CCI RCS 4 — Questions and Answers
Question 1: During a dobutamine stress echocardiogram, a new wall motion abnormality appears at peak stress in the mid-inferior wall. This suggests ischemia in the territory of which coronary artery?
- Left anterior descending artery
- Right coronary artery (Correct answer)
- Left circumflex artery
- Left main coronary artery
Correct answer: Right coronary artery
The mid-inferior wall is supplied by the right coronary artery (RCA) in right-dominant circulations, the most common coronary anatomy.
Question 2: A patient with an atrial septal defect (ASD) shows a dilated right ventricle and flattening of the interventricular septum in diastole. This septal morphology indicates:
- Left ventricular volume overload
- Right ventricular volume overload (Correct answer)
- Right ventricular pressure overload
- Biventricular pressure overload
Correct answer: Right ventricular volume overload
Diastolic septal flattening (D-shaped LV in short axis) indicates right ventricular volume overload, as seen in large ASDs with significant left-to-right shunting.
Question 3: Which echocardiographic measurement is used to calculate Qp/Qs (pulmonary-to-systemic flow ratio) noninvasively?
- Peak LVOT and RVOT velocities
- RVOT VTI × RVOT area divided by LVOT VTI × LVOT area (Correct answer)
- Tricuspid annular plane systolic excursion divided by mitral annular plane systolic excursion
- Peak mitral E velocity divided by peak tricuspid E velocity
Correct answer: RVOT VTI × RVOT area divided by LVOT VTI × LVOT area
Qp/Qs = (RVOT VTI × RVOT CSA) ÷ (LVOT VTI × LVOT CSA), using stroke volumes through the pulmonic and aortic valves respectively.
Question 4: Which measurement on M-mode echocardiography is used to calculate fractional shortening (FS)?
- LV end-diastolic and end-systolic volumes
- LV end-diastolic and end-systolic internal dimensions (Correct answer)
- LV posterior wall and septal thicknesses
- Left atrial and aortic root dimensions
Correct answer: LV end-diastolic and end-systolic internal dimensions
FS = (LVIDd – LVIDs) ÷ LVIDd × 100%, using M-mode LV internal dimensions at end-diastole and end-systole.
Question 5: A 'smoke-like' spontaneous echo contrast is observed in the left atrium during TEE. This finding is associated with:
- Increased cardiac output
- Increased risk of thrombus formation and systemic embolism (Correct answer)
- Normal variant in athletes
- Pericardial effusion
Correct answer: Increased risk of thrombus formation and systemic embolism
Left atrial spontaneous echo contrast ('smoke') reflects blood stasis due to low-flow states such as atrial fibrillation and is associated with thromboembolic risk.
Question 6: The hepatic vein Doppler waveform shows blunted systolic filling fraction and systolic flow reversal. This pattern is MOST consistent with:
- Severe tricuspid regurgitation (Correct answer)
- Severe mitral regurgitation
- Cardiac tamponade
- Constrictive pericarditis
Correct answer: Severe tricuspid regurgitation
Severe tricuspid regurgitation causes systolic flow reversal in the hepatic veins as regurgitant volume is transmitted backward into the right atrium and venous system.
Question 7: Which structure is identified by its characteristic 'seagull' appearance on parasternal long-axis echocardiography in a patient with rheumatic mitral stenosis?
- Thickened, fused mitral leaflet tips with diastolic doming (Correct answer)
- Calcified aortic valve leaflets
- Thickened pericardium
- Dilated coronary sinus
Correct answer: Thickened, fused mitral leaflet tips with diastolic doming
Rheumatic mitral stenosis causes commissural fusion and leaflet thickening, producing characteristic diastolic doming ('hockey stick' or 'seagull' appearance) on 2D echo.
CCI RCS 4
During a dobutamine stress echocardiogram, a new wall motion abnormality appears at peak stress in the mid-inferior wall.
This suggests ischemia in the territory of which coronary artery?