1. Correct Answer: D. All of the above

Rationale: The pulmonic valve may be seen in the parasternal long axis with the transducer tilted toward the RVOT and in the parasternal short axis angled toward the RVOT. The pulmonic valve may also be seen in the subcostal view with an anterior orientation. Depending on the patient’s windows, the pulmonic valve can be challenging to view on 2D echocardiography. Spectral and color Doppler are tools that improve valve assessment.

1. Mitchell C, Rahko PS, Blauwet LA, et al. Guidelines for performing a comprehensive transthoracic echocardiographic examination in adults: recommendations from the American Society of Echocardiography. J Am Soc Echocardiogr. 2019;32(1):1-64.

2. Quader N, Makan M, Perez J. The Washington Manual of Echocardiography. 2nd ed. Wolters Kluwer; 2017.

2. Correct Answer: B. Pulmonic stenosis

Rationale: The RVSP is used as a surrogate measurement for the pulmonary artery systolic pressure in echocardiography. The RVSP is estimated using the Bernoulli equation: RVSP = 4(V)²+ right atrial (RA) pressure, where V is the peak velocity (m/s) of the tricuspid valve regurgitant jet and RA pressure is in mm Hg. There is institutional variation in estimating the RA pressure. Some institutions may estimate the RA pressure using changes in inferior vena cava (IVC) diameter with respiratory variation. In the setting of normal RA pressure, the IVC should collapse by >50% with inspiration (decreased intrathoracic pressure). However, other institutions use a fixed value for the RA pressure (such as at Massachusetts General Hospital where the value of 10 mm Hg is used). The Bernoulli equation and RVSP are not accurate estimates of pulmonary artery systolic pressure when there is obstruction along the RVOT such as pulmonic stenosis or a double-chamber right ventricle.

1. Rudski LG, Lai WW, Afilalo J, et al. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. J Am Soc Echocardiogr. 2010;23(7):685-788.

3. Correct Answer: A. Parasternal long-axis RV outflow view and parasternal pulmonary artery bifurcation view

Rationale: Pulmonary insufficiency can be evaluated in the parasternal long-axis RV outflow view, parasternal pulmonary artery bifurcation view, parasternal short-axis aortic valve/RVOT level view, and subcostal aortic valve, and RVOT view. The apical, right parasternal, and suprasternal views do not show the RVOT or pulmonic valve. Both color Doppler and continuous-wave Doppler aid in the evaluation of pulmonary regurgitation.

1. Mitchell C, Rahko PS, Blauwet LA, et al. Guidelines for performing a comprehensive transthoracic echocardiographic examination in adults: recommendations from the American Society of Echocardiography. J Am Soc Echocardiogr. 2019;32(1):1-64.

2. Quader N, Makan M, Perez J. The Washington Manual of Echocardiography. 2nd ed. Wolters Kluwer; 2017.

4. Correct Answer: D. All of the above

Rationale: A dense regurgitant jet on continuous-wave Doppler is one echocardiographic sign of severe pulmonary regurgitation. In general, increased density of a wave on continuous-wave or color Doppler signifies a higher severity of regurgitation. Early termination of diastolic regurgitant flow is a sign of severe pulmonic insufficiency because it results in early diastolic equalization of pressure between the pulmonary artery and the right ventricle. With chronic volume overload, the RV cavity may dilate, resulting in an enlarged and often hypertrophied RV cavity; however, this may be absent in acute pulmonic regurgitation.

1. Asher CR, Griffin BP. Manual of Valvular Heart Disease. Wolters Kluwer; 2018.

5. Correct Answer: D. Both A and B

Rationale: Patients with pulmonic stenosis have a range of clinic presentations from asymptomatic to RV failure. Continuous-wave Doppler and color Doppler are crucial in evaluating pulmonary valvular disease. Severe pulmonic stenosis is defined by peak velocity >4 m/s across the pulmonic valve and peak gradient >64 mm Hg measured by continuous-wave Doppler. Acceleration of the color Doppler below the pulmonic valve suggests subvalvular stenosis such as RVOT obstruction or double-chamber right ventricle. Other echocardiographic features associated with pulmonic stenosis include poststenotic dilation of the pulmonary artery (although this is nonspecific). The right ventricle may hypertrophy as a response to chronic pressure overload. Pulmonic stenosis is often associated with other congenital heart disease. Care should be taken to evaluate for other forms of structural heart disease in patients with pulmonic stenosis.

1. Asher CR, Griffin BP. Manual of Valvular Heart Disease. Wolters Kluwer; 2018.

2. Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;63(22):e57-e185.

6. Correct Answer: C. McConnell sign (RV dysfunction sparing the apex)

Rationale: See Figure 27.1. TTE may be used to look for right heart strain in the setting of pulmonary embolism and may even visualize proximal, saddle emboli in the main pulmonary artery at the pulmonary artery bifurcation view. Evidence of RV strain on echocardiogram in addition to McConnell sign includes RV fractional area of change <35%, a tricuspid annular plane systolic excursion (TAPSE) <1.6 cm, S′ of <10 cm/s (obtained via tissue Doppler of the RV free wall at the tricuspid annulus) or interventricular septal bowing into the left ventricle (due to right ventricular overload). Because pulmonary embolism causes acute increases in RV afterload, the right ventricle does not have time to adapt and hypertrophy would suggest a more chronic process. The pulmonic valve may be noted to close in midsystole due to the increase in pulmonary arterial systolic pressure. As a result, there may not be a large increase in the estimated RVSP (estimated using the Bernoulli equation and the tricuspid regurgitant jet).