CET Case Analysis & Practical Application 2 ā Questions and Answers
Question 1: A 65-year-old patient with dyspnea shows a parasternal long-axis view with a dilated left ventricle, reduced wall motion, and an EF of 25%. The mitral valve appears to have incomplete leaflet coaptation. Which condition best explains these findings?
- Primary mitral valve prolapse
- Functional mitral regurgitation due to dilated cardiomyopathy (Correct answer)
- Hypertrophic obstructive cardiomyopathy
- Rheumatic mitral stenosis
Correct answer: Functional mitral regurgitation due to dilated cardiomyopathy
Dilated cardiomyopathy causes annular dilation and papillary muscle displacement, leading to functional (secondary) mitral regurgitation with incomplete leaflet coaptation.
Question 2: During a stress echo, a patient develops new regional wall motion abnormality in the mid-anterior and anteroseptal segments at peak stress that was absent at rest. Which coronary artery territory is most likely ischemic?
- Right coronary artery
- Left circumflex artery
- Left anterior descending artery (Correct answer)
- Posterior descending artery
Correct answer: Left anterior descending artery
The mid-anterior and anteroseptal walls are supplied by the LAD; new WMA in these segments at stress indicates LAD territory ischemia.
Question 3: A neonate presents with cyanosis. Echo shows a large VSD, an overriding aorta, right ventricular hypertrophy, and pulmonary stenosis. Which diagnosis does this constellation represent?
- Transposition of the great arteries
- Truncus arteriosus
- Tetralogy of Fallot (Correct answer)
- Total anomalous pulmonary venous return
Correct answer: Tetralogy of Fallot
The four components describedāVSD, overriding aorta, RVH, and pulmonary stenosisāare the classic tetrad of Tetralogy of Fallot.
Question 4: A patient recovering from a large anterior MI is found to have a thin, akinetic apical segment that bulges outward during systole. Color Doppler shows slow swirling flow within this segment. What complication has developed?
- Ventricular septal rupture
- Left ventricular pseudoaneurysm
- True left ventricular aneurysm with thrombus risk (Correct answer)
- Papillary muscle rupture
Correct answer: True left ventricular aneurysm with thrombus risk
A dyskinetic, thin-walled apical segment post-MI represents a true LV aneurysm; slow swirling flow indicates stagnant blood with high thrombus risk.
Question 5: On TEE, a patient with atrial fibrillation scheduled for cardioversion shows a spontaneous echo contrast ('smoke') in the left atrial appendage but no discrete thrombus. What is the most appropriate next step based on echocardiographic findings?
- Proceed immediately with cardioversion; smoke alone is not a contraindication
- Report the finding as normal for AF patients
- Defer cardioversion and extend anticoagulation, as smoke indicates stasis and elevated thrombus risk (Correct answer)
- Repeat TTE in 48 hours
Correct answer: Defer cardioversion and extend anticoagulation, as smoke indicates stasis and elevated thrombus risk
Spontaneous echo contrast represents red cell aggregation due to stasis and is associated with thromboembolic risk, indicating the need for extended anticoagulation before cardioversion.
Question 6: A patient presents with fever, bacteremia, and a new holosystolic murmur. TEE reveals an oscillating echodense mass attached to the atrial side of the posterior mitral leaflet. What is the most likely diagnosis?
- Myxoma
- Mitral annular calcification
- Mitral valve endocarditis vegetation (Correct answer)
- Papillary fibroelastoma
Correct answer: Mitral valve endocarditis vegetation
An oscillating mass on the atrial side of the mitral leaflet in a febrile patient with bacteremia is classic for infective endocarditis vegetation.
Question 7: A 72-year-old patient with exertional syncope has a peak instantaneous gradient of 72 mmHg across the aortic valve and an AVA of 0.7 cmĀ² by continuity equation. The LVEF is 60%. How should these findings be classified?
- Mild aortic stenosis
- Moderate aortic stenosis
- Severe aortic stenosis (Correct answer)
- Very mild aortic stenosis with preserved flow
Correct answer: Severe aortic stenosis
An AVA ā¤0.8 cmĀ² and mean gradient typically >40 mmHg (peak >64 mmHg) with preserved EF fulfill criteria for severe aortic stenosis.
CET Case Analysis & Practical Application 2
A 65-year-old patient with dyspnea shows a parasternal long-axis view with a dilated left ventricle, reduced wall motion, and an EF of 25%.
The mitral valve appears to have incomplete leaflet coaptation.
Which condition best explains these findings?