ESP Hints

Which valve separates the areas of greatest pressure differences? (lowest?)

Mitral valve (Pulmonic Valve)

LAD lies in the \_____interventicular groove or sulcus?

Anterior

Which aortic leaflet is the superior one in the PLAX?

Right leaflet (the posterior leaflet is the noncoronary)

From the parasternal window, which of the following are you most likely to get accurate velocity measurements?
a) LVOT
b) Mitral Stenosis
c) Pulmonary artery
d) Mitral Regurgitation

C) Pulmonary Artery

Name the tricuspid leaflets

Posterior and Anterior

Where is the LAA on TTE?

Sometimes in the parasternal SAX Ao valve level (better seen in the apical 2 chamber)

The coronary arteries come off the:
a) descending Ao
b) coronary sinuses
c) Pulmonary artery
d) sinuses of valsalva

d) Sinuses of valsalva

During which phase do the coronaries fill?
a)early systole
b)late systole
c) Early diastole
d) Late diastole

C) Early diastole

The best images of the ascending ao are often obtained from which transducer window?
a) apical
b) subcostal
c) suprasternal
d) right parasternal

C) suprasternal

Name the vessels coming off the arch and most proximal or distal

Innominate (proximal), left carotid and left subclavian (distal)

What cardiac pathology is associated with bicuspid aortic valves?

Coarctation of the Aorta

Which window do you use to look for the secondary finding in bicuspid valves?

Suprasternal notch/arch

Where do most aortic coarctations occur?

The aortic isthmus (after the takeoff of the left subclavian artery)

Where are the pulmonary veins located?

Branching off the left atrium
Right and left lower (inferior) pulmonary veins are commonly seen in Apical views

From the Apical 4 chamber view, how do you rotate the transducer to obtain the apical LAX?
a) Clockwise 90 degrees
b) Clockwise 120 degrees
c) Counterclockwise 90 degrees
d) Counterclockwise 120 degrees

D) Counterclockwise 120 degrees

Where is the coronary sinus located?

Posterior AV groove

Which view do you use to evaluate coronary sinus?

PLAX

To visualize the coronary sinus in the apical 4 chamber you should tilt the transducer
a) medical
b) anterior
c) lateral
d) posterior

D) Posterior

Which valve sits at the opening of the coronary sinus?
a) Todaro
b) Vieussens
c) Thesbesian
d) Eustachian

C) Thesbesian

Where is the Chiari Network located?

Right Atrium

What portion of the pulmonary venous PW Doppler represents atrial systole?
a) A Wave
b) S Wave
c) D wave
d) E wave

A) A Wave

What is the absolute refractory state?

That period when a muscle cell is not excitable - from phase one until into phase three; the "relative" refractory period is during phase three and the muscle cell might contract if the stimulus is strong

On an EKG the P wave represents:

Atrial Systole

On an EKG the P-R interval represents:

Atrial to ventricular depolarization

On an EKG the QRS complex represents

Ventricular Systole (depolarization)

On an EKG the T wave represents

Ventricular diastole (repolarization)

What is the normal duration for the QRS complex?
a) 0.10 msec
b) 1.0 msec
c) 0.10sec
d) 1.0 sec

C) 0.10 sec

Normal value of R-R intervals

between 3 to 5 big boxes (60-100 beats/minute)

Normal value of QRS complex

less than 3 little boxes (less than 0.12sec)

Normal value of a PR interval

less than 1 big box (less than 0.2 sec)

What is the Frank-Starling law?

Increased volume (preload) = increased contractility (to a physiological limit)
Increased myocardial fiber length = increased tension (rubber band theory)

Acute AI is \_____ because we shift up the Starling curve. Chronic AI is \_____ when we drop off the end.

Hypercontractile;
Failure

Preload versus Afterload

Preload: Dilatation; referring to volume; thin walls
Afterload: Hypertrophy; referring to pressure; thick walls

Which study does not allow for the calculation of ejection fraction?
a) 2D echo
b) Cardiac angio
c) Chest Xray
d) Cardiac nuclear study

C) Chest XRay

What is the Cardiac Output equation

CO (cardiac output) = SV (stroke volume) x HR (heart rate)

What is the Bernoulli Equation?

4v^2
V= velocity

How do you eliminate ailiasing on PW doppler?
a) Increase the PRF
b) switch to a lower frequency transducer
c) switch to a higher frequency transducer
d) switch to continuous wave doppler

D) Switch to continuous wave doppler

What is the doppler stroke volume equation?

VTI (velocity time integral) x CSA (Cross-sectional Area)

Does venous return increase or decrease with inspiration?

Increase

Inhalation of amyl nitrite causes:
a) increased preload
b) decreased preload
c) increased afterload
d) decreased afterload

d) Decreased afterload (drops BP)

Mitral valve velocity during inspiration:
a) Increases
b) Decreases
c) remains the same
d) Gets obstructed by air

B) decreases

Isovolumic contraction and relaxation timing on an EKG: (after which wave forms?)

After the R Wave = Isovolumic contraction
After the T wave = Isovolumic relaxation

On the Wigger's Diagram when is the mitral valve open?
a) 3-4
b) 4-1
c) 1-2
d) 2-3

B) 4-1

What is the duration of IVRT and IVCT

70msec

The duration of isovolumetric relaxation time will be increased with:
a) Tachycardia
b) Bradycardia
c) Increased sweep speed
d) Increased wall filter

B) Bradycardia

When is the LA/LV volume the highest?

LA: End-systole
LV: End-diastole

What is the correct order for the cardiac cycle?

1. Mechanical diastole
2. Electrical diastole
3. Electrical systole
4. Mechanical systole

What are the normal pressures in the following areas of the heart?
-Right atrium
-Right ventricle
-Left atrium
-Left ventricle
-Pulmonary artery
-Aorta
-PCW

-Right atrium: 8/5
-Right ventricle: 25/0/5
-Left atrium: 10/12
-Left ventricle: 120/0/12
-Pulmonary artery: 25/10
-Aorta: 120/80
-PCW: 10

Where is the O2 saturation the lowest?
a) Right Atrium
b) IVC
c) Pulmonary Artery
d) Coronary sinus

d) Coronary sinus

What is the O2 saturation in the pulmonary veins and arteries?

Pulmonary Veins: 95%
Pulmonary Arteries: 75%

What is the best cath technique for LV function?

LV angiogram

What is PCW (Pulmonary Capillary Wedge) measuring?

Left atrial pressure

To determine Aortic Stenosis 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 separate sensors

Apical swirling of echo contrast for LVO is caused by
a) High MI
b) Negative jet
c) too much contrast
d) 2D focus too low

A) High MI (Mechanical index)

A secondary finding in Aortic Stenosis is?
a) Left atrial enlargement
b) left ventricular enlargement
c) Left ventricular hypertrophy
d) Aortic Regurgitation

C) Left ventricular hypertrophy

In aortic stenosis is pulse pressure wide or narrow?

Narrow (pulse pressure is the difference between systolic and diastolic pressures-it is wide in AI and narrow in AS)

What are the severe aortic stenosis ranges for the following:
-Aortic jet velocity
-Mean gradient
-AVA
-Indexed AVA
-Dimensionless index

-Aortic jet velocity: \>or= 4.0
-Mean gradient: \>or= 40
-AVA:

The best view to diagnosis a bicuspid AoV is the parasternal:
a) short-axis diastole
b) short-axis systole
c) long-axis diastole
d) long-axis systole

B) Short-axis Systole

What is a common symptom of aortic coarctation?

Systemic Hypertension

What is Takayasu's Arteritis?

Also called aortic arch syndrome this disease occurs more in young women from Asia. There is fibrosis of the arch and descending Aortic of unknown etiology. In advances stated multiple Coarctations may occur (look for Supravalvular Aortic Stenosis).

What are the ranges for an aortic valve area?

Normal: 3.0-4.0
Mild: \>1.5
Moderate: 1.5-1.0
Severe:

Using the continuity equation when would the severity of Aortic Stenosis be underestimated?
a) LVOT measured too large
b) LVOT measured too small
c) Peak aortic velocity too high
d) mean aortic velocity too high

a) LVOT measured too large

Which pressure is obtained during Doppler?

Peak or peak instantaneous (for AS it's the highest gradient anytime during systole)

Echo gradients are usually \_____ than cath gradients

higher

What is Noonan Syndrome?

Classified as a cardiofacial syndrome with PS, HCM, and ASD (30%)

Pulmonic stenosis (does/does not) cause pulmonary hypertension

Does not

If unable to obtain pulmonic stenosis gradient from the parasternal window where else can you go?

Subcostal short axis

Pulmonic Stenosis severity:
Peak velocity:
Peak gradient:

Peak velocity: \>4.0
Peak gradient: \>64

Mitral Stenosis murmur:

Low frequency "Diastolic Rumble" with an opening snap

Which cardiac valve is the second most common to be affected by rheumatic heart disease?

Aortic Valve

Patients with Mitral Stenosis often develop:
a) Heart Block
b) Aortic Stenosis
c) Atrial Fibrillation
d) Pulmonary Hypertension

C) Atrial Fibrillation

Mitral Valve Area ranges:

Normal: 4-5
Mild: \>1.5
Moderate: 1.5-1
Severe:

With atrial fibrillation mitral stenosis velocity calculations are best performed
a) Averaged over two beats
b) Averaged over 5-10 beats
c) Averaged over 20 beats
d) Unable to measure in A-Fib

B) Averaged over 5-10 beats

In the PSAX view which method is used to assess the MV area?
a) planimetry
b) pressure half time
c) Continuity equation
d) dimensionless index

A) Planimetry

How do you calculate the mitral valve area?

220/pressure half time

Carcinoid versus rheumatic

Carcinoid: Fixed body of the leaflets
Rheumatic: tethered leaflet tips

Which anomaly goes with aortic dissection?
a) Turner syndrome
b) Down syndrome
c) Marfan Syndrome
d) Pulmonary Hypertension

C) Marfan Syndrome

Murmur of patient with ruptured sinus of valsalva
a) Diastolic blowing
b) Harsh systolic
c) Diastolic Rumble
d) Continuous

D) continuous

What is the "diastolic blow" murmur related to?

Aortic regurgitation murmur

What does aortic regurgitation cause on a Mitral valve M-Mode?

Diastolic Mitral Valve fluttering

What causes MV preclosure?

An elevated LVEDP (end diastolic pressure)

JH/LVOT ratio ranges

Mild:

Ao Pressure 1/2 Time

Mild: \>500
Moderate 500-200
Severe:

How do you calculate LVEDP?

LVEDP= diastolic BP - end diastolic gradient

Antegrade flow versus Retrograde flow:

Antegrade = normal flow direction
Retrograde = Flow in the opposite direction

How do you calculate pulmonary artery end diastolic pressure?
a) Tricuspid peak velocity
b) Pulmonic Peak velocity
c) Pulmonic insufficiency velocity
d) Tricuspid Regurgitation velocity

C) Pulmonic insufficiency velocity

What is the most common valvular problem associated with carcinoid syndrome?
a) Mitral Regurgitation
b) Mitral Stenosis
c) Tricuspid regurgitation
d) Tricuspid stenosis

c) Tricuspid regurgitation

CVP (central venous pressure) refers to

the IVC pressure close to the right atrium

Hepatic Venous Flow Reversal indicates\_____ TR
a) Trace
b) Mild
c) Moderate
d) Severe

D) severe

Equation for RVSP

RVSP=TR gradient + RA Pressure (RAP)

A vena contracta might be seen in which type of cardiomyopathy?
a) Dilated
b) Restrictive
c) Inflitrative
d) HOCM

A) Dilated

Vena Contracta size indicating severe MR

\>or= 0.7

JA/LAA ratio ranges

Mild:

What is the Coanda Effect?

Happens with wall hugging jets. May underestimate jet size

If you suspect severe MR where else should you look?

Pulmonary veins

The greatest source of error in measuring PISA is with:
a) Length of the regurgitant jet
b) vena contracta measurement
c) radius of the flow convergence
d) peak velocity measurement

C) Radius of flow convergence

Which of the following is used in echo to measure dP/dt?
a) pulmonic insufficiency
b) aortic insufficiency
c) tricuspid regurgitation
d) mitral regurgitation

D) Mitral Regurgitation

What is dP/dt?

*The rate of rise in the LV pressure

*Think of it as the change (d)(delta) in pressure (P) over change (d) in time (t)

*measure of directional LV contractility

*written as mmHg/sec

*difficult to measure even in cath lab

*in echo lab the measurement is taken from the MR Doppler jet

dP/dt measurement of mitral regurgitation assesses what?

LV systolic function

Normal LV dP/dt is

\>1200mmHg/sec