Mock Cardiology Module 3

A 62-year-old woman with a history of hypertension and type 2 diabetes presents with progressive exertional dyspnoea over 6 months.

On examination, she has bibasal crackles and a third heart sound.

A transthoracic echocardiogram is performed. Using Simpson’s biplane method, the left ventricular end-diastolic volume (LVEDV) is 150 mL and the left ventricular end-systolic volume (LVESV) is 95 mL. Her NT-proBNP is 1,800 pg/mL (reference: <125 pg/mL).

Which of the following best describes her heart failure classification based on the echocardiographic findings?

A 48-year-old woman with HER2-positive breast cancer is receiving adjuvant trastuzumab following completion of doxorubicin-based chemotherapy.

Her baseline left ventricular ejection fraction was 62% with a global longitudinal strain (GLS) of -21%.

At the 6-month surveillance echocardiogram, her LVEF is 58% and GLS is -14.5%. She is asymptomatic.

Which of the following is the most appropriate next step in management?

A 78-year-old man with progressive exertional syncope undergoes transthoracic echocardiography.

Continuous-wave Doppler across the aortic valve demonstrates a peak aortic jet velocity of 4.5 m/s. The left ventricular outflow tract (LVOT) diameter is 2.0 cm and the LVOT velocity time integral (VTI) is 22 cm. The aortic valve VTI is 105 cm.

What is the calculated aortic valve area using the continuity equation?

A 55-year-old man is admitted to the intensive care unit following a motor vehicle accident with suspected cardiac contusion.

The patient is intubated and ventilated.

The sonographer reports difficulty obtaining parasternal and apical views due to extensive chest wall subcutaneous emphysema and bilateral chest drains.

Which echocardiographic window is most likely to provide adequate cardiac imaging in this clinical scenario?

A 70-year-old woman with known rheumatic mitral stenosis and atrial fibrillation presents with worsening dyspnoea.

Her transthoracic echocardiogram demonstrates moderate tricuspid regurgitation.

The peak tricuspid regurgitant jet velocity on continuous-wave Doppler is 3.5 m/s. The right atrial pressure is estimated at 10 mmHg based on IVC size and collapsibility.

What is the estimated systolic pulmonary artery pressure?

A 65-year-old man with severe aortic stenosis is being assessed for transcatheter aortic valve implantation (TAVI).

His transthoracic echocardiogram shows a left ventricular outflow tract (LVOT) diameter of 2.2 cm and an LVOT VTI of 18 cm. His heart rate is 72 beats per minute.

What is the approximate cardiac output?

A 58-year-old woman with breast cancer is undergoing surveillance echocardiography during anthracycline-based chemotherapy.

Her 2D Simpson’s biplane LVEF is reported as 52%, which is a borderline value.

The treating oncologist is uncertain whether to continue or withhold chemotherapy and requests further clarification of LV function.

Which of the following echocardiographic techniques provides the most accurate and reproducible assessment of LVEF in this clinical scenario?

A 54-year-old man presents to the emergency department with acute chest pain. His ECG shows ST-segment elevation in leads II, III, and aVF.

Emergency echocardiography demonstrates akinesis of the basal and mid inferior and basal inferoseptal segments, with preserved wall motion elsewhere. The LVEF is 45%.

Which coronary artery territory is most likely responsible for these wall motion abnormalities?

A 72-year-old woman with a history of infective endocarditis presents with increasing dyspnoea and orthopnoea.

Transthoracic echocardiography with colour Doppler imaging demonstrates a large, eccentric, wall-hugging jet of mitral regurgitation that fills more than 50% of the left atrial area.

The left atrium is severely dilated at 55 mm (reference: 27–38 mm) and the left ventricle is dilated with an end-diastolic diameter of 62 mm (reference: 39–53 mm). The LVEF is 55%.

Which of the following statements about colour Doppler assessment of mitral regurgitation severity is most accurate?

A 68-year-old man with longstanding hypertension and obesity (BMI 35 kg/m²) presents with exertional dyspnoea, lower limb oedema, and elevated jugular venous pressure. His NT-proBNP is 650 pg/mL (reference: <125 pg/mL).

Transthoracic echocardiography demonstrates a left ventricular ejection fraction of 62% with concentric left ventricular hypertrophy, a left atrial volume index of 42 mL/m² (reference: <34 mL/m²), and a septal e’ velocity of 6 cm/s (reference: >7 cm/s). The E/e’ ratio is 16 (reference: <14).

Which of the following echocardiographic parameters is most consistent with the underlying diagnosis?

A 68-year-old woman with a history of hypertension and type 2 diabetes presents with exertional dyspnoea.

Her left ventricular ejection fraction is 62%. Echocardiography reveals a mitral E/A ratio of 1.4, average E/e’ of 16, tricuspid regurgitation velocity of 3.0 m/s, and left atrial volume index of 38 mL/m².

Which of the following best describes her diastolic function grading?

A 72-year-old man with ischaemic cardiomyopathy (LVEF 30%) is referred for echocardiographic assessment.

His tricuspid regurgitation peak velocity is 4.4 m/s and the average E/e’ ratio is 20.

The estimated right atrial pressure is 10 mmHg.

Which of the following best characterises the haemodynamic profile?

A 55-year-old man with a family history of premature coronary artery disease undergoes exercise stress echocardiography.

At peak exercise, new hypokinesis of the anterior wall and apex is identified before any ST-segment changes or chest pain occur.

Which of the following best explains this observation?

A 64-year-old woman presents with atrial fibrillation of uncertain duration. She is haemodynamically stable and rhythm control is planned.

A transoesophageal echocardiogram (TOE) is performed and shows no thrombus in the left atrial appendage.

Which of the following statements is most accurate regarding a TOE-guided strategy compared to conventional anticoagulation for 3 weeks prior to cardioversion?

A 58-year-old woman presents with exertional breathlessness and a normal resting echocardiogram with an LVEF of 58%, resting E/e’ of 8, and no regional wall motion abnormalities.

She undergoes treadmill exercise stress echocardiography.

At peak exercise, there are no regional wall motion abnormalities but the E/e’ has increased to 16.

Which of the following is the most appropriate interpretation?

A 62-year-old man presents with an acute non-ST elevation myocardial infarction. Bedside echocardiography shows an LVEF of 45% with anterior hypokinesis.

The mitral inflow E velocity is 90 cm/s and the average e’ velocity is 6 cm/s.

Which of the following best describes the clinical significance of the calculated E/e’ ratio?

A 48-year-old intravenous drug user presents with fever, new-onset aortic regurgitation murmur, and positive blood cultures for Staphylococcus aureus.

Transthoracic echocardiography shows a thickened aortic valve but no definite vegetations.

Which of the following is the most appropriate next step?

A 56-year-old woman with progressive exertional dyspnoea undergoes echocardiography. The peak tricuspid regurgitation velocity is 3.5 m/s. The inferior vena cava diameter is 2.3 cm with less than 50% inspiratory collapse.

What is her estimated right ventricular systolic pressure?

A 70-year-old man with persistent atrial fibrillation undergoes a transoesophageal echocardiogram prior to planned electrical cardioversion.

Dense spontaneous echo contrast (“smoke”) and a low left atrial appendage emptying velocity are identified, but no definite thrombus is seen.

Which of the following is the most appropriate management?

A 70-year-old man with systolic heart failure (LVEF 25%) presents with worsening dyspnoea and peripheral oedema.

His echocardiogram shows a dilated left ventricle with severe global hypokinesis, and his estimated left atrial pressure by E/e’ ratio is elevated at 22 mmHg.

According to the Frank-Starling mechanism and the haemodynamic response to heart failure, which of the following best explains the elevated left atrial pressure in this patient?

A 78-year-old woman presents with progressive exertional dyspnoea over 6 months. She has a history of hypertension.

On examination, there is a slow-rising carotid pulse and an ejection systolic murmur radiating to the carotids.

Transthoracic echocardiography reveals an aortic valve area (AVA) of 0.8 cm², a mean transaortic gradient of 28 mmHg, a left ventricular ejection fraction (LVEF) of 62%, and a stroke volume index (SVi) of 30 mL/m².

Which of the following findings would most strongly support a diagnosis of severe aortic stenosis in this patient?

A 72-year-old man with ischaemic cardiomyopathy is referred for assessment of aortic stenosis. His echocardiogram shows an AVA of 0.9 cm², mean gradient of 22 mmHg, LVEF of 32%, and SVi of 28 mL/m².

A low-dose dobutamine stress echocardiogram is performed.

Which of the following findings on dobutamine stress echocardiography would most reliably distinguish true severe aortic stenosis from pseudo-severe aortic stenosis?

A 74-year-old man with severe symptomatic aortic stenosis (AVA 0.7 cm², mean gradient 52 mmHg, peak velocity 4.6 m/s) presents with NYHA class III dyspnoea.

He has a Society of Thoracic Surgeons (STS) predicted risk of mortality of 2.1%.

His coronary angiogram shows no significant coronary artery disease. He has no significant comorbidities.

Which of the following is the most appropriate management?

A 52-year-old man with known bicuspid aortic valve is found to have severe aortic regurgitation on echocardiography. He is asymptomatic and exercises regularly without limitation.

Echocardiography shows LVEF 58%, left ventricular end-systolic diameter (LVESD) 46 mm, and left ventricular end-diastolic diameter (LVEDD) 68 mm.

What is the most appropriate next step in management?

A 62-year-old man presents to the emergency department with acute dyspnoea and hypotension. He has a history of poorly controlled hypertension.

On examination, he is diaphoretic with blood pressure 90/60 mmHg, heart rate 120 bpm. Auscultation reveals a soft, short early diastolic murmur and bilateral crackles.

Chest X-ray shows pulmonary oedema without cardiomegaly.

Echocardiography shows severe aortic regurgitation with early mitral valve closure and a non-dilated left ventricle.

Which of the following is contraindicated in this patient?

A 58-year-old woman is found to have severe primary mitral regurgitation due to posterior leaflet prolapse (P2 scallop). She is completely asymptomatic.

Echocardiography demonstrates LVEF 64%, left ventricular end-systolic diameter (LVESD) 36 mm, effective regurgitant orifice area (EROA) 0.45 cm², regurgitant volume 65 mL, and no pulmonary hypertension.

She is referred to a comprehensive valve centre where surgical repair success rate exceeds 95% with expected mortality less than 1%.

What is the most appropriate management?

A 68-year-old man with non-ischaemic dilated cardiomyopathy, LVEF 28%, and NYHA class III heart failure remains symptomatic despite maximal guideline-directed medical therapy (GDMT) including sacubitril/valsartan, carvedilol, spironolactone, dapagliflozin, and a CRT-D device.

Echocardiography shows severe secondary mitral regurgitation with EROA 0.42 cm², regurgitant volume 62 mL, LVESD 55 mm, and estimated PASP 40 mmHg. His mitral valve anatomy is favourable for transcatheter repair.

What is the most appropriate next step?

A 34-year-old Aboriginal Australian woman from a remote community presents with palpitations and dyspnoea. She has a history of recurrent acute rheumatic fever.

On examination, she has an irregularly irregular pulse at 130 bpm, a loud first heart sound, an opening snap, and a low-pitched diastolic rumble at the apex.

Echocardiography confirms severe rheumatic mitral stenosis (MVA 0.9 cm², mean gradient 14 mmHg) with atrial fibrillation and a left atrial diameter of 52 mm.

Regarding thromboembolic risk assessment and anticoagulation in this patient, which of the following statements is most accurate?

A 28-year-old woman from the Torres Strait Islands presents with NYHA class III dyspnoea.

Echocardiography confirms severe rheumatic mitral stenosis with an MVA of 0.8 cm², mean gradient of 12 mmHg, and pulmonary artery systolic pressure of 60 mmHg. She is in sinus rhythm.

Echocardiographic assessment reveals pliable leaflets, mild subvalvular thickening, no commissural calcification, and no left atrial thrombus. There is mild (1+) mitral regurgitation. Her Wilkins score is 6.

What is the most appropriate intervention?

A 79-year-old man is referred to the cardiology clinic after his general practitioner detected a cardiac murmur during a routine health assessment. He reports mild exertional dyspnoea (NYHA class II).

On examination, his blood pressure is 128/78 mmHg with a slow-rising carotid pulse.

Auscultation at the right upper sternal edge reveals a harsh, late-peaking ejection systolic murmur radiating to the carotids.

At the apex, a high-pitched, musical systolic murmur is heard that could be mistaken for mitral regurgitation. The second heart sound is soft and single. There is a palpable fourth heart sound.

Which of the following best explains the high-pitched musical systolic murmur heard at the apex?