Cardiology Practice Questions

Q: All are true regarding tricuspid atresia except –

Split S2. ***Split S2*** - This is the **EXCEPTION** – tricuspid atresia typically presents with a **SINGLE S2**, not a split S2. - The second heart sound (S2) splitting occurs when aortic (A2) and pulmonary (P2) valve closures are audibly separate. - In tricuspid atresia, the **hypoplastic or absent right ventricle** and **reduced pulmonary blood flow** result in a diminished or absent pulmonary component (P2), leading to a single S2 sound. - The lack of normal right ventricular ejection eliminates the typical splitting pattern. *Left axis deviation in ECG* - This is **TRUE** for tricuspid atresia and therefore not the exception. - Tricuspid atresia classically shows **marked left axis deviation** (typically -30° to -90° on ECG). - This occurs because the **left ventricle is dominant and hypertrophied**, as it must handle both systemic and, indirectly, pulmonary circulation. - The right ventricle is hypoplastic or absent, so left ventricular forces dominate the ECG axis. *Pulmonary oligemia in chest X-ray* - This is **TRUE** for tricuspid atresia and therefore not the exception. - **Pulmonary oligemia** (decreased pulmonary vascular markings) is characteristic on chest X-ray. - Results from **reduced pulmonary blood flow** due to the absence of direct right atrial to right ventricular flow. - Blood reaches the lungs only via a VSD or PDA, leading to diminished pulmonary vasculature appearance. *Patent foramen ovale* - This is **TRUE** for tricuspid atresia and therefore not the exception. - An **atrial septal defect (ASD) or patent foramen ovale (PFO)** is **essential for survival**. - Provides the only pathway for systemic venous return to reach the left atrium and subsequently the systemic circulation. - Without this right-to-left atrial shunt, no blood could reach the systemic circulation, resulting in immediate cardiovascular collapse.

Q: Most characteristic feature of TOF is

Cyanotic spells. ***Cyanotic spells*** - **Cyanotic spells**, also known as "tet spells," are acute episodes of profound hypoxemia that are characteristic of Tetralogy of Fallot (TOF), especially in infants. - These spells are caused by increased right-to-left shunting across the **ventricular septal defect** due to infundibular spasm that increases **pulmonary outflow obstruction**, leading to sudden severe cyanosis, dyspnea, and decreased consciousness. *Squatting* - While **squatting** is a common compensatory mechanism used by older children with TOF to improve oxygen saturation, it is a behavioral adaptation rather than a primary physiological feature. - Squatting increases **systemic vascular resistance**, which reduces right-to-left shunting and forces more blood into the pulmonary circulation. *Clubbing of feet* - **Clubbing of fingers and toes** is a common sign of chronic hypoxemia, which can be seen in various cyanotic congenital heart diseases, including TOF. - However, it is a long-term consequence of hypoxemia rather than a characteristic acute or primary feature specific to TOF. *Recurrent chest infection* - Children with TOF may have an increased risk of **recurrent chest infections** due to their underlying compromised cardiovascular status and hypoxemia. - However, recurrent chest infections are not a unique or characteristic feature of TOF, as they can occur in various pediatric conditions that affect respiratory health.

Q: A child after 4 weeks of birth, is acyanotic. Ejection systolic murmur detected on auscultation. Probable diagnosis is:

Coarctation of aorta. ***Coarctation of aorta*** - **Coarctation of the aorta** commonly presents with an **ejection systolic murmur** due to increased flow velocity through the narrowed segment. - Infants are often **acyanotic**, and symptoms like poor feeding or heart failure may develop as the **ductus arteriosus closes**. - The murmur is typically heard at the **left infraclavicular area and back** (interscapular region). *TOF* - **Tetralogy of Fallot** (TOF) is a **cyanotic heart defect**, which contradicts the patient's acyanotic presentation. - It typically presents with a **harsh systolic ejection murmur** at the upper left sternal border and **cyanotic spells**. *VSD* - A **ventricular septal defect** (VSD) typically produces a **holosystolic (pansystolic) murmur** best heard at the lower left sternal border, not an ejection systolic murmur. - While VSD is the most common congenital heart defect, the **murmur type** (holosystolic vs ejection systolic) is the key differentiating feature in this case. *PDA* - A **patent ductus arteriosus** (PDA) leads to a **continuous, machinery-like murmur** due to constant flow between the aorta and pulmonary artery. - It's not typically described as an ejection systolic murmur and can present with signs of **heart failure** or **pulmonary hypertension**.

Q: In the evaluation of congenital heart disease, which of the following findings is considered the LEAST specific diagnostic indicator?

Abnormal ECG findings. ***Abnormal ECG findings*** - While an electrocardiogram (ECG) is an important tool in evaluating congenital heart disease, **abnormal ECG findings** are relatively **non-specific** and can be seen in many conditions. - ECG changes may include axis deviation, chamber hypertrophy patterns, or conduction abnormalities, but these findings alone do not establish the specific diagnosis of congenital heart disease. - Some children with congenital heart disease may have **normal ECG findings**, particularly in mild cases or certain lesions like small atrial septal defects. - ECG serves as a supportive tool but requires correlation with clinical findings and echocardiography for definitive diagnosis. *Presence of a diastolic murmur* - A **diastolic murmur in a child** is highly pathological and almost always indicates significant cardiac pathology. - Diastolic murmurs suggest **aortic regurgitation**, **pulmonary regurgitation**, or **mitral stenosis**, which can be associated with congenital heart defects. - The presence of a diastolic murmur warrants immediate further investigation with echocardiography. *Congestive heart failure* - **Congestive heart failure (CHF)** in infancy or childhood is a critical clinical manifestation often indicating significant congenital heart disease. - Symptoms include tachypnea, failure to thrive, hepatomegaly, and poor feeding in infants. - CHF in children is highly specific for significant cardiac pathology, particularly left-to-right shunts (VSD, PDA) or left-sided obstructive lesions. *Cyanosis as a clinical sign* - **Cyanosis** (bluish discoloration of skin and mucous membranes) indicates arterial oxygen desaturation below 85%. - It is a cardinal sign of **cyanotic congenital heart disease** involving right-to-left shunting (Tetralogy of Fallot, Transposition of Great Arteries) or severe pulmonary obstruction. - Central cyanosis in a neonate is a medical emergency requiring urgent evaluation and management.

Q: A young boy presents to you with history of breathlessness on exertion. You being an intern proceed with auscultation of the patient's chest. Your findings are ejection systolic murmur in the left 2nd intercostal space, S1 is normal and has wide and fixed split S2. You then send the patient for an ECG, what would be the most likely finding in the ECG report?

Right axis deviation. ***Right axis deviation*** - The clinical presentation of **breathlessness on exertion**, an **ejection systolic murmur in the left 2nd intercostal space**, and a **wide and fixed split S2** are classic signs of an **atrial septal defect (ASD)** [2]. - An ASD leads to a **left-to-right shunt**, causing **volume overload** in the right atrium and right ventricle, which results in **right ventricular hypertrophy** and consequently **right axis deviation** on an ECG [1]. *Left axis deviation* - **Left axis deviation** is typically associated with conditions causing **left ventricular hypertrophy** or conduction defects involving the left bundle branch, which are not directly indicated by the described cardiac findings. - While some complex congenital heart defects can present with left axis deviation, it is not the most common finding with an isolated **atrial septal defect**. *Large p waves* - **Large P waves** (P pulmonale) indicate **right atrial enlargement**, which can occur in an ASD due to volume overload [1]. - However, while right atrial enlargement is common, **right axis deviation** due to right ventricular hypertrophy is a more specific and prominent ECG finding in symptomatic **atrial septal defects**. *Absent p waves* - **Absent P waves** are characteristic of conditions like **atrial fibrillation** or **junctional rhythms**. - These are not typical findings in an isolated **atrial septal defect** and would not explain the other clinical signs.

Q: NOT an indication for surgery in a Ventricular septal defect

Eisenmenger's Syndrome. ***Eisenmenger's Syndrome*** - This condition represents **irreversible pulmonary hypertension** due to long-standing, high-volume, high-pressure shunting, leading to a reversal of the shunt (right-to-left). - In **Eisenmenger's syndrome**, the benefits of VSD closure are outweighed by the risks, as closing the defect can acutely increase **pulmonary vascular resistance (PVR)** and right ventricular overload, leading to fatal outcomes. *Suck- Rest-Suck cycle while feeding* - This symptom indicates significant **heart failure** and **poor feeding** in an infant, often due to a large VSD causing increased pulmonary blood flow and work of breathing. - It is a clear sign of clinical compromise and is generally an **indication for surgical intervention** to improve feeding and reduce symptoms. *Pulmonary: Systemic blood flow > 2:1* - A pulmonary to systemic blood flow ratio (Qp:Qs) greater than 2:1 signifies a **large left-to-right shunt** through the VSD, leading to significant volume overload in the pulmonary circulation. - This degree of shunting is a strong **indication for surgery** to prevent the development of pulmonary hypertension and right ventricular dysfunction. *Hepatomegaly* - **Hepatomegaly** (enlarged liver) in the context of a VSD often suggests **right-sided heart failure**, a common complication of large left-to-right shunts and increased pulmonary vascular resistance. - It is a clinical sign of significant cardiac dysfunction and typically indicates the need for **surgical repair** to alleviate the underlying cardiac load.

Q: Commonest congenital heart disease is:

Ventricular septal defect. ***Ventricular septal defect*** - A **ventricular septal defect (VSD)** is the most frequently observed type of congenital heart disease, accounting for approximately 25-30% of all congenital heart lesions. - It involves an opening in the **interventricular septum**, allowing blood to shunt between the left and right ventricles. *Persistent ductus arteriosus* - While common, **patent ductus arteriosus (PDA)** is not as prevalent as VSDs overall. - PDA is more frequently seen in **premature infants**, but VSDs are the most common in the general population of live births with congenital heart disease. *Atrial septal defect* - **Atrial septal defect (ASD)** is a common congenital heart defect, but its incidence is lower than that of VSDs. - ASDs involve a hole in the **interatrial septum**, leading to shunting of blood between the atria. *Mitral valve prolapse* - **Mitral valve prolapse (MVP)** is a relatively common valvular anomaly but is generally considered a minor congenital heart abnormality or sometimes an acquired condition, not typically classified as the most common "congenital heart disease" in the same category as septal defects. - It involves the leaflets of the **mitral valve bulging into the left atrium** during systole.

Q: The following cardiac defects are characterized by ductus dependent blood flow except –

Truncus arteriosus. ***Truncus arteriosus*** - **Truncus arteriosus** is a congenital heart defect where a single arterial trunk arises from the heart, supplying the systemic, pulmonary, and coronary circulations. - Blood mixing occurs **within the heart itself** at the level of the common truncal valve and ventricular septal defect (VSD), which is always present. - The ductus arteriosus is **not required** for survival because the truncal vessel directly supplies both the systemic and pulmonary circulations. - Therefore, truncus arteriosus is **NOT a ductus-dependent lesion**. *Transposition of great arteries with intact septum* - In **TGA with intact ventricular septum**, the aorta arises from the right ventricle and the pulmonary artery from the left ventricle, creating **parallel circulations**. - The patent ductus arteriosus (PDA) is **critical for mixing** oxygenated and deoxygenated blood, allowing survival until surgical correction. - This is a classic **ductus-dependent lesion** for mixing. *Hypoplastic left heart syndrome* - **HLHS** involves severe underdevelopment of the left ventricle, mitral valve, aortic valve, and ascending aorta. - The **PDA is essential** for providing systemic blood flow, as the right ventricle must supply both pulmonary and systemic circulations via the ductus. - This is a **ductus-dependent systemic circulation** - closure of the PDA is lethal. *Interrupted aortic arch* - **IAA** involves complete discontinuity of the aortic arch, preventing blood flow to the descending aorta. - The **PDA is critical** for perfusing the lower body and abdominal organs. - This is a **ductus-dependent systemic circulation**.

Q: A child comes with cyanotic spells and chest X-ray was as shown below; What is the most probable diagnosis?

Tetralogy of Fallot. ***Tetralogy of Fallot*** - The **boot-shaped heart** (Coeur en sabot) seen on the chest X-ray is virtually pathognomonic for **Tetralogy of Fallot** due to right ventricular hypertrophy and a concave pulmonary artery segment. - **Cyanotic spells** (hypercyanotic or "tet" spells) are characteristic clinical features resulting from increased right-to-left shunting across the ventricular septal defect. *Tricuspid atresia* - While tricuspid atresia causes **cyanosis**, the classic radiographic finding is usually a **small right ventricle** and a large left ventricle, affecting heart size and shape differently, often with normal or decreased pulmonary vascularity. - A **boot-shaped heart** is not a typical finding; it might show a normal or slightly enlarged heart with distinct chamber enlargement patterns. *TAPVC* - Total anomalous pulmonary venous connection (TAPVC) typically presents with **cyanosis** and can have increased pulmonary vascular markings on CXR, but the classic X-ray finding is a **"snowman" or "figure-of-8" heart** in the supracardiac type due to dilated SVC and anomalous vertical vein. - A **boot-shaped heart** is not associated with TAPVC. *Pulmonary atresia with intact ventricular septum* - This condition presents with **severe cyanosis** at birth. The chest X-ray typically shows a **markedly enlarged right atrium** due to severe tricuspid regurgitation and a small, hypoplastic right ventricle, along with decreased pulmonary vascular markings. - A **boot-shaped heart** is not a characteristic finding; the cardiac silhouette is often described as globular or enlarged differently.

Q: A five-year-old girl presents with fever and conjunctivitis. Physical examination is significant for oral erythema and fissuring along with a generalized maculopapular rash and cervical lymphadenopathy. What is the most likely diagnosis?

Kawasaki disease. ***Kawasaki disease*** - This constellation of symptoms, including prolonged **fever**, **conjunctivitis**, **oral erythema** and **fissuring**, a generalized **rash**, and **cervical lymphadenopathy**, is highly characteristic of incomplete or classic Kawasaki disease. - It is a **vasculitis** primarily affecting **medium-sized arteries**, and early diagnosis and treatment are crucial to prevent **coronary artery aneurysms**. *Henoch-Schönlein purpura* - Characterized by **palpable purpura**, **arthralgia**, **abdominal pain**, and **renal involvement**, often after an upper respiratory infection. - While a rash is present, the specific features of oral changes and generalized erythema are not typical. *Takayasu arteritis* - A rare, large-vessel vasculitis primarily affecting the **aorta** and its major branches, leading to **claudication**, **pulse deficits**, and **hypertension**. - It most commonly affects **young women** and does not present with the acute mucocutaneous and lymph node findings seen in this child. *Polyarteritis nodosa* - A **necrotizing vasculitis** of **medium-sized arteries**, typically presenting with non-specific symptoms such as fever, weight loss, and myalgia, along with organ involvement (e.g., kidney, gastrointestinal, peripheral nerve). - It primarily affects adults and does not usually present with the specific mucocutaneous and lymphatic features seen in this pediatric case.

Question 1

All are true regarding tricuspid atresia except –

Accepted Answer

Split S2

Answer

Left axis deviation in ECG.

Answer

Pulmonary oligemia in chest X–ray

Answer

Patent foramen ovale

Question 2

Most characteristic feature of TOF is

Accepted Answer

Cyanotic spells

Answer

Squatting

Answer

Clubbing of feet

Answer

Recurrent chest infection

Question 3

A child after 4 weeks of birth, is acyanotic. Ejection systolic murmur detected on auscultation. Probable diagnosis is:

Accepted Answer

Coarctation of aorta

Answer

TOF

Answer

VSD

Answer

PDA

Question 4

In the evaluation of congenital heart disease, which of the following findings is considered the LEAST specific diagnostic indicator?

Accepted Answer

Abnormal ECG findings

Answer

Presence of a diastolic murmur

Answer

Congestive heart failure

Answer

Cyanosis as a clinical sign

Question 5

A young boy presents to you with history of breathlessness on exertion. You being an intern proceed with auscultation of the patient's chest. Your findings are ejection systolic murmur in the left 2nd intercostal space, S1 is normal and has wide and fixed split S2. You then send the patient for an ECG, what would be the most likely finding in the ECG report?

Accepted Answer

Right axis deviation

Answer

Left axis deviation

Answer

Large p waves

Answer

Absent p waves

Question 6

NOT an indication for surgery in a Ventricular septal defect

Accepted Answer

Eisenmenger's Syndrome

Answer

Suck- Rest-Suck cycle while feeding

Answer

Pulmonary: Systemic blood flow > 2:1

Answer

Hepatomegaly

Question 7

Commonest congenital heart disease is:

Accepted Answer

Ventricular septal defect

Answer

Patent ductus arteriosus

Answer

Atrial septal defect

Answer

Mitral valve prolapse

Question 8

The following cardiac defects are characterized by ductus dependent blood flow except –

Accepted Answer

Truncus arteriosus

Answer

Hypoplastic left heart syndrome

Answer

Interrupted aortic arch

Answer

Transposition of great arteries with intact septum

Question 9

A child comes with cyanotic spells and chest X-ray was as shown below; What is the most probable diagnosis?

Accepted Answer

Tetralogy of Fallot

Answer

Tricuspid atresia

Answer

TAPVC

Answer

Pulmonary atresia with intact ventricular septum

Question 10

A five-year-old girl presents with fever and conjunctivitis. Physical examination is significant for oral erythema and fissuring along with a generalized maculopapular rash and cervical lymphadenopathy. What is the most likely diagnosis?

Accepted Answer

Kawasaki disease

Answer

Henoch-Schönlein purpura

Answer

Takayasu arteritis

Answer

Polyarteritis nodosa

Cardiology — MCQs

Cardiology — MCQs

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