ARDMS Adult Echocardiography (AE) Exam Prep

Answer: B. 39 mmHg

RVSP = 4(V²) + right atrial pressure (RAP). 4 × 3.0² = 36 mmHg. An IVC of 2.1 cm or less that collapses at least 50% with a sniff gives an RAP of 3 mmHg. 36 + 3 = 39.

• A forgets to add right atrial pressure.
• C uses the intermediate RAP (8 mmHg), which is for indeterminate IVC findings.
• D uses 15 mmHg, the value for a dilated IVC (>2.1 cm) that collapses less than 50%.

Without pulmonic stenosis, right ventricular outflow tract (RVOT) obstruction, or proximal pulmonary artery (PA) stenosis, RVSP equals PA systolic pressure.

Source: ASE right heart guideline (2025), Right Atrial Pressure and RVSP sections, pp. 160–164 and Table 4.

Measurement Techniques, Maneuvers, and Sonographic Views — pulmonary artery pressure (4.A.9)

Answer: A

During isovolumic relaxation, both the aortic and mitral valves are closed and the left ventricular (LV) pressure falls. It ends when LV pressure drops below left atrial (LA) pressure and the mitral valve opens. You measure it with continuous-wave (CW) Doppler through the left ventricular outflow tract (LVOT) from an apical 5-chamber or long-axis view, catching the aortic closing click and the onset of mitral inflow.

B is isovolumic contraction. C is the PR interval. D is the early filling acceleration, not an isovolumic phase.

Why it matters: IVRT lengthens with impaired relaxation and shortens as LA pressure rises. The 2025 ASE update treats an IVRT of 70 ms or less as consistent with elevated LA pressure when it's used as a supplemental measure.

Source: ASE diastolic function update (2025), Tables 3–4, Figure 3 and Section 11, p. 554.

Anatomy and Physiology — phases of the cardiac cycle (1.B.4)

Answer: B. 0.63 cm²

Using the circular-LVOT assumption, aortic valve area (AVA) = (LVOT area × LVOT VTI) ÷ aortic valve (AV) VTI. LVOT area = π × (2.0 ÷ 2)² = 3.14 cm². LVOT stroke volume = 3.14 cm² × 20 cm = 62.8 mL. AVA = 62.8 cm³ ÷ 100 cm ≈ 0.63 cm².

That's in the severe range for aortic stenosis (AS; AVA under 1.0 cm²). Final AS grading integrates velocity, mean gradient, flow, and measurement quality.

• A is the VTI ratio (dimensionless index), 20 ÷ 100. Useful on its own (0.20 is below the 0.25 severe cutoff), but it's not an area.
• C uses π × diameter instead of π × radius².
• D uses the diameter as the radius, quadrupling the area.

The LVOT diameter is squared, so it's the biggest source of error in this equation. Measure it in a zoomed parasternal long-axis view, inner edge to inner edge, in mid-systole.

Source: EACVI/ASE aortic stenosis update (2017), Aortic Valve Area section, pp. 379–381, and Table 3, p. 383.

Measurement Techniques, Maneuvers, and Sonographic Views — aortic valve (4.A.1)

Answer: D

This is low-flow, low-gradient AS with reduced EF: AVA under 1.0 cm², mean gradient under 40 mmHg, EF under 50%, SVi under 35 mL/m². A weak ventricle may not open a moderately diseased valve fully, which makes the area look small. Low-dose dobutamine increases flow. If the valve area stays at 1.0 cm² or less while velocity reaches 4 m/s or more (or mean gradient climbs past 30–40 mmHg), that suggests true severe stenosis. If the area rises above 1.0 cm², that suggests the stenosis isn't severe (pseudosevere). A stroke volume increase of more than 20% shows contractile (flow) reserve.

• A isn't the guideline tool for this question.
• B measures anatomic area, which doesn't answer whether low flow is shrinking the valve opening. Effective orifice area is the stronger outcome predictor.
• C does not assess how the valve area and gradient respond to increased flow. Inadequate flow augmentation can leave the dobutamine study inconclusive.

Source: EACVI/ASE aortic stenosis update (2017), Low Flow, Low Gradient AS with Reduced Ejection Fraction, pp. 384–385.

Pathology — aortic valve (2.A.12)

Answer: C

EROA = (2πr² × Va) ÷ peak MR velocity, with radius in cm and both velocities in cm/s. Flow rate = 2 × 3.14 × 1.0² × 40 ≈ 251 mL/s. EROA = (251 mL/s) ÷ (500 cm/s) ≈ 0.50 cm². An EROA of 0.40 cm² or more is a severe-range finding in primary MR; grade severity using the integrated assessment.

• A skips the surface area entirely.
• B uses πr² (a flat circle) instead of 2πr² (a hemisphere).
• D has the right number and the wrong threshold.

The stem says holosystolic for a reason. Peak PISA EROA is a single-frame measurement, so treating it as a holosystolic value can overestimate severity when MR occurs only in late systole, as it often does with prolapse. In that case, regurgitant volume is the better index.

Source: ASE native valvular regurgitation guideline (2017), Flow Convergence (PISA) sections, pp. 312–313, and MR grading/Table 7, p. 325.

Pathology — mitral valve (2.A.13)

Answer: D. Grade 3

The 2025 American Society of Echocardiography (ASE) algorithm starts with three markers:

1. Reduced e′: septal ≤6 or lateral ≤7 cm/s. ✔
2. Increased E/e′: average ≥14. ✔
3. TR velocity ≥2.8 m/s (when RAP can't be estimated). ✔

All three abnormal means elevated LA pressure. Then grade by E/A: under 2 is grade 2; 2 or more is grade 3. E/A is 2.2, so grade 3 (marked increase in LA pressure).

• A does not fit these three abnormal markers; the all-normal branch leads to normal LA pressure and diastolic function.
• B does not fit this elevated-pressure branch. The direct grade-1 branch has reduced e′, normal E/e′ and PA pressure, and E/A ≤0.8.
• C would require an E/A under 2 in this elevated-pressure branch.

The 2025 update replaced the 2016 algorithm and starts with e′ as the marker of impaired relaxation. If your review material predates this update, check which algorithm it teaches.

Source: ASE diastolic function update (2025), Figure 3 and Section 11, pp. 553–554.

Pathology — diastolic function (2.A.4)

Answer: B

Agitated saline bubbles are too large to cross a normal pulmonary capillary bed. Early appearance usually suggests an intracardiac shunt, but timing alone cannot reliably localize it. Late arrival, with bubbles seen entering from the pulmonary veins rather than across the septum, points to an intrapulmonary shunt.

• A would be supported by bubbles crossing the atrial septum.
• C is wrong: in a normal study, saline bubbles stay on the right side.
• D describes left-to-right flow. A positive saline study shows bubbles moving right to left.

Source: ASE/SCAI ASD and PFO guideline (2015), Assessment of Shunting and Figure 29, p. 933; ASE cardiac source of embolism guideline (2016), p. 31, timing limitations.

Instrumentation, Optimization, and Contrast — agitated saline (5.B.1)

Answer: A

In uncomplicated constriction, myocardial relaxation is often preserved, while the pericardium limits filling. Septal e′ is usually above 7 cm/s and often higher than lateral e′ ("annulus reversus," because the lateral wall is tethered). Ventricular interdependence produces respirophasic septal shift. Hepatic veins show expiratory diastolic reversal.

• B: restrictive cardiomyopathy is a myocardial problem, so septal e′ is usually 5 cm/s or less.
• C doesn't explain the septal shift or hepatic vein reversal.
• D causes systolic hepatic vein reversal, not expiratory diastolic reversal.

Clinical tip: preserved septal e′ together with respirophasic septal shift and expiratory hepatic diastolic reversal should raise suspicion for constriction.

Source: ASE diastolic function update (2025), Pericardial Constriction and Restrictive Cardiomyopathy sections, pp. 561–562.

Pathology — pericardial disease (2.A.16)

Answer: D

Esophageal stricture is on the ASE list of absolute contraindications, along with perforated viscus, esophageal tumor, esophageal perforation or laceration, esophageal diverticulum, and active upper GI bleed.

A, B, and C are relative contraindications. Those patients are evaluated case by case, sometimes with GI clearance and precautions like limiting probe manipulation.

Source: ASE/SCA comprehensive TEE guideline (2013), Table 6, p. 927.

Clinical Care and Safety — contraindications (3.B.1)

Answer: C. 1.4

Stroke volume = 0.785 × diameter² × VTI. Qp (pulmonary) = 0.785 × 2.5² × 18 = 88 mL. Qs (systemic) = 0.785 × 2.0² × 20 = 63 mL. 88 ÷ 63 = 1.4, a net left-to-right shunt.

• A inverts the ratio (Qs/Qp).
• B forgets to square the diameters.
• D compares the squared diameters but ignores the VTIs.

Significant semilunar valve regurgitation distorts stroke volume and limits this method.

Source: ASE/SCAI ASD and PFO guideline (2015), Assessment of Shunting, pp. 929–930; ASE valvular regurgitation guideline (2017), stroke volume formula.

Measurement Techniques, Maneuvers, and Sonographic Views — shunt ratios (4.A.11)

Answer: C

Septal flattening in diastole (LVEI over 1 at end-diastole) suggests RV volume overload: ASD, significant TR or PR, anomalous pulmonary venous drainage. Flattening in systole suggests pressure overload. Flattening at both times suggests pressure overload, with or without volume overload.

• A would flatten the septum at end-systole.
• B doesn't push the septum into a D shape.
• D: normal is an LVEI of 1 in both phases (a round LV).

Source: ASE right heart guideline (2025), Interventricular Septum section and key points, pp. 146 and 150.

Pathology — abnormal right ventricle (2.A.18 / 2.A.21)

Answer: A

A Chiari network is an embryologic remnant of the right valve of the sinus venosus. It looks filamentous and moves freely near the IVC and coronary sinus entry. It's found in about 2–3% of people and is associated with PFO and atrial septal aneurysm. The eustachian valve, a related remnant, is a ridge extending forward from the IVC–RA junction.

B, C, and D are pathologic findings you'd weigh against clinical context (fever, catheters, devices, stasis). The question asks for the most likely finding in an asymptomatic patient with this appearance and location.

Source: ASE/SCAI ASD and PFO guideline (2015), Eustachian Valve and Chiari Network, p. 916.

Anatomy and Physiology — normal variants (1.A.2)

Answer: C

A lower Nyquist limit displays slower-moving blood, including blood entrained around the jet, so the jet looks bigger. ASE recommends a Nyquist limit of 50–70 cm/s for grading regurgitant jets, with color gain set just below random speckle.

• A and D misread aliasing. Aliasing changes the colors, not the jet's presence.
• B ignores how much instrument settings and driving pressure affect jet area.

This is why you don't grade MR by jet area alone. Use an integrated assessment that includes vena contracta and quantitative measures when their acquisition requirements and limitations are satisfied.

Source: ASE native valvular regurgitation guideline (2017), Color Doppler Imaging and Table 2, p. 308.

Instrumentation, Optimization, and Contrast — Doppler settings (5.A.3)

Answer: B. 0.80 cm²

MVA = 220 ÷ pressure half-time. 220 ÷ 275 = 0.80 cm².

• A uses the wrong constant (150 instead of 220).
• C inverts the formula (275 ÷ 220).
• D confuses this with aortic regurgitation (AR) pressure half-time, which contributes to AR assessment; it does not calculate aortic valve area.

Know the limits. Pressure half-time is unreliable right after balloon commissurotomy and in degenerative calcific MS, and it isn't valid with severe AR. That's why the stem rules those out.

Source: EAE/ASE valve stenosis recommendations (2009), Pressure Half-Time, pp. 12–13, and Associated Lesions, p. 15.

Measurement Techniques, Maneuvers, and Sonographic Views — mitral valve (4.A.2)

Answer: D

Dynamic obstruction builds as the ventricle empties, so the velocity peaks late. Fixed obstruction usually has a more rounded contour; severe fixed AS can also peak late.

• A and B are both fixed obstructions. The concave-upward, dagger-shaped contour favors dynamic obstruction; timing alone is not enough.
• C: a holosystolic MR signal is longer than the outflow signal. It starts at mitral closure and lasts until mitral opening.

Dynamic obstruction also changes with loading: it gets worse when the ventricle is smaller or contracting harder. That's why provocative maneuvers matter in hypertrophic cardiomyopathy (HCM).

Source: EACVI/ASE aortic stenosis update (2017), Etiologies and Peak Jet Velocity (Figure 3), pp. 374–378, and Mitral Regurgitation, p. 389.

Pathology — cardiomyopathies (2.A.8)

Answer: A

Life-threatening reactions are very rare, about 1 in 10,000, and most reactions occur right away or within the first 30 minutes. Labs using UEAs should have a response policy and an allergy kit; auto-injectable epinephrine is its most important component.

• B and C misstate the timing and frequency.
• D is outdated. Pulmonary hypertension alone is not a blanket contraindication. Current labels still require product-specific precautions, including assessment for embolic phenomena in patients with cardiac shunts.

Labeled contraindications are product-specific hypersensitivities: Definity includes perflutren lipid microspheres or components such as polyethylene glycol (PEG); Optison includes perflutren or albumin. Check the actual label, have trained resuscitation personnel and equipment available, and monitor for acute reactions.

Source: ASE UEA guideline update (2018), Section V, p. 263, and Table 3; Definity prescribing information (revised March 2024) and Optison prescribing information (revised May 2025), Sections 4–5.

Clinical Care and Safety — medical emergencies (3.B.2)

Answer: C

The normal RV is smaller than the LV and doesn't reach the apex. When the RV forms the apex or matches the LV, think dilation.

• A and B describe RV enlargement.
• D is wrong: the 2025 ASE guideline's normal RV basal diameter is under 4.1 cm, and over 4.9 cm is severely dilated.

Measure RV size from an RV-focused apical view, not the standard 4-chamber, for reproducible numbers.

Source: ASE right heart guideline (2025), Right Ventricle section and Table 1, pp. 144–145.

Anatomy and Physiology — normal anatomy (1.A.2)

Answer: A

[(1.3 − 0.6) ÷ 1.3] × 100 ≈ 54%. A fall in E/A of 50% or more with Valsalva is highly specific for increased LV filling pressure. Valsalva lowers preload and unmasks impaired relaxation hiding behind a "normal-looking" E/A.

• B: this degree of reduction argues against normal filling in this context.
• C is backwards. A drop in E is expected; an adequate Valsalva is defined as reducing peak E by more than 10%.
• D: an irreversible restrictive pattern wouldn't change this much.

Record mitral inflow continuously for about 10 seconds during the strain phase.

Source: ASE diastolic function update (2025), Tables 3–4 and Section 5, pp. 540–552.

Measurement Techniques, Maneuvers, and Sonographic Views — maneuvers (4.A.12)

Answer: B

Apical sparing on the strain polar map is the distinctive phenotype described for cardiac amyloidosis. Other red flags in the stem: thick walls, biatrial enlargement, preserved EF. This pattern supports suspicion; it is not diagnostic by itself.

• A: apical HCM is defined by apical hypertrophy (a spade-shaped cavity), not preserved apical strain with abnormal basal strain.
• C: a left anterior descending (LAD) coronary-territory infarct would be expected to produce a territorial pattern rather than the described circumferential basal and mid reduction.
• D: athletic remodeling can enlarge the atria, but it does not characteristically explain this combined wall-thickness and strain pattern.

Source: ASE diastolic function update (2025), Restrictive Cardiomyopathy, p. 561, and LA-size context, p. 552; ASE UEA guideline (2018), apical HCM description.

Pathology — strain (2.A.10)

Answer: D

In acute severe AR, LV diastolic pressure can rise rapidly before the ventricle has time to adapt. When LV diastolic pressure rises above LA pressure before atrial contraction, the mitral valve closes early. Diastolic MR has the same cause. Both findings indicate elevated LV filling pressure from a hemodynamically significant lesion.

• A: these findings indicate elevated LV diastolic pressure; they do not establish low LA pressure.
• B doesn't cause premature closure.
• C isn't how this pattern arises in acute severe AR.

Source: ASE diastolic function update (2025), Aortic Stenosis and Aortic Regurgitation section, p. 558.

Pathology — aortic valve (2.A.12)