Anesthesiology APPLIED Exam › OSCE: echocardiography and POCUS

Basic valvular lesions on 2D and color

OSCE: echocardiography and POCUS·~5 min read· Physician-reviewed✓ Sourced · 4

Stem

Monitors and echo station. A 76-year-old man, 80 kg, with a loud systolic murmur that was never worked up, becomes hypotensive after induction for a hip fracture repair, and a TEE probe is placed. The first loop is a midesophageal aortic valve short-axis view: three heavily calcified cusps that barely separate, with a planimetered opening of 0.8 cm². The second is a midesophageal long-axis view with color: a thick, concentrically hypertrophied LV and a mosaic jet above the valve in systole.

Question

What is the lesion, how severe is it, and what are your hemodynamic goals?

Ideal answer

HeadlineSevere aortic stenosis: calcified, restricted cusps, planimetered area below 1.0 cm².¹ My goals: sinus rhythm, rate 60–80, full preload, normal-to-high pressure with phenylephrine early.

View, then leaflets on 2D: midesophageal aortic valve short-axis; cusps thickened, calcified and restricted.
The chamber that pays: the long-axis shows concentric hypertrophy, paying the pressure load.
Color, Nyquist 50–70 cm/s, gain just below speckle:² turbulent mosaic flow above the valve in systole, no diastolic jet into the outflow tract.
Grade on leaflet opening, not color turbulence, because turbulence does not measure severity.

Regurgitant instead: the opposite, a normal-to-fast rate and lower afterload, to cut the regurgitant volume.

Breaking down the answer

The outline limits valve disease to what I can see on 2D and color flow; there is no pulsed or continuous-wave Doppler on the exam.³ It tests recognition from structure and jet, a rough grade, and the goals.

Lesion	Best view	2D and color findings	Severe when
Aortic stenosis	ME AV short-axis, ME long-axis	Calcified cusps, restricted opening, concentric LVH, turbulent flow above the valve	Planimetered area <1.0 cm²¹
Aortic regurgitation	ME long-axis	Diastolic jet into the LVOT from the cusps, dilated LV in chronic disease	Central jet width ≥65% of LVOT; vena contracta >6 mm²
Mitral regurgitation	ME four-chamber, two-chamber, long-axis	Systolic jet into the LA; prolapse or flail leaflet; eccentric jets hug the wall	Vena contracta ≥7 mm; central jet >50% of LA area, or an eccentric wall-impinging jet²
Mitral stenosis	ME four-chamber, long-axis	Thickened leaflets, "hockey-stick" anterior leaflet doming, big LA, spontaneous contrast	Severe restriction with marked LA enlargement
Tricuspid regurgitation	ME four-chamber, RV inflow-outflow	Systolic jet into the RA, dilated RV and annulus	Vena contracta >7 mm; central jet >50% of RA; flail or no coaptation²

Vena contracta over jet area — jet area depends on gain, the Nyquist limit and loading; the narrowest neck is far less load-dependent, so it is my main severity grade.
Eccentric jets are underestimated — a jet hugging the atrial wall loses momentum and looks smaller than a central jet of the same severity. The prolapsing or flail leaflet is usually opposite the jet direction, which tells the surgeon which leaflet to repair.²
Why the AS goals — the atrial kick and diastolic time fill a stiff ventricle, and a fall in diastolic pressure starves the hypertrophied subendocardium; goals stated after the lesion show judgment.
Regurgitant lesions — rate 80–100 and lower afterload shorten the time and lower the gradient driving backward flow; I avoid bradycardia and pure vasoconstrictors.
Mitral stenosis goals — a slow rate to lengthen diastolic filling, rate control of atrial fibrillation, and no hypoxia, hypercarbia or acidosis, which raise pulmonary pressure on a hard-working RV.

Follow-up question

Next scenario: after a mitral valve repair, the patient is hypotensive. The loop shows a mosaic color jet in the LV outflow tract in systole, a posteriorly directed mitral regurgitant jet, and the anterior leaflet swinging toward the septum. What is this, and how do you treat it?

Follow-up answer

HeadlineSystolic anterior motion with dynamic LV outflow obstruction; I tell the surgeon the finding and mechanism, because the instinctive treatment worsens it.

Stop inotropes, give volume, raise afterload with phenylephrine, slow the rate with esmolol, lighten the dilators. I reassess outflow jet and regurgitation on the next loop; if obstruction persists, the surgeon revises the repair. The same picture appears in an underfilled patient with a septal bulge. The other variant, acute severe MR from papillary muscle rupture after an infarct: a flail leaflet, wide jet, hyperdynamic LV; I lower afterload, support with an inotrope, and call for an intra-aortic balloon pump and surgery.

Pitfalls that cost points

Grading regurgitation on jet area with the Nyquist limit set too low.
Calling a stenosis severe from color turbulence alone, ignoring leaflet opening.
Offering a Doppler gradient the exam does not ask for and cannot show.
Treating hypotension from systolic anterior motion with epinephrine.

Rapid-fire

Q: Why does color mosaic appear? A: Velocities above the Nyquist limit alias, so high-speed turbulent flow shows as a mix of colors.

Q: Why are eccentric jets underestimated? A: The Coanda effect pulls the jet along the atrial wall, so its visible area shrinks while the regurgitant volume does not.

Q: Why does an empty, fast heart worsen systolic anterior motion? A: A small LV cavity and high outflow velocity drag the anterior leaflet into the outflow tract by flow drag and Venturi forces.

Q: Which view shows the aortic valve as three cusps? A: The ME aortic valve short-axis at about 25–45°.⁴

Numbers to know

Item	Value
Color Nyquist limit	50–70 cm/s²
Severe AS area	<1.0 cm²¹
Severe AR vena contracta	>6 mm²
Severe MR vena contracta	≥7 mm²
AS heart-rate goal	60–80 bpm
Regurgitant heart-rate goal	80–100 bpm

Sources

1.Echocardiographic Assessment of Valve Stenosis: EAE/ASE Recommendations for Clinical Practice · EAE/ASE, 2009 · asecho.orgASE note: use ACC/AHA staging for mitral stenosis instead of the 2009 values.
2.Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation · ASE/SCMR, 2017 · asecho.orgNyquist 50-70 cm/s; severity tables for MR, AR, TR.
3.APPLIED Exam Objective Structured Clinical Examination (OSCE) Content Outline · ABA · theaba.org
4.Guidelines for Performing a Comprehensive Transesophageal Echocardiography Examination · ASE/SCA, 2013 · asecho.org

Facts on this page were checked against these sources on Oct 14, 2026. Guidelines change; confirm doses against current institutional protocols.