GENERAL INSTRUCTIONS: For each question, select the best answer. Select only one answer for each question unless otherwise specified.
1. What is the most common type of atrial septal defect?
(A) primum
(B) secundum
(C) sinus venosus
(D) single atrium
2. Which transducer position is most helpful in the 2-D visualization of atrial septal defects?
(A) left parasternal
(B) apical
(C) subxiphoid
(D) right parasternal
3. Partial anomalous pulmonary venous return is most commonly associated with which type of atrial septal defect?
(A) secundum
(B) primum
(C) sinus venosus
(D) coronary sinus
4. What is the most common congenital heart lesion in the pediatric population?
(A) mitral stenosis
(B) atrial septal defect
(C) ventricular septal defect
(D) pulmonary stenosis
5. A “T-sign” artifact demonstrated by _____ is useful in the detection of ventricular septal defects.
(A) M-mode
(B) 2-D
(C) pulsed-wave Doppler
(D) continuous-wave Doppler
(E) color-flow Doppler
6. A small muscular ventricular septal defect may be most easily localized by which of the following?
(A) M-mode
(B) 2-D
(C) pulsed-wave Doppler
(D) continuous-wave Doppler
(E) color-flow Doppler
7. Which of the following will not cause a reversal of flow in the descending aorta during diastole?
(A) large patent ductus arteriosus with severe pulmonary hypertension (suprasystemic pulmonary pressures)
(B) severe aortic insufficiency
(C) surgically created systemic to pulmonary shunt with normal pulmonary artery pressures
(D) large patent ductus arteriosus with normal pulmonary artery pressures
8. Which of the following may be associated with valvar aortic stenosis?
(A) patent ductus arteriosus
(B) Coarctation of the Aorta
(C) ventricular septal defect
(D) pulmonary stenosis
(E) all of the above
9. Which of the following is the most commonly associated findings in patients with Coarctation of the Aorta?
(A) ventricular septal defect
(B) bicuspid aortic valve
(C) patent ductus arteriosus
(D) aortic stenosis
(E) mitral stenosis
10. In the normally related heart, where does the aortic valve lie?
(A) anterior and to the left of the pulmonary valve
(B) anterior and to the right of the pulmonary valve
(C) posterior and to the right of the pulmonary valve
(D) posterior and to the left of the pulmonary valve
11. Which of the following surgical procedures is not frequently used to treat transposition of the great arteries?
(A) Senning procedure
(B) Mustard procedure
(C) arterial switch procedure
(D) Fontan procedure
12. Which of the following is also known as the arterial switch procedure?
(A) Rashkind procedure
(B) Mustard procedure
(C) Jatene procedure
(D) Senning procedure
13. When the aorta and pulmonary artery are transposed, they course______ as they exit the heart.
(A) parallel to each other
(B) perpendicular to each other
(C) wound around each other
(D) in no particular relationship to each other
14. Balloon atrial septostomy is most commonly performed in infants who have which of the following?
(A) Ebstein’s anomaly of the tricuspid valve
(B) transposition of the great arteries
(C) truncus arteriosus
(D) tetralogy of Fallot
15. Of all children who suffer from Kawasaki disease, what percentage will develop coronary artery aneurysms?
(A) 2%
(B) 15%
(C) 50%
(D) 75%
(E) 100%
16. Which of the following groups is most likely to develop coronary artery aneurysms as a complication of Kawasaki disease?
(A) toddlers
(B) infants
(C) adolescents
(D) adults
17. Which of the following is useful in the assessment of pulmonary artery pressure?
(A) peak Doppler gradient through a patent ductus arteriosus
(B) peak Doppler gradient of tricuspid regurgitation
(C) end-diastolic Doppler gradient of pulmonary insufficiency
(D) acceleration time to ejection time ratio calculated from a right ventricular outflow tract velocity curve
(E) all of the above are useful in estimating pulmonary artery pressure
18. A child with tetralogy of Fallot is upset and crying during the echocardiogram. The Doppler gradient through the right ventricular outflow tract will be ______than if the child were sleeping peacefully.
(A) greater
(B) less
(C) outflow obstruction in tetralogy of Fallot is not affected by the patient’s activity
19. A 3-year old child with Kawasaki disease undergoes an echocardiogram. Which of the following views is not really necessary in the 2-D evaluation of the coronary arterial system?
(A) subcostal transverse
(B) parasternal short axis
(C) apical five chamber
(D) subcostal coronal
(E) all views are helpful
20. Which of the following Doppler findings is not characteristic of Coarctation of the Aorta?
(A) forward flow through the descending aorta extending throughout diastole
(B) normal or slightly increased velocity of flow in the aorta proximal to the left subclavian artery
(C) rapid acceleration and deceleration of the Doppler signal taken from the descending aorta
(D) Doppler signal from the descending aorta does not return to baseline during diastole
(E) high-velocity flow detected in the descending aorta distal to the left subclavian artery
21. Careful echocardiographic evaluation of a child with complex congenital heart disease reveals absence of the inferior vena cava above the level of the renal arteries. The aorta is to the left of the spine. What is this child’s situs mostly likely to be?
(A) solitus
(B) inversus
(C) left atrial isomerism
(D) right atrial isomerism
22. Which of the following characteristics will be demonstrated on the aortic valve M-mode tracing from a patient with discrete membranous subaortic stenosis?
(A) an asymmetric closure line
(B) early closure and partial reopening
(C) gradual closure (drifting closed)
(D) prolonged ejection time
23. Which of the following should not be included in the differential diagnosis when a Doppler tracing such as that in Fig. 3–1 is obtained from the descending aorta?
(A) patent ductus arteriosus
(B) severe aortic regurgitation
(C) arteriovenous malformation
(D) aortic to pulmonary window
(E) Coarctation of the Aorta
FIGURE 3–1. Pulsed Doppler spectral tracing of flow in the descending aorta as obtained from the suprasternal notch view.
24. An echocardiogram was requested for a premature infant in the neonatal intensive care unit who appeared clinically to be in congestive failure and in whom a murmur was heard. The color-flow Doppler image in Fig. 3–2 was taken from the ductus view, which is a parasternal sagittal view. The closed aortic valve may be appreciated in the center of the image. What does this image demonstrate?
(A) a small patent ductus arteriosus
(B) a moderate patent ductus arteriosus
(C) a large patent ductus arteriosus
(D) no ductus arteriosus
FIGURE 3–2. Color-flow Doppler image of a modified short-axis parasternal view, known as the “ductus view.” The patient is a premature infant in congestive heart failure in whom a murmur is heard.
25. The image in Fig. 3–3 was taken from an 8-month-old female with trisomy 21. The color-flow Doppler image was taken from the subcostal four-chamber view. What does the image demonstrate?
(A) a left-to-right shunt through a primum atrial septal defect
(B) a right-to-left shunt through a primum atrial septal defect
(C) a left-to-right shunt through a secundum atrial septal defect
(D) a right-to-left shunt through a secundum atrial septal defect
(E) a normal heart
FIGURE 3–3. Color-flow Doppler image of a subcostal four-chamber view presented with the apex down (anatomically correct) presentation. The patient is an 8-month-old female with trisomy 21.
26. The images presented in Fig. 3–4 were taken from the cardiac apex of a cyanotic infant. What do these images demonstrate?
(A) a normal heart
(B) an isolated inflow ventricular septal defect
(C) single atrium
(D) tricuspid atresia with ventricular septal defect
(E) tricuspid atresia with intact ventricular septum
FIGURE 4–4. Apical four-chamber view presented with the apex down. (A) 2-D image. (B) Color-flow Doppler image. The patient is a cyanotic infant.
27. The color-flow Doppler image presented in Fig. 3–5 was taken from an 8-year-old boy with a systolic murmur. The image is of the parasternal short-axis view during early systole and demonstrates a left to right shunt through which of the following?
(A) inflow ventricular septal defect
(B) membranous ventricular septal defect
(C) muscular ventricular septal defect
(D) doubly committed subarterial ventricular septal defect
FIGURE 5–5. Color-flow Doppler image of the parasternal short-axis view at the level of the semilunar valves taken in early systole. The patient is an 8-year-old boy in whom a systolic murmur may be heard.
28. The 2-D image in Fig. 3–6 was taken from the cardiac apex. What does the image demonstrate?
(A) a normal apical four-chamber view
(B) tricuspid atresia
(C) Ebstein’s anomaly of the tricuspid valve
(D) ventricular inversion
FIGURE 6–6. 2-D image of the apical four-chamber view presented with the apex down.
29. The 2-D image of the parasternal long-axis view presented in Fig. 3–7 was taken during diastole. What does the image demonstrate?
(A) a normal heart
(B) valvular aortic stenosis
(C) discrete membranous subaortic stenosis
(D) idiopathic hypertrophic subaortic stenosis
FIGURE 7–7. 2-D image of a parasternal long-axis view taken in diastole.
30. If the left ventricular outflow tract of the patient presented in Fig. 3–7 was interrogated by pulsed-wave Doppler, what is the most proximal location at which an increase in velocity would be detected?
(A) just proximal to the aortic valve
(B) at the aortic valve
(C) just distal to the aortic valve
(D) in the aortic root
(E) distal to the left subclavian artery
31. The 2-D parasternal short-axis view image presented in Fig. 3–8 was taken from a young child who had recently had Kawasaki disease. What does this view demonstrate?
(A) left coronary artery involvement
(B) right coronary artery involvement
(C) both left and right coronary arteries are involved
(D) normal coronary arteries
FIGURE 8–8. 2-D image of a parasternal short-axis view at the level of the semilunar valves. The patient is a young child who is in the convalescent phase of Kawasaki’s disease.
32. The 2-D parasternal short-axis view image presented in Fig. 3–9 was taken from an infant who was diagnosed as having tetralogy of Fallot. What does this image demonstrate?
(A) a normal right ventricular outflow tract
(B) infundibular pulmonary stenosis only
(C) infundibular and valvular pulmonary stenosis
(D) infundibular pulmonary stenosis with hypoplasia of the pulmonary valve and main pulmonary artery
FIGURE 9–9. 2-D image of a parasternal short-axis view at the level of the semilunar valves. This infant has been diagnosed as having tetralogy of Fallot.
33. Which of the following views would not be helpful in delineating the size of left and right pulmonary arteries in the patient imaged for Fig. 3–9?
(A) suprasternal coronal view
(B) apical outflow view
(C) subcostal short axis (sagittal) view
(D) high left parasternal view
(E) all of the above views would be useful
34. Which of the following methods is most reliable for estimating pulmonary artery pressures?
(A) thickness of the right ventricular free wall
(B) determination of the peak regurgitant gradient through the tricuspid valve
(C) determination of the peak regurgitant gradient through the pulmonic view
(D) dividing the acceleration time by the ejection time of flow as obtained from the main pulmonary artery
35. In which of the following surgically created shunts is the shunt originating from the innominate artery?
(A) central
(B) Glenn
(C) Waterston
(D) Blalock-Taussig
(E) Potts
36. What is needed to estimate Qp:Qs in a patient with a ventricular septal defect?
(A) diameters and peak flow velocities through the pulmonary and aortic valves
(B) peak pressure gradient through a tricuspid regurgitation jet
(C) diameters and peak flow velocities through the tricuspid and aortic valves
(D) diameters and peak flow velocities through the pulmonary and mitral valves
37. Which of the following is true about the shunt through the atrial septal defect of a patient with tricuspid atresia?
(A) always left to right
(B) always right to left
(C) may be bidirectional
(D) nonexistent
38. The 2-D image parasternal view presented in Fig. 3–10 was taken from an adolescent girl with Marfan syndrome. What abnormalities may be seen that are frequently associated with Marfan syndrome?
(A) dilated aortic root and mitral valve prolapse
(B) aortic aneurysm dissection
(C) idiopathic hypertrophic subaortic stenosis
(D) herniation of the sinus of Valsalva
FIGURE 10–10. 2-D image of a parasternal long-axis view. The patient is an adolescent girl thought to have Marfan syndrome.
39. The 2-D image presented in Fig. 3–11 was taken from the apex in a child who has had corrective surgery for transposition of the great arteries. What does the echogenic line in the left atrium represent?
(A) cor triatriatum
(B) supramitral ring
(C) total anomalous pulmonary venous return
(D) an interatrial baffle
FIGURE 11–11. 2-D image of an apical four-chamber view presented with the apex down. This young child has had a previous repair for transposition of the great vessels.
40. If a patient has total anomalous pulmonary venous return, which of the following is descriptive of the right atrium?
(A) atretic
(B) small
(C) normal in size
(D) dilated
41. What is the most useful modality in the delineation of anatomy in total anomalous pulmonary venous return?
(A) 2-D
(B) M-mode
(C) pulsed-wave Doppler
(D) continuous-wave Doppler
(E) color-flow Doppler
TRUE OR FALSE: Indicate whether each of the following statements is true or false.
42. Patent ductus arteriosus is more commonly seen in low-birth-weight premature infants than in term infants.
43. Patency of the ductus arteriosus may be desirable in some cases.
44. In cor triatriatum, the left atrial appendage is continuous with the anatomic left atrium and not with the proximal chamber that receives flow directly from the pulmonary veins.
45. Children with trisomy 21 frequently have partial atrioventricular septal defects.
46. Patients with truncus arteriosus are usually quite cyanotic in infancy.
47. Individuals with Ebstein’s anomaly of the tricuspid valve are always symptomatic.
48. Distal coronary artery aneurysms are common in the absence of proximal aneurysm formation in patients who have had Kawasaki disease.
49. In patients with Coarctation of the Aorta, the gradient through the obstruction should approximate the difference in systolic blood pressures taken from the arm and leg of the patient.
50. Persistent left superior vena cava may exist in the absence of a dilated coronary sinus.
For each of the following transducer positions, indicate (true or false) whether the position could yield the highest pressure gradient estimate in a patient with valvular pulmonary stenosis.
51. parasternal
52. apical
53. subcostal
54. suprasternal
The 2-D image in Fig. 3–12 was obtained by placing the transducer at the cardiac apex of an infant. The infant was referred to echocardiology because of an enlarged heart on chest x-ray and cardiac failure. A systolic murmur may be heard at the apex. Indicate whether statements 55–60 are true or false for this image.
FIGURE 12–12. 2-D image of an apical four-chamber view presented with the apex down. This infant was in cardiac failure and reportedly had an enlarged heart on chest-x-ray. A systolic murmur may be heard at the apex.
55. There is a secundum atrial septal defect.
56. There is a primum atrial septal defect.
57. The tricuspid valve appears normal.
58. The left ventricle is significantly smaller in size than the right ventricle.
59. The diagnosis for this patient is Ebstein’s anomaly of the tricuspid valve.
60. The systolic murmur is probably caused by aortic stenosis.