CCI Valvular Pathology Assessment 5 — Questions and Answers
Question 1: A patient with mitral valve prolapse and a flail posterior leaflet has a regurgitant volume of 72 mL/beat. According to ASE guidelines, this represents:
- Severe mitral regurgitation (≥60 mL/beat) (Correct answer)
- Moderate mitral regurgitation (30–59 mL/beat)
- Mild mitral regurgitation (<30 mL/beat)
- Moderate-to-severe mitral regurgitation (45–59 mL/beat)
Correct answer: Severe mitral regurgitation (≥60 mL/beat)
Regurgitant volume ≥60 mL per beat meets the quantitative threshold for severe mitral regurgitation according to 2017 ASE valve guidelines.
Question 2: Which of the following is the most common cause of aortic stenosis in patients younger than 70 years in the United States?
- Bicuspid aortic valve disease (Correct answer)
- Rheumatic disease
- Degenerative calcific disease
- Infective endocarditis
Correct answer: Bicuspid aortic valve disease
Bicuspid aortic valve, occurring in 1–2% of the population, is the most common cause of aortic stenosis requiring surgery in patients under 70 years of age in developed countries.
Question 3: In assessing pulmonic stenosis severity, a peak instantaneous Doppler gradient of 65 mmHg indicates:
- Severe pulmonic stenosis (>64 mmHg) (Correct answer)
- Mild pulmonic stenosis (<36 mmHg)
- Moderate pulmonic stenosis (36–64 mmHg)
- Trivial pulmonic stenosis
Correct answer: Severe pulmonic stenosis (>64 mmHg)
A peak gradient exceeding 64 mmHg defines severe pulmonic stenosis; these patients typically qualify for percutaneous balloon pulmonic valvuloplasty.
Question 4: Which finding on intraoperative transesophageal echocardiography (TEE) after mitral valve repair would prompt the surgeon to return to bypass for revision?
- Residual mitral regurgitation >2+ (moderate or greater) (Correct answer)
- Trivial residual MR on color Doppler
- Mean mitral gradient of 3 mmHg post-repair
- Left ventricular EF of 55% post-bypass
Correct answer: Residual mitral regurgitation >2+ (moderate or greater)
Residual MR of moderate or greater severity (>2+) after mitral repair is an indication to return to cardiopulmonary bypass for revision, as significant residual MR predicts early repair failure.
Question 5: In a patient with suspected aortic stenosis and atrial fibrillation, which adaptation to the Doppler technique improves AVA accuracy?
- Averaging gradients and VTI over at least 5 cardiac cycles to account for beat-to-beat variability (Correct answer)
- Using the highest single-beat gradient recorded
- Measuring only during sinus beats if AV node is conducting
- Applying pressure half-time instead of continuity equation
Correct answer: Averaging gradients and VTI over at least 5 cardiac cycles to account for beat-to-beat variability
In atrial fibrillation, stroke volume varies cycle to cycle; averaging Doppler measurements over a minimum of 5 beats reduces variability and improves reliability of the continuity equation AVA.
Question 6: The PISA (proximal isovelocity surface area) method assumes that the convergence zone proximal to a regurgitant orifice has what geometric shape?
- Hemispheric shell (Correct answer)
- Cylindrical tube
- Ellipsoid
- Flat disk
Correct answer: Hemispheric shell
PISA assumes that blood converges toward a regurgitant orifice in concentric hemispheric shells of equal velocity, allowing flow rate calculation as 2π × r² × aliasing velocity.
Question 7: Which congenital cardiac lesion most commonly produces isolated pulmonic regurgitation in adults?
- Prior surgical or balloon repair of pulmonic stenosis or tetralogy of Fallot (Correct answer)
- Bicuspid pulmonic valve
- Rheumatic heart disease involving the pulmonic valve
- Carcinoid heart disease
Correct answer: Prior surgical or balloon repair of pulmonic stenosis or tetralogy of Fallot
The most common cause of significant pulmonic regurgitation in adults is iatrogenic, resulting from prior repair of pulmonic stenosis or right ventricular outflow tract reconstruction in tetralogy of Fallot.
CCI Valvular Pathology Assessment 5
A patient with mitral valve prolapse and a flail posterior leaflet has a regurgitant volume of 72 mL/beat.
According to ASE guidelines, this represents: