1. Correct Answer: B. Systolic ejection

Rationale: The image depicts the Doppler interrogation of transmitral inflow. This image was taken in the apical four-chamber view, with the sample volume at the coaptation of the mitral valve leaflets. The time period marked 1 indicates the diastolic filling phase, comprised of a large peak due to early diastolic filling (referred to as the E wave) and a smaller peak due to atrial contraction (referred to as the A wave). This is followed by isovolumic contraction (2), systolic ejection (3), and isovolumic relaxation (4).

1. Armstrong WF, Ryan T. Feigenbaum’s Echocardiography. 8th ed. Wolters Kluwer; 2019.

2. Correct Answer: A. Isovolumic contraction

Rationale: The phase of the cardiac cycle seen in this image is isovolumic contraction. The ventricle is in an isovolumic state because the aortic and mitral valves are closed. The ventricle is in a contractile state (compared to relaxation) because the electrocardiogram (ECG) is at the QRS complex. Figure 22.8 outlines the relationship between phases of the cardiac cycle and the ECG tracing.

1. Sheth PJ, Danton GH, Siegel Y, et al. Cardiac physiology for radiologists: review of relevant physiology for interpretation of cardiac MR imaging and CT. Radiographics. 2015;35(5):1335-1351.

3. Correct Answer: B.

Rationale: Internal linear dimensions of the left ventricle (such as the left ventricular end-diastolic diameter) are typically obtained from the parasternal long-axis view. Electronic calipers are positioned at the interface of the myocardial wall and cavity, with the axis of measurement perpendicular to the long axis of the left ventricle. The measurement is made at or immediately below the level of the mitral valve leaflet tips. Linear measures of left ventricular systolic function use this view. Use of M-mode to obtain internal linear dimensions offers improved spatial and temporal resolution but may not allow measurement perpendicular to the long axis of the left ventricle. Of note, E-point Septal Separation (EPSS) is measured from the parasternal longaxis view at the level of the mitral valve leaflet tips. EPSS measures the distance separating the anterior mitral valve leaflet at maximal excursion during systole and the septal wall, and an EPSS of >7 mm has been shown to be 87% sensitive and 75% specific at identifying reduced EF (<50%). EPSS has limited accuracy when there is significant aortic regurgitation, mitral stenosis, or inferior wall motion abnormalities present. Answer A is the posterior wall, answer C is the interventricular septum, and answer D is the aortic root. Figure 22.9 shows examples of EPSS in patients with anterior and inferior myocardial infarction.

1. Ahmadpour H, Shah AA, Allen JW, et al. Mitral E point septal separation: a reliable index of left ventricular performance in coronary artery disease. Am Heart J. 1983;106(1 Pt 1):21-28.

2. Lang RM, Badano LP, Mor-Avi V, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2015;28(1):1-39.e14.

4. Correct Answer: C. Concentric hypertrophy

Rationale/Critique: Hypertrophy (vs. normal geometry or concentric remodeling) is defined as elevated left ventricular mass, which can be estimated from linear measurements using formulas that you should not be expected to memorize. Practically speaking, knowledge of normal chamber dimensions may be used to diagnose hypertrophy. Normal values for both septal and posterior wall thickness are generally about 0.6 to 0.9 cm. This patient clearly has significant hypertrophy, particularly of the septal wall.

To then characterize the hypertrophy as concentric or eccentric, relative wall thickness may be used. Relative wall thickness is calculated as:

(2 × posterior wall thickness)/end-diastolic diameter

Concentric hypertrophy is defined as a relative wall thickness >0.42 and eccentric hypertrophy is defined as a relative wall thickness ≤0.42. This patient has a relative wall thickness of 0.65, so the hypertrophy is concentric. Note that the relationship between the posterior and septal walls is not used in characterizing hypertrophy as concentric versus eccentric.

1. Armstrong WF, Ryan T. Feigenbaum’s Echocardiography. 8th ed. Wolters Kluwer; 2019.

2. Lang RM, Badano LP, Mor-Avi V, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2015;28(1):1-39.e14.

5. Correct Answer: B. Eccentric hypertrophy

Rationale: Hypertrophy (vs. normal geometry or concentric remodeling) is defined as elevated left ventricular mass. Boxes 2 and 4 show enlarged ventricles with increased left ventricular mass, so Boxes 1 (concentric remodeling) and 3 (normal left ventricular geometry) can be eliminated. To then characterize the hypertrophy as concentric versus eccentric, the relative wall thickness is used. A relative wall thickness >0.42 defines concentric hypertrophy and a relative wall thickness ≤0.42 defines eccentric hypertrophy. Box 4 shows eccentric hypertrophy.

1. Armstrong WF, Ryan T. Feigenbaum’s Echocardiography. 8th ed. Wolters Kluwer; 2019.

2. Lang RM, Badano LP, Mor-Avi V, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2015;28(1):1-39.e14.

6. Correct Answer: A. White

Rationale: An apical four-chamber view is shown in Figure 22.5. Quantification of the left ventricular ejection fraction using a biplane method of discs involves estimating left ventricular end-diastolic volume using an area tracing. The endocardial border should be traced, while papillary muscles (red line) and trabeculations (yellow line) should not be included in the tracing. This method of tracing results in volume estimates that most closely match magnetic resonance imaging (MRI) measurements. For illustrative purposes, another example is provided in Figure 22.10. The left panel shows a tracing that does not track the endocardial border for the lateral wall, resulting in an underestimation of left ventricular volume. The right panel shows a corrected tracing that does not involve tracing the borders of either trabeculations or papillary muscles.

1. Armstrong WF, Ryan T. Feigenbaum’s Echocardiography. 8th ed. Wolters Kluwer; 2019.

7. Correct Answer: C. Reduced

Rationale: Fractional shortening is defined as:

(Left ventricular end-diastolic diameter – left ventricular end-systolic diameter)/left ventricular end-systolic diameter

The measurements required may be obtained from a parasternal long axis as shown in Figure 22.15 or from an M-mode tracing if the M-mode interrogation beam is perpendicular to the long axis of the left ventricle. Fractional shortening may be a useful way to assess left ventricular systolic function in the absence of regional wall motion abnormalities, conduction abnormalities, and abnormal left ventricular geometry. A fractional shortening ≥25% implies normal left ventricular function. A value <25% implies reduced function. This patient’s fractional shortening is 12.7%, suggesting reduced left ventricular systolic function.

1. Armstrong WF, Ryan T. Feigenbaum’s Echocardiography. 8th ed. Wolters Kluwer; 2019.

2. Lang RM, Bierig M, Devereux RB, et al. Recommendations for chamber quantification: a report from the American Society of Echocardiography’s Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. J Am Soc Echocardiogr. 2005;18(12):1440-1463.

8. Correct Answer: C. Avoidance of measurements oblique to the long axis of the ventricle

Rationale: M-mode offers superior temporal and spatial resolution compared to 2D echocardiography. However, these advantages are becoming less pronounced as 2D echocardiography has improved. In general, 2D echocardiography on modern echocardiography machines offer sufficient resolution to make linear measurements in different phases of the cardiac cycle. The advantages of M-mode are more pronounced when interrogating rapidly moving objects such as valve leaflets. 2D echocardiography offers the advantage of being able to ensure linear measurements are taken in the correct axis. As illustrated in Figure 22.11, the M-mode interrogation beam may not be perpendicular to the left ventricular long axis.

1. Armstrong WF, Ryan T. Feigenbaum’s Echocardiography. 8th ed. Wolters Kluwer; 2019.

2. Lang RM, Badano LP, Mor-Avi V, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2015;28(1):1-39.e14.

9. Correct Answer: A. Qualitative assessment using the apical four-chamber view

Rationale: Although qualitative assessment of left ventricular systolic function by experienced echocardiographers is felt to be accurate, in the context of a myocardial infarction, a single view may not accurately assess the systolic function. In particular, the apical four-chamber view typically shows the anterolateral and inferoseptal walls. However, severe hypokinesis or akinesis of the inferior or anterior walls (such as a right coronary artery or left anterior descending [LAD] infarct) may not be completely appreciated in this view, leading to an overestimation of left ventricular systolic function. See Figure 22.12 for additional details.

1. Lang RM, Badano LP, Mor-Avi V, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2015;28(1):1-39.e14.

10. Correct Answer: A.

Rationale: This is a parasternal short-axis view of the left ventricle. Arrow A points to the posteromedial papillary muscle. Arrow B points to the anterolateral papillary muscle. Arrow C points to the right ventricular free wall, and arrow D points to the interventricular septum.

Although coronary blood supply may vary in individual patients, the anterolateral papillary muscle most commonly draws its blood supply from both the left anterior descending and the left circumflex coronary arteries. In contrast, the posteromedial papillary muscle most commonly draws its blood supply from the right coronary artery. The posteromedial papillary muscle is more likely to rupture in the context of a myocardial infarction because of its single coronary blood supply compared to the dual blood supply of the anterolateral papillary muscle. Rupture of the interventricular spectrum or right ventricular free wall is a rarer event. See Figure 22.12 for additional details.

1. Lang RM, Badano LP, Mor-Avi V, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2015;28(1):1-39.e14.

11. Correct Answer: B. Apical two chamber

Rationale: As shown in Figure 22.13, the apical two-chamber view typically allows visualization of the mid-anterior wall.

1. Lang RM, Badano LP, Mor-Avi V, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2015;28(1):1-39.e14.

12. Correct Answer: A. Mid-inferior wall; right coronary artery

Rationale/Critique: Figure 22.7 is an apical two-chamber view. It is apical because the apex of the left ventricle is at the top of the image. The papillary muscle on the left of the image (as well as the absence of the right ventricle from Figure 22.7) is a clue that it is an apical two chamber. The arrow points to a papillary muscle, which by definition is at a “mid”-level of the ventricle. The papillary muscle in Figure 22.7 is the posteromedial papillary muscle. In the American Society of Echocardiography’s 17-segment model (Figure 22.13), there is no posterior wall (answer choices B and C). The wall segment designated by the arrow is the mid-inferior wall, which is supplied by the right coronary artery. The mid-anterolateral wall (answer choice D) is supplied by both the left anterior descending and left circumflex and the arrow does not point to this wall segment in Figure 22.7.

1. Lang RM, Badano LP, Mor-Avi V, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2015;28(1):1-39.e14.