National Dental Examining Board of Canada Written Examination (NDEB Written)

Correct: In the context of reporting myocardial disease, asymmetric septal hypertrophy (ASH) is defined by a disproportionate thickening of the interventricular septum compared to the posterior wall. A ratio of 1.3:1 or greater is the established diagnostic threshold for ASH in patients with hypertrophic cardiomyopathy. This finding is critical for accurate clinical reporting and differentiation from other forms of cardiomyopathy.

Correct: According to the American Society of Echocardiography (ASE) guidelines, the standard for measuring the aortic root and ascending aorta in adults via transthoracic echocardiography is the leading edge-to-leading edge (L-L) convention. These measurements must be taken in the parasternal long-axis view, perpendicular to the long axis of the aorta, and specifically at end-diastole. This methodology ensures the highest level of reproducibility for serial monitoring of aortic diameters.

Incorrect: The inner edge-to-inner edge technique mentioned in one option is generally reserved for the aortic annulus or specific pediatric protocols, and peak systole is not the standard timing for measuring the aortic root in adults. Another option suggests using the outer edge-to-outer edge method, which is more common in CT or MRI imaging but does not align with the standard TTE L-L protocol. The suggestion to use the apical three-chamber view as the primary measurement site is incorrect, as the parasternal long-axis view provides the necessary perpendicular orientation for accurate aortic root and ascending aorta assessment.

Takeaway: Standardized aortic reporting requires perpendicular measurements using the leading edge-to-leading edge technique at end-diastole to ensure clinical consistency and accurate monitoring of disease progression.

Correct: In a pulmonary artery sling, the left pulmonary artery (LPA) does not arise from the main pulmonary artery. Instead, it arises anomalously from the right pulmonary artery (RPA). It then tracks posteriorly and to the left, passing between the trachea and the esophagus to reach the left lung. Documenting this specific ‘sling’ around the airway is the definitive echocardiographic finding required for accurate reporting and risk assessment in these cases.

Incorrect: A right-sided aortic arch with an aberrant left subclavian artery describes a type of vascular ring, but not a pulmonary artery sling. A normal bifurcation of the main pulmonary artery excludes a sling by definition. A double aortic arch is a common cause of a complete vascular ring but involves the aortic arches rather than the pulmonary artery anatomy.

Takeaway: The diagnostic hallmark of a pulmonary artery sling is the anomalous origin of the left pulmonary artery from the right pulmonary artery, creating a vascular course between the trachea and esophagus.

Correct: Right ventricular diastolic collapse is a highly specific echocardiographic sign of cardiac tamponade, occurring when the intrapericardial pressure exceeds the intracardiac pressure during diastole. In the context of cardiac trauma, reporting this finding along with respiratory variations in transvalvular flow (the sonographic equivalent of pulsus paradoxus) is critical for identifying life-threatening hemodynamic compromise that requires immediate clinical intervention.

Incorrect: A small echo-free space posterior to the left atrium is often a normal finding or a small, non-hemodynamically significant effusion. A decrease in left ventricular end-diastolic volume is non-specific and can occur in various states of dehydration or shock without tamponade. Pericardial thickening without fluid suggests a chronic inflammatory process rather than the acute fluid accumulation typically seen in traumatic cardiac tamponade.

Takeaway: In cardiac trauma reporting, the identification of right ventricular diastolic collapse is the most critical echocardiographic finding for diagnosing life-threatening cardiac tamponade and must be prioritized in audit and clinical documentation.

Correct: In significant coarctation of the aorta, the pressure gradient across the narrowing is maintained throughout the cardiac cycle, resulting in a characteristic Doppler profile in the descending aorta known as diastolic runoff or a diastolic tail. Documenting this is critical for assessing the severity of the anomaly and is a key requirement for clinical risk management and diagnostic accuracy.

Correct: The coronary sinus is anatomically situated within the posterior atrioventricular groove. In echocardiography, specifically the parasternal long-axis view, the coronary sinus is visualized in cross-section at the junction of the left atrium and the posterior wall of the left ventricle. When reporting on cardiac devices, identifying a lead in this specific groove is the primary method to confirm it is in the coronary sinus (typically for left ventricular pacing) rather than the right ventricle.

Incorrect: The right ventricular inflow tract is the standard anatomical path for a right ventricular lead but does not provide the specific landmark needed to identify the coronary sinus. The anterior interventricular groove is the location of the left anterior descending artery, not the coronary sinus. The fossa ovalis is a landmark of the interatrial septum and is not used to verify the position of leads within the coronary venous system.

Takeaway: The posterior atrioventricular groove is the definitive echocardiographic landmark for identifying the coronary sinus and verifying the placement of cardiac pacing leads within it.

Correct: In the context of cardiac imaging, regulatory and professional standards require clear, standardized documentation of all findings. Updating the reporting template to include specific morphological descriptors ensures that critical diagnostic information, such as the presence of daughter cysts or wall calcification, is not lost and facilitates accurate interpretation. Flagging the finding for urgent review is a standard professional requirement for significant or unusual findings to ensure timely clinical management.

Incorrect: Classifying a cyst as an effusion is clinically inaccurate and could lead to inappropriate treatment or incorrect billing codes. Relying on verbal communication or waiting for a physician to ask for clarification risks the loss of vital diagnostic data and fails to meet professional documentation standards. Providing a diagnosis or recommending specific follow-up imaging directly to the patient exceeds the professional scope of practice for a cardiac sonographer and can cause unnecessary patient anxiety.

Takeaway: Standardized documentation and proactive communication with the interpreting physician are essential for the accurate reporting of cardiac cysts and adherence to professional sonography standards.

Correct: In the assessment of pulmonary hypertension, the morphology of the interventricular septum provides critical information regarding the pressure relationship between the ventricles. Septal flattening during systole indicates that right ventricular pressure is approaching or exceeding left ventricular pressure. A professional report must integrate these qualitative findings with quantitative chamber measurements to accurately convey the severity of the hemodynamic burden and the structural remodeling of the right heart.

Correct: Cardiac amyloidosis is an infiltrative cardiomyopathy where amyloid proteins deposit within the myocardial wall layers. This typically results in a characteristic granular or sparkling appearance of the myocardium on ultrasound. Because the infiltration causes significant stiffness and restrictive physiology, the atria must compensate for high filling pressures, leading to marked biatrial enlargement. Furthermore, amyloid can deposit in the interatrial septum and valves, causing them to appear thickened, which is a key differentiator from hypertensive heart disease where the septum usually remains thin.

Incorrect: Asymmetric septal hypertrophy and systolic anterior motion of the mitral valve are classic indicators of Hypertrophic Cardiomyopathy (HCM), not amyloidosis. Left ventricular dilation and thinning of the wall layers are characteristic of Dilated Cardiomyopathy, whereas amyloidosis typically presents with a non-dilated, thickened ventricle. Normal atrial dimensions and preserved diastolic filling pressures are highly unlikely in amyloidosis, as the restrictive nature of the disease almost always leads to atrial enlargement and diastolic dysfunction.

Takeaway: The hallmark echocardiographic findings of cardiac amyloidosis include a granular myocardial texture, biatrial enlargement, and thickening of the interatrial septum due to protein infiltration.

Correct: In the context of echocardiographic reporting, the sonographer must provide a detailed morphological assessment. This includes describing the borders (well-defined vs. poorly defined), the internal appearance (anechoic, septated, or containing daughter cysts), and the physiological impact on the heart, such as chamber compression. This level of detail is essential for the interpreting physician to differentiate between benign pericardial cysts, hydatid cysts, or other masses, ensuring clinical safety and diagnostic accuracy.

Incorrect: Calculating volume via Simpson’s method is a standard for ventricular volumes but is not the primary reporting requirement for cysts, where linear dimensions in multiple planes are more common. Recommending pharmacological interventions is outside the scope of a sonographer’s professional practice and is a clinical management decision made by the physician. Excluding extracardiac structures is a failure of comprehensive imaging, as the relationship between the cyst and surrounding thoracic structures is vital for a complete diagnostic picture and surgical planning.

Takeaway: Effective reporting of cardiac cysts requires precise morphological description and assessment of their hemodynamic impact on adjacent cardiac structures to ensure accurate differential diagnosis.