Free ARDMS AE-Adult-Echocardiography Practice Exam with Questions & Answers | Set: 3

Comprehensive and Detailed Explanation From Exact Extract:

Anteroseptal hypokinesis is most often due to ischemia or infarction in the left anterior descending (LAD) artery territory, a major branch of the left coronary artery. The LAD supplies the anterior wall and the interventricular septum.

The right coronary artery generally supplies the inferior wall and right ventricle. The circumflex artery supplies the lateral wall. The posterior descending artery supplies the inferior wall.

This coronary artery distribution and wall motion correlation is fundamental in stress echocardiography and ischemic heart disease assessment as detailed in ASE guidelines and clinical echocardiography references【12:ASE Stress Echocardiography Guidelines†p.300-310】【16:Textbook of Clinical Echocardiography, 6e†p.380-385】.

In significant aortic valve regurgitation (AR), the continuous wave Doppler signal across the valve demonstrates a rapid decline in regurgitant jet velocity, resulting in a pressure half-time (PHT) less than 250 milliseconds. A short PHT indicates severe AR with rapid equalization of aortic and left ventricular pressures during diastole.

Pulsed wave Doppler forward flow in the abdominal aorta evaluates stroke volume but does not directly indicate AR severity. Vena contracta to LVOT diameter ratio less than 25% would indicate mild AR, not significant. Peak velocity ≥4.5 m/s is more characteristic of aortic stenosis rather than regurgitation.

This criterion for AR severity using CW Doppler PHT is described in the "Textbook of Clinical Echocardiography, 6e", Chapter on Aortic Regurgitation Doppler Assessment【20:375-380†Textbook of Clinical Echocardiography】.

To obtain the apical five-chamber view from the apical four-chamber, the transducer is angled anteriorly (towards the patient’s chest). This brings the left ventricular outflow tract and aortic valve into the imaging plane anterior to the left ventricle and mitral valve seen in the four-chamber view.

Posterior, medial, or lateral angulations do not adequately visualize the aortic valve in this context.

This technique is described in adult echocardiography imaging protocols and ASE chamber quantification guidelines【12:ASE Imaging Protocols†p.30-35】【16:Textbook of Clinical Echocardiography, 6e†p.70-75】.

Severe mitral regurgitation (MR) is typically characterized by significant left atrial dilation due to volume overload, and systolic flow reversal in the pulmonary veins caused by retrograde flow from the left ventricle into the left atrium during systole.

An eccentric mitral regurgitant jet is common in severe MR, often due to leaflet prolapse or flail, resulting in directed jets that hug the atrial wall.

Mitral regurgitant jet velocity, however, is usually significantly higher in severe MR due to the high pressure gradient between the left ventricle and left atrium during systole. A jet velocity less than 0.5 cm/sec is extremely low and inconsistent with severe MR. Typically, MR jet velocities are in the range of several meters per second.

Thus, a mitral regurgitant jet velocity less than 0.5 cm/sec is NOT associated with severe MR.

This is detailed in echocardiography literature discussing MR quantification and Doppler findings, emphasizing high-velocity regurgitant jets in severe MR and hemodynamic consequences seen on pulmonary vein flow and LA size .

Comprehensive and Detailed Explanation From Exact Extract:

The suprasternal long axis window is best accessed with the patient in the supine position with the neck extended. To optimize image quality, instructing the patient to turn their head slightly toward the left side moves the trachea and clavicle away from the ultrasound beam path, allowing better visualization of the aortic arch and great vessels.

Moving the probe inferior to the sternum accesses the subxiphoid window rather than suprasternal. Left lateral decubitus improves parasternal and apical windows but not suprasternal. Rotating the transducer indicator toward the patient's right shoulder would change the imaging plane but is not a primary method to improve image quality.

This technique is highlighted in the "Textbook of Clinical Echocardiography, 6e", Chapter on Echocardiographic Windows and Acoustic Access【20:90-95†Textbook of Clinical Echocardiography】.

Comprehensive and Detailed Explanation From Exact Extract:

The left atrial volume index (LAVI) is the left atrial volume normalized to the patient's body surface area (BSA), which accounts for patient size. To calculate BSA, height and weight are required, most commonly using formulas such as the Mosteller formula.

Therefore, height is a necessary parameter to calculate the left atrial volume index. Age, blood pressure, and cardiac output are not used in the calculation of LAVI but may be clinically relevant for interpretation.

This approach standardizes LA size across patients of different body habitus, making LAVI a more accurate and reproducible measure of LA remodeling and a predictor of cardiovascular outcomes.

The echocardiography guidelines and textbooks emphasize the importance of indexing LA volume to BSA and highlight height as a required measurement for this purpose .

The echocardiographic image is a four-chamber view focusing on the mitral valve apparatus. The arrow points to the anterior leaflet of the mitral valve, which is typically more prominent, triangular in shape, and located adjacent to the aortic valve in the left ventricular outflow tract region.

The posterior leaflet of the mitral valve is generally smaller, has multiple scallops, and is located posteriorly relative to the anterior leaflet. The septal leaflet is part of the tricuspid valve on the right side of the heart. The "left leaflet" is a non-specific term and not an anatomical descriptor.

This differentiation between anterior and posterior leaflets is important for understanding mitral valve pathology and for interventions such as mitral valve repair. These features are clearly explained in echocardiography texts and ASE valve imaging guidelines【12:ASE Valve Imaging Guidelines†p.180-185】【16:Textbook of Clinical Echocardiography, 6e†p.200-205】.

The echocardiographic video shows hypokinesis or akinesis of the inferolateral wall of the left ventricle. This myocardial territory is predominantly supplied by the left circumflex coronary artery.

The right coronary artery primarily supplies the inferior wall and right ventricle. The left anterior descending artery supplies the anterior and septal walls. The posterior descending artery supplies the inferior wall, usually supplied by the right coronary artery or sometimes the circumflex.

These segmental coronary territories are described in ASE stress echocardiography and regional wall motion assessment guidelines【12:ASE Stress Echocardiography Guidelines†p.300-310】【16:Textbook of Clinical Echocardiography, 6e†p.380-385】.

The mid to distal interventricular septum is supplied predominantly by the left anterior descending (LAD) coronary artery. Post-stress echocardiography showing akinesis or hypokinesis of these segments is highly suggestive of ischemia or infarction in the LAD territory.

The posterior descending artery supplies the inferior wall, the obtuse marginal supplies lateral walls, and the left circumflex supplies lateral and posterior walls.

This coronary artery segmental relationship is a cornerstone of ischemic heart disease evaluation by stress echocardiography and is well documented in ASE guidelines and clinical echocardiography literature【16:Textbook of Clinical Echocardiography, 6e†p.380-385】【12:ASE Stress Echocardiography Guidelines†p.300-310】.

The arrow points to the left coronary cusp of the aortic valve, identifiable in the short axis view as one of the three cusps. The left coronary cusp is adjacent to the left coronary artery origin and lies anteriorly.

The posterior leaflet is part of the mitral valve, septal leaflet refers to the tricuspid valve, and non-coronary cusp is another aortic cusp located posteriorly.

This identification is found in the "Textbook of Clinical Echocardiography, 6e", Chapter on Aortic Valve Anatomy【20:50-55†Textbook of Clinical Echocardiography】.