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This quiz will highlight segmental wall motion abnormalities and coronary artery distribution. Try not to get frustrated, this can be a real challenge and you cannot get enough practice. Remember, some of these will have normal wall motion! And if you’re thinking “This would be a lot easier if the images were more crisp” you’re absolutely right. On the other hand it’s not looking at easy images that really makes you better.
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Question 1 of 53
1. Question
Where’s the coronary lesion?
Correct
Very good, you’re correct. It can be a little challenging when the patient is tachycardiac, but this image shows severe hypokinesis of most of the inferolateral wall.
Incorrect
Not exactly, try another look. It can be a little challenging when the patient is tachycardiac, but this image shows severe hypokinesis of most of the inferolateral wall. That would be an RCA problem, right?
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Question 2 of 53
2. Question
Where’s the coronary lesion?
Correct
Nicely done, my friend!
Incorrect
Not quite, better luck next time!
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Question 3 of 53
3. Question
Where’s the coronary lesion?
Correct
Nice! It looks like someone took a bite out of this LV, doesn’t it? You can see a clear step-off between the basal and mid inferoseptum.
Incorrect
Bzztt! Not quite. This is LAD disease and no mistake. It looks like someone took a bite out of this LV, doesn’t it? You can see a clear step-off between the basal and mid inferoseptum.
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Question 4 of 53
4. Question
Where’s the coronary lesion?
Correct
Exactly! Well done. The mid and apical inferoseptum and apex are all down here. Classic LAD disease.
Incorrect
Not exactly, but hopefully you were close…take another look and commit this to memory. The mid and apical inferoseptum and apex are all down here. Classic LAD disease.
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Question 5 of 53
5. Question
Where’s the coronary lesion?
Correct
Boom! The inferolateral wall is moving, but not thickening. Its being pulled by adjacent myocardium. Well done!
Incorrect
Take another look, I put this clip in for a particular reason. The inferolateral wall is moving, but not thickening. Its being pulled by adjacent myocardium. It is myocardial thickening that you want to look for.
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Question 6 of 53
6. Question
Where’s the coronary lesion?
Correct
Yep, you got it. Well done! And not only is there RCA disease, there is an inferior PSEUDOANEURYSM! This is an area of contained rupture of the myocardium, and can be distinguished from a true aneurysm by the appearance of a “neck.” What else distinguished true aneurysm from pseudoaneurysm?
Incorrect
Well…maybe you should take another look. In this image we see some significant RCA problems. And not only is there RCA disease, there is an inferior PSEUDOANEURYSM! This is an area of contained rupture of the myocardium, and can be distinguished from a true aneurysm by the appearance of a “neck.” What else distinguished true aneurysm from pseudoaneurysm?
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Question 7 of 53
7. Question
Where’s the coronary lesion?
Correct
Exactly! Well done. This patient’s in bad shape, with evidence of anterior and inferior abnormalities likely indicating RCA and LAD ischemia.
Incorrect
Not exactly, but hopefully you were close…take another look and commit this to memory. The patient has akinesis of the mid anterior segment through basically the entire inferior wall. This likely represents both LAD and RCA disease.
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Question 8 of 53
8. Question
Where’s the coronary lesion?
Correct
Exactly, the apical half of the LV here is down – typical for LAD.
Incorrect
Well…maybe you should take another look. In this image we see at least severe hypokinesis of the entire apical half of the LV. Classic for LAD.
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Question 9 of 53
9. Question
Where’s the coronary lesion?
Correct
Precisely! In this parasternal short axis we see an area of thin, fibrotic myocardium consistent with an old transmural infarct. This scar is in the mid inferior segment, maybe extending a little bit into the inferolateral.
Incorrect
Well…maybe you should take another look. In this parasternal short axis we see an area of thin, fibrotic myocardium consistent with an old transmural infarct. This scar is in the mid inferior segment, maybe extending a little bit into the inferolateral. That’s the RCA territory.
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Question 10 of 53
10. Question
Where’s the coronary lesion?
Correct
Nailed another one! I didn’t fool you with the normal image, well done.
Incorrect
Did I get you again? Sorry, this is another normal.
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Question 11 of 53
11. Question
Where’s the coronary lesion?
Correct
Didn’t fool you with a normal, huh? Well done!
Incorrect
Rats, I got you! Its another normal, doesn’t that just stick in your craw?
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Question 12 of 53
12. Question
Where’s the coronary lesion?
Correct
Exactly! Well done. It can be tough to call something normal when you’re looking very closely.
Incorrect
Whoops, gotcha! This is a normal transgastric short axis.
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Question 13 of 53
13. Question
Where’s the coronary lesion?
Correct
Well done, this one wasn’t so easy! The basal and mid inferior segments are akinetic here, just as you suggested.
Incorrect
This one was a little challenging. Take another look. The basal and mid inferior segments are akinetic, suggesting RCA disease.
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Question 14 of 53
14. Question
What’s the problem here?
Correct
Exactly! Well done. Bad news with so much akinetic myocardium.
Incorrect
Close but no cigar. The basal anteroseptal segment thickens and maybe the basal inferolateral wall (maybe) but little else. This patient had RCA and LAD disease in a big way.
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Question 15 of 53
15. Question
Where’s the coronary lesion?
Correct
Nicely done! I like this clip because there is a relatively small amount of abnormal myocardium and its easy to miss.
Incorrect
Don’t feel too badly, this is challenging. I like this clip because there is a relatively small amount of abnormal myocardium and its easy to miss. Its only the mid inferior segment that is akinetic.
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Question 16 of 53
16. Question
Where’s the coronary lesion?
Correct
Perfect, you got it!
Incorrect
Well, not quite. Take another look. This parasternal short axis shows fibrosis in the anterior and anteroseptal segments (at least.) Typical for an old LAD MI.
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Question 17 of 53
17. Question
Where’s the coronary lesion?
Correct
Perfect, well done!
Incorrect
Rats, I got you! This is a normal image, look again.
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Question 18 of 53
18. Question
Where’s the coronary lesion?
Correct
Yep, you got it. Well done! And not only is there akinesis in the inferior wall, there is a basal inferior ventricular aneurysm. See the bulging area near the base?
Incorrect
Take another look at this one, its important. Not only is there akinesis in the inferior wall (RCA troubles), there is a basal inferior ventricular aneurysm. See the bulging area near the base?
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Question 19 of 53
19. Question
Where’s the coronary lesion?
Correct
Exactly! Another nice example of RCA disease, resulting in… an inferior aneurysm. Remind me how we distinguish between aneurysm and pseudoaneurysm?
Incorrect
Take another look, this is a classic basal inferior aneurysm. Remind me the difference between an aneurysm and a pseudoaneurysm?
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Question 20 of 53
20. Question
Where’s the coronary lesion?
Correct
Yep, you got it. Well done! You can clearly see akinesis in the inferolateral wall here, typical for RCA dz.
Incorrect
Well…maybe you should take another look. We’re seeing an apical long axis here, with akinesis in the inferolateral wall. That would be an RCA issue.
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Question 21 of 53
21. Question
Where’s the coronary lesion?
Correct
Exactly! Well done. We see akinesis from the mid anteroseptal segment to the apex.
Incorrect
Not exactly, but hopefully you were close…take another look and commit this to memory. We see akinesis from the mid anteroseptal segment to the apex, classic LAD disease.
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Question 22 of 53
22. Question
Where’s the coronary lesion?
Correct
Yep, you got it. Well done! In this image we see a parasternal long axis with akinesis in the inferolateral wall, typical for RCA disease.
Incorrect
Well…maybe you should take another look. In this image we see a parasternal long axis with akinesis in the inferolateral wall, typical for RCA disease.
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Question 23 of 53
23. Question
Where’s the coronary lesion?
Correct
Exactly! Well done. This patient has akinesis in the LAD distribution, but hasn’t yet formed the thin, scarred myocardium that may come later.
Incorrect
Not exactly, but hopefully you were close…take another look and commit this to memory. This patient has akinesis in the LAD distribution, but hasn’t yet formed the thin, scarred myocardium that may come later.
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Question 24 of 53
24. Question
Where’s the coronary lesion?
Correct
Exactly! Well done. This is an example of an old LAD MI. The LV is thin and scarred, with evidence of an apical aneurysm. The basal anteroseptal segment thickens but you can see a clear step-off in the middle of the anteroseptal wall, through the apex and into the inferolateral wall. Look closely for mural thrombus in these cases!
Incorrect
Not exactly, but hopefully you were close…take another look and commit this to memory. This is an example of an old LAD MI. The LV is thin and scarred, with evidence of an apical aneurysm. Look closely for mural thrombus in these cases!
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Question 25 of 53
25. Question
Where’s the coronary lesion?
Correct
Perfect, another normal. Didn’t fool you, though!
Incorrect
Take another look, I fooled you with a normal. Sorry, its for your own good!
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Question 26 of 53
26. Question
Where’s the coronary lesion?
Correct
Perfect, you got it! This is a pretty nice one, I must say.
Incorrect
OK, this one isn’t totally easy so don’t feel badly. The apex and mid and lateral anterolateral wall are down. There could be multiple causes depending on coronary distribution, but that mid anterolateral segment is most likely circumflex distribution. The most important thing is that you recognize which segments are not normal.
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Question 27 of 53
27. Question
Where’s the coronary lesion?
Correct
Exactly! Well done.
Incorrect
Well…not exactly. Take another look, I’m sure you’ll get it next time.
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Question 28 of 53
28. Question
Where’s the coronary lesion?
Correct
Nicely done, my friend. This patient’s apex is down, and you’re going to look closely for mural thrombus right?
Incorrect
Well…maybe you should take another look. In this image we see an apex in trouble. You’re going to want to check this patient for a mural thrombus.
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Question 29 of 53
29. Question
Where’s the coronary lesion?
Correct
Exactly! Well done. We see akinesis in the mid and apical anterior walls as well as the apex. Classic LAD dz.
Incorrect
Not exactly, but hopefully you were close…take another look and commit this to memory. We see akinesis in the mid and apical anterior walls as well as the apex. Classic LAD dz.
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Question 30 of 53
30. Question
Where’s the coronary lesion?
Correct
Boom, nailed it!
Incorrect
Not quite, give it another try.
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Question 31 of 53
31. Question
Where’s the coronary lesion?
Correct
Nailed another one, well done!
Incorrect
Take another look here, you didn’t quite get it.
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Question 32 of 53
32. Question
Where’s the coronary lesion?
Correct
Yep, you got it. Well done!
Incorrect
No, but this one is definitely a little tough to see so don’t get down. This is another example of a basal inferior aneurysm – see the defect around 8 o’clock? Look closely.
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Question 33 of 53
33. Question
Where’s the coronary lesion?
Correct
Yep, you got it. And this one wasn’t easy.
Incorrect
OK, look again. This one isn’t easy, so don’t feel badly. Inferolateral wall looks good, as does the base of the anteroseptal wall, but the mid anteroseptum stops working. LAD again.
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Question 34 of 53
34. Question
Where’s the coronary lesion?
Correct
Exactly! Well done. You see evidence of an old LAD MI with thin, fibrotic, dyskinetic myocardium starting in the mid inferoseptum through the apex. Look for thrombus!
Incorrect
Hopefully you were close on this one. Take another look. You see evidence of an old LAD MI with thin, fibrotic, dyskinetic myocardium starting in the mid inferoseptum through the apex. Look for thrombus!
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Question 35 of 53
35. Question
Where’s the coronary lesion?
Correct
You nailed it, nice! The whole apex is totally down here.
Incorrect
Not quite, but take another look. The entire apex is down here.
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Question 36 of 53
36. Question
Where’s the coronary lesion?
Correct
Exactly. Well done!
Incorrect
Look more closely, this one isn’t easy either. There is no myocardial thinning, but starting somewhere around the anteroseptal segment, including anterior and maybe a little anterolateral we see severe hypokinesis or akinesis. LAD again.
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Question 37 of 53
37. Question
Where’s the coronary lesion?
Correct
Perfect, I didn’t fool you. Not easy to call things normal when you’re looking for trouble, huh?
Incorrect
Sorry, I tricked you. But it will make you stronger, take another look.
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Question 38 of 53
38. Question
Where’s the coronary lesion?
Correct
Exactly! Well done.
Incorrect
Not exactly, but hopefully you were close…take another look and commit this to memory. The inferior segment is definitely not normal here.
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Question 39 of 53
39. Question
Where’s the coronary lesion?
Correct
Boom, nailed it. This patient has a large area of (at least) severe hypokinesis. The only segments that are contracting appear to be the basal and mid anterolateral.
Incorrect
Well…maybe you should take another look. In this image we see a large area of (at least) severe hypokinesis. The only segments that are contracting appear to be the basal and mid anterolateral.
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Question 40 of 53
40. Question
Where’s the coronary lesion?
Correct
Nicely done, my friend. You found another normal!
Incorrect
Dang, I thought you had it, but I slid another normal one in there didn’t I?
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Question 41 of 53
41. Question
Where’s the coronary lesion?
Correct
Perfect! Is this an awesome clip or what?
Incorrect
Sorry, take another look. This clip is awesome, isn’t it? We’re looking at a basal inferior aneurysm, see how it bulges out in systole? You can identify the location based on the numbering in the corner, tricky huh?
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Question 42 of 53
42. Question
Where’s the coronary lesion?
Correct
Boom, you nailed it!
Incorrect
I’m sure you were close, better luck next time!
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Question 43 of 53
43. Question
Where’s the coronary lesion?
Correct
Exactly! Well done.
Incorrect
Not exactly, but hopefully you were close…take another look and commit this to memory.
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Question 44 of 53
44. Question
Where’s the coronary lesion?
Correct
Another sweet clip, and you nailed it!
Incorrect
Take another look at this parasternal LAX. Look at the difference in thickening between the anteroseptal and inferolateral wall.
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Question 45 of 53
45. Question
Where’s the coronary lesion?
Correct
Yep, you got it. Well done!
Incorrect
Well…maybe you should take another look. In this image we see a subcostal 4 chamber with dyskinesis of the LV apex. I know the image isn’t perfect, but you can see it. Sometimes it helps if you let your eyes unfocus and try to take in the whole image at once.
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Question 46 of 53
46. Question
Where’s the coronary lesion?
Correct
Exactly! Well done.
Incorrect
Not exactly, but hopefully you were close…take another look and commit this to memory. In this SAX we see akinesis (maybe even dyskinesis) and thinning of the inferior and inferolateral segments. Typical of RCA disease.
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Question 47 of 53
47. Question
Where’s the coronary lesion?
Correct
You got it, nice! You can see the step off in function between the anterolateral and anterior segments.
Incorrect
Not exactly, but don’t be too hard on yourself. This LAD lesion has caused akinesis of the anterior segment, notice the hinge-point between the anterolateral and anterior segments?
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Question 48 of 53
48. Question
Where’s the coronary lesion?
Correct
Exactly! Well done.
Incorrect
Not exactly, but hopefully you were close…take another look and commit this to memory.
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Question 49 of 53
49. Question
Where’s the coronary lesion?
Correct
Nailed it again, I’m so proud…
Incorrect
Well…maybe you should take another look. In this image we see akinesis and some thinning in the inferior segment, with 2 reasonably obvious hinge points. A good example of RCA disease.
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Question 50 of 53
50. Question
Where’s the coronary lesion?
Correct
Exactly, well done. This one is a little harder to see for some, but not you.
Incorrect
Don’t take it too hard, this one is a little tough. You can see a hinge-point between the anterolateral and anterior segments here, though, with hypokinesis of the inferoseptum, anteroseptum, and anterior segments.
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Question 51 of 53
51. Question
Where’s the coronary lesion?
Correct
Yep, you got it. Well done! Sometimes its hard to call things normal!
Incorrect
OK, this was tricky. This is normal, and it can be hard to say that. Take another look.
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Question 52 of 53
52. Question
Where’s the coronary lesion?
Correct
Yep, you got it my friend. In this image we see a basal short axis of the LV from the parasternal window. There is an akinetic area corresponding to the inferior/inferolateral segments. Typical RCA infarct.
Incorrect
Well…maybe you should take another look. In this image we see a basal short axis of the LV from the parasternal window. There is an akinetic area corresponding to the inferior/inferolateral segments. Typical RCA infarct.
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Question 53 of 53
53. Question
Where’s the coronary lesion?
Correct
Exactly! Well done. Check this one for thrombus.
Incorrect
Not exactly, but hopefully you were close…take another look and commit this to memory. This should shout old LAD MI, with a thin akinetic (maybe slightly dyskinetic) apex.