit. The Nyquist limit is ½ the pulse repetition frequency. 124. What typically happens to blood flow as it goes through a stenosis? - Blood flow accelerates, or speeds up, as it goes through a stenosis. 125. The angle of incidence during a Doppler exam should be between ______ and _______ degrees? - 0 and 20 degrees o If the angle is off greater than 20 degrees from flow, significant calculation errors can occur 126. What effect does straight leg raises have on the patient? - Straight leg raises may increase venous return 127. The following parasternal view demonstrates a __________. - Posterior leaflet mitral valve prolapse 128. What structure is the arrow pointing to? - Descending aorta 129. The following m-mode tracing of the left ventricle suggests ____________. - Concentric left ventricular hypertrophy

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130. This parasternal long axis view is from a patient presenting with symptoms of heart failure. Additional echocardiographic findings included a decreased motion of the aortic root, biventricular dilatation, biatrial enlargement, and mild to moderate mitral and tricuspid regurgitation. These findings may suggest ______. - Dilated cardiomyopathy

CARDIAC EXAM REVIEW

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