1. Correct Answer: D. Moderator band

Rationale: The moderator band (also known as the septomarginal trabecula) is a muscular structure that connects the interventricular septum with the anterolateral wall of the right ventricle. During contraction together with anterior papillary muscle it prevents the tricuspid regurgitation through applying tension on the chordae tendineae. False tendon is usually found in the left ventricle. There is a normal level of insertion of tricuspid valve, so Ebstein anomaly is incorrect. Moderator band has a myocardial-like echogenicity and contracts synchronously with the rest of the ventricle, making a diagnosis of thrombus and/or artifact very unlikely.

1. Lee J-Y, Hur M-S. Morphological classification of the moderator band and its relationship with the anterior papillary muscle. Anat Cell Biol. 2019 Mar;52(1):38-42.

2. Correct Answer: D. Eustachian valve

Rationale/Critique: The transthoracic parasternal RV inflow view demonstrates the right atrium and right ventricle with the arrow pointing to the Eustachian valve at the cavoatrial junction. The Eustachian valve may be a nidus for thrombus or infection. Cor triatriatum is more frequently associated with the left atrium and is typically seen as a thin membrane that crosses from the atrial septum in the region of the fossa ovalis to the lateral wall of the atrium. A Chiari network is a right atrial structure typically seen as a mobile thin reticulated network of fibers originating from the Eustachian valve, occasionally fenestrated, connecting to various parts of the right atrium. An atrial myxoma is more likely to be seen as a pedunculated rounded mass more frequently arising from the septum. However, myxomas have been reported to arise from a Eustachian valve.

1. Onwuanyi AE, Brown RJ, Vahedi M, Narayanan R, Nash IS, Goldman ME. Eustachian valve thrombus: critical factor in outcome of venous thromboembolism. Echocardiography. 2003;20(1):71-73.

3. Correct Answer: C. Pressure half-time (PHT) of the aortic valve regurgitant jet

Rationale: Numerous modalities exist to help quantify regurgitant jets. Figure 29.3 displays an apical four-chamber TTE view of the left ventricle with continuous-wave Doppler interrogating the aortic valve. The resulting “jets” point up or toward the probe, in this view indicating flow into the left ventricle, and in diastole, consistent with aortic regurgitation. In this case, the calipers are measuring the downward slope of the jet used for calculating the PHT. PHT more specifically measures the interval between the maximal transvalvular gradient and when it is half the maximum. Computer analysis determines PHT from the slope, with a value of <200 ms suggesting severe aortic regurgitation. PHT can be affected by LV compliance, systemic vascular resistance, and aortic compliance. Increasing LV diastolic pressure shortens PHT while the chronic adaptation to severe aortic regurgitation prolongs PHT.

1. Cohen IS. Aortic regurgitation. In: Perrino AC, Reeves ST, eds. A Practical Approach to Transesophageal Echocardiography. 2nd ed. Wolters Kluwer; 2008:226-240.

2. de Marchi SF, Windecker S, Aeschbacher BC, Seiler C. Influence of left ventricular relaxation on the pressure half time of aortic regurgitation. Heart. 1999;82(5):607-613.

3. Zoghbi WA, Adams D, Bonow RO, et al. Recommendations for noninvasive evaluation of native valvular regurgitation: a report from the American Society of Echocardiography developed in collaboration with the society for cardiovascular magnetic resonance. J Am Soc Echocardiogr. 2017;30(4):303-371.

4. Correct Answer: B. Percutaneous device closure

Rationale: The primary variant demonstrated in this case is a PFO. Up to 40% of all ischemic strokes are considered cryptogenic, implying a stroke without a definitive etiology, and a PFO is found in half of younger patients (<60 years) with a cryptogenic stroke. PFOs are reported in up to 29% of the population. Device closure is frequently indicated in the setting of PFO history of cryptogenic strokes

There is no mention of wall motion abnormalities or other signs of coronary disease; hence, bypass surgery is not indicated. Pulmonary thromboendarterectomy is indicated in chronic thromboembolic pulmonary hypertension, which is not described in the case patient. Though stroke may be related to left atrial appendage thrombus, the case patient has no data indicating this as her source.

1. Hagen PT, Scholz DG, Edwards WD. Incidence and size of patent foramen ovale during the first 10 decades of life: an autopsy study of 965 normal hearts. Mayo Clin Proc. 1984;59:17-20.

2. Kent DM, Dahabreh IJ, Ruthazer R, et al. Device closure of patent foramen ovale after stroke: pooled analysis of completed randomized trials. J Am Coll Cardiol. 2016;67:907-917.

3. Kerut EK, Norfleet WT, Plotnick GD, Giles TD. Patent foramen ovale: a review of associated conditions and the impact of physiological size. J Am Coll Cardiol. 2001;38(3):613-623.

5. Correct Answer: D. Implanted cardiac devices or catheters may inadvertently cross the presented pathology

Rationale: Figure 29.4 TTE demonstrates a small PFO by CFD; however, the “gold standard” for diagnosing PFO entails a bubble study while administering a Valsalva maneuver along with CFD. PFO and ASA are related structural abnormalities of the atrial septum. PFOs are reported in up to 29% of the population. ASA is defined as ≥1 cm of septal excursion toward either the right or left atrium, with a base excursion ≥1.5 cm. The association between PFO and ASA is derived from the observation that in patients with a stroke history and the combined PFO and ASA abnormalities, the recurrent stroke risk is significantly higher than in those with an isolated PFO.

1. Hari P, Pai RG, Varadarajan P. Echocardiographic evaluation of patent foramen ovale and atrial septal defect. Echocardiography. 2015;32 Suppl 2:S110-S124.

6. Correct Answer: C. Paravalvular regurgitation

Rationale: Figure 29.5 TEE shows a mechanical valve placed into the mitral position (mid-esophageal probe position, 0-20° angulation). TEE is invaluable in helping to evaluate a newly placed valve for regurgitation, valve stenosis, and valve malposition. In the above image, an eccentrically directed paravalvular regurgitant jet (paravalvular leak [PVL]) is noted, usually caused by incomplete fixation of the prosthetic sewing ring to the native annulus, or dehiscence of the sewing ring. In the past, surgical closure was the treatment of choice for symptomatic patients with PVLs. The less invasive alternative, transcatheter PVL closure, is safe and effective, with lower procedural morbidity and mortality. However, transcatheter PVL is not available for all types of valves and anatomy and requires meticulous preprocedural planning.

Mechanical valves normally permit some “leakage regurgitant jets” preventing thrombus formation on the valve; these are generally small, symmetric, lower flow jets. Pathologic transvalvular jets in mechanical valves are often from chronic degenerative changes but can occur acutely if a valve leaflet malfunctions and will not close properly. This image can mimic flow from the left atrial appendage into the left atrium, but one can see the mechanical valve leaflet immediately adjacent to the jet. Also, the higher velocity/aliased jet with a definitive vector argues against it being flow from the left atrial appendage.

1. Cheung AT. Prosthetic valves. In: Perrino AC, Reeves ST, eds. A Practical Approach to Transesophageal Echocardiography. 2nd ed. Wolters Kluwer; 2008:257-280.

2. Cruz-Gonzalez I, Rama-Merchan JC, Rodríguez-Collado J, et al. Transcatheter closure of paravalvular leaks: state of the art. Neth Heart J. 2017 Feb;25(2):116-124.

7. Correct Answer: D. Surgical or percutaneous removal of the pacemaker leads is indicated.

Rationale: Infections related to implantable cardiac electronic devices (ICEDs) are increasing in incidence and can be life-threatening. An early diagnosis and appropriate management can help to decrease infection-related morbidity and mortality. TEE is preferred to visualize lead infections and also to determine whether the tricuspid valve is affected. TTE has a lower sensitivity than TEE (22%-43% vs 90%-96%). Lack of appropriate antimicrobial prophylaxis has been the most consistently identified risk factor. Valve involvement is often not limited to the tricuspid valve, with the aortic or mitral valve affected in 10% to 15% of patients. Multivalvular involvement is associated with higher mortality. Surgical or percutaneous removal of infected leads is recommended.

1. Saghir MK, Banerjee S, Cooper DH. Infective endocarditis. In: Rasalingam R, Majesh M, Pérez JE, eds. The Washington Manual of Echocardiography. Wolters Kluwer; 2012: 180-191; Chapter 14.

2. Sandoe JAT, Barlow G, Chambers JB, et al. Guidelines for the diagnosis, prevention and management of implantable cardiac electronic device infection. Report of a joint Working Party project on behalf of the British Society for Antimicrobial Chemotherapy (BSAC, host organization), British Heart Rhythm Society (BHRS), British Cardiovascular Society (BCS), British Heart Valve Society (BHVS) and British Society for Echocardiography (BSE). J Antimicrob Chemother. 2015;70(2):325-359. doi: 10.1093/jac/dku383

8. Correct Answer: D. Lipomatous hypertrophy of the atrial septum (LHAS)

Rationale: LHAS is usually a benign anomaly of the heart. Lipomatous infiltration involves the upper and lower portions of atrial septum, sparing the fossa ovalis, which gives a characteristic hourglass-shaped appearance. One of the rare risk factors is emphysema with chronic steroid therapy, causing a mediastinal and intracardiac deposition of adipose tissue. LHAS has been associated with various atrial arrhythmias, including atrial fibrillation and rarely sudden death.

1. Bielicki G, Lukaszewski M, Kosiorowska K. Lipomatous hypertrophy of the atrial septum – a benign heart anomaly causing unexpected surgical problems: a case report. BMC Cardiovasc Disord. 2018;18:152.

2. Arnold SV. Cardiac masses. In: Rasalingam R, Majesh M, Pérez JE, eds. The Washington Manual of Echocardiography. Wolters Kluwer; 2012: 251-260; Chapter 18.

9. Correct Answer: A. Thrombus

Rationale: It is important to appreciate that as a clinician, one cannot make a tissue diagnosis solely based on echocardiography. The TTE parasternal RV inflow image (Figure 29.7) clearly demonstrates an abnormality associated with the tricuspid valve. It is not an artifact but any further details about the echogenic mass are indeterminate. The differential diagnosis for a valvular-associated echogenic mass include tumor, thrombus, and vegetation. There is no visible implanted catheter, making catheter-associated infection incorrect. A Chiari network is a right atrial structure typically seen as a thin reticulated network of fibers originating from the Eustachian valve, occasionally fenestrated, connecting to various parts of the right atrium.

1. Baddour LM, Wilson WR, Bayer AS, et al. Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Scientific Statement for Healthcare Professionals From the American Heart Association. Circulation 2015;132:1435.

2. Habib G, Lancellotti P, Antunes MJ, et al. 2015 ESC Guidelines for the management of infective endocarditis: The Task Force for the Management of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM). Eur Heart J. 2015;36:3075.

3. Onwuanyi AE, Brown RJ, Vahedi M, Narayanan R, Nash IS, Goldman ME. Eustachian valve thrombus: critical factor in outcome of venous thromboembolism. Echocardiography. 2003;20(1):71-73.

10. Correct Answer: B. LV false tendon

Rationale: The arrow in this apical long-axis TTE (Figure 29.9) indicates an LV false tendon, which is a fibromuscular band extending across the LV cavity from the septum to the lateral wall. A moderator band would be located in a similar region but in the right ventricle. The Eustachian valve is a valve flap at the inferior vena cava-right atrial junction. A coumadin ridge is actually normal cardiac anatomy; it is a ridge of tissue separating the left atrial appendage from the left upper pulmonary vein. The crista terminalis is a vertical ridge of myocardium located at the orifice of the superior vena cava-right atrial junction.

1. Arnold SV. Cardiac masses. In: Rasalingam R, Majesh M, Pérez JE, eds. The Washington Manual of Echocardiography. Wolters Kluwer; 2012: 251-260; Chapter 18.

2. Rajiah P, MacNamara J, Chaturvedi A, Ashwath R, Fulton NL, Goerne H. Bands in the heart: multimodality imaging review. Radiographics. 2019:180176. doi: 10.1148/rg.2019180176. [Epub ahead of print]