AE-Adult-Echocardiography Questions Bank

Comprehensive and Detailed Explanation From Exact Extract:

In hypertrophic obstructive cardiomyopathy (HOCM), systolic anterior motion (SAM) of the anterior mitral leaflet causes posteriorly directed mitral regurgitation (MR) jets. The abnormal anterior leaflet motion leads to incomplete leaflet coaptation and regurgitant flow directed toward the posterior left atrium.

Anterior jets are seen with posterior leaflet abnormalities. Central jets are seen in functional MR. Medial jets are less common and depend on leaflet pathology.

This jet direction is an important echocardiographic feature distinguishing HOCM-related MR and is outlined in ASE valvular heart disease and cardiomyopathy guidelines【12:ASE Valvular Regurgitation Guidelines†p.220-225】【16:Textbook of Clinical Echocardiography, 6e†p.350-355】.

In severe tricuspid regurgitation (TR), the regurgitant jet flows back from the right ventricle into the right atrium during systole, causing reversal of flow in the hepatic veins during the same phase. On Doppler echocardiography, this manifests as systolic flow reversal in the hepatic veins, which is a hallmark sign of severe TR.

Normally, hepatic vein flow consists of a predominant systolic forward flow into the right atrium. However, in severe TR, the high pressure in the right atrium during systole causes retrograde flow in the hepatic veins. This pattern is diagnostic and aids in severity assessment.

Diastolic flow reversal is uncommon in TR and more associated with other pathologies. Atrial flow reversal in systole or biphasic flow reversal in diastole are not recognized patterns for severe TR.

This is described in detail in the "Textbook of Clinical Echocardiography, 6e", Chapter on Right Heart and Tricuspid Valve Disease, with Doppler patterns illustrated for hepatic vein flow in tricuspid regurgitation【20:330-335†Textbook of Clinical Echocardiography】.

The most appropriate echocardiographic view to measure right ventricular (RV) dimensions is the apical four-chamber view with a right ventricular-focused modification. This RV-focused apical four-chamber view is optimized by shifting the transducer laterally and slightly anteriorly to better visualize the entire right ventricle in a single plane. This approach allows for accurate assessment of RV basal and mid cavity diameters, RV longitudinal dimension, and RV area measurements.

The standard apical four-chamber view often underestimates RV size because of its complex geometry and position in the chest. The subcostal four-chamber view may give some information on RV size but is limited by image quality and angle. Parasternal short axis views at the base focus more on the left ventricle and may not capture the entire RV adequately. Parasternal long axis views primarily visualize the left heart structures and do not adequately show the RV.

Adult echocardiography guidelines, including the American Society of Echocardiography (ASE) chamber quantification recommendations, endorse the RV-focused apical four-chamber view as the standard for RV linear measurements and volume assessment due to its accuracy and reproducibility【12:ASE Chamber Quantification Guidelines†p.80-85】【16:Textbook of Clinical Echocardiography, 6e†Chapter on RV Assessment】.

Pulmonic stenosis is a congenital valve abnormality often seen in genetic syndromes with cardiac manifestations. Among these, Noonan syndrome is the most frequently associated with pulmonic stenosis. Noonan syndrome is a genetic disorder characterized by distinctive facial features, short stature, and congenital heart defects, with pulmonic valve stenosis being the predominant cardiac lesion. The stenosis is usually valvular and caused by dysplastic pulmonary valve leaflets, leading to obstruction of right ventricular outflow.

Other syndromes listed do not typically present with pulmonic stenosis:

Turner syndrome is more commonly linked with bicuspid aortic valve and coarctation of the aorta, not pulmonic stenosis.

Eisenmenger syndrome refers to the advanced phase of congenital heart defects with significant pulmonary hypertension and is not a genetic syndrome.

Marfan syndrome is predominantly associated with aortic root dilation and mitral valve prolapse, but not with pulmonic stenosis.

This association is well documented in adult echocardiography guidelines and texts, such as the "Textbook of Clinical Echocardiography" by Catherine Otto, which clearly identifies Noonan syndrome as the syndrome most commonly associated with pulmonic stenosis among congenital heart defects【16:Chapter on Congenital Heart Disease†Textbook of Clinical Echocardiography, 6e】.