Normal Anatomy & Physiology
15%of exam
Segmental Situs & Ventricular LoopFetal Shunts & Postnatal ClosureCoronary Ostia & Arch SidednessPLSVC & Conotruncal Embryology
Acquired Heart Disease
12%of exam
Kawasaki Coronary Z-Score CutoffsDCM vs HCM FeaturesEndocarditis & Pulmonary HypertensionCardiac Tamponade & Myocarditis
Congenital Anomalies
25%of exam
Postoperative Anatomy
19%of exam
BTT Shunt vs Sano ConduitNorwood, Glenn & FontanJatene ASO vs Mustard/SenningRastelli, Ross & Repaired TOF
Performing the Exam
29%of exam
Bernoulli, Qp:Qs & RVSPPediatric Z-Scores & WindowsLV SF, RV TAPSE & TeiDoppler Angle & Bubble Contrast
Quick Facts
- Exam
- ARDMS Pediatric Echocardiography (PE)
- Credential
- RDCS (requires SPI + PE)
- Questions
- ~145 MCQ and hotspot items
- Time Limit
- 3-hour examination period
- Pass Score
- 555 on 300-700 scale
- Initial Credential Timing
- Calendar-based ARDMS five-year rule
- Pass Rate
- 88% first-time (2023 ARDMS)
- Retake Wait
- ≥60 days; eligible later PE window
Morphologic RV vs Morphologic LV
Morphologic Right Ventricle
- Apically offset trileaflet tricuspid valve
- Septal chordal attachments + moderator band
- Coarse trabeculations + muscular conus
Morphologic Left Ventricle
- Basal bileaflet mitral valve
- No septal chordal attachments
- Finer trabeculations; evaluate complete connections
Integrate morphology; position alone is insufficient
Segmental Situs & Fetal Circulation
- Situs Solitus Abdominal Pattern
- Aorta left; IVC right/anterior
- Right Atrial Isomerism
- Bilateral right atrial appendage morphology
- Left Atrial Isomerism
- Bilateral left atrial appendage morphology
- Morphologic RV Markers
- Moderator band; coarse trabeculations; tricuspid valve
- Three Fetal Shunts
- Ductus venosus, foramen ovale, ductus arteriosus
- PLSVC Clue
- Dilated coronary sinus; trace venous drainage
Coronaries, Arch Sidedness & Embryology
- Coronary Origins
- Trace ostia and proximal courses
- Coronary Dominance
- Defined by posterior descending artery supply
- Arch Sidedness
- Trace arch relative to trachea
- Common Arch Branching Variant
- Shared brachiocephalic/left carotid origin
- Conotruncal Development
- Outflow alignment and septation are complex
- AV Septal Defect Morphology
- Common AV junction; variable bridging leaflets
AHA Kawasaki Z-Score Thresholds
Z thresholds: 2 dilation; 2.5 small; 5 medium; 10 giant
<2: No current involvement2 to <2.5: Dilation2.5 to <5: Small5 to <10 AND <8mm: Medium≥10 OR ≥8mm: Giant
Pediatric DCM vs Pediatric HCM
Dilated Cardiomyopathy (DCM)
- Ventricular dilation with systolic dysfunction
- Assess size using appropriate pediatric models
- Secondary mitral regurgitation may occur
Hypertrophic Cardiomyopathy (HCM)
- Hypertrophy beyond expected loading conditions
- Obstructive and nonobstructive phenotypes exist
- SAM/dagger jet only when applicable
Dilation/dysfunction vs inappropriate myocardial hypertrophy
AHA 2024 Current Coronary Classification
- Coronary Z <2→No current coronary involvement
- Coronary Z ≥2 and <2.5→Dilation only
- Coronary Z ≥2.5 and <5→Small aneurysm
- Z ≥5, <10 AND diameter <8mm→Medium aneurysm
- Z ≥10 OR diameter ≥8mm→Large/giant aneurysm
Kawasaki Z-Scores & Pediatric Acquired
- Kawasaki Small Aneurysm
- Z ≥2.5 and <5
- Kawasaki Medium Aneurysm
- Z ≥5, <10 AND diameter <8mm
- Kawasaki Giant Aneurysm
- Z ≥10 OR diameter ≥8mm
- Endocarditis Vegetation Pattern
- Often upstream; negative echo cannot exclude
- Pediatric Pulmonary Hypertension Clues
- Septal flattening; contextual Doppler pressure estimates
- Tamponade Collapse Pattern
- RA systolic; RV early diastolic collapse
Tetralogy of Fallot Four Components
PROVe: Pulmonary obstruction, RV hypertrophy, Overriding aorta, VSD
P: Pulmonary/infundibular stenosisR: Right ventricular hypertrophyO: Overriding aorta; assess connectionsVe: Large malaligned VSD
Common D-TGA vs ccTGA Connections
D-TGA (Simple Transposition)
- AV concordance + VA discordance
- Parallel circulations; cyanotic neonate
- Often anterior/rightward aorta; variants exist
ccTGA (Double Discordance)
- Double discordance (AV and VA)
- Physiologic series flow; systemic RV
- Associated VSD, PS, Ebstein, CHB
VA discordance vs double discordance
ASD, VSD, PDA & CAVSD
- Sinus Venosus Defect
- Caval junction; assess pulmonary venous connections
- Significant Atrial Left-to-Right Shunt
- May cause RA/RV volume loading
- Outlet VSD
- Assess adjacent aortic cusp support
- PDA Imaging
- Trace duct; interpret directional Doppler
- Complete AV Septal Defect
- Common AV junction; atrial/ventricular communications
- Rastelli AVSD Types A/C
- A: crest-attached; C: free bridging leaflet
Darling Four Types of TAPVR
I Supracardiac, II Cardiac, III Infracardiac, IV Mixed drainage
I Supracardiac: above-heart drainageII Cardiac: Coronary sinus or RAIII Infracardiac: below-heart drainageIV Mixed: Multiple drainage levels
ALCAPA vs AAOCA Coronary Anomalies
ALCAPA (Bland-White-Garland)
- LCA arises from main PA
- Infant DCM + bright papillary muscle
- Septal collaterals + retrograde PA flow
AAOCA (Opposite Sinus)
- Coronary arises from opposite sinus
- Course may be interarterial/intramural
- Risk depends on detailed anatomy
Pulmonary origin vs opposite aortic sinus
TOF, TGA, CoA, HLHS & TAPVR
- TOF Defining Pattern
- Malalignment VSD, overriding aorta, RVOT obstruction
- TOF Coronary Check
- Identify coronary branches crossing RVOT
- Coarctation Assessment
- Anatomy plus flow; low output masks
- HLHS Spectrum
- Underdeveloped left heart; assess systemic pathway
- Infracardiac TAPVR
- Below-diaphragm drainage; frequent obstruction
- Ebstein Supportive Displacement
- ≥8mm/m² supportive; assess complete morphology
Truncus Arteriosus & Coronary Anomalies
- Truncus Type I
- Short main pulmonary artery then bifurcation
- Truncus Types II/III
- Separate branch origins: posterior/lateral patterns
- Truncus Associations
- Assess arch; consider 22q11.2 deletion
- ALCAPA Clues
- LV dysfunction, MR, bright papillary muscles
- ALCAPA Flow
- May show retrograde LCA-to-PA flow
- AAOCA Risk Features
- Assess ostium, interarterial and intramural course
Three-Stage Single-Ventricle Palliation
Stage 1 Norwood, Stage 2 Glenn, Stage 3 Fontan completion
1 Norwood: Neoaorta + BTT/Sano2 Glenn: SVC to RPA3 Fontan: IVC to PA
Modified BTT Shunt vs Sano Conduit
Modified BTT Shunt
- Innominate/subclavian artery to PA
- Continuous systole-diastole forward flow
- May produce diastolic systemic runoff
Sano Conduit
- Systemic RV infundibulum to PA
- To-and-fro systolic/diastolic Doppler
- Avoids direct systemic arterial shunt runoff
Systemic artery source vs RV source
Postoperative Anatomy Assessment
- Known arterial switch repair→Assess transferred coronaries and both outflows
- Known Rastelli repair→Assess LV tunnel and RV–PA conduit
- Historic Mustard/Senning baffle→Assess venous baffles and systemic RV
- Known Ross repair→Assess autograft and RV–PA conduit
- Single-ventricle staged palliation→Identify actual systemic/pulmonary venous pathways
Norwood, Glenn & Fontan Palliation
- Norwood Palliation
- Systemic neoaorta plus pulmonary flow source
- Bidirectional Glenn
- SVC connects to pulmonary arterial circulation
- Glenn Doppler
- Assess venous phasicity and focal acceleration
- Fontan Completion
- Systemic venous return bypasses subpulmonary ventricle
- Fontan Fenestration
- Usually venous-to-atrial decompression; assess gradient
- Glenn Pulmonary AV Malformations
- May cause delayed pulmonary bubble transit
Jatene ASO, Rastelli, Ross & TOF
- Arterial Switch LeCompte Maneuver
- Pulmonary bifurcation positioned anterior to aorta
- Arterial Switch Follow-up
- Coronaries, outflows, neoaortic valve and root
- Mustard/Senning Baffles
- Trace venous pathways; assess systemic RV
- Rastelli Anatomy
- LV-to-aorta tunnel plus RV-to-PA conduit
- Ross Procedure
- Pulmonary autograft replaces aortic valve
- Repaired TOF
- Quantify PR, obstruction and RV response
Intracardiac Shunt vs Isolated PDA Flow
ASD or VSD (L-to-R)
- Shunt enters upstream of PV
- RVOT stroke volume > LVOT
- Loading depends on shunt magnitude
- Assumes no significant semilunar regurgitation
Isolated PDA (L-to-R)
- Shunt enters distal to PV
- LVOT stroke volume > RVOT
- Significant shunt loads LA/LV
- Assumes no significant semilunar regurgitation
RVOT exceeds LVOT vs opposite
Shunt Pattern Interpretation
- Suspected apical atrial septal dropout→Confirm anatomy/flow from additional windows
- Left-arm contrast fills coronary sinus→Evaluate PLSVC and coronary sinus drainage
- Agitated saline: LA within 3–6 cycles→Likely interatrial shunt; confirm pathway(Count cardiac cycles after RA opacification)
- Agitated saline: LA after >6 cycles→Likely pulmonary transit; confirm circulation(Count cardiac cycles after RA opacification)
- Isolated left-to-right PDA→LVOT flow can exceed RVOT flow
Bernoulli, Qp:Qs & Pressure Calculations
- Simplified Bernoulli
- ΔP = 4v²; negligible proximal velocity
- Non-negligible Proximal Velocity
- Consider 4(v₂²−v₁²); verify assumptions
- Stroke Volume
- Area × VTI; area = πd²/4
- Shunt Flow Ratio
- Define sampling sites and shunt anatomy
- VSD-Derived RVSP
- SBP − 4v²; appropriate L→R assumptions
- PASP With RVOT Obstruction
- RVSP minus simultaneous RV-to-PA pressure drop
Measurement Method and Assumptions
- Proximal velocity negligible; assumptions satisfied→Estimate peak instantaneous gradient: 4v²
- Proximal velocity not negligible→Assess expanded Bernoulli and lesion geometry
- Distorted LV invalidates linear shortening→Use suitable volumetric assessment
- Complex or systemic RV anatomy→Integrate multiple suitable function indices
- PW aliasing limits velocity measurement→Adjust PRF or use appropriate CW
Z-Scores, Views & Ventricular Function
- Pediatric Z-Score
- Match method, model and body size
- Pediatric Aortic Root
- Inner edges; peak-flow midsystolic measurement
- LV Shortening Fraction
- (LVIDd − LVIDs) / LVIDd ×100%
- RV Function Assessment
- Integrate age-adjusted and geometry-sensitive indices
- Tei Index
- (IVCT + IVRT) / ejection time
- Pulmonary Venous Assessment
- Trace connections using multiple windows
Common Traps
Dropout vs True Septal Defect
Septal dropout ≠ confirmed ASD ≠ Multiview anatomy ≠ isolated dropout artifact
PDA vs Intracardiac Flow Sampling
PDA entry ≠ upstream pulmonary-valve entry ≠ PDA Qp:Qs ≠ RVOT÷LVOT
Pediatric vs Adult Root Convention
Pediatric inner-edges ≠ traditional adult leading-edges ≠ Z-score model convention ≠ interchangeable methods
Outlet VSD and Cusp Support
Outlet VSD ≠ guaranteed aortic regurgitation ≠ Cusp prolapse ≠ preserved cusp support
TOF Coronary Variants
LAD crossing RVOT ≠ normal course ≠ Normal ostium ≠ confirmed proximal course
Doppler vs Catheter Gradients
Maximum instantaneous ≠ catheter peak-to-peak ≠ Peak fenestration gradient ≠ measured PVR
Last Minute
- 1.PE: ≈145 items; 3 hours
- 2.Passing scaled score: 555 on 300–700
- 3.Five-year deadline uses calendar years
- 4.Kawasaki giant: Z≥10 OR diameter≥8mm
- 5.Medium: Z≥5,<10 AND diameter<8mm
- 6.Ebstein ≥8mm/m² supports morphology
- 7.Subcostal or parasternal protocol starts
- 8.Root: inner-edge peak-flow midsystole
- 9.RVOT diameter: end diastole
- 10.LV shortening fraction depends on geometry
- 11.RV adult cutoffs need pediatric context
- 12.MPI = (IVCT+IVRT)/ET
- 13.Bubble timing depends on circulation
- 14.Agitated saline detects right-to-left shunt pathways
- 15.Manufactured microbubbles normally cross pulmonary circulation
- 16.PW baseline shift preserves Nyquist limit
- 17.Doppler alignment affects squared gradient
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