Free ARDMS Adult Echocardiography Practice Test
Sixty original, unofficial practice questions for the ARDMS Adult Echocardiography (AE) exam, with an explanation of each option and the source behind it. These are text-only items written by Castleport Test Prep, not real exam questions, so they don't reproduce the exam's image-based hotspot items.
Domain 1: Anatomy and Physiology (9 questions)
Question 1 · AE-A01 · Task 1.A.6
In a standard apical two-chamber view, which two left ventricular walls are displayed?
Show answer and explanation
Answer: B. Anterior and inferior
The apical two-chamber view drops the RV and septum out of the plane and shows the anterior and inferior walls.
Why the others are wrong:
- A: Inferoseptal and anterolateral are the walls of the apical four-chamber view.
- C: Anteroseptal and inferolateral are the walls of the apical three-chamber (apical long-axis) view.
- D: “Septal” and “lateral” are used for apical segments, but they are not the opposing walls of the standard two-chamber plane.
Source: ASE/EACVI Chamber Quantification (Lang et al., JASE 2015), §3.1 LV segmentation and Figures 3–4, printed pp.10–12 / PDF pp.10–12; Figure 4 directly labels the three apical planes.
Jump to: Anatomy & Physiology · Pathology · Clinical Care & Safety · Measurement & Views · Instrumentation & Contrast · Review your answers
Question 2 · AE-A02 · Task 1.A.2
During a routine TTE on an asymptomatic patient, you see fine, highly mobile, net-like filaments in the right atrium. They seem to arise near the IVC orifice and wave freely with each beat. Which structure best fits?
Show answer and explanation
Answer: C. Chiari network
A Chiari network is a remnant of the embryologic sinus venosus valve. It looks like a lacy, fenestrated, very mobile web in the right atrium and is usually a normal variant.
Why the others are wrong:
- A: The crista terminalis is a fixed muscular ridge near the SVC entry, not a mobile web.
- B: The eustachian valve is a related remnant, but it appears as a single ridge or flap at the IVC–RA junction, not a lacy net.
- D: A thrombus is usually a discrete mass, often with low flow or a catheter nearby. A new or atypical mass should still be reported for correlation.
Source: ASE/SCA Comprehensive TEE (Hahn et al., JASE 2013), Right Atrium and Venous Connections: Eustachian Valve and Chiari Network; Crista Terminalis; printed p.955 / PDF p.35; Figure 17; ASE ASD and PFO guideline (Silvestry et al., JASE 2015), Eustachian Valve and Chiari Network, printed p.916 / PDF p.7; Figure 20, printed p.925 / PDF p.16.
Question 3 · AE-A03 · Task 1.A.2
Which feature identifies a ventricle as the morphologic right ventricle?
Show answer and explanation
Answer: D. A moderator band crossing from the septum to the anterior free wall
The moderator band is a muscular band that carries part of the right bundle branch. Along with coarse apical trabeculations, it marks the morphologic RV. It is normal anatomy, not a mass.
Why the others are wrong:
- A: Aortic–mitral fibrous continuity is a feature of the morphologic left ventricle.
- B: Two well-formed papillary muscles are a left ventricular pattern.
- C: A smooth septum with fine trabeculations is also a left ventricular pattern.
Source: BSE practical guideline for comprehensive TTE in congenital heart disease (Corbett et al., 2022), Atrioventricular connections, printed/PDF p.3; Figure 3 p.5; Table 1 ventricular morphology row p.13; Anatomical Study of the Moderator Band (Raghavendra et al.,2013), Introduction paragraph 2 and Materials and Methods: septum-to-parietal-wall band carrying a right-bundle fascicle; primary cadaveric anatomic study; ASE Right Heart and Pulmonary Hypertension guideline (Mukherjee et al., JASE 2025), Right Ventricle section, printed p.144 / PDF p.4: RV anatomic components, apical trabeculation and moderator band.
Question 4 · AE-A04 · Task 1.B.4
Isovolumic relaxation time (IVRT) is the interval from:
Show answer and explanation
Answer: B. Aortic valve closure to mitral valve opening
After the aortic valve closes, the LV relaxes with both valves shut. IVRT ends when LV pressure falls below LA pressure and the mitral valve opens.
Why the others are wrong:
- A: Mitral closure to aortic opening is isovolumic contraction time.
- C: Mitral opening to peak E is early filling, not an isovolumic period.
- D: QRS onset to aortic opening is the pre-ejection period.
Source: ASE LV Diastolic Function and HFpEF update (Nagueh et al., JASE 2025), Table 3, IVRT acquisition/measurement row, printed p.543 / PDF p.7; Table 4 IVRT physiologic-background row, printed p.549 / PDF p.13; Figure 1 p.540.
Question 5 · AE-A05 · Task 1.B.2
A healthy 30-year-old with normal LV relaxation is in sinus rhythm at 65 bpm. Which mitral inflow pattern is most typical on pulsed-wave Doppler?
Show answer and explanation
Answer: A. E velocity greater than A velocity
In young adults with brisk relaxation, most LV filling happens early, so E is usually larger than A. The 2025 ASE reference range for E/A at ages 20–39 is about 0.88 to 2.73.
Why the others are wrong:
- B: E and A can fuse at fast heart rates or with a long PR interval. Fusion is not the typical pattern in this healthy adult at 65 bpm.
- C: An A-dominant pattern with a long deceleration time suggests impaired relaxation, which becomes more common with age.
- D: An absent A wave suggests atrial fibrillation, which contradicts sinus rhythm.
Source: ASE LV Diastolic Function and HFpEF update (Nagueh et al., JASE 2025), Table 4, mitral E/A and mitral A-wave rows, printed p.547 / PDF p.11; Table 5 age 20–39 reference E/A range 0.88–2.73, printed p.551 / PDF p.15.
Question 6 · AE-A06 · Task 1.A.5
In normal pulmonary venous Doppler flow, the brief reversal wave (Ar) occurs during:
Show answer and explanation
Answer: A. Atrial contraction
When the left atrium contracts, some blood is pushed back into the pulmonary veins. That produces the small Ar reversal.
Why the others are wrong:
- B: Ventricular systole produces the forward S wave.
- C: Early diastole, with the mitral valve open, produces the forward D wave.
- D: Isovolumic contraction does not create the Ar wave.
A high Ar velocity (over 35 cm/s) or an Ar duration more than 30 ms longer than mitral A duration points to elevated LV end-diastolic pressure.
Source: ASE LV Diastolic Function and HFpEF update (Nagueh et al., JASE 2025), Table 3 pulmonary vein inflow timing, printed p.543 / PDF p.7; Table 4 pulmonary vein inflow and Ar–A duration rows, printed p.549 / PDF p.13; Figure 1 p.540.
Question 7 · AE-A07 · Task 1.B.1
What is the normal LV response at peak exercise on stress echocardiography?
Show answer and explanation
Answer: C. Hyperdynamic motion in all segments with a smaller end-systolic cavity
Normal myocardium becomes hyperdynamic with stress. Wall thickening increases and the end-systolic cavity gets smaller.
Why the others are wrong:
- A: A new wall motion abnormality is the classic marker of inducible ischemia.
- B: Failure to augment with cavity dilation is abnormal.
- D: A drop in global function with stress is abnormal.
Source: ASE Stress Echocardiography (Pellikka et al., JASE 2020), Table 3, normal and ischemic responses, printed/PDF p.11; §IV Interpretation of Stress Echocardiograms, printed/PDF p.13.
Question 8 · AE-A08 · Task 1.A.3
In the parasternal long-axis view, an echo-free space lies posterior to the left ventricle. Which landmark best separates a pericardial effusion from a left pleural effusion?
Show answer and explanation
Answer: D. Descending thoracic aorta
Pericardial fluid collects anterior to the descending thoracic aorta, between the aorta and the heart. Left pleural fluid extends posterior to the descending aorta.
Why the others are wrong:
- A: The coronary sinus marks the AV groove but doesn’t reliably separate the two spaces.
- B: The RVOT lies anterior and plays no role here.
- C: The LAA isn’t seen in this view.
Source: ASE Pericardial Disease imaging (Klein et al., JASE 2013), Pericardial effusion section, Figures 25–26, printed p.982 / PDF p.18; ASE Comprehensive Adult TTE (Mitchell et al., JASE 2019), Table 2.1–2.2, standard PLAX anatomy and increased-depth pericardial/pleural survey, printed/PDF p.19.
Question 9 · AE-A09 · Task 1.A.5
In the parasternal long-axis view, a small circular echo-free structure sits in the posterior atrioventricular groove next to the mitral annulus. It is most likely the:
Show answer and explanation
Answer: B. Coronary sinus
The coronary sinus runs in the posterior AV groove and drains into the right atrium. In PLAX it appears as a small circle near the mitral annulus.
Why the others are wrong:
- A: The descending aorta is also a circle, but it sits farther posterior, behind the left atrium.
- C: The right pulmonary artery is seen superiorly, in suprasternal views above the LA.
- D: The LAA isn’t displayed in a standard PLAX.
A dilated coronary sinus deserves a search for a cause (see Question 18).
Source: BSE practical guideline for comprehensive TTE in congenital heart disease (Corbett et al., 2022), Table 1, Left PLAX / Coronary sinus row, printed/PDF p.20: CS en face in posterior left AV groove; A4C RV / CS row p.17: CS drains into RA; ASE Comprehensive Adult TTE (Mitchell et al., JASE 2019), Table 12.11–12.13 suprasternal views, printed/PDF p.63, RPA above LA; Table 2.1–2.2 standard PLAX anatomy p.19.
Domain 2: Pathology (23 questions)
Question 10 · AE-P01 · Task 2.A.12
A 74-year-old with LVEF 60% has a heavily calcified, restricted aortic valve. Aortic jet Vmax is 4.3 m/s, mean gradient 46 mm Hg, and continuity-equation AVA 0.8 cm². Acquisition is technically adequate. How is the aortic stenosis best classified?
Show answer and explanation
Answer: C. Severe, high-gradient
All three measures meet severe criteria: Vmax ≥4 m/s, mean gradient ≥40 mm Hg, and AVA <1.0 cm². With a high gradient, this is high-gradient severe AS.
Why the others are wrong:
- A: Mild AS has a Vmax under 3 m/s.
- B: Moderate AS has a Vmax of about 3–3.9 m/s and a mean gradient of 20–39 mm Hg.
- D: Low-flow, low-gradient AS requires a mean gradient below 40 mm Hg despite a small valve area.
Source: EACVI/ASE Aortic Stenosis focused update (Baumgartner et al., JASE 2017), Table 3 and Basic Grading Criteria, printed p.383 / PDF p.12; low-flow, low-gradient AS with preserved LVEF, pp.385–386 / PDF pp.14–15.
Question 11 · AE-P03 · Task 2.A.4
A 62-year-old in sinus rhythm has normal LVEF. There is no mitral stenosis, significant mitral regurgitation, mitral annular calcification, mitral repair or prosthesis, pericardial constriction, heart transplant, LV assist device, noncardiac pulmonary hypertension, or pulmonary parenchymal or vascular disease. RAP cannot be estimated because the IVC window is poor. Septal e′ is 4 cm/s, lateral e′ 5 cm/s, average E/e′ 18, peak TR velocity 3.2 m/s, and mitral E/A 2.3. Using the 2025 ASE diastolic function algorithm, how is this classified?
Show answer and explanation
Answer: D. Grade 3 diastolic dysfunction with increased LA pressure
All three first-step markers are abnormal: reduced e′ (septal ≤6, lateral ≤7 cm/s), average E/e′ ≥14, and TR velocity ≥2.8 m/s. The TR velocity is used because RAP can’t be estimated. Together they indicate elevated LA pressure. The grade then depends on E/A, and an E/A of 2 or more means grade 3.
Why the others are wrong:
- A: Normal function would need all three markers to be normal.
- B: Grade 1 has normal LA pressure. This case instead has three abnormal first-step markers and elevated LA pressure.
- C: Grade 2 also has increased LA pressure, but it requires an E/A below 2.
The 2025 update replaced the 2016 diastolic guideline. The currently linked AE content outline does not specify clinical guideline editions.
Source: ASE LV Diastolic Function and HFpEF update (Nagueh et al., JASE 2025), Figure 3 and its full caption, printed p.554 / PDF p.18; adjacent text on use of TR velocity when RAP cannot be estimated and absence of pulmonary parenchymal/vascular disease; ASE publishes updated LV diastolic function guideline (2025), ASE announcement: updated guidance replaces the 2016 version; AE Examination Content Outline, Version 24.2, Current linked Adult Echocardiography Examination Content Outline, Version 24.2, pp.1–5: task categories and knowledge/skills list; no clinical guideline editions specified.
Question 12 · AE-P04 · Task 2.A.13
Hypothetical measurements for a single holosystolic primary mitral regurgitation jet with a hemispheric PISA: radius 1.0 cm at an aliasing velocity of 40 cm/s, measured at the same time as peak MR velocity 5 m/s. What is the EROA, and which severity range does it fall in?
Show answer and explanation
Answer: C. 0.50 cm² — severe
EROA = 2πr² × Va ÷ Vmax = 6.28 × 1.0 × 40 ÷ 500 = 0.50 cm². An EROA of 0.40 cm² or more is in the severe range for primary MR; final grading integrates the other findings. Keep both velocities in cm/s.
Why the others are wrong:
- A: This is tenfold too small. A velocity of 5 m/s equals 500 cm/s, not 5,000 cm/s.
- B: Using πr² instead of 2πr² halves the hemispheric surface area and gives about 0.25 cm².
- D: This is tenfold too large. Using 50 cm/s instead of the correct 500 cm/s for peak MR velocity would give about 5.0 cm².
Source: ASE Native Valvular Regurgitation (Zoghbi et al., JASE 2017), §II.B.6.b PISA equations, timing, geometry and limitations, printed pp.312–313 / PDF pp.10–11; primary-MR EROA thresholds p.329 / PDF p.27; Table 8 and integrated assessment p.332 / PDF p.30.
Question 13 · AE-P05 · Task 2.A.13
A patient with a flail posterior mitral leaflet has an eccentric MR jet that hugs the left atrial wall. The displayed color jet area looks small. Which additional finding most strongly supports severe MR?
Show answer and explanation
Answer: B. Systolic flow reversal in the pulmonary veins
Pulmonary vein systolic flow reversal is a specific supportive sign of severe MR. Wall-hugging eccentric jets lose energy against the atrial wall, so their color area underestimates severity. Integrate the other findings instead.
Why the others are wrong:
- A: An A-dominant inflow argues against severe MR, which usually produces an E-dominant pattern.
- C: Jet area alone doesn’t grade MR, and it is especially unreliable for eccentric jets.
- D: A small, brief flow-convergence zone points toward lesser MR.
Source: ASE Native Valvular Regurgitation (Zoghbi et al., JASE 2017), §III.D.1 color Doppler/jet area, printed p.324 / PDF p.22; Table 7 pulmonary vein limitations p.326 / PDF p.24; §III.D.3–4 mitral inflow and pulmonary vein flow, p.330 / PDF p.28; Table 8 p.332 / PDF p.30.
Question 14 · AE-P06 · Task 2.A.12
Chronic aortic regurgitation shows a vena contracta of 0.7 cm, a pressure half-time of 180 ms, and prominent holodiastolic flow reversal in the proximal descending aorta. What is the best grade?
Show answer and explanation
Answer: C. Severe
Each finding meets a severe criterion: vena contracta >0.6 cm, PHT <200 ms, and prominent holodiastolic reversal in the descending aorta. The signs agree with each other.
Why the others are wrong:
- A: Mild AR has a long PHT (over 500 ms) and only brief early-diastolic reversal.
- B: Moderate AR has intermediate values.
- D: Concordant transthoracic findings are sufficient here, so TEE isn’t required.
Source: ASE Native Valvular Regurgitation (Zoghbi et al., JASE 2017), Table 11 grading chronic AR and §IV.D Role of TEE, printed p.340 / PDF p.38; aortic diastolic flow reversal and PHT caveats, printed pp.336–337 / PDF pp.34–35.
Question 15 · AE-P07 · Task 2.A.13
A patient with rheumatic mitral stenosis, sinus rhythm, and no significant aortic regurgitation has a mitral pressure half-time of 200 ms. Assume the pressure half-time method is applicable. What are the estimated mitral valve area and severity category under the 2023 ASE rheumatic heart disease guideline?
Show answer and explanation
Answer: B. 1.1 cm² — severe
MVA ≈ 220 ÷ PHT = 220 ÷ 200 = 1.1 cm². The 2023 ASE rheumatic heart disease guideline classifies an MVA of 1.5 cm² or less as severe.
Why the others are wrong:
- A: Inverting the formula gives 200 ÷ 220 ≈ 0.9. The correct order is 220 ÷ 200.
- C: The area is correct, but 1.1 cm² is not moderate.
- D: The calculated area is 220 ÷ 200 = 1.1 cm², not 2.2 cm². Under the specified guideline, 2.2 cm² would also fall in the moderate range.
PHT is unreliable immediately after balloon valvotomy and with significant AR or abnormal LV compliance.
Source: ASE Recommendations for Echocardiography in Evaluation of Rheumatic Heart Disease (Pandian et al.,2023), §IV.A.2 PHT equation, limitations and Table 1 severity categories, printed p.8 / PDF p.6; Figure 3 p.9 / PDF p.7.
Question 16 · AE-P08 · Task 2.A.13
Which 2D appearance is most characteristic of rheumatic mitral stenosis?
Show answer and explanation
Answer: A. Diastolic doming of the anterior leaflet with commissural fusion
Commissural fusion tethers the leaflet tips, so the body of the anterior leaflet domes in diastole. This gives the “hockey-stick” shape in PLAX.
Why the others are wrong:
- B: Systolic anterior motion belongs to dynamic LVOT obstruction.
- C: Bowing above the annular plane in systole describes prolapse.
- D: Degenerative calcific disease involves the annulus and leaflet bases, without commissural fusion.
Source: ASE Recommendations for Echocardiography in Evaluation of Rheumatic Heart Disease (Pandian et al.,2023), §IV.A.1 anatomic rheumatic-MS features and Figure 4, printed pp.7–10 / PDF pp.5–8; p.8 comparison with degenerative annular calcification; ASE Multimodality Imaging in HCM (Nagueh et al., JASE 2022), §1.E Assessment of Dynamic Obstruction and Mitral Valve Anatomy, printed pp.543–545 / PDF pp.11–13; ASE Native Valvular Regurgitation (Zoghbi et al., JASE 2017), §III.B Identifying the Mechanism of MR, primary MR and prolapse/flail definitions, printed pp.319–320 / PDF pp.17–18; Figure9.
Question 17 · AE-P09 · Task 2.A.8
A patient has asymmetric septal hypertrophy and systolic anterior motion of the mitral valve. Apical continuous-wave Doppler through the LVOT shows a mid-to-late-peaking, “dagger-shaped” systolic signal. This most likely represents:
Show answer and explanation
Answer: D. Dynamic LVOT obstruction
Dynamic obstruction builds as the LV empties and SAM increases. Velocity rises slowly, then peaks in mid-to-late systole, which gives the concave dagger shape.
Why the others are wrong:
- A: Fixed valvular obstruction produces a more rounded envelope. Severe AS can also peak later in systole, so timing alone does not distinguish it from dynamic obstruction.
- B: An MR jet usually starts earlier, lasts longer, is more rounded, and is always faster than the LVOT jet. Be cautious calling any signal over 5.5 m/s LVOT flow.
- C: A fixed membrane produces a more rounded, earlier-peaking envelope.
SAM and dynamic obstruction are typical of HCM but not specific to it.
Source: ASE Multimodality Imaging in HCM (Nagueh et al., JASE 2022), §1.E, Echocardiographic Techniques (Continuous-Wave Doppler) and differential diagnosis of LVOTO (Mitral Regurgitation; Discrete Subvalvular Stenosis), printed p.545 / PDF p.13; Figures13–16 and key points pp.547–548 / PDF pp.15–16; EACVI/ASE Aortic Stenosis focused update (Baumgartner et al., JASE 2017), Aortic jet velocity waveform shape, printed p.378 / PDF p.7; Figure3.
Question 18 · AE-P10 · Task 2.A.19
A markedly dilated coronary sinus is seen. Agitated saline injected into a left arm vein opacifies the coronary sinus before the right atrium. The most likely explanation is:
Show answer and explanation
Answer: B. A persistent left superior vena cava draining into the coronary sinus
A persistent left SVC usually drains into the coronary sinus and dilates it. Saline from the left arm reaches the coronary sinus first, which confirms the connection.
Why the others are wrong:
- A: Anomalous pulmonary venous return doesn’t route left-arm venous blood into the coronary sinus.
- C: Cor triatriatum is a membrane inside the LA.
- D: A secundum ASD wouldn’t make the coronary sinus fill before the RA.
Source: ASE ASD and PFO guideline (Silvestry et al., JASE 2015), Assessment of Shunting: contrast-injection site selection, printed p.931 / PDF p.22, left antecubital injection for PLSVC draining to CS; A rare case of isolated persistent left superior vena cava diagnosed by echocardiography (2024), Case presentation, Figure 1, and Discussion: coronary sinus opacification before the right atrium; International Society for Adult Congenital Heart Disease: CHD Glossary, Glossary entries: persistent left superior vena cava; cor triatriatum sinister; anomalous pulmonary venous connection.
Question 19 · AE-P11 · Task 2.A.10
A patient has concentrically thickened LV walls and low-voltage QRS complexes on ECG. The longitudinal strain bull’s-eye shows markedly reduced basal and mid strain with relatively preserved apical strain. Which diagnosis does this pattern most suggest?
Show answer and explanation
Answer: C. Cardiac amyloidosis
Relative apical sparing of longitudinal strain is a recognized pattern in cardiac amyloidosis, especially with thick walls and low ECG voltage. Echo raises the suspicion, and confirmation needs further testing.
Why the others are wrong:
- A: Athlete’s heart doesn’t typically show this base-to-apex strain gradient.
- B: Hypertensive heart disease doesn’t typically show this base-to-apex strain gradient.
- D: Apical HCM tends to reduce strain at the apex, the opposite pattern.
Source: ASE Multimodality Imaging in HCM (Nagueh et al., JASE 2022), Table1 cardiac amyloidosis, printed p.537 / PDF p.5; §1.B.3 amyloidosis and §1.C regional strain in apical HCM, printed p.539 / PDF p.7; ASE LV Diastolic Function and HFpEF update (Nagueh et al., JASE 2025), §15.E Restrictive Cardiomyopathy, printed p.561 / PDF p.25: relative apical sparing versus hypertensive heart disease/HCM/AS.
Question 20 · AE-P12 · Task 2.A.9
A new akinetic inferior wall is seen. In most patients, which coronary artery supplies this territory?
Show answer and explanation
Answer: B. Right coronary artery
The inferior wall is usually supplied by the RCA, which is the dominant vessel in most people. In a left-dominant circulation, the circumflex can supply it instead, so territory assignment is a best fit, not a certainty.
Why the others are wrong:
- A: The LAD supplies the anterior and anteroseptal walls and usually the apex.
- C: Left main disease can affect multiple LAD and circumflex territories; isolated inferior akinesis does not identify left main disease.
- D: The first diagonal supplies anterolateral myocardium, not the usual inferior-wall territory.
Source: ASE Stress Echocardiography (Pellikka et al., JASE 2020), Figure 8, p.9: typical coronary distributions and variability; Anatomic variations of the coronary arteries supplying the anterolateral aspect of the left ventricle (Levin et al., Invest Radiol 1982), Abstract: diagonal supply to anterolateral LV wall; Coronary anatomy, anatomic variations and anomalies: a retrospective coronary angiography study (Altin et al., Singapore Med J 2015), Introduction and Results: coronary origins and dominance.
Question 21 · AE-P13 · Task 2.A.6
Three days after an inferior MI, a patient develops sudden pulmonary edema and a new murmur. Echo shows a flail mitral leaflet with a mobile mass attached to the chordae and a severe, eccentric MR jet. The most likely complication is:
Show answer and explanation
Answer: C. Papillary muscle rupture
A ruptured papillary muscle head stays attached to the chordae, causing a flail leaflet and acute severe MR. The posteromedial papillary muscle, which has a single blood supply, is classically involved after inferior MI.
Why the others are wrong:
- A: Free-wall rupture presents with an effusion and tamponade.
- B: Septal rupture shows a shunt across the septum, not a flail leaflet.
- D: A thrombus sits in the LV cavity and doesn’t flail a leaflet.
This is a critical finding that needs immediate physician notification.
Source: Mechanical Complications of Acute Myocardial Infarction: A Scientific Statement From the AHA (Damluji et al., Circulation 2021), Acute MR Secondary to Papillary Muscle Rupture; Table 1; ASE Echocardiography Reporting guideline (JASE 2025), Table 14, p.766: critical findings.
Question 22 · AE-P14 · Task 2.A.7
After a myocardial infarction, an outpouching of the LV inferolateral wall connects to the cavity through a narrow neck. Its wall shows an abrupt break in the myocardium. This is most consistent with:
Show answer and explanation
Answer: B. LV pseudoaneurysm
A pseudoaneurysm is a contained rupture held in by pericardium or scar. It has a narrow neck, an abrupt myocardial break, and a high risk of rupture.
Why the others are wrong:
- A: A true aneurysm has a wide neck and a thinned wall that still contains myocardium.
- C: A thrombus is a mass, not an outpouching.
- D: Noncompaction shows deep trabecular recesses, not a contained cavity.
This is a critical finding.
Source: Mechanical Complications of Acute Myocardial Infarction: A Scientific Statement From the AHA (Damluji et al., Circulation 2021), Left Ventricular Pseudoaneurysm and LV Aneurysms; Table 1; ASE Echocardiography Reporting guideline (JASE 2025), Table 14, p.766: critical findings.
Question 23 · AE-P15 · Task 2.A.16
A hypotensive patient has a moderate circumferential pericardial effusion. Which echo finding most supports tamponade physiology?
Show answer and explanation
Answer: D. RV free-wall collapse in early diastole
RV early-diastolic collapse supports tamponade physiology, along with RA collapse, a plethoric IVC, and exaggerated respiratory variation in inflow.
Why the others are wrong:
- A: A small, collapsing IVC argues against elevated right-sided pressure.
- B: LVH is unrelated.
- C: Tamponade typically exaggerates respiratory variation in spontaneously breathing patients; reduced variation is not the characteristic supporting sign.
Tamponade is a clinical diagnosis, and effusion size alone doesn’t establish it. Communicate these findings urgently.
Source: ASE Pericardial Disease imaging (Klein et al., JASE 2013), §D.3.a–b, pp.987–990: chamber collapse, IVC and respiratory Doppler.
Question 24 · AE-P16 · Task 2.A.16
Which combination favors constrictive pericarditis over restrictive cardiomyopathy?
Show answer and explanation
Answer: B. Medial (septal) e′ above 7 cm/s and higher than lateral e′, a respiratory septal shift, and expiratory diastolic flow reversal in the hepatic veins
In constriction without coexisting myocardial disease, medial e′ is preserved, often above 7 cm/s. The tethered lateral wall can make medial e′ exceed lateral e′ (annulus reversus). Respiratory septal shift and expiratory hepatic-vein reversal reflect ventricular interdependence.
Why the others are wrong:
- A: Reduced e′ at both sites, typically 5 cm/s or less, with lateral above medial points to restrictive myocardial disease.
- C: E/A over 2.5 with a short IVRT describes advanced restrictive filling, and constriction usually shows marked respiratory variation.
- D: A large effusion with RA collapse raises concern for tamponade; it does not establish the constrictive pattern described here.
Source: ASE LV Diastolic Function and HFpEF update (Nagueh et al., JASE 2025), §15.F, p.561; Figure 7 and Key Points, p.562; ASE Pericardial Disease imaging (Klein et al., JASE 2013), §D.3.a, p.987: RA collapse limitations; Introduction: mixed myocardial/pericardial disease.
Question 25 · AE-P17 · Task 2.A.18
In parasternal short-axis view, the interventricular septum is flattened at end-systole and end-diastole, so the LV looks D-shaped throughout the cardiac cycle. This pattern indicates:
Show answer and explanation
Answer: A. RV pressure overload, with or without volume overload
Flattening at end-systole signals RV pressure overload, as in pulmonary hypertension. Flattening at both phases means pressure overload with or without added volume load. The LV eccentricity index is then above 1 at both phases.
Why the others are wrong:
- B: Isolated volume overload flattens the septum mainly in diastole.
- C: LV pressure overload keeps the LV round.
- D: Persistent flattening is not normal.
Source: ASE Right Heart and Pulmonary Hypertension guideline (Mukherjee et al., JASE 2025), Interventricular Septum, p.146; Key Points, p.150.
Question 26 · AE-P18 · Task 2.A.18
Which regional pattern is classically described in acute pulmonary embolism?
Show answer and explanation
Answer: C. RV mid free-wall akinesis with relatively preserved apical motion
This is McConnell’s sign. It suggests acute PE but isn’t specific, because RV infarction can look similar.
Why the others are wrong:
- A: Apical ballooning with basal hyperkinesis describes stress (takotsubo) cardiomyopathy.
- B: Diffuse LV hypokinesis with dilation is a dilated cardiomyopathy pattern.
- D: Isolated inferior akinesis is an LV regional wall-motion finding, not McConnell’s RV pattern.
Source: Regional right ventricular dysfunction detected by echocardiography in acute pulmonary embolism (McConnell et al., Am J Cardiol 1996), Abstract: regional RV pattern; Regional right ventricular dysfunction in acute pulmonary embolism and right ventricular infarction (Casazza et al., Eur J Echocardiogr 2005), Abstract: PE versus RV infarction comparison and conclusion.
Question 27 · AE-P19 · Task 2.A.5
In native mitral valve endocarditis, vegetations most typically attach to the:
Show answer and explanation
Answer: A. Atrial side of the mitral leaflets
Mitral vegetations most often attach to the atrial surface of the leaflets, although other surfaces can be involved.
Why the others are wrong:
- B: The ventricular side is the high-pressure side of the mitral valve.
- C: For the aortic valve, the upstream side is the ventricular side, so this is also wrong.
- D: Papillary muscles are not the typical attachment site.
Source: ASE Guidelines for the Use of Echocardiography in the Evaluation of a Cardiac Source of Embolism (Saric et al., JASE 2016), Table 5, item 1, p.17; Figure 14: vegetation location.
Question 28 · AE-P20 · Task 2.A.21
With agitated saline injected at rest and after Valsalva release, bubbles appear in the left atrium within three cardiac cycles of right atrial opacification. This most suggests:
Show answer and explanation
Answer: C. An intracardiac right-to-left shunt, such as a PFO
Early appearance, within about three cycles, points to an intracardiac shunt. Valsalva release briefly raises RA pressure and can open a PFO.
Why the others are wrong:
- A: Agitated saline bubbles normally don’t cross the pulmonary capillaries.
- B: Intrapulmonary shunting typically shows later appearance.
- D: A thrombus is unrelated to bubble transit.
Source: ASE ASD and PFO guideline (Silvestry et al., JASE 2015), Assessment of Shunting, pp.930–931: agitated saline and Valsalva; ASE Guidelines for the Use of Echocardiography in the Evaluation of a Cardiac Source of Embolism (Saric et al., JASE 2016), PFO bubble timing and limitations, p.31.
Question 29 · AE-P21 · Task 2.A.22
Suprasternal CW Doppler of the descending aorta shows a high systolic velocity with forward flow continuing into diastole (a “diastolic tail”). The most likely diagnosis is:
Show answer and explanation
Answer: D. Aortic coarctation
A significant coarctation keeps a pressure gradient across the narrowing, so flow continues forward through diastole. Look for an associated bicuspid aortic valve.
Why the others are wrong:
- A: A PDA shows continuous flow into the pulmonary artery.
- B: A dissection shows an intimal flap rather than this flow signature.
- C: Severe AR causes diastolic flow reversal, not forward flow.
Source: 2025 ACC/AHA/HRS/ISACHD/SCAI Guideline for Management of Adults With Congenital Heart Disease — official AHA clinical slide series, Official slide series, slide 125, Table 25: Doppler-profile row; 2022 ACC/AHA Guideline for Diagnosis and Management of Aortic Disease, §9.4 and §9.4.1 synopsis: associated BAV.
Question 30 · AE-P22 · Task 2.A.22
Which finding defines Ebstein anomaly?
Show answer and explanation
Answer: A. Apical displacement of the septal tricuspid leaflet with an “atrialized” portion of the RV
In Ebstein anomaly, the septal leaflet (often the posterior leaflet too) attaches abnormally far toward the apex, so part of the RV functions as atrium.
Why the others are wrong:
- B: Fused, doming leaflets describe rheumatic tricuspid stenosis.
- C: Fixed, retracted leaflets fit carcinoid heart disease.
- D: Prolapse is a separate entity.
Source: ASE Right Heart and Pulmonary Hypertension guideline (Mukherjee et al., JASE 2025), §G, Tricuspid Valve Disease, p.175: Ebstein morphology; Congenital Heart International Professionals Network — Supplementary ACHD Echo Acquisition Protocol: Ebstein Anomaly, Ebsteins Anomaly → Definition.
Question 31 · AE-P23 · Task 2.A.23
In Marfan syndrome, aortic dilation is typically:
Show answer and explanation
Answer: B. Centered at the sinuses of Valsalva (aortic root), often with mitral valve prolapse
Marfan syndrome classically dilates the root at the sinuses of Valsalva and effaces the sinotubular junction. Mitral valve prolapse is common.
Why the others are wrong:
- A: Mid-ascending dilation that spares the sinuses fits hypertension or bicuspid-related aortopathy better.
- C: Isolated descending-aorta disease is not the classic Marfan pattern.
- D: Coarctation is not the classic Marfan pattern.
Source: 2022 ACC/AHA Guideline for Diagnosis and Management of Aortic Disease, Table 7; §6.1.2.2.1 synopsis/supportive text 1; §6.1.3 supportive text 1.
Question 32 · AE-P24 · Task 2.B.1
TEE of a well-functioning bileaflet mechanical mitral prosthesis shows several small, symmetric regurgitant jets arising within the sewing ring. These most likely represent:
Show answer and explanation
Answer: D. Normal “washing” jets built into the valve design
Bileaflet mechanical valves have small, built-in leakage (“washing”) jets that are normal. Their location inside the ring and their small, symmetric pattern help identify them.
Why the others are wrong:
- A: A paravalvular leak arises outside the sewing ring.
- B: Obstructive thrombosis can restrict leaflet motion and raise gradients; it does not explain this normal jet pattern.
- C: Patient–prosthesis mismatch means the prosthetic effective opening is too small for body size; it is not identified by washing jets.
Always compare with the valve type, size, and baseline study.
Source: ASE Prosthetic Valve Function (Zoghbi et al., JASE 2024), §I.E–G, p.10; §I.B.iv, p.6; Figure 19, p.28; §I.C, p.7.
Domain 3: Clinical Care and Safety (7 questions)
Question 33 · AE-C01 · Task 3.A.3
During a routine outpatient TTE, you see a mobile linear flap in the proximal ascending aorta and a new aortic regurgitation jet. What should you do first?
Show answer and explanation
Answer: B. Notify the interpreting physician immediately, following your lab’s critical-findings procedure
A possible aortic dissection is a critical finding. It needs prompt, direct communication to the interpreting physician, documented per your facility’s procedure.
Why the others are wrong:
- A: Waiting for a routine report delays care.
- C: Do not independently give the patient an unconfirmed diagnosis; first alert the interpreting physician.
- D: Do not independently order additional imaging in this scenario; alert the interpreting physician first.
Source: AE Examination Content Outline, Version 24.2, Task 3.A.3, p.3; ASE Echocardiography Reporting guideline (JASE 2025), Communication of Results, p.757; Table 14, p.766.
Question 34 · AE-C02 · Task 3.B.1
Which condition is an absolute contraindication to transesophageal echocardiography?
Show answer and explanation
Answer: C. Esophageal stricture
Esophageal stricture is an absolute contraindication because passing the probe risks perforation. The same list includes esophageal tumor, perforation or laceration, diverticulum, perforated viscus, and active upper GI bleeding. Escalate before the study proceeds.
Why the others are wrong:
- A: AF is a common indication for TEE, for example to exclude LAA thrombus.
- B: Prior bypass surgery doesn’t block probe passage.
- D: Hypertension doesn’t block probe passage.
Source: ASE/SCA Comprehensive TEE (Hahn et al., JASE 2013), Table 6, p.927.
Question 35 · AE-C03 · Task 3.A.5
After a TEE study, the probe has been cleaned. What level of reprocessing does it require next?
Show answer and explanation
Answer: A. High-level disinfection following the manufacturer’s instructions
A TEE probe contacts mucous membranes, which makes it a semicritical device. After cleaning, it needs at least high-level disinfection with a method compatible with the manufacturer’s instructions.
Why the others are wrong:
- B: A probe cover doesn’t lower the required level.
- C: Heat-sensitive TEE probes can’t be autoclaved.
- D: Cleaning removes soil but doesn’t disinfect.
Low-level disinfection is appropriate for transducers that touch only intact skin.
Source: CDC Disinfection and Sterilization summary recommendations, Recommendations 2.b, 3.b–c and 10.b.
Question 36 · AE-C04 · Task 3.A.2
Why must patients fast before an elective TEE?
Show answer and explanation
Answer: D. To reduce aspiration risk during sedation and probe insertion
Fasting reduces stomach contents and lowers aspiration risk with sedation and topical throat anesthesia.
Why the others are wrong:
- A: The purpose of fasting before TEE is aspiration-risk reduction, not improving a transthoracic imaging window.
- B: Fasting has no effect on contrast reactions.
- C: Fasting is not used for heart-rate control.
Source: ASE/SCA Comprehensive TEE (Hahn et al., JASE 2013), Management of Patient Sedation, p.928: fasting and aspiration risk.
Question 37 · AE-C05 · Task 3.B.2
During a stress echo, the patient suddenly becomes unresponsive. You find no normal breathing and no definite pulse within 10 seconds. What is the immediate action?
Show answer and explanation
Answer: B. Call for help, activate the emergency response, and start high-quality chest compressions
Cardiac arrest calls for immediate emergency activation and CPR, with an AED or defibrillator as soon as one is available.
Why the others are wrong:
- A: Finishing the images delays CPR, and delay worsens outcomes.
- C: Oral glucose is dangerous in an unresponsive patient.
- D: Waiting delays CPR, and delay worsens outcomes.
Source: Part 7: Adult Basic Life Support — 2025 AHA Guidelines for CPR and ECC, §6.1 Recognition of Cardiac Arrest; §6.2 Initiation of Resuscitation; adult healthcare-professional algorithm.
Question 38 · AE-C06 · Task 3.B.2
During a dobutamine stress echo, which event requires stopping the infusion for safety?
Show answer and explanation
Answer: C. Sustained ventricular tachycardia
Sustained VT is a safety endpoint that ends the test. Other endpoints include significant hypotension, a significant new wall motion abnormality, and intolerable symptoms.
Why the others are wrong:
- A: A rising heart rate below target is expected.
- B: Isolated PVCs are common and don’t by themselves require stopping.
- D: Hyperdynamic motion is the normal response.
Source: ASE Stress Echocardiography (Pellikka et al., JASE 2020), §III.b, p.9: dobutamine test endpoints; Table 3, p.11.
Question 39 · AE-C07 · Task 3.A.4
A sonographer removes gloves after a patient contact and needs to type the exam into the workstation next. What is correct?
Show answer and explanation
Answer: A. Perform hand hygiene before touching the workstation
Gloves don’t replace hand hygiene. Hands should be cleaned after glove removal and before touching clean surfaces.
Why the others are wrong:
- B: Hands can be contaminated during glove use or removal.
- C: Changing gloves still requires hand hygiene first.
- D: Cleaning the keyboard afterward doesn’t prevent the contamination already transferred.
Source: CDC Core Infection Prevention and Control Practices, §5a, Hand Hygiene, recommendation 2: immediately after glove removal.
Domain 4: Measurement Techniques, Maneuvers, and Sonographic Views (15 questions)
Question 40 · AE-P02 · Task 4.A.1
Hypothetical measurements: LVOT diameter 2.0 cm, LVOT VTI 20 cm, aortic valve VTI 100 cm. What is the aortic valve area by the continuity equation?
Show answer and explanation
Answer: B. 0.6 cm²
LVOT area = 0.785 × 2.0² = 3.14 cm². Stroke volume = 3.14 × 20 = 62.8 mL. AVA = 62.8 ÷ 100 ≈ 0.63 cm², which rounds to 0.6 cm² and is in the severe range.
Why the others are wrong:
- A: 0.4 cm² multiplies the diameter, not the LVOT area, by the VTI ratio (2.0 × 20 ÷ 100).
- C: 1.0 cm² is the severe cutoff, not the calculated value.
- D: 1.6 cm² inverts the final division (100 ÷ 62.8).
Source: EACVI/ASE Aortic Stenosis focused update (Baumgartner et al., JASE 2017), Continuity Equation Valve Area and Figure 4, printed pp.379–382 / PDF pp.8–11; severity range Table 3 p.383 / PDF p.12.
Question 41 · AE-M01 · Task 4.A.9
Hypothetical values: peak TR velocity 3.5 m/s from a dense, complete envelope, and estimated right atrial pressure 8 mm Hg. There is no pulmonic stenosis, RVOT obstruction, or proximal pulmonary artery stenosis. What is the estimated RV systolic pressure?
Show answer and explanation
Answer: D. 57 mm Hg
RVSP = 4v² + RAP = 4 × 3.5² + 8 = 49 + 8 = 57 mm Hg. With no outflow obstruction, this approximates PA systolic pressure.
Why the others are wrong:
- A: This uses v instead of v².
- B: 36 mm Hg is too low: 4 × 3.5² alone is 49 mm Hg, before RAP is added.
- C: This forgets to add RAP.
An echo estimate supports the assessment of pulmonary hypertension. A definitive diagnosis requires right heart catheterization.
Source: ASE Right Heart and Pulmonary Hypertension guideline (Mukherjee et al., JASE 2025), C. Hemodynamics: Right Ventricular Systolic Pressure, p.160; Table 4, p.161; RVSP Key Points, p.166 (PDF pages 20, 21, 26).
Question 42 · AE-M02 · Task 4.A.6
In a spontaneously breathing adult, the IVC measures 2.4 cm at end-expiration from the subcostal view and collapses about 30% with a sniff. What is the standard echocardiographic estimate of right atrial pressure?
Show answer and explanation
Answer: C. 15 mm Hg
A dilated IVC (over 2.1 cm) that collapses less than 50% with a sniff suggests elevated RAP, reported as 15 mm Hg (range 10–20).
Why the others are wrong:
- A: 3 mm Hg fits an IVC of 2.1 cm or less that collapses 50% or more.
- B: 8 mm Hg is the intermediate value for indeterminate cases.
- D: 20 mm Hg may be considered with a markedly enlarged IVC (>2.5 cm), limited respiratory collapse, dilated hepatic veins, and additional signs of markedly elevated RAP; those features are not given here.
Source: ASE Right Heart and Pulmonary Hypertension guideline (Mukherjee et al., JASE 2025), C. Hemodynamics: Right Atrial Pressure, p.160; Table 4, p.161; Figure 3, p.164 (PDF pages 20, 21, 24).
Question 43 · AE-M03 · Task 4.A.8
Using the biplane method of disks, LV end-diastolic volume is 150 mL and end-systolic volume is 60 mL. What is the LV ejection fraction?
Show answer and explanation
Answer: B. 60%
EF = (150 − 60) ÷ 150 × 100 = 60%. Biplane disks is the recommended 2D method because it makes fewer shape assumptions than single-diameter formulas.
Why the others are wrong:
- A: 40% is the fraction left in the ventricle after systole.
- C: 67% divides the remaining 60 mL by the ejected 90 mL.
- D: 90 is the stroke volume in mL, not a percentage.
Source: ASE/EACVI Chamber Quantification (Lang et al., JASE 2015), §1.2 Volumetric Measurements, pp.3–5; §2.2 Ejection Fraction, p.7.
Question 44 · AE-M04 · Task 4.A.7
For a biplane left atrial volume, which technique is correct?
Show answer and explanation
Answer: A. Freeze the end-systolic frame just before mitral valve opening and trace the LA, excluding the pulmonary veins and LA appendage
The LA is largest at the end of ventricular systole, one or two frames before the mitral valve opens. Trace in dedicated, non-foreshortened apical views, exclude the pulmonary veins and LAA, then index to body surface area.
Why the others are wrong:
- B: At end-diastole the LA is partly emptied, so the volume is underestimated. The LAA should be excluded.
- C: At mid-diastole the LA is partly emptied, and the vein confluences should be excluded.
- D: During atrial contraction the LA is emptying, not at its largest.
Source: ASE LV Diastolic Function and HFpEF update (Nagueh et al., JASE 2025), Table 3, LAVi row: acquisition, advantages, and limitations, p.542 (PDF page 6); ASE/EACVI Chamber Quantification (Lang et al., JASE 2015), §9.2 Linear Dimensions and Area Measurements and §9.3 Volume Measurements, pp.25–26.
Question 45 · AE-M05 · Task 4.A.1
The true aortic jet velocity is 4.0 m/s, but the CW beam is 30° off-axis to the jet. Without angle correction, about what velocity will be recorded?
Show answer and explanation
Answer: B. 3.5 m/s
Measured velocity = true velocity × cos θ = 4.0 × cos 30° ≈ 3.46 m/s, or about 3.5 m/s. With negligible proximal velocity, the simplified Bernoulli estimate using the unrounded value is about 48 mm Hg instead of 64.
Why the others are wrong:
- A: 2.0 m/s is what a 60° angle would give.
- C: At this 30° angle, the uncorrected measurement underestimates the true velocity.
- D: This alignment error lowers the recorded velocity; it does not raise it.
Source: ASE Identification and Mitigation of Cardiac Ultrasound Artifacts (Saric et al., JASE 2026;39:435–475), §4.4 Noncoaxial Intercept Angle Doppler Artifact, pp.450–451 (PDF pages 16–17); EACVI/ASE Aortic Stenosis focused update (Baumgartner et al., JASE 2017), Peak Jet Velocity, p.375; Pressure Gradient, p.378.
Question 46 · AE-M06 · Task 4.A.1
Apical CW Doppler records an aortic jet of 3.6 m/s in a patient with a heavily calcified valve. What is the best next step?
Show answer and explanation
Answer: C. Interrogate from the right parasternal and suprasternal windows, using a dedicated non-imaging CW probe if available, and report the highest velocity
Jet direction varies between patients, so a single window can underestimate severity. Interrogate from multiple windows and report the highest velocity.
Why the others are wrong:
- A: Reporting now risks underestimating severity.
- B: PW Doppler aliases at these velocities.
- D: Raising the wall filter clips low velocities and doesn’t fix alignment.
Source: EACVI/ASE Aortic Stenosis focused update (Baumgartner et al., JASE 2017), Peak Jet Velocity, p.375; Table 1, p.375; Key Points on aortic stenosis velocity measurement, p.382.
Question 47 · AE-M07 · Task 4.A.1
The LVOT diameter is measured 10% too small (1.8 cm instead of a true 2.0 cm). Every other input is unchanged. How will the continuity-equation AVA be affected?
Show answer and explanation
Answer: B. About 19% too small
Area depends on diameter squared, so 0.9² = 0.81. The LVOT area and the calculated AVA both come out about 19% too small.
Why the others are wrong:
- A: This forgets that the diameter is squared.
- C: An underestimated diameter shrinks the area; it doesn’t enlarge it.
- D: The VTIs don’t correct an error in the area.
Source: EACVI/ASE Aortic Stenosis focused update (Baumgartner et al., JASE 2017), Valve Area: continuity equation, p.379; Limitations of the standard approach continuity-equation valve area, p.381.
Question 48 · AE-M08 · Task 4.A.11
Hypothetical measurements for a suspected ASD: RVOT diameter 2.5 cm with RVOT VTI 20 cm, and LVOT diameter 2.0 cm with LVOT VTI 20 cm. Assume circular outflow tracts, matched diameter/VTI sampling sites, a stable heart rate, and no significant aortic or pulmonic regurgitation. What is Qp/Qs?
Show answer and explanation
Answer: A. 1.56
Pulmonary stroke volume = 0.785 × 2.5² × 20 ≈ 98 mL per beat. Systemic stroke volume = 0.785 × 2.0² × 20 ≈ 63 mL per beat. At the same heart rate, Qp/Qs is the ratio of these stroke volumes: (2.5² × 20) ÷ (2.0² × 20) = 1.5625, or 1.56.
Why the others are wrong:
- B: 1.25 is the ratio of the diameters without squaring them.
- C: Equal VTIs do not cancel the unequal outflow areas. A ratio of 1.0 would mean equal pulmonary and systemic flows.
- D: 0.64 is the inverted ratio.
Source: ASE ASD and PFO guideline (Silvestry et al., JASE 2015), Assessment of Shunting, pp.929–930 (PDF pages 20–21): RV/LV stroke-volume ratio, circular-area assumption, matched sampling, and semilunar regurgitation limitations.
Question 49 · AE-M09 · Task 4.A.12
In sinus rhythm, with no significant mitral valve disease and clearly separated E and A waves, mitral inflow shows E/A 1.3 at rest. During the strain phase of an adequate Valsalva maneuver, E/A falls to 0.6. What does this suggest?
Show answer and explanation
Answer: B. Elevated LV filling pressure (a pseudonormal pattern unmasked)
Valsalva lowers preload. A fall in E/A of 50% or more (here 1.3 → 0.6, about 54%) is highly specific for increased LV filling pressure.
Why the others are wrong:
- A: A fall of more than 50% argues against a normal filling pattern in this setting.
- C: This change alone does not identify constriction; constriction requires its own pattern of myocardial and respiratory findings.
- D: Valsalva inflow change doesn’t diagnose severe MR.
A reduction in peak E greater than 10% helps confirm an adequate maneuver. Record continuously through the strain phase.
Source: ASE LV Diastolic Function and HFpEF update (Nagueh et al., JASE 2025), Table 3, Valsalva Maneuver row, p.544 (PDF page 8); §5 age-independent indices, p.552; supplemental parameters, p.555.
Question 50 · AE-M10 · Task 4.A.12
A patient with suspected obstructive HCM has a low resting LVOT gradient. Which bedside maneuver is most useful to provoke latent obstruction?
Show answer and explanation
Answer: C. The strain phase of the Valsalva maneuver
The strain phase of Valsalva reduces venous return and preload, shrinking the LV cavity and worsening dynamic obstruction. Squat-to-stand and exercise are also used.
Why the others are wrong:
- A: Sustained squatting increases venous return, which reduces the gradient.
- B: A passive leg raise increases venous return, which reduces the gradient.
- D: Handgrip primarily raises afterload; it is not a reliable way to provoke a higher LVOT gradient.
Source: ASE Multimodality Imaging in HCM (Nagueh et al., JASE 2022), §1.E.3 Provoking Obstruction, pp.547–549 (PDF pages 15–17); The effect of different exercise modalities on the maximal left ventricular outflow tract gradient in patients with obstructive hypertrophic cardiomyopathy (Möbius-Winkler et al., Echo Research & Practice 2026;13:39), Results and Discussion: handgrip and LVOT gradients; single-center study of 20 patients.
Question 51 · AE-M11 · Task 4.A.5
Hypothetical values in sinus rhythm: mitral E 100 cm/s, septal e′ 5 cm/s, lateral e′ 7 cm/s. What is the average E/e′, and how does this numerical result compare with the increased-E/e′ threshold in Figure 3 of the 2025 ASE guideline?
Show answer and explanation
Answer: C. 16.7 — above the cutoff of 14
Average e′ = (5 + 7) ÷ 2 = 6 cm/s, so E/e′ = 100 ÷ 6 ≈ 16.7. An average E/e′ ≥14 meets that algorithm’s increased-E/e′ criterion.
Why the others are wrong:
- A: 6.0 is e′ itself, not the ratio.
- B: 14.3 uses lateral e′ only.
- D: 20 uses septal e′ only. Single-site cutoffs differ: septal ≥15, lateral ≥13.
Source: ASE LV Diastolic Function and HFpEF update (Nagueh et al., JASE 2025), Table 3, E/e′ acquisition and limitations, p.541; Table 4, p.548; Figure 3, p.554 (PDF pages 5, 12, 18); ASE Comprehensive Adult TTE (Mitchell et al., JASE 2019), §VII.H Tissue Doppler of the Mitral and Tricuspid Annuli, p.44: average e′ used for E/e′.
Question 52 · AE-M12 · Task 4.B.2
Which view shows all six mid-ventricular LV segments at once?
Show answer and explanation
Answer: A. Parasternal short-axis at the papillary muscle level
A short-axis slice at the papillary muscles shows the anterior, anteroseptal, inferoseptal, inferior, inferolateral, and anterolateral mid segments in one ring.
Why the others are wrong:
- B: The apical four-chamber view shows only two walls.
- C: The parasternal long-axis view shows only two walls.
- D: The subcostal IVC view doesn’t display the LV segments.
Source: ASE/EACVI Chamber Quantification (Lang et al., JASE 2015), §3.1 Segmentation of the Left Ventricle, p.10; Figure 3, p.11; ASE Comprehensive Adult TTE (Mitchell et al., JASE 2019), §IV.B parasternal short-axis views at papillary-muscle level, p.26; Table 2.12, p.21.
Question 53 · AE-M13 · Task 4.B.4
Which transthoracic window best displays the aortic arch and proximal descending aorta for suspected coarctation?
Show answer and explanation
Answer: C. Suprasternal notch
The suprasternal long-axis view shows the arch and its branches and lines up CW Doppler with flow in the descending aorta.
Why the others are wrong:
- A: A standard PLAX view shows the root and proximal ascending aorta, not the arch in long axis.
- B: The subcostal four-chamber view displays cardiac chambers rather than the aortic arch.
- D: The apical two-chamber view displays the left atrium and left ventricle, not the aortic arch.
Source: ASE Comprehensive Adult TTE (Mitchell et al., JASE 2019), §IV.E SSN Long-Axis View, p.31; §VII.E Aortic Arch and Desc Ao, p.44.
Question 54 · AE-M14 · Task 4.B.3
Which TTE window best evaluates the interatrial septum for a secundum ASD because the beam is closer to perpendicular to the septum?
Show answer and explanation
Answer: D. Subcostal
Subcostal views place the septum more perpendicular to the beam, which reduces false “dropout.”
Why the others are wrong:
- A: In the apical four-chamber view the septum runs parallel to the beam, so the thin fossa ovalis can falsely appear absent.
- B: PLAX doesn’t profile the septum well.
- C: The suprasternal view doesn’t profile the septum well.
Source: ASE ASD and PFO guideline (Silvestry et al., JASE 2015), Subxiphoid Frontal (Four-Chamber) TTE View and Apical Four-Chamber TTE View, p.924 (PDF page 15); ASE Comprehensive Adult TTE (Mitchell et al., JASE 2019), §IV.D.1 SC Four-Chamber View, p.31.
Domain 5: Instrumentation, Optimization, and Contrast (6 questions)
Question 55 · AE-M15 · Task 5.A.5
When imaging is needed before elective cardioversion, which of these echocardiographic studies is preferred to exclude left atrial appendage thrombus?
Show answer and explanation
Answer: B. Transesophageal echocardiography
The LAA is often poorly seen on TTE. TEE images it up close from multiple midesophageal planes.
Why the others are wrong:
- A: This TTE approach can’t reliably exclude LAA thrombus.
- C: This TTE approach can’t reliably exclude LAA thrombus.
- D: M-mode can’t reliably exclude LAA thrombus.
Source: ASE/SCA Comprehensive TEE (Hahn et al., JASE 2013), Left Atrium and Pulmonary Veins, p.953; LA and LAA Three-Dimensional TEE and Figure 15, p.954; AE Examination Content Outline, Version 24.2, AE Content Outline Version 24.2, p.4, task 5.A.5.
Question 56 · AE-I01 · Task 5.A.3
A pulsed-wave Doppler signal wraps around the baseline (aliases). Which adjustment helps most?
Show answer and explanation
Answer: C. Increase the scale (PRF), shift the baseline, or switch to CW Doppler
Aliasing occurs when the Doppler frequency shift exceeds half the PRF; the corresponding velocity limit also depends on transmit frequency and beam angle. Increasing PRF raises the limit. Baseline shifting can display a unidirectional signal within the available range but does not increase PRF. If the required velocity still cannot be recorded with conventional PW Doppler, CW avoids aliasing but loses depth specificity.
Why the others are wrong:
- A: A higher frequency lowers the Nyquist velocity and makes aliasing worse.
- B: A deeper sample volume lowers the maximum PRF and makes aliasing worse.
- D: Gain doesn’t affect aliasing.
Source: ASE Comprehensive Adult TTE (Mitchell et al., JASE 2019), §III.B.1 Velocity Scale, p.8; §III.B.6 PW/HPRF/CW discussion, pp.12–15; Table 1.18 Baseline, p.14; ASE Identification and Mitigation of Cardiac Ultrasound Artifacts (Saric et al., JASE 2026;39:435–475), §4.3 Velocity Scale Error/Aliasing, p.450 (PDF page 16), recommendations and range-ambiguity limitation.
Question 57 · AE-I02 · Task 5.A.1
A linear echo appears inside the ascending aorta at exactly twice the depth of a bright anterior structure. It moves in parallel with that structure, and color flow passes across it undisturbed. This is most likely:
Show answer and explanation
Answer: D. Reverberation artifact
Reverberations appear at multiples of a real reflector’s depth, move in step with it, and don’t split color flow into two channels.
Why the others are wrong:
- A: A true flap defines separate lumens; the reproducible double-depth, parallel-motion pattern favors artifact.
- B: Thrombus appears as wall-based thickening or a mass, not a repeated line at a multiple of a reflector’s depth.
- C: Hematoma appears as wall-based thickening, not a repeated line at a multiple of a reflector’s depth.
Check other views and motion, including M-mode when useful, before reporting.
Source: ASE Identification and Mitigation of Cardiac Ultrasound Artifacts (Saric et al., JASE 2026;39:435–475), §2.2 Reverberation Artifact, pp.438–439 (PDF pages 4–5); §9 Special Considerations in Aortic Imaging, p.469; Table 2, p.470 (PDF pages 35–36).
Question 58 · AE-I03 · Task 5.A.4
What is a known trade-off of tissue harmonic imaging?
Show answer and explanation
Answer: A. It improves endocardial border definition but can make valve leaflets look thicker
Harmonics reduce clutter and sharpen borders, but they can exaggerate leaflet thickness. Judge valve thickness carefully, sometimes in fundamental mode.
Why the others are wrong:
- B: Harmonics don’t guarantee a higher frame rate.
- C: Harmonics don’t remove the need for gain adjustment.
- D: Harmonics reduce near-field artifact but don’t eliminate it.
Source: ASE Comprehensive Adult TTE (Mitchell et al., JASE 2019), §III.A.5 Harmonic Imaging, pp.7–8; Tissue harmonic imaging in echocardiography: better valve imaging, but at what cost? (Hawkins et al., Echocardiography 2008;25:119–123), Abstract, Results and Conclusions: paired fundamental/harmonic valve-thickness comparison.
Question 59 · AE-I04 · Task 5.B.1
Despite optimization, two contiguous LV segments are still not adequately visualized for EF and wall-motion assessment on a resting TTE. The ordering physician has authorized enhancement and there is no contraindication. What helps most?
Show answer and explanation
Answer: B. An ultrasound enhancing agent for LV opacification
When two or more LV segments aren’t seen, a UEA improves endocardial border definition and the accuracy of volumes and EF.
Why the others are wrong:
- A: Agitated saline is filtered by the lungs and doesn’t opacify the LV in a normal circulation.
- C: Over-gaining adds noise and can create false borders.
- D: A higher frequency reduces penetration.
Product selection and dosing must follow the authorized order, current product labeling, and facility protocol.
Source: ASE Ultrasound Enhancing Agents (Porter et al., JASE 2018), §IV.A Assessment of Global LV Function, pp.247–249; Recommendations and Key Points, recommendation 1, p.249 (PDF page 9).
Question 60 · AE-I05 · Task 5.A.4
The image looks choppy when you track a fast-moving valve. Depth extends well past the heart and the sector is wider than the region you need. What is the best first adjustment?
Show answer and explanation
Answer: B. Reduce depth and narrow the sector to the region of interest
Less depth and a narrower sector shorten each frame’s acquisition time, which raises the frame rate and improves temporal resolution.
Why the others are wrong:
- A: Increasing acoustic output does not correct this frame-rate problem and adds unnecessary exposure.
- C: Gain doesn’t change frame rate.
- D: Adding focal zones lowers frame rate.
Source: ASE Comprehensive Adult TTE (Mitchell et al., JASE 2019), §III.A.6 Sector Size and Depth; §III.A.7 Transducer Beam Focus; §III.A.8 Gain; §III.A.10 Frame Rate, p.8; AIUM ALARA principle statement, Principles 1–6, especially principle 2: lowest output that yields an adequate diagnostic image; reapproved August 17, 2026.
Review your answers
Count your correct answers in each domain. Use the totals as feedback on these 60 questions only. They are not an ARDMS scaled score and don't predict a pass. The real exam reports a scaled score from 300 to 700, and 555 passes. ARDMS states that scaled points don't correspond to a percentage correct.
| Domain | Share of the real exam | Questions here | Your score |
|---|---|---|---|
| Anatomy and Physiology | 15% | 9 | ___ / 9 |
| Pathology | 40% | 23 | ___ / 23 |
| Clinical Care and Safety | 11% | 7 | ___ / 7 |
| Measurement Techniques, Maneuvers, and Sonographic Views | 25% | 15 | ___ / 15 |
| Instrumentation, Optimization, and Contrast | 9% | 6 | ___ / 6 |
| Total | 100% | 60 | ___ / 60 |
Each domain has only a small sample of its topics, so treat a weak area as a lead, not a verdict. A miss pattern in Pathology or Measurement deserves attention first, because those two domains make up 65% of the exam.
Then work through your misses in four steps:
- Name the concept. Write the rule you didn't apply, not just the right letter.
- Reread the explanation, especially the line about the option you picked.
- Open the cited source for anything that still feels shaky.
- Retry the question a day or two later without looking at the answer. Include questions you got right by guessing.
A quick mistake log
| Question | What I missed | Rule or method to remember | Recheck date |
|---|---|---|---|
| 43 (example) | Used EF = ESV ÷ EDV | EF = (EDV − ESV) ÷ EDV × 100 | |
| Entry 2 | |||
| Entry 3 | |||
| Entry 4 |
What this practice set covers
The 60 questions cover selected topics in all five domains of the AE Content Outline, Version 24.2, which is the outline linked from the official exam page. The 9/23/7/15/6 allocation does not exactly reproduce the official domain percentages. Each question is tagged with its outline task code, such as 2.A.12 for aortic valve pathology. The calculations use hypothetical inputs, and every one has been re-checked.
This is a selected-topic set. It touches every domain but doesn't sample every task, lesion, device, or TEE view in the outline. Check the version before you plan study time around a domain split.
Formulas to review
| Formula | Use |
|---|---|
| EF = (EDV − ESV) ÷ EDV × 100 | LV ejection fraction |
| ΔP = 4v² (simplified Bernoulli) | Peak gradients; RVSP = 4(TR v)² + RAP |
| LVOT area = 0.785 × D² | Stroke volume and continuity equation |
| AVA = (LVOT area × LVOT VTI) ÷ AV VTI | Aortic valve area |
| DVI = LVOT VTI ÷ AV VTI | Diameter-free aortic stenosis check (below 0.25 supports severe) |
| EROA = 2πr² × Va ÷ Vmax | PISA for mitral regurgitation |
| MVA ≈ 220 ÷ PHT | Mitral stenosis, with known limitations |
| Qp/Qs = (RVOT area × RVOT VTI) ÷ (LVOT area × LVOT VTI) | Shunt ratio |
| Measured v = true v × cos θ | Doppler angle error |
| Nyquist frequency limit = PRF ÷ 2 | Aliasing; the corresponding velocity limit also depends on transmit frequency and beam angle |
Use velocity in m/s for pressure gradients in mm Hg. For the area and flow calculations, use diameters and VTIs in cm; area is then in cm² and stroke volume in mL per beat. In the PISA formula, use the same units for Va and Vmax, with the radius in cm; the formula assumes hemispheric flow convergence. PHT is in milliseconds, Qp/Qs is dimensionless, and PRF is in Hz for a Nyquist frequency limit in Hz. The corresponding question explanations give the measurement assumptions and limitations; the aortic stenosis guideline, Table 3, supports the DVI reference.
The AE exam at a glance
| Exam feature | Official detail |
|---|---|
| Who runs it | ARDMS, governed and managed by Inteleos; Pearson delivers testing. You receive your score report at the test center and in your Pearson account. |
| Credential | AE is a qualifying specialty exam for RDCS; SPI and the applicable prerequisites are also required. Either exam can come first. For a first ARDMS credential, the second pass is due by December 31 of the fifth calendar year after the year of the first pass. The five-year rule does not apply to adding a specialty to a credential you already hold. |
| Format | About 150 multiple-choice questions in 3 hours, including hotspot questions where you mark directly on an image. |
| Scoring | Pass/fail on a 300–700 scale; 555 or higher passes. |
| Fee | $300 for AE and $275 for SPI. Both include a $100 non-refundable processing fee. Test centers outside the US, Canada, and Mexico add $50. |
| If you don't pass | You can reapply after 3 days but must wait 60 days to retest. |
| Published 2023 pass rates | 78% for first-time takers, 71% overall. |
Sources: official AE exam page, RDCS certification, fee schedule, 5-Year Rule, ARDMS/Inteleos relationship, and Pearson delivery.
ARDMS RDCS is a different credential from CCI's RCS. Check which one your program or employer expects.
What this practice set can't simulate
Our questions are text-only, but the real AE exam includes hotspot and image-based items. To prepare for those:
- Practice naming structures on real images. Label views, walls, and structures on clips from your lab or program.
- Watch the official hotspot video. ARDMS explains how to answer a hotspot question.
Skip any site selling "recalled" or "dumped" AE questions. Using them breaks ARDMS exam security rules and can cost you the credential.
Common questions
Is this an SPI or CCI RCS practice test too? No. This set targets ARDMS AE only. SPI covers ultrasound physics and is a separate exam; try our free ARDMS SPI practice test and see ARDMS SPI exam requirements. CCI's RCS is a different certification with its own exam.
Which guideline editions do the answers follow? Each explanation names its source. Where the American Society of Echocardiography updated a guideline in 2025, as it did for diastolic function and right heart assessment, we used the 2025 version. Those are the sources for this practice set; the currently linked AE content outline does not specify clinical guideline editions.
I didn't pass the AE exam. What now? See the ARDMS exam retake policy for the waiting period and how to reapply, and ARDMS exam results for help reading your score report. When you're ready to book, our ARDMS exam registration guide walks through the steps.
Sources
Official exam information
- ARDMS/Inteleos, Adult Echocardiography (AE) exam page
- ARDMS, AE Examination Content Outline, Version 24.2
- Inteleos, Passing Standard
- Inteleos, Exam Fee Schedule
- Inteleos, 5-Year Rule
- ARDMS/Inteleos RDCS certification: Road to Certification
- Inteleos: ARDMS member community and governance
- Inteleos: Schedule or Change an Exam
- ARDMS/Inteleos Sonography Principles and Instrumentation exam
- CCI Registered Cardiac Sonographer (RCS)
- Inteleos, Exam Security
Guidelines and supporting references
- ASE/EACVI Cardiac Chamber Quantification, Lang et al., J Am Soc Echocardiogr 2015
- ASE LV Diastolic Function and HFpEF update, Nagueh et al., JASE 2025;38:537-69
- ASE Right Heart and Pulmonary Hypertension guideline, Mukherjee et al., JASE 2025;38:141-86
- EACVI/ASE Aortic Stenosis focused update, Baumgartner et al., JASE 2017
- ASE Native Valvular Regurgitation, Zoghbi et al., JASE 2017
- ASE Comprehensive Adult TTE, Mitchell et al., JASE 2019
- ASE Prosthetic Valve Function, Zoghbi et al., JASE 2024
- ASE Multimodality Imaging in Hypertrophic Cardiomyopathy, Nagueh et al., JASE 2022;35:533-69
- ASE Stress Echocardiography, Pellikka et al., JASE 2020
- ASE Echocardiography Reporting guideline, JASE 2025
- ASE Pericardial Disease imaging, Klein et al., JASE 2013
- ASE/SCA Comprehensive TEE, Hahn et al., JASE 2013
- ASE Ultrasound Enhancing Agents, Porter et al., JASE 2018
- AIUM ALARA principle statement
- CDC Disinfection and Sterilization summary recommendations and CDC Core Infection Prevention Practices
- ASE ASD and PFO guideline (Silvestry et al., JASE 2015)
- 2022 ACC/AHA Guideline for Diagnosis and Management of Aortic Disease
- Part 7: Adult Basic Life Support — 2025 AHA Guidelines for CPR and ECC
- BSE practical guideline for comprehensive TTE in congenital heart disease (Corbett et al., 2022)
- Anatomical Study of the Moderator Band (Raghavendra et al.,2013)
- ASE Recommendations for Echocardiography in Evaluation of Rheumatic Heart Disease (Pandian et al.,2023)
- ASE publishes updated LV diastolic function guideline (2025)
- A rare case of isolated persistent left superior vena cava diagnosed by echocardiography (2024)
- International Society for Adult Congenital Heart Disease: CHD Glossary
- Anatomic variations of the coronary arteries supplying the anterolateral aspect of the left ventricle (Levin et al., Invest Radiol 1982)
- Coronary anatomy, anatomic variations and anomalies: a retrospective coronary angiography study (Altin et al., Singapore Med J 2015)
- Mechanical Complications of Acute Myocardial Infarction: A Scientific Statement From the AHA (Damluji et al., Circulation 2021)
- Regional right ventricular dysfunction detected by echocardiography in acute pulmonary embolism (McConnell et al., Am J Cardiol 1996)
- Regional right ventricular dysfunction in acute pulmonary embolism and right ventricular infarction (Casazza et al., Eur J Echocardiogr 2005)
- ASE Guidelines for the Use of Echocardiography in the Evaluation of a Cardiac Source of Embolism (Saric et al., JASE 2016)
- 2025 ACC/AHA/HRS/ISACHD/SCAI Guideline for Management of Adults With Congenital Heart Disease — official AHA clinical slide series
- Congenital Heart International Professionals Network — Supplementary ACHD Echo Acquisition Protocol: Ebstein Anomaly
- ASE Identification and Mitigation of Cardiac Ultrasound Artifacts (Saric et al., JASE 2026;39:435–475)
- Tissue harmonic imaging in echocardiography: better valve imaging, but at what cost? (Hawkins et al., Echocardiography 2008;25:119–123)
- The effect of different exercise modalities on the maximal left ventricular outflow tract gradient in patients with obstructive hypertrophic cardiomyopathy (Möbius-Winkler et al., Echo Research & Practice 2026;13:39)
Last verified: October 29, 2026. We checked the exam format, scoring, fees, retake wait, published pass-rate year, five-year rule, and outline version against the official ARDMS/Inteleos sources above. We checked the question answers and explanations against their cited references and recalculated the numerical examples.
This resource was developed with AI assistance. The checks described above are source and editorial checks, not a credentialed clinical review. How we develop and check our resources.
Written by the Castleport Test Prep Editorial Team. Castleport Test Prep is an independent exam prep publisher. It is not affiliated with, endorsed by, or approved by ARDMS or Inteleos. Exam and credential names identify their subjects, and trademarks belong to their respective owners. All questions on this page are original and unofficial, not actual exam questions. Practice results don't guarantee a passing score or certification.