CET Case Analysis & Practical Application 3 — Questions and Answers
Question 1: A patient with known hypertension has concentric LV hypertrophy (relative wall thickness 0.52) with normal cavity size and an EF of 65%. Diastolic assessment shows E/e' ratio of 16 and LAVi of 38 mL/m². What grade of diastolic dysfunction is present?
- Normal diastolic function
- Grade I (impaired relaxation)
- Grade II (pseudonormal) (Correct answer)
- Grade III (restrictive)
Correct answer: Grade II (pseudonormal)
E/e' >14 combined with enlarged LAVi in a patient with LVH and normal EF meets criteria for Grade II (pseudonormal/moderate) diastolic dysfunction.
Question 2: During examination of a premature infant, you identify a continuous 'machinery' murmur and echo demonstrates a tubular connection between the descending aorta and the pulmonary artery with left-to-right shunting. What structure has failed to close?
- Foramen ovale
- Ductus venosus
- Patent ductus arteriosus (Correct answer)
- Aortopulmonary window
Correct answer: Patent ductus arteriosus
Persistence of the ductus arteriosus after birth creates the classic continuous murmur and aorta-to-pulmonary artery shunt seen in PDA.
Question 3: A patient with systemic lupus erythematosus has small, irregular, non-mobile vegetations on both surfaces of the mitral and aortic valves. Cultures are negative. Which condition should be suspected?
- Infective endocarditis
- Libman-Sacks endocarditis (Correct answer)
- Carcinoid heart disease
- Marantic endocarditis
Correct answer: Libman-Sacks endocarditis
Libman-Sacks endocarditis is the non-bacterial thrombotic endocarditis associated with SLE, characterized by small verrucous lesions on both valve surfaces.
Question 4: On 2D echo, a patient with chest pain has an aortic root measuring 5.2 cm at the sinuses of Valsalva with a Type A dissection flap visible on TEE extending into the ascending aorta. The aortic valve shows moderate AR. Which is the most critical immediate finding to report?
- Moderate aortic regurgitation
- Dilated aortic root
- Dissection flap in the ascending aorta (Type A) (Correct answer)
- Normal LV function
Correct answer: Dissection flap in the ascending aorta (Type A)
Type A aortic dissection involving the ascending aorta is a surgical emergency requiring immediate reporting as it carries high mortality without intervention.
Question 5: A 55-year-old with progressive dyspnea shows echo findings of right heart enlargement, RV pressure overload pattern (D-shaped septum in systole), tricuspid regurgitation with peak velocity 4.5 m/s, and no left-sided disease. What condition should be the primary consideration?
- Left ventricular systolic failure with pulmonary edema
- Pulmonary arterial hypertension (Correct answer)
- Pericardial effusion causing tamponade
- Ebstein anomaly
Correct answer: Pulmonary arterial hypertension
TR jet velocity of 4.5 m/s yields an estimated RVSP of >80 mmHg, and the septal flattening with RV enlargement without left-sided cause points to pulmonary arterial hypertension.
Question 6: A patient post-cardiac surgery presents with hypotension, elevated JVP, and muffled heart sounds. Echo shows a moderate circumferential pericardial effusion with right atrial collapse lasting more than one-third of systole and right ventricular diastolic collapse. What hemodynamic state is present?
- Constrictive pericarditis
- Restrictive cardiomyopathy
- Cardiac tamponade (Correct answer)
- Severe biventricular failure
Correct answer: Cardiac tamponade
RA collapse >1/3 systole and RV diastolic collapse with circumferential effusion and clinical signs indicate cardiac tamponade physiology.
Question 7: Spectral Doppler across a bioprosthetic mitral valve shows mean gradient of 8 mmHg and PHT of 230 ms. Effective orifice area by PHT is 0.96 cm². How should this prosthetic valve be assessed?
- Normal bioprosthetic function
- Possible prosthetic mitral stenosis warranting further evaluation (Correct answer)
- Severe prosthetic regurgitation
- Normal findings consistent with a mechanical valve
Correct answer: Possible prosthetic mitral stenosis warranting further evaluation
PHT >200 ms and elevated mean gradient for a bioprosthetic mitral valve suggest possible prosthetic stenosis and warrant correlation with clinical findings and prior studies.
CET Case Analysis & Practical Application 3
A patient with known hypertension has concentric LV hypertrophy (relative wall thickness 0.52) with normal cavity size and an EF of 65%.
Diastolic assessment shows E/e' ratio of 16 and LAVi of 38 mL/m².
What grade of diastolic dysfunction is present?