1. Correct Answer: B. 58%

Rationale: Measurement of LVEF when end systolic (LVESV) and end diastolic (LVEDV) volumes have been measured via 3D echocardiography or Simpson disks by the formula:

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. Eur Heart J Cardiovasc Imaging. 2016;17:412.

2. Correct Answer: A. TAPSE is 12 mm, RV function is reduced

Rationale: TAPSE is a measurement of the longitudinal movement of the right ventricle during systole that correlates with overall RV function. This is measured by aligning a M-mode Doppler through the tricuspid annulus and measuring the movement by comparing the position of the annulus in systole and diastole. Here the TAPSE is 30 – 18 = 12 mm. TAPSE values under 16 mm are indicative of reduced RV function.

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. Eur Heart J Cardiovasc Imaging. 2016;17:412.

3. Correct Answer: D. Maximum gradient over the aortic valve is 64 mm Hg

Rationale: Figure 20.2 shows blood flow through a stenotic aortic valve. The maximum velocity through the stenotic orifice is around 4 m/s, and per the simplified Bernoulli equation this translates to a maximum pressure gradient of Δ P = 4v² = 4 × 4² = 64 mm Hg over the aortic valve.

1. Baumgartner H, Hung J, Bermejo J, et al. Recommendations on the echocardiographic assessment of aortic valve stenosis: a focused update from the European Association of Cardiovascular Imaging and the American Society of Echocardiography. J Am Soc Echocardiogr. 2017;30:372-392.

4. Correct Answer: A. Dimensionless index is 0.25 supporting a diagnosis of severe aortic stenosis

Rationale: Figure 20.2 shows blood flow through a stenotic aortic valve. Clearly pictured is a “double envelope” where the smaller envelope describes the blood flow through the LVOT and the larger envelope through the stenotic valve. The ratio of blood flow velocities through the LVOT and the aortic valve is commonly called dimensionless index or velocity ratio and either includes the maximum velocity or the VTI. This ratio ranges from 0 to 1, where a higher ratio indicates a more similar flow velocity through both LVOT and aortic valve, suggesting no marked stenosis. A dimensionless index of 0.25 and less is indicative of severe aortic stenosis.

1. Baumgartner H, Hung J, Bermejo J, et al. Recommendations on the echocardiographic assessment of aortic valve stenosis: a focused update from the European Association of Cardiovascular Imaging and the American Society of Echocardiography. J Am Soc Echocardiogr. 2017;30:372-392.

5. Correct Answer: B. 0.79 cm²

Rationale: The continuity equation can be used to calculate the aortic valve area given the LVOT diameter as well as a VTI through both the aortic valve and the LVOT. Figure 20.2 shows both integrals, where the smaller and denser envelope represents the LVOT and the larger and less dense envelope represents the aortic valve. Hence, the .

1. Baumgartner H, Hung J, Bermejo J, et al. Recommendations on the echocardiographic assessment of aortic valve stenosis: a focused update from the European Association of Cardiovascular Imaging and the American Society of Echocardiography. J Am Soc Echocardiogr. 2017;30:372-392.

6. Correct Answer: A. Valve area of 1.41 cm² and max velocity of 3.5 m/s support moderate aortic stenosis.

Rationale/Critique: The continuity equation can be used to calculate the aortic valve area:

Both this area as well as the max velocity support the assessment of moderate aortic stenosis (see Table 20.1).

1. Baumgartner H, Hung J, Bermejo J, et al. Recommendations on the echocardiographic assessment of aortic valve stenosis: a focused update from the European Association of Cardiovascular Imaging and the American Society of Echocardiography. J Am Soc Echocardiogr. 2017;30:372-392.

7. Correct Answer: D. The pressure half-time is 180 ms supporting severe AR

Rationale: Figure 20.3 depicts a continuous-wave Doppler assessment of flow velocity that can be used to quantify pressure half-time. This needs to be converted to pressure to accurately detect the time point (x-axis) where pressure is halved. The peak velocity is 2 m/s, corresponding to a pressure of P = 4v² = 4 × 2² = 16 mm Hg per the simplified Bernoulli equation. Utilizing this equation to calculate the velocity matching 50% of the maximum pressure we find that the corresponding velocity is m/s. This velocity is reached at approximately 180 ms. Therefore pressure half-time is 180 ms, and this corresponds to severe AR. For AR, pressure half-time of 200-500 ms corresponds to moderate regurgitation and pressure half-time of less than 200 ms corresponds to severe regurgitation.

1. 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;30:303-371.

8. Correct Answer: B. Pressure half-time of 240 ms supports severe mitral stenosis.

Rationale: Figure 20.4 depicts a continuous-wave Doppler assessment of flow velocity that can be used to quantify pressure half-time. This needs to be converted to pressure to accurately detect the time point (x-axis) where pressure is halved. The peak velocity is 2 m/s, corresponding to a pressure of P = 4v² = 4 × 2² = 16 mm Hg per the simplified Bernoulli equation. Utilizing this equation to calculate the velocity with 50% of the maximum pressure we find that the corresponding velocity is m/s This velocity is reached at approximately 240 ms. Therefore, pressure half-time is 240 ms, and this can be converted to estimate effective mitral valve orifice using the equation cm², which corresponds to a severely stenotic mitral valve. Quantification of mitral stenosis is shown in Table 20.2.

1. Baumgartner H, Hung J, Bermejo J, et al. Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice. J Am Soc Echocardiogr. 2009;22:1-23; quiz 101-102.