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Fibromas_____ are rare tumors that typically occur within the septal myocardium and are predominantly found in infants and children.Rhabdomyomas_____ are the most common primary cardiac tumors found in infants and children. They are usually multiple and are embedded in the septum or free wall of the left ventricle and is often associated with tuberous sclerosis.sarcomasApproximately one-fourth of primary cardiac tumors are malignant _____.Angiosarcoma, Rhabdomyosarcoma, fibrosarcoma, osteosarcomaThe various subtypes of sarcomas are _____, _____, _____ and _____.Angiosarcomas, Rhabdomyosarcomas_____ are the most common sarcomas and tend to be found in the right heart. _____ can arise in more than one area of the heart.40, malignantSecondary tumors are ____ times more common that primary tumors and are usually _____.brainAlmost any type of cancer, with the exception of _____ tumors, can spread to the heart and pericardium.breast, lung, melanomaCarcinomas arising from the _____ and _____ are the most common. _____ has the highest risk of metastasizing to the heart.anteriorlyA secondary mass from Lymphoma is usually seen _____ in the heart.pericardiumA secondary mass from breast and/or lung cancer is usually seen in the _____.pericardial cysts______ _____ are the most common benign tumor of the pericardium.Endocarditis_____ is an infection of the membrane lining of the heart, usually near or on a valve.bacterial, viridansEndocarditis is usually ____ and most commonly streptococcus _____.prosthetic, native, marfans, IVPatients at high risk of endocarditis are those with _____ valves, other disease _____ valves, those with _____ syndrome, and ____ drug users.Positive blood, endocardial, fever, heart, IVDuke Criteria for diagnosis of endocarditis include: a _____ ____ culture, evidence of _____ involvement through positive echo, ____, a predisposing _____ condition, and ____ drug use.atrial, ventricularEndocarditis is usually located on the _____ side of the tricuspid and mitral valve and the _____ side of the aortic and pulmonic valves.thrombusA ____ can be mural (immobile), mobile or free, have an irregular surface and located near the wall of the chamber.popcornA thrombus in transit can have a _____ like appearance.appendage, posteriorIn the LA, a thrombus is often found in the _____ or near the ____ wall.lower, catheterA thrombus in the RA is usually a migration from ______extremities or from a _____.infarction, cardiomyopathyA thrombus in the LV, is usually seen post _____ or with a ______.contusion, cardiomyopathy, infarctionA thrombus in the RV, is usually seen after a _____, with a _____, or post _____.TEEThe best imaging technique to help differentiate benign from malignant tumors is a ____.interatrial septum, adjacentBenign tumors arise from _____ _____ while malignant tumors extend into _____ structures such as IVC and pulmonic veins.eustachian, chiari, annular, valvular, Lambls, epicardialCommon masqueraders of tumors are the _____ valve, the _____ network, _____ calcification, myxomatous _____ apparatus, _____ excrescenses, and _____ fat.embolusAn ______________ is an intravascular mass, which usually comprises a thrombus, atheromatous, or cellular matter that has entered the circulation and causes symptoms by lodging in end arteries and interrupting blood flow to the organs.venous, leftEmboli from the ___________ system can enter the right side of the heart and cause pulmonary emboli,whereas those originating from the ________ side of the heart and great arteries can cause infarcts in the brain, kidneys, intestines, and skin.embolus, heartAlthough small strokes and transient ischemic attacks (TIAs) are often caused by atheromatous debris from the aorta or major cerebral arteries, an _____________ large enough to occlude multiple major peripheral or visceral arteries is more likely to originate from the ______________.paradoxical, shuntA _____________ embolus is a systemic infarct in which the source of the embolus is thought to be from the venous system, which has bypassed the pulmonary circulation by means of an intracardiac ___________, and crossed into the arterial circulation.infarcts, strokesBrain ___________, or _____________, are the most frequent embolic disease, particularly in the elderly.tiaA _________ is a temporary loss of blood flow to a region of the brain, which does not have the lasting clinical sequelae of a stroke but which represents a passing embolic event that has spontaneously resolved.atrial fibrillation________ _____________ with associated thrombus forming in the left atrial appendage is one of the most frequent causes of embolic stroke.atherosclerosis, atheromatousIn elderly patients (>55 yr old), ________________ of the great arteries and internal carotid arteries are thought to account for 20-60% of embolic strokes. These patients often have coexisting cardioaortic disease and internal carotid artery disease, rendering it difficult to identify which vessel is the culprit source of embolus in many cases. Younger patients (<55 yrs old) with embolic strokes are less likely to have significant _______________ disease, and more likely to have cardiogenic sources of embolus or hypercoagulable states.cardiacOther systemic emboli—those targeting the eye, kidney, spleen, or skin—are usually the result of vegetation or thrombus shed from an abnormal or prosthetic _________ valve, or the result of atheromatous debris dislodged by intra-arterial catheter procedures.pulmonaryA ____________ embolus is the result of a deep venous thrombosis, which has broken free and traveled to the lung bed.thrombus, vegetations, myxoma, fibroelastoma, thromboemboliPotential cardiovascular etiologies of stroke A. From great arteries Internal carotid artery atheroma Aortic root and ascending aortic atheroma Arterial dissection Vasculitis B. Cardioembolic Atrial fibrillation, rheumatic heart disease → atrial _________ Left ventricular dysfunction → ventricular thrombus Mitral stenosis, prolapse, mitral annular calcification Endocarditis → valvular ____________; marantic endocarditis Tumors: ____________ (rhymes with dyxoma), papillary ______________, fibrin strands Mitral valve and aortic valve prostheses, particularly mechanical → _________________ Intracardiac shunts: Patent foramen ovale and/or atrial septal aneurysm Atrial septal defect Ventricular septal defect Hematologic hypercoagulable state: activated protein C resistance/Factor V Leiden mutation, anticardiolipin antibody, Lupus anticoagulant, prothrombin mutationAtheroma____________ may be seen as irregular thickening of the aortic wall in the aortic root, ascending aorta, arch, and descending abdominal aorta. (these are small fatty lumps that develop on the inside of vessel walls).plaques, thrombusCalcified __________ tend to appear very jagged and echobright, and associated ____________ can appear as tethered but mobile elements. ____________ (same as first) that are more than 4 mm in thickness, or which contain mobile or protruding elements, are associated with a higher risk of stroke.atrial fibrillationThe presence of _________ ____________, particularly in the presence of rheumatic heart disease, increases the risk of atrial thrombus formation.spontaenous echoAtrial thrombi often occur in association with _____________ ______ contrast, which is thought to represent increased fibrin and red blood cells in the early stages of coagulation.thrombiAlthough TTE often does not fully visualize the left atrial appendage, __________ may occasionally be seen in the body of the left or right atrium. Figure 4 is a parasternal short-axis view of a ____________ (same thing, singular) within the left atrial appendage.aneurysmal, thrombusThe presence of a dyskinetic or _____________ area of left ventricle in a patient with a history of myocardial infarction should always prompt evaluation for an associated intramural ____________, which can vary greatly in shape and mobility.stenosis, calcification, prolapseMitral __________, stranding, and mitral annular ____________ have all been suggested to be associated with risk of embolus, although there are often confounding risk factors. Mitral valve ___________ was historically implicated as a risk factor, but this appears to be an artifact of overdiagnosis of mitral valve prolapse in this population (elderly), rather than comprising a true etiological substrate.vegetations, echodensities, shadowingBacterial _____________ are more likely to occur on abnormal native valves, such as bicuspid aortic or myxomatous mitral valves. Prosthetic valve thrombus or vegetation may be detected as independently mobile _____________, predominantly located on the low-pressure side of the valve. On mechanical prosthetic valves, the masses may not be clearly visualized because of acoustic _____________ by the prosthesis, but if one or more discs appear immobile or an unusually high transvalvular gradient is detected by Doppler, suspicion for obstruction remains high and a TEE should be performed.valves, embolizeThe epidemiology of cardiogenic emboli in younger patients is different from that of older subjects. Those with abnormal native _________, such as myxomatous or prolapsed mitral valve or bicuspid aortic valves are susceptible to endocarditis and resultant vegetation, which can ___________.10In the young, vegetations which are more than ____mm are at the highest risk for causing embolic complications.myxomasAmong intracardiac tumors, __________ are also more often found in younger patients owing to embolization.paradoxical, intracardiac, dilated____________ embolus is a well-known risk of congenital heart disease with _____________ shunting, as in the case of atrial septal defects or ventricular septal defects. The presence of a ___________ right atrium and/or right ventricle in the absence of other causes should prompt adiligent search for intracardiac shunting by both two-dimensional imaging and Color Doppler.pfo, intracardiac______ is a condition in which the ostium primum arises from the left atrial side and spans the fossa ovalis, but does not fuse completely with the apposing ostium secundum. ______ (same as first blank; don't type) is essentially a normal variant, occurring in 25-30% of the population. Under conditions in which right atrial pressure exceeds left atrial pressure, the ________(same as first and second blank; don't type) can allow right-to-left _____________ flow to occur (similar to a trap door or flap).septum, interatrial, subcostalThe potential channel of the PFO is typically not visible on two-dimensional echocardiography, although increased mobility of the ________ in the fossa ovalis area can be a clue to the presence of one. A careful color Doppler scan of a sector zoomed in on the _________ septum, particularly in the ___________ window, can occasionally detect flow across the PFO as a narrow red jet of transient left-to-right flow.bubble study, shuntingA "__________ ________" or injection of intravenous saline that has been agitated with air to produce echo contrast, is an echocardiographic method used to detect PFO. Because the bubbles produced by agitation within a syringe are relatively large and usually filtered by the pulmonary bed, the appearance of echogenic bubbles in the left side of the heart immediately (within six beats of opacifying the right atrium) is indicative of right-to-left ___________.left, right, PFOBecause ______ atrial pressure is usually higher than ________ atrial pressure, manuevers, which transiently increase right atrial pressure such as the Valsalva maneuver, coughing or sniffing, abdominal compression, or raising the legs can increase the sensitivity of a bubble study for detecting ______.pfos, stroke_____ can allow paradoxical emboli from the venous system to lodge in the systemic arteries, although the actual passage of a thromboembolus through a PFO is only rarely captured on echocardiographic views. The incidence of PFO appears to be higher in patients with ischemic _______ , exceeding threefold higherin patients younger than 55 yr old.atrial septal aneurysm, pfo, 10An ________ _________ ___________(ASA) is an excessively redundant hypermobile area of the interatrial septum,which can be seen on echocardiogram. It is very frequently associated with ______, and typically involves the area of the fossa ovalis, but can extend to include the surrounding limbic areas or even the entire interatrial septum. The criteria for the diagnosis of ASA vary, but it is generally accepted that maximal excursion of the interatrial septum more than _____ mm from centerline defines an ASA.embolic, aspirinThe incidence of both a PFO and an ASA is markedly increased in patients with ________ stroke, more than 15-fold in one meta-analysis. Options for therapy and secondary risk prevention at this point include_________, plus additional anticoagulation and/or closure ofthe PFO by surgery or transcatheter devices.youngerThe utility and yield of echocardiography in searching for a presumed cardiac source of embolus will vary with patient's age and comorbidities. Echocardiography is more likely to be useful in __________ patients, or those with known predisposing cardiac conditions. In contrast, the workup of most elderly patients with a stroke should start with an imaging modality of the internal carotid arteries .peripheral, visceral, cerebrovascular, neurologicalClass I (definitely proven to be of benefit) American College of Cardiology/American Heart Association guidelines for clinical application of echocardiography in neurological disease include: 1. Patients of any age with abrupt occlusion of a major ___________ or ___________ artery. 2. Younger patients (<45 yr) with _______________ events. 3. Older patients (>45 yr) with ____________events, without evidence of cerebrovascular disease or other obvious causes. 4. Patients for whom a clinical therapeutic decision (e.g., anticoagulation) will depend on the results of the echocardiogram.secundum, patency_____________ ASDs are one of the most frequently encountered congenital cardiac defects in clinical practice along with bicuspid aortic valves. The lesion results from the incomplete development of the septum secundum, leaving a central ___________ between the right and left atria.fenestrated, pulseOccasionally, there may be more than one opening in the septum so that a ___________ septum results. This is often clearly delineated on transthoracic imaging with the use of color flow Doppler around the area of the central portion of the septum. Shunt flow can be seen with the use of ________ wave Doppler across the defectcontraction, negative contrast, IVCUsually some transient right-to-left shunting can be seen with these defects, typically corresponding with ventricular ____________. Occasionally, with the use of intravenous agitated saline in the right heart, an echolucent silhouette of blood flow may be seen in the right atrium when predominant left-to-right shunting is present, the so-called "____________ __________ effect." However, because saline contrast is often injected from an upper extremity, this "negative contrast effect" should be interpreted with caution as this can also be produced by contrast-free caval blood flow emanating from the _______ flushing against the area of the fossa ovalis.aneurysms, hypermobile, Lutembacher'sOccasionally, atrial septal _____________ may be seen with secundum ASDs. In these cases, the atrial septum is ____________ and bows into either atrial chamber, varying with respiratory variation. When rheumatic involvement of the mitral valve is concomitantly present with an ASD, ______________ syndrome is said to be present.primum_________ASDs result from the incomplete development of the septum primum with the endocardial cushions in the region of the atrioventricular (AV) valves.mitral, regurgitationAlso called partial AV canal defects, this lesion (primum ASD) results in an atrial communication that is seen inferiorly, in the lower portion of the atrial septum that normally is fused with the AV valvular apparatus. The AV valves are therefore affected, typically involving the ________ valve, where a cleft may be seen in the anterior leaflet. Mitral _____________ may also be seen. Interventricular shunts are not generally seen with this abnormality.echolucentThe features of a primum ASD defect can usually been seen with transthoracic imaging. In the four-chamber view (apical or subcostal), the AV valves may appear to lieon the same plane, forming a "T," referring to the alignment of the AV valves with the ventricular septum. An ___________ space can be seen above the AV valves, usually with a nonrestrictive shunt seen by color flow Doppler. The "goose neck" deformity seen angiographically on left ventriculography can occasionally be seen echocardiographically as an abnormal appearing left ventricular outflow tract.sinus venosus, SVCThe ________ __________ ASD is an interatrial communication that arises near the junction of the vena cava with the right atrium. Therefore, this defect can present in two distinct morphologies. More commonly, the defect is located superiorly at the site of the _____ drainage to the right atrium but can be present inferiorly at the junction of the IVC and right atrium. In either case, these defects may be difficult to define anatomically via transthoracic imaging alone. However, transesophageal echocardiography can easily define the defect and any associated pathology.coronary sinusA ___________ ________ ASD is a rare type of ASD that presents an interatrial communication via an unroofed coronary sinus. Therefore, the defect is seen at the site of origin of the coronary sinus. A persistent left SVC is associated with this defect and can often be seen to drain into the coronary sinus or left atrium.coronary sinusA __________ ________ ASD may not be visualized on routine transthoracic echocardiography. However, the defect may be suggested by the constellation of right heart overload, a dilated coronary sinus, and the presence of a persistent left SVC. Multiplane transesophageal echocardiography should be used to confirm the presence of this defect and associated pathology.patent foramen ovale, pfoA __________ __________ ________ or ______ is not a true defect in embryological development of the either the septum primum or secundum. Rather, this lesion is the result of the failure of permanent fusion of the normally developed atrial septa.Valsalva, coughingA dynamically patent orifice acting similar to a flap valve is present in patients with a PFO and may respond to interatrial pressure changes.Thus a right-to-left shunt may be present when right atrial pressures increase higher than left atrial pressures, such as with ___________, ___________, and so on. The defect may be functionally sealed when left atrial pressures exceed right, with only occasional right-to-left shunting.saline, ValsalvaThe presence of a PFO defect is easily evaluated with agitated _________ contrast injection. Normally, the procedure is performed with and without _________ maneuver, as right-to-left shunting may not be seen under baseline conditions. The presence of contrast bubbles early after appearance in the right heart indicates the presence of right-to-left shunting.atrial septal defect, left, right_____ _____ ____ is an acyanotic congenital heart defect with _____ to _____ shunt.congenital, females, sizeAtrial Septal Defect is the most common ______ abnormality in adults, it is more prevalent in _____, the severity depends on the _____ of the defect.secundum, primum, venosus, coronaryThe four types of Atrial Septal Defect are septum ______, septum _____, sinus _____, and _____ sinus defect.secundum, primum, venosus, coronaryTypically _____ and _____ septal defects can be seen with a TTE. However multiplane TEE may be needed to visualize sinus _____ and ____ sinus defect.unroofedCoronary sinus defect is a rare type of ASD and presents an interatrial communication via an _____ coronary sinus.Patent foramen ovaleWhen the septum primum and septum secundum do not fuse after birth, a _____ _____ _____ may be present.SVC, IVC, pulmonarySinus venosus can present more commonly, high in the atrial septum, near the site of ____ drainage to the right atrium. It can also present lower in the atrial septum at the junction of the ____ and right atrium. It is associated with abnormal _____ venous drainage.atrioventricular, down, mitralSeptum primum is adjacent to the ______ valves ; either of which may be incompetement (regurgiation). It is common in _____ syndrome. It is commonly associated with a cleft _____ valve.ovalis, atrial, aneurysmSeptum secundum is the most common congenital cardiac defect. It involves the fossa _____ and is mid septal in location. It is commonly associated with an ____ septal _____.rheumatic, Lutembacher'sWhen _____ involvement of the mitral valve is present with an ASD, ______ syndrome is said to be present.diastolic, right, pulmonary, paradoxicalThe pathophysiology of ASD, is a left to right shunt resulting in _____ overloading of the _____ ventricle and increased _____ blood flow. Ventricular septal motion may be abnormal and display _____ motion.pulmonic, systemicEisenmenger's physiology is when the _____ pressures are equal to or higher than ______ blood pressureaortic, four, subcostalThe three main views in a TTE for viewing ASD's are the parasternal short axis at the level of _____ valve, the apical _____ chamber, and the _____ four chamber view.asymptomatic, thrive, recurrentIn early life most ASD's are _____. There may be some failure to _____ and ______ upper respiratory tract infections.arrythmias, pulmonary, bidirectional, CHFLater in life many patients with ASD's will develop atrial ______, ______ hypertension, _____ and then right to left shunting which will ultimately lead to _____.Qp/QsThe ____/____ ratio can be used to measure the hemodynamic impact of the ASD.pulmonary, aorticThe Qp/Qs ratio can be found by calculating flow across the _____ valve and dividing this by the flow across the _____ valve. Flow is calculated by multiplying the CSA of the outflow tract with the VTI .π x (radius of RVOT)^2 x RVOT VTI ____________________________________ π x (radius of LVOT)^2 x LVOT VTIQp/Qs formula is:C. The most common primary benign intracardiac tumor is the myxoma. Myxoma occurs most often in the left atrium, is usually attached to the interatrial septum via a stalk near the area of the fossa ovalis, is mobile, prolapsing into the orifice of the mitral valve resulting in obstruction.The most common primary benign intracardiac tumor in adults is the: A. Fibroma B. Lipoma C. Myxoma D. PapillomaD. Rhabdomyoma is the most common primary benign cardiac tumor found children. It occurs more often in the right ventricle than in the left ventricle and is associated with tuberous sclerosis.The most common primary benign intracardiac tumor found in children is: A. Myxoma B. Papilloma C. Rhabdomyosarcoma D. RhabdomyomaB. The papilloma or papillary fibroelastoma is a small (usually < 1cm) benign tumor that occurs on the endocardial surface of the atrioventricular valves on the downstream side of the valve or endocardium. This benign tumor is often attached by a short stalk and is capable of embolizing.The most common primary benign valvular tumor in adults is the: A. Angiosarcoma B. Fibroelastoma C. Myxoma D. RhabdomyomaB. The inter-atrial septum tends to accumulate fat. Lipomatous hypertrophy of the inter-atrial septum can produce a dumbbell-shaped configuration of the inter-atrial septum with thick fat-laden echoes surrounding a thin echo at the level of the fossa ovalis.A dumbbell-shaped configuration of the inter-atrial septum is associated with: A. Amyloidosis B. Lipomatous hypertrophy C. Sarcoidosis D. SarcomaC. Angiosarcoma are most often found in or around the right atrium with pericardial effusion. Angiosarcoma are common in men (3:1) in the third to fifth decade of life.The most common primary malignant intracardiac tumor in adults is the: A. Myxoma B. Papillary fibroelastoma C. Angiosarcoma D. FibromaD. Metastatic (non-primary) tumors are twenty times more common than primary cardiac tumors. Nearly 75% of cardiac metastases in adults are due to lung, breast or hematologic malignancies.The most common intracardiac tumor in adults is (the): A. Myxoma B. Rhabdomyoma C. Angiosarcoma D. MetastaticA. An unattached freely moving thrombus moving within the left atrium is called a left atrial ball-valve thrombus. The mobile thrombus moves throughout the left atrium and can move in and out of the mitral valve orifice causing intermittent obstruction.An unattached freely moving thrombus within the left atrium is referred to as a: A. Ball-valve thrombus B. Pedunculated thrombus C. Sessile thrombus D. MyxomaC. Right atrial thrombus are very important because they are frequently associated with pulmonary emboli. Often the right atrial thrombus form within the systemic veins and pass through the right atrium.Complications of a right atrial thrombus include: A. Interatrial septal aneurysm B. Patent foramen ovale C. Pulmonary embolism D. Valvular prolapse

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