23204989

Section X – Cardiac Radiology

Figure 1A
239. You are shown a posteroanterior (PA) and lateral chest radiograph of a 64-year-old man with
chest pain (Figures 1A and 1B). What is the MOST likely diagnosis?

A. Congestive heart failure
B. Aortic stenosis
C. Mitral valve disease
D. Pericardial effusion

1
Diagnostic In-Training Exam 2006


Figure 1B

2 American College of Radiology

Question #239
Rationales:
A. Incorrect. The chest radiograph shows normal heart size and vascularity. There is no evidence of
pulmonary edema.
B. Correct. The chest radiograph shows normal heart size and vascularity. On the lateral view, there is
calcification of the aortic valve, consistent with aortic stenosis. Identification of calcification of the
aortic valve on a chest radiograph is usually associated with clinically significant aortic stenosis.
C. Incorrect. The chest radiograph shows normal heart size and vascularity. There is no evidence of
left atrial enlargement or pulmonary venous hypertension.
D. Incorrect. The chest radiograph shows normal heart size and vascularity. There is no evidence of
pericardial effusion.

3


Figure 2A
240. You are shown two images from a non-enhanced CT scan in a 77-year-old woman who has
undergone pacemaker placement (arrow) and mitral valve replacement (arrowhead) (Figures 2A
and 2B). The calcifications are related to which one of the following?

A. Pericarditis
B. Pulmonary hypertension
C. Rheumatic heart disease
D. Coronary atherosclerosis



Figure 2B

5

Question #240
Rationales:
A. Incorrect. The calcifications are located in the wall of the left atrium.
B. Incorrect. Calcification of the pulmonary arteries may occur in patients with longstanding, severe
pulmonary arterial hypertension. The calcifications in this case are located in the wall of the left
atrium.
C. Correct. The calcifications are secondary to endocarditis from rheumatic heart disease. Other caus-
es of endocarditis can also cause calcification of the left atrial wall.
D. Incorrect. The areas of calcification do not correspond with the anatomic location of the coronary
arteries.



Figure 3A
241. You are shown a posteroanterior (PA) and lateral chest radiograph of a 75-year-old woman
(Figures 3A and 3B). What is the MOST likely diagnosis?

A. Atrial septal defect
B. Chronic pulmonary embolism
C. Pulmonary venous hypertension
D. Cor pulmonale



Figure 3B

8

Question #241
Rationales:
A. Incorrect. The chest radiograph shows enlargement of the central pulmonary arteries with diminu-
tion of the peripheral vasculature, consistent with pulmonary arterial hypertension. If the left-to-
right shunt in atrial septal defect is 2:1 or greater, the chest radiograph will show evidence of over-
circulation which is characterized by enlargement of all segments of the pulmonary arteries
throughout the lung (shunt vascularity). Right heart enlargement is also a feature of atrial septal
defect, a finding which is not present in this case.
B. Incorrect. Chronic thromboembolic disease is an uncommon cause of pulmonary arterial hyperten-
sion. The chest radiograph in this case demonstrates marked hyperinflation of the lungs and emphy-
sema, making pulmonary arterial hypertension secondary to chronic lung disease the most likely
diagnosis.
C. Incorrect. Early radiographic changes of pulmonary venous hypertension are characterized by pul-
monary venous distention, equalization of the size of upper and lower lobe vessels and indistinct
vessel margins. This case does not demonstrate these findings.
D. Correct. This case shows enlargement of the central pulmonary arteries with diminished size of the
peripheral vasculature, characteristic of pulmonary arterial hypertension. In this patient, the pul-
monary arterial hypertension is a result of the severe emphysema as manifested by markedly
increased lung volumes, flattening of the diaphragm and increase in AP diameter of the chest. Cor
pulmonale is defined as pulmonary hypertension secondary to chronic lung disease.



Figure 4
242. You are shown an axial contrast-enhanced CT scan of the chest (Figure 4). What is the MOST
LIKELY diagnosis?

A. Ostium primum defect
B. Ostium secundum defect
C. Sinus venosus defect
D. Patent foramen ovale


Question #242
Rationales:
A. Incorrect. Ostium primum defects are the second most common atrial septal defects (ASD),
accounting for about 15 percent of all ASDs. The primum portion of the atrial septum is located
inferiorly at the level of the mitral and tricuspid valves. Ostium primum defects are often associated
with atrioventricular defects. The abnormality on the image is not in this location.
B. Incorrect. Ostium secundum defects are the most common ASD, accounting for approximately 75
percent of all ASDs, and are located near the fossa ovalis, in the middle of the atrial septum. The
abnormality on the image is not in this location.
C. Correct. Sinus venosus defects are the third most common ASD accounting for approximately 10
percent of all cases. The sinus venosus portion of the atrial septum separates the left atrium from the
superior vena cava. The defect in this case is located in the superolateral aspect of the atrial septum
at the junction of the superior vena cava and right atrium, near the insertion of the right pulmonary
veins, consistent with a sinus venosus ASD.
D. Incorrect. Patent foramen ovale occurs in up to 25 percent of adults. The flap of tissue covering the
foramen ovale typically closes the defect since the left atrial pressure is higher than the right atrial
pressure. Normally, this flap of tissue fuses with the septum after the first year of life. The abnor-
mality on the image is not in the location of the foramen ovale.

11


Figure 5
243. You are shown an oblique coronal reformatted image from a contrast-enhanced CT (Figure 5).
Which coronary artery is depicted by the arrow?

A. Diagonal branch
B. Obtuse marginal branch
C. Ramus intermedius
D. Septal branch


Question #243
Rationales:
A. Incorrect. The left anterior descending artery gives off epicardial diagonal branches over the antero-
lateral wall. The artery shown in this image does not arise from the left anterior descending artery.
Instead, it arises between the left anterior descending artery and the left circumflex artery.
B. Incorrect. The left circumflex artery arises from the left main artery and gives off obtuse marginal
branches which supply the lateral wall of the left ventricle. The artery shown in this image does not
arise from the left circumflex artery. Instead, it arises between the left anterior descending artery
and the left circumflex artery.
C. Correct. The left main coronary artery may trifurcate giving off the left anterior descending artery,
the left circumflex artery and the ramus intermedius, or intermediate artery, which arises between
the left anterior descending and left circumflex arteries as shown in this case.
D. Incorrect. The left anterior descending coronary artery gives off septal branches that supply the
interventricular septum. The artery shown in this image does not arise from the left anterior
descending artery. Instead, it arises between the left anterior descending artery and the left circum-
flex artery.

13


Figure 6A

Figure 6B



Figure 6C
244. You are shown axial (see Figures 6A and 6B) and sagittally-reconstructed (Figure 6C) images
from a contrast-enhanced CT scan of the chest obtained after a motor vehicle collision. What is
the MOST LIKELY diagnosis?

A. Patent ductus arteriosus
B. Traumatic aortic tear
C. Ductus diverticulum
D. Penetrating ulcer

15

Question #244
Rationales:
A. Incorrect. There is only a tiny strand of soft tissue density material connecting the proximal
descending aorta and the left pulmonary artery. This represents the ligamentum arteriosum.
B. Incorrect. The bulge along the underside of the aorta is smooth and there is no evidence of any flap
or periaortic hematoma. These findings make traumatic laceration highly unlikely.
C. Correct. The combination of a small, smooth bump along the bottom edge of the aorta along with
the lack of any evidence of flap or mediastinal hematoma is typical of a ductus diverticulum. The
soft tissue strand joining the bump to the pulmonary artery represents the ligamentum arteriosum,
the remnant of the ductus arteriosus.
D. Incorrect. The bump has none of the hallmarks of penetrating atherosclerotic ulcer


245. Concerning the morphologic right ventricle, which of the following is the MOST
reliable indicator?

A. Anterior location of the ventricle
B. Trabeculation of the ventricular wall
C. Separation of the inflow and outflow valves by a muscular infundibulum
D. The ventricle receives blood from the right atrium

Question #245
Rationales:
A. Incorrect. Normally, the right ventricle receives blood from the right atrium, lies anterior to and is
more trabeculated than the left ventricle. The inflow and outflow valves of the right ventricle are
separated by the muscular infundibulum in contrast to the left ventricle where the valves are con-
tiguous. In complex congenital cardiac anomalies, the separation of the inflow and outflow valves is
the most reliable indicator of the morphologic right ventricle.
B. Incorrect. Normally, the right ventricle receives blood from the right atrium, lies anterior to and is
C. Correct. Normally, the right ventricle receives blood from the right atrium, lies anterior to and is
D. Incorrect. Normally, the right ventricle receives blood from the right atrium, lies anterior to and is


246. Concerning the location of cardiac valves on a posteroanterior (PA) and lateral chest radiograph,
which one is TRUE?

A. The aortic valve is located superior to the other valves.
B. The tricuspid valve is the most anteriorly located valve.
C. The mitral valve lies inferior to the other valves.
D. The aortic valve lies closest to the pulmonary valve.

Question #246
Rationales:
A. Incorrect. The aortic valve lies inferior to the pulmonary valve. The pulmonary valve is the most
superiorly located valve.
B. Correct. The tricuspid valve is the most anteriorly located valve.
C. Incorrect. The mitral valve is the most posteriorly located valve. The tricuspid valve lies inferior to
the mitral valve.
D. Incorrect. The aortic valve is contiguous with the mitral valve and shares a common fibrous skele-
ton.

18

247. Concerning the position of the interventricular septum on short axis images of the heart,
which one is TRUE?

A. It has a normal convexity toward the right ventricle.
B. It has a sinusoid shape.
C. It has a straight course separating the right and left ventricles.
D. Its convexity varies in position during the cardiac cycle.

Question #247
Rationales:
A. Correct. On short axis images, the interventricular septum is curved with the convexity toward the
right ventricle. This appearance is maintained during systole and diastole. Straightening, bowing
with convexity toward the left ventricle and sinusoidal appearance of the interventricular septum are
abnormal.
B. Incorrect. On short axis images, the interventricular septum is curved with the convexity toward the
abnormal.
C. Incorrect. On short axis images, the interventricular septum is curved with the convexity toward the
abnormal.
D. Incorrect. On short axis images, the interventricular septum is curved with the convexity toward the
abnormal.


Concerning cardiac aneurysms, which one is TRUE?
248.

A. True aneurysms of saphenous vein grafts are a manifestation of atherosclerosis.
B. Rupture of a sinus of Valsalva aneurysm occurs more commonly on the left.
C. Left ventricular pseudoaneurysms typically occur at the cardiac apex.
D. The neck of a left ventricular aneurysm is typically narrow.

Question #248
Rationales:
A. Correct. It is thought that atherosclerosis of saphenous vein bypass grafts results in decreased wall
elasticity and resulting dilatation of the graft lumen over time.
B. Incorrect. Rupture of a sinus of Valsalva aneurysm typically involves the right sinus. Rupture of the
left sinus is rare.
C. Incorrect. True aneurysms of the left ventricle most commonly occur in the anterolateral and apical
wall. In contrast, false aneurysms are most commonly located in the posterolateral and diaphragmat-
ic aspect of the left ventricle.
D. Incorrect. Left ventricular pseudoaneurysms typically have a narrow communication between the
pseudoaneurysm and the left ventricular cavity. In contrast, the neck of a left ventricular true
aneurysm is typically broad.

20

Concerning coronary artery atherosclerosis, which one is TRUE?
249.

A. Coronary artery calcification is strongly associated with coronary atherosclerosis.
B. On angiography, a stenosis greater than 40 percent of the luminal diameter is considered
to be significant.
C. On angiography, a stenosis greater than 60 percent of the luminal diameter is considered
to be severe.
D. When present, coronary artery calcifications make up about 50 percent of the total plaque
burden.

Question #249
Rationales:
A. Correct. Coronary artery calcification is almost always associated with coronary atherosclerosis.
B. Incorrect. On angiography, a significant stenosis is one in which there is obstruction of at least 50
percent of the diameter or 75 percent of the cross-sectional area of the vessel lumen.
C. Incorrect. On angiography, a severe stenosis is one in which there is obstruction of at least 75 per-
cent of the diameter or 90 percent of the cross-sectional area of the vessel lumen.
D. Incorrect. Coronary artery calcification, when present, accounts for approximately 20 percent of the
total plaque burden.


Which one of the following congenital anomalies is MOST commonly associated with
250.
anomalous pulmonary venous drainage?

A. Ostium primum atrial septal defect
B. Ostium secundum atrial septal defect
C. Ventricular septal defect
D. Sinus venosus atrial septal defect

Question #250
Rationales:
A. Incorrect. Drainage of the pulmonary veins should be assessed in all patients with congenital anom-
alies. Nearly all patients with sinus venosus atrial septal defect have anomalous pulmonary venous
drainage, most commonly drainage of the right upper lobe to the superior vena cava. Approximately
10 percent of patients with an ostium secundum atrial septal defect will have anomalous pulmonary
venous drainage.
B. Incorrect. Drainage of the pulmonary veins should be assessed in all patients with congenital anom-
venous drainage.
C. Incorrect. Drainage of the pulmonary veins should be assessed in all patients with congenital anom-
venous drainage.
D. Correct. Drainage of the pulmonary veins should be assessed in all patients with congenital anom-
venous drainage.

22

251. What is the greatest advantage of conventional CR imaging systems over DR imaging systems?

A. Better detective quantum efficiency with lower dose
B. Positioning flexibility
C. Instantaneous readout of the latent image
D. Better intrinsic spatial resolution

Question #251
Rationales:
A. Incorrect. CR typically exhibits lower detection effiency and lower detective quantum efficiency (a
measure of the information transfer from the input x-rays to the information content of the output
image), chiefly due to thinner screens (compared to CsI structured phosphors) or lower atomic num-
ber (compared to Gd2O2S screens : Gd, Z=53 versus BaFBr CR screens : Br, Z=35)
B. Correct. This is the main advantage of CR…. A passive, cassette-based imaging detector that emu-
lates the screen-film paradigm, allowing use of conventional imaging equipment and providing
excellent positioning flexibility that active, DR detectors in their current technology state cannot
provide.
C. Incorrect. This is the advantage of DR over conventional CR (not including the newer line-scan and
mechanical CR automatic readers)
D. Incorrect. The intrinsic (prior to sampling) resolution of CR is lower than that of scintillator and
photoconductor-based DR units. This is easily discerned by the MTF curves of each modality. The
reasons are chiefly due to the use of a structured scintillator (CsI) used for most DR indirect detec-
tor systems, which confines the emitted light without spreading, and the use of high voltage placed
across the semiconductor materials of DR direct detector, which actively collects the electron/hole
pairs from spreading out during acquisition. Of all detector converters, the semiconductor detector
has the highest intrinsic spatial resolution.


Which one of the following structures directly communicates with the transverse sinus?
252.

A. Oblique sinus
B. Postcaval recess
C. Superior aortic recess
D. Posterior pericardial recess

Question #252
Rationales:
A. Incorrect. The oblique sinus is separated from the transverse sinus by a pericardial reflection.
B. Incorrect. The postcaval recess arises from the pericardial cavity proper and is separated from the
transverse sinus by a pericardial reflection
C. Correct. The superior aortic recess arises from the transverse sinus and extends superiorly to sur-
round the posterior, right lateral and anterior aspect of the ascending aorta.
D. Incorrect. The posterior pericardial recess is a superior extension of the oblique sinus, which does
not communicate directly with the transverse sinus.

24

Concerning coronary artery dominance, which one is TRUE?
253.

A. It is determined by which coronary artery supplies the majority of the heart.
B. 85 percent of patients have a codominant system.
C. It is determined by which artery supplies the posterior descending artery.
D. 70 percent of patients have a left dominant system.

Question #253
Rationales:
A. Incorrect. Coronary dominance is determined by which artery supplies the posterior descending
artery (PDA). In most patients (85%), the PDA is supplied by the right coronary artery and there-
fore is a right dominant system. If the PDA is supplied by the circumflex coronary artery, it is con-
sidered to be a left dominant system. A codominant system is one in which both the right coronary
artery and circumflex coronary artery supply the PDA or when the right coronary artery supplies the
PDA and the left circumflex coronary artery supplies the inferior left ventricular wall.
B. Incorrect. Dominance is determined by which artery supplies the posterior descending artery
(PDA). In most patients (85%), the PDA is supplied by the right coronary artery and therefore is a
right dominant system. If the PDA is supplies by the circumflex coronary artery, it is considered to
be a left dominant system. A codominant system is one in which both the right coronary artery and
circumflex coronary artery supply the PDA or when the right coronary artery supplies the PDA and
the left circumflex coronary artery supplies the inferior left ventricular wall.
C. Correct. Dominance is determined by which artery supplies the posterior descending artery (PDA).
In most patients (85%), the PDA is supplied by the right coronary artery and therefore is a right
dominant system. If the PDA is supplies by the circumflex coronary artery, it is considered to be a
left dominant system. A codominant system is one in which both the right coronary artery and cir-
cumflex coronary artery supply the PDA or when the right coronary artery supplies the PDA and
D. Incorrect. Dominance is determined by which artery supplies the posterior descending artery
(PDA). In most patients (85%), the PDA is supplied by the right coronary artery and therefore is a
right dominant system. If the PDA is supplies by the circumflex coronary artery, it is considered to
be a left dominant system. A codominant system is one in which both the right coronary artery and
circumflex coronary artery supply the PDA or when the right coronary artery supplies the PDA and


254. Concerning a patient presenting with an acute myocardial infarction accompanied by severe
bradycardia, which coronary artery or branch is MOST LIKELY involved?

A. Diagonal branch
B. Left anterior descending coronary artery
C. Right coronary artery
D. Circumflex artery

Question #254
Rationales:
A. Incorrect. The diagonal artery is a branch of the left anterior descending coronary artery. The atri-
oventricular (AV) node artery, supplies the AV node. In 85-90 percent of patients, the AV node
artery arises from the right coronary artery at the point where it gives off the posterior descending
artery.
B. Incorrect. The atrioventricular (AV) node artery, supplies the AV node. In 85-90 percent of patients,
the AV node artery arises from the right coronary artery at the point where it gives off the posterior
descending artery.
C. Correct. The atrioventricular (AV) node artery, supplies the AV node. In 85-90 percent of patients,
descending artery.
D. Incorrect. The atrioventricular (AV) node artery, supplies the AV node. In 85-90 percent of patients,
descending artery. A branch of the circumflex artery supplies the AV node in the remaining cases.

26

Concerning pulmonary vein ablation, which one is TRUE?
255.

A. Accessory pulmonary veins are more common on the left.
B. Myocardial sleeves are longest and thickest in the inferior pulmonary veins.
C. The presence of left atrial thrombus is a contraindication.
D. A common pulmonary vein is more common on the right.

Question #255
Rationales:
A. Incorrect. Accessory pulmonary veins are more common on the right.
B. Incorrect. Myocardium extends 2-17 mm into the pulmonary veins and is called the myocardial
sleeve. The myocardial sleeve is thickest at the atriopulmonary venous junction of the left superior
vein. The myocardial sleeves are longer in the superior pulmonary veins than in the inferior pul-
monary veins.
C. Correct. Due to the risk of stroke following manipulation of the left atrium, the presence of left
atrial thrombus is a contraindication to pulmonary vein ablation.
D. Incorrect. Pulmonary venous anatomy varies widely. A common variation is a common pulmonary
vein draining the entire lung, which typically occurs on the left.


Concerning the Ross procedure, which one is TRUE?
256.

A. It is suitable for children because the pulmonary autograft grows with the child.
B. Patients undergoing the Ross procedure require lifelong anticoagulation.
C. It is preferred because it is technically easier to perform than standard valve replacement.
D. The procedure is performed to correct pulmonary valve stenosis.

Question #256
Rationales:
A. Correct. The Ross procedure replaces the aortic valve with the patient’s pulmonary valve and
replaces the pulmonary valve with a cryopreserved pulmonary valve homograft. Follow-up studies
have shown interval growth of the aortic valve graft in children and infants.
B. Incorrect. The Ross procedure replaces the aortic valve with the patient’s pulmonary valve and
replaces the pulmonary valve with a cryopreserved pulmonary valve homograft. Because a homo-
graft is used, anticoagulation is not necessary.
C. Incorrect. The Ross procedure replaces the aortic valve with the patient’s pulmonary valve and
replaces the pulmonary valve with a cryopreserved pulmonary valve homograft. Because both the
pulmonary and aortic valves are replaced, the Ross procedure is a more extensive operation com-
pared to conventional aortic valve replacement.
D. Incorrect. The Ross procedure is performed to correct aortic valve disease.

28

Concerning the Blalock-Taussig shunt, which one is TRUE?
257.

A. It connects the subclavian artery to the pulmonary artery.
B. It creates a conduit between the right atrium and the pulmonary artery.
C. It creates an atrial switch using an intra-atrial baffle made of pericardium.
D. It connects the superior vena cava with the pulmonary artery.

Question #257
Rationales:
A. Correct. The Blalock-Taussig shunt creates a connection between the systemic and arterial systems
and is a palliative procedure that increases systemic arterial oxygenation by increasing blood flow to
the pulmonary artery.
B. Incorrect. The Fontan procedure creates a conduit between the right atrium and the pulmonary
artery.
C. Incorrect. The Mustard procedure creates an atrial switch using an intra-atrial baffle made of peri-
cardium
D. Incorrect. The Glenn procedure connects the superior vena cava with the pulmonary artery.


258. What is the MOST common congenital heart defect?

A. Tetralogy of Fallot
B. Atrial septal defect
C. Bicuspid aortic valve
D. Ventricular septal defect

Question #258
Rationales:
A. Incorrect. Tetralogy of Fallot is the most common cyanotic heart disease occurring at a rate of 3.53
per 10,000 live births.
B. Incorrect. Atrial septal defect is the most common congenital heart disease to remain undetected
until adulthood. The occurrence rate is 3.78 per 10,000 live births.
C. Correct. Bicuspid aortic valve is the most common congenital heart defect and occurs at a rate of
50-200 per 10,000 live births.
D. Incorrect. Ventricular septal defect occurs at a rate of 14.8 per 10,000 live births.

30

259. Regarding cardiac CT scans, keeping all scan parameters the same, the dose to the patient with
retrospective ECG gating when compared to prospective ECG triggering.

A. Increases
B. Decreases
C. Remains the same

Question #259
Rationales:
A. Correct. During retrospective ecg gating with multidetector CT (MDCT), the x-rays are ON
throughout the cardiac cycle, however, only part of the data is used for reconstruction to achieve
high temporal resolution with minimal motion artifacts. Whereas in prospective ecg triggering, the
x-rays are ON only during certain part of the ecg signals, there by yielding lower radiation dose to
the patient.
B. Incorrect. See correct answer.
C. Incorrect. See correct answer.


260. Concerning isolated aortic valve stenosis, what is the MOST likely cause in an adult?

A. Rheumatic heart disease
B. Calcific degeneration
C. Congenitally stenotic aortic valve
D. Infective endocarditis

Question #260
Rationales:
A. Incorrect. Almost all patients with rheumatic aortic valve involvement also have mitral valve
stenosis.
B. Correct. Congenital aortic stenosis implies that the valve is stenotic at birth. Congenital bicuspid
aortic valves are usually not stenotic at birth. Due to increased turbulence, the valve becomes trau-
matized leading to fibrosis and calcification.
C. Incorrect. Although most adults with aortic valve stenosis who are under age 65 will have a bicus-
pid aortic valve, the cause is calcification of the valve, not the bicuspid nature per se. Furthermore,
patients over the age of 65 years of age with aortic stenosis typically have a tricuspid valve.
D. Incorrect. Endocarditis results in aortic regurgitation, not stenosis.

32

261. What is the MOST likely explanation for enlargement of the right atrium in a patient with mitral
valve stenosis?

A. Tricuspid valve regurgitation
B. Pulmonary valve stenosis
C. Tricuspid valve stenosis
D. Tricuspid valve prolapse

Question #261
Rationales:
A. Correct. Chronic pulmonary venous hypertension in patients with mitral stenosis leads to elevated
pulmonary arterial and right ventricular pressures. If severe, these will result in failure of the right
ventricle, usually with tricuspid regurgitation.
B. Incorrect. The most frequent cause of pulmonary valve stenosis is a congenital valvular defect.
Pulmonary valve stenosis secondary to rheumatic heart disease is very rare.
C. Incorrect. Rheumatic heart disease is the predominant cause of mitral stenosis. The tricuspid valve
is primarily affected in only 5% of patients with rheumatic heart disease.
D. Incorrect. Tricuspid valve prolapse is associated with mitral valve prolapse and can result in tricus-
pid regurgitation and subsequent right atrial enlargement. Tricuspid valve prolapse is not associated
with mitral stenosis.


262. Concerning differentiation of pseudoaneurysms from true aneurysms of the left ventricle, what is
the MOST reliable imaging finding?

A. Identification of the number of myocardial layers in the wall of the aneurysm
B. Involvement of the posterior or inferior walls of the left ventricle
C. Size of aneurysm neck or mouth
D. Thrombus lining the aneurysm.

Question #262
Rationales:
A. Incorrect. One cannot determine scarred myocardium from thickened pericardium containing a
myocardial rupture with any imaging technique.
B. Incorrect. Although pseudoaneurysms of the left ventricle almost always occur in these locations,
true ventricular aneurysms also may occur inferiorly or posteriorly.
C. Correct. Regardless of the imaging technique employed or the vascular structure involved, the sine
qua non of a pseudoaneurysm is a narrow neck or mouth.
D. Incorrect. Clot may line the wall of either type of aneurysm.

34

263. Concerning left atrial enlargement in a patient with dilated (congestive) cardiomyopathy,
what cause is MOST LIKELY?

A. Mitral valve regurgitation secondary to displacement of the papillary muscles
B. Mitral valve regurgitation secondary to fusion and shortening of the chordae tendinae
C. High left ventricular end-diastolic pressure resulting in left atrial hypertension
D. Mitral valve regurgitation secondary to ischemic papillary muscle dysfunction

Question #263
Rationales:
A. Correct. Left ventricular dilatation results in lateral displacement of the papillary muscles rendering
them less efficient and resulting in mitral regurgitation.
B. Incorrect. Rheumatic endocarditis can cause fusion and shortening of the chordae tendinae leading
to mitral regurgitation. Shortening and fusion of the chordae tendinae is not a feature of dilated car-
diomyopathy.
C. Incorrect. Most patients with dilated cardiomyopathy are relatively well compensated and tend to
have fairly normal LV end-diastolic and thus left atrial and pulmonary venous pressures.
D. Incorrect. Patients with dilated (congestive) cardiomyopathy by definition do not have myocardial
ischemia as the cause of their dysfunction.


264. Concerning tricuspid valve regurgitation in adults, what is the MOST common etiology?

A. Infective endocarditis
B. Right ventricular hypertension
C. Ebstein’s’ anomaly of the tricuspid valve
D. Rheumatic heart disease

Question #264
Rationales:
A. Incorrect. Although tricuspid regurgitation frequently occurs in intravenous drug abusers with bacter-
ial endocarditis, it is not as common as tricuspid regurgitation secondary to pulmonary hypertension.
B. Correct. The majority of cases of tricuspid regurgitation in adults result from high right sided pres-
sures with or without right ventricular failure.
C. Incorrect. Ebstein’s anomaly may result in tricuspid regurgitation, but is a rare disease.
D. Incorrect. Although patients with rheumatic valvular heart disease frequently have tricuspid regurgi-
tation, it almost always results from high right sided pressures related to mitral stenosis. Primary
involvement of the tricuspid valve occurs in only about 5% of patients with rheumatic heart disease.

36

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