Pass the ARDMS RDCS AE-Adult-Echocardiography Questions and answers with CertsForce

Comprehensive and Detailed Explanation From Exact Extract:

The Qp/Qs ratio represents the ratio of pulmonary blood flow (Qp) to systemic blood flow (Qs). It is commonly calculated to quantify the magnitude of a left-to-right shunt in congenital heart disease.

To calculate Qp/Qs using echocardiography, stroke volumes across both the pulmonary and systemic outflow tracts are measured by combining the cross-sectional area of the outflow tract and the velocity time integral (VTI) of flow through it.

Pulmonary blood flow (Qp) is calculated using the right ventricular outflow tract (RVOT) diameter and RVOT VTI. Systemic blood flow (Qs) is calculated using the left ventricular outflow tract (LVOT) diameter and aortic valve VTI.

Thus, RVOT VTI is essential for Qp calculation, making option D correct.

This method is explained in detail in the "Textbook of Clinical Echocardiography, 6e", Chapter on Congenital Shunts and Quantification of Flow【20:360-365†Textbook of Clinical Echocardiography】.

The Valsalva maneuver transiently reduces preload, which can unmask or exaggerate diastolic dysfunction during mitral inflow Doppler assessment. During Valsalva, changes in mitral E and A wave velocities can differentiate between normal and pseudonormal filling patterns by observing alterations in filling pressures.

Hand grip, leg air cycling, and squatting affect afterload and preload differently but are less specific for assessing diastolic dysfunction via mitral Doppler.

This technique is outlined in the "Textbook of Clinical Echocardiography, 6e", Chapter on Diastolic Function Assessment and Maneuvers【20:210-215†Textbook of Clinical Echocardiography】.

Acoustic shadowing is the artifact caused by calcified structures like the mitral annulus, resulting in attenuation or loss of echoes from structures posterior to the calcification. The calcification absorbs or reflects the ultrasound waves, preventing them from reaching deeper structures and causing a "dropout" or dark shadow behind the calcified area.

Reverberation involves repeated reflections creating multiple echoes. Side lobe artifacts arise from off-axis beams. Ring-down artifacts result from resonance in fluid or gas bubbles, not calcifications.

This artifact is explained in the "Textbook of Clinical Echocardiography, 6e", Chapter on Ultrasound Artifacts【20:75-80†Textbook of Clinical Echocardiography】.QUESTION NO: 134

What is the range of the aortic valve area in normal adults?

A. 1 - 2 cm2

B. 3 - 4cm2

C. 5 - 6cm2

D. 7- 8cm2

Answer: B

Comprehensive and Detailed Explanation From Exact Extract:

The normal aortic valve area (AVA) in adults typically ranges from 3 to 4 cm². This measurement is important for assessing aortic stenosis severity; values below this range suggest valve narrowing.

AVA values of 1-2 cm² indicate mild to moderate stenosis, while less than 1 cm² reflects severe stenosis. Larger areas like 5-6 or 7-8 cm² are not physiologically typical.

This normal range is documented in the "Textbook of Clinical Echocardiography, 6e", Chapter on Aortic Valve Anatomy and Function【20:360-365†Textbook of Clinical Echocardiography】.

Osler nodes are tender, erythematous nodules typically located on the fingers and toes, and are a classic sign of infective endocarditis (IE). They represent immune complex deposition and microemboli causing localized vasculitis.

Carcinoid heart disease presents with right-sided valve fibrosis and not with Osler nodes. Lambl excrescences are small filiform valvular strands without clinical manifestations such as Osler nodes. Papillary fibroelastomas are benign cardiac tumors that may cause emboli but not immune-mediated skin lesions.

This classic clinical sign and its echocardiographic correlation in IE are discussed in the "Textbook of Clinical Echocardiography, 6e", Chapter on Infective Endocarditis【20:400-405†Textbook of Clinical Echocardiography】.

The echocardiographic image shows a mobile, highly echogenic, mesh-like structure within the right atrium consistent with the Chiari network. The Chiari network is an embryologic remnant of the right valve of the sinus venosus, appearing as a fenestrated, reticulated membrane that is usually thin and mobile, found near the orifice of the inferior vena cava or the coronary sinus.

This structure is benign and often an incidental finding but can be confused with thrombus or atrial tumors. Unlike left atrial thrombus, which appears as a more solid, immobile mass often located in the left atrial appendage, the Chiari network is mobile and located in the right atrium. Cor triatriatum is a rare congenital membrane dividing the left atrium into two chambers and appears differently on echocardiography. Artifact refers to non-anatomic echoes which do not persist or move consistently.

Recognition of Chiari network is important to avoid misdiagnosis, and its characteristics are well described in echocardiography literature such as the "Textbook of Clinical Echocardiography" and ASE imaging guidelines【16:Textbook of Clinical Echocardiography, 6e†p.400-402】【12:ASE Guidelines on Cardiac Masses†p.150-155】.

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 .

The combination of chronic elevated Wood units (indicative of pulmonary hypertension), severe back pain, and a new diastolic murmur strongly suggests an acute aortic dissection involving the ascending aorta or aortic valve.

Aortic dissection can cause tearing of the intima and compromise the aortic valve, leading to acute aortic regurgitation manifesting as a new diastolic murmur. Back pain is a classic symptom due to the dissection extending along the aorta.

Aortic aneurysm may cause symptoms but usually not acute severe pain and murmur. Left ventricular rupture and ruptured papillary muscle are typically complications of myocardial infarction and present differently.

This clinical presentation and echocardiographic assessment are described in the "Textbook of Clinical Echocardiography, 6e", Chapter on Aortic Pathology and Emergencies【20:380-385†Textbook of Clinical Echocardiography】.

Comprehensive and Detailed Explanation From Exact Extract:

Contrast echocardiography is recommended to enhance the visualization of left ventricular endocardial borders when the image quality is suboptimal. Specifically, contrast agents should be used when at least three contiguous left ventricular segments are poorly visualized on standard two-dimensional imaging. This approach improves the accuracy and reliability of assessing regional wall motion and global systolic function.

The use of contrast is particularly important during stress echocardiography to ensure detection of ischemic segments, which might otherwise be missed due to inadequate image quality. Studies suggest that contrast enhancement is required in approximately 30% to 50% of stress echocardiographic studies depending on patient factors and laboratory practices.

These recommendations are detailed in the echocardiography guidelines and in the "Textbook of Clinical Echocardiography, 6e" (Chapter 8: Coronary Artery Disease and Stress Echocardiography) which emphasize the utility of contrast agents for better endocardial border definition when at least three segments are not clearly seen .

Comprehensive and Detailed Explanation From Exact Extract:

Constrictive pericarditis is characterized by thickening and fibrosis of the pericardium which restricts diastolic filling of the ventricles. Key echocardiographic features include a characteristic interventricular septal "bounce" or shift during early diastole due to the abrupt cessation of ventricular filling imposed by the rigid pericardium. This septal bounce reflects rapid early diastolic filling followed by a sudden halt as filling pressures equalize, a hallmark of constriction physiology.

Additionally, Doppler studies show marked respiratory variation in mitral and tricuspid inflow velocities (>25%), with an inspiratory increase in tricuspid inflow and a decrease in mitral inflow velocity, reflecting ventricular interdependence caused by the noncompliant pericardium. The mitral inflow typically shows a large E-wave with a small or absent A-wave and a steep deceleration slope, but importantly these velocities vary significantly with respiration, which is not the case in restrictive cardiomyopathy.

Hepatic vein Doppler often reveals a prominent a-wave and a deep y-descent with increased diastolic flow reversal during expiration, indicating elevated right atrial pressures and constrictive physiology.

The inferior vena cava (IVC) is usually dilated and shows no inspiratory collapse (i.e., no normal collapse with sniff test) because of elevated right atrial pressure and impaired venous return.

Therefore:

Option A is incorrect because mitral inflow in constrictive pericarditis shows significant respiratory variation, not absence of it.

Option B is incorrect because the hepatic vein is typically dilated with abnormal flow patterns, not normal size.

Option C is incorrect because the IVC is dilated and does NOT collapse normally with inspiration/sniff in constrictive pericarditis.

Option D is correct because the interventricular septal bounce is a classic feature reflecting ventricular interdependence and constrictive physiology.

These findings are summarized in the "Textbook of Clinical Echocardiography, 6e" (Catherine M. Otto, MD), Chapter 10 (Pericardial Disease), pages 280–285, with key illustrations showing septal bounce, Doppler inflow variations, hepatic vein flow patterns, and IVC findings in constrictive pericarditis. The "Mayo Clinic criteria" for echocardiographic diagnosis also emphasize ventricular septal shift as a critical feature, often combined with tissue Doppler annular velocity patterns and hepatic vein diastolic flow reversal for high diagnostic accuracy.

The mitral valve filling pattern characterized by a long deceleration time and a reduced E/A ratio (less than 1, such as 0.6) is consistent with impaired relaxation. This pattern is typically seen in early diastolic dysfunction, where there is slowed ventricular relaxation, resulting in reduced early diastolic filling (E wave) and a compensatory increase in atrial contraction contribution (A wave).

Impaired relaxation pattern shows:

E/A ratio < 1 (e.g., 0.6)

Prolonged deceleration time (>200 ms)

Prolonged isovolumic relaxation time (IVRT)

This pattern differs from restrictive filling, which has a high E/A ratio (>2), shortened deceleration time (<150 ms), and elevated left atrial pressures. Pseudonormal filling has a normal or near-normal E/A ratio but elevated filling pressures that mask underlying dysfunction and requires further evaluation with tissue Doppler or pulmonary venous flow for diagnosis. Normal filling has a typical E/A ratio around 1 to 1.5 with normal deceleration times.

The textbook details that impaired relaxation is the earliest sign of diastolic dysfunction and describes the prolongation of the deceleration time and reduced E/A ratio as hallmark findings of this stage.