Sample Questions

Explanation

Normokinesia can be defined visually as myocardial systolic thickening ≥50% or systolic excursion > 5mm

Explanation

The right side of the heart is identified by relative positions of the atrioventricular valves (apical displacement of the tricuspid valve relative to the mitral valve)
LV systolic function is visually preserved

Explanation

Aortic valve M mode demonstrates normal cusp motion during diastole (cusp closure and line joining) and systole (cusp opening and line separation)

Explanation

Mild AR: EROA < 0.1cm²
Moderate AR: EROA 0.1 - 0.3cm²
Severe AR: EROA > 0.3cm²

Explanation

The law of conservation of mass states that in a closed system, mass cannot be created or destroyed. The PISA method (also known as the flow convergence method) uses the continuity equation to calculate regurgitant orifice area and is therefore an example of the law of conservation of mass

Explanation

In contrast, calculation of AR volume by the flow continuity equation (based on the law of conservation of mass) compares stroke volume across the mitral valve and LVOT stroke volume. AR volume = LVOT SV - MV SV

Explanation

Antegrade systolic flow is identified by flow away from the probe (blue on color doppler). Retrograde diastolic flow is identified by flow towards the probe (red on color doppler) 
The duration of flow can be estimated using the ECG markings to identify systole (between R wave and middle of T wave) and diastole (from middle of T wave to R wave)

Explanation

There are two formulae for Dimensionless Index (DI): 

1.     DI = LVOT VTI / Aortic valve VTI 
2.     DI = LVOT Vmax / Aortic valve Vmax 

DI 0.25 - 0.5 is suggestive of moderate AS 
DI < 0.25 is suggestive of severe AS

Explanation

This is a common error due to:
1. Often elliptical shape of the LVOT rather than circular
2. Measurement of anteroposterior LVOT diameter in parasternal long axis while the largest diameter may be in fact be lateral 

Underestimation of LVOT diameter results in underestimation of AVA (aortic valve area) and therefore overestimation of AS severity

Explanation

Severe AS overestimates MR severity due to elevation of left ventricular pressure with resultant increase in transmitral pressure gradient and appearance of larger MR jet on color doppler

Explanation

LVEF is moderately impaired (35%) and Stroke Volume index (SVi) is impaired (29.3mls/m²)
Classic LFLG AS is associated with impaired LVEF and SVi
In contrast paradoxical LFLG AS is associated with preserved LVEF and impaired SVi 

LVOT SV = LVOT cross sectional area (πr²) x LVOT VTI  and LVOT SVi = LVOT SV / BSA 
Therefore LVOT SV = π1²  x  16.8
LVOT SV = 52.67 mls
LVOT SVi = 52.67 / 1.8 = 29.3mls/m²

Explanation

Mitral valve scallops visible on apical and parasternal views are as follows: 

Apical 2 chamber (A2C) : P1A2P3
Apical 3 chamber (A3C): A2P2
Apical 4 chamber (A4C): P1A2A3
Parasternal long axis (PLAX): A2P2
Parasternal short axis (PSAX): All scallops

Explanation

Calculation of Mitral Valve Area (MVA) by Pressure Half Time (PHT) method is given by the following formula: 
MVA = 220 / PHT 

The doppler waveform demonstrated here is biphasic which can suggest atrial fibrillation or severe MS
By convention the slope is traced from the peak of the waveform and does not include the second peak

Explanation

HCM-SCD risk score calculators use the following datapoints: 

1. Age at time of evaluation
2. Family history of SCD
3. Max ventricular wall thickness 
4. Left atrial diameter in PLAX
5. Maximum LVOT gradient
6. Non sustained or Sustained VT 
7. Unexplained syncope

Explanation

Restrictive cardiomyopathy (RCM) and constrictive pericarditis (CP) are distinguished by the following echo parameters: 

• Septal and lateral E' (or e'): Reduced (<7cm/s) in RCM. Normal (>7cm/s) in CP 
• E/E' ratio (or E/e ratio): Typically increased in both conditions 
• Respiratory variation of mitral and tricuspid inflow: Exaggerated in CP. Normal in RCM 
• Pulmonary venous Doppler: 
• Interventricular septal motion: "Jerky" septal motion in CP, normal in RCM 
• Pericardium: CP is associated with pericardial thickening +/- pericardial effusion 
•  

Explanation

Grade 0 diastolic dysfunction: E/A ratio typically 1-2 
Grade I diastolic dysfunction: E/A ratio reduced, typically < 1 
Grade II diastolic dysfunction: E/A ratio pseudonormalised, typically 1-2 
Grade III diastolic dysfunction: E/A ratio increased, > 2 
Grade IV diastolic dysfunction: E/A ratio increased, > 2

Explanation

Grade 0 diastolic dysfunction (normal diastolic function): 
E/A ratio normal, typically 1-2
Septal E' (also known as Septal e) > 8 cm/s 
Septal E/e < 10 

Grade I diastolic dysfunction:
E/A ratio reduced, typically < 1
Septal E' (also known as Septal e) < 8 cm/s 
Septal E/e < 10 

Grade II diastolic dysfunction:
E/A ratio pseudonormalised, typically 1-2
Septal E' (also known as Septal e) < 8 cm / s 
Septal E/e > 10 

Grade III diastolic dysfunction:
E/A ratio increased, > 2
Septal E' (also known as Septal e) < 8 cm/s 
Septal E/e > 10 

Grade IV diastolic dysfunction:
E/A ratio increased, > 2
Septal E' (also known as Septal e) 
Septal E/e > 10

Explanation

This waveform demonstrates diastolic dysfunction. Overall the data are suggestive of grade II diastolic dysfunction

• PVs > PVd. Pulmonary vein S/D ratio < 1  is indicative of grade II diastolic dysfunction and above
• adur > Adur, with difference < 30msec, consistent with either grade I or II diastolic dysfunction
• PVa < 35cm/s (<0.35 m/s) which is consistent with grade I and II dysfunction 

Explanation

Respiratory variation requires visualization of a greater number of inflow waveforms to assess for changes during inspiration and expiration.
Decreasing sweep speed increases the number of visible waveforms and thus allows accurate assessment for variation of flow over a greater time period

Explanation

Bicuspid aortic valve is demonstrated with approximately horizontal commissural line (anterior / posterior orientation) 
Bicuspid aortic valve occurs in 1-2% of the general population. Bicuspid aortic valve morphology is classified by the Sievers classification