Cardiology Practice Questions

Q: Most common cardiac anomaly in Turner syndrome: CMC (Vellore) 07; CMC (Ludhiana) 13; UPSC 14

Bicuspid aortic valve. ***Bicuspid aortic valve*** - A **bicuspid aortic valve** is the most frequently observed cardiac anomaly in individuals with Turner syndrome, occurring in approximately 15-30% of cases. - This condition involves the **aortic valve** having two leaflets instead of the usual three, which can lead to complications such as **aortic stenosis** or **aortic regurgitation** over time. *Bifurcation of aorta* - **Aortic bifurcation** is a normal anatomical structure where the aorta divides into the common iliac arteries at the level of L4. - This is not a cardiac anomaly, but rather a standard vascular branching pattern. *Coarctation of aorta* - **Coarctation of the aorta** is a narrowing of the aorta, typically near the ductus arteriosus, and is also common in Turner syndrome (occurring in about 10-15%). - Although common, it is **less frequent** than a bicuspid aortic valve. *Aortic stenosis* - **Aortic stenosis** (narrowing of the aortic valve) can be a consequence of a bicuspid aortic valve, but it is not the primary or most common congenital anomaly itself. - The most common **structural defect** that predisposes to aortic stenosis in Turner syndrome is the bicuspid aortic valve.

Q: PDA true is all except -

More common in term baby. ***More common in term baby*** ✗ (EXCEPTION - This is FALSE) - This statement is **INCORRECT** and is the exception among the options. - PDA is actually significantly **more prevalent in premature infants**, not term babies, due to the immaturity of the ductus arteriosus and its closure mechanisms. - The persistence of the ductus arteriosus is a major complication of **prematurity**, with incidence inversely proportional to gestational age. *More common in preterm baby* ✓ - **TRUE statement**: Patency of ductus arteriosus (PDA) is indeed much more common in preterm babies, especially those with very low birth weight. - The physiological closure mechanisms, including increased oxygen tension and decreased prostaglandin E2 levels, are less effective in **premature infants**. - Incidence can be as high as **60-70% in infants <28 weeks gestation**. *Left to right shunt* ✓ - **TRUE statement**: In most cases, the pressure in the aorta is higher than in the pulmonary artery, leading to a **left-to-right shunt** of blood through the PDA. - This shunting causes increased pulmonary blood flow, which can lead to **pulmonary congestion** and heart failure if significant. - Creates the characteristic **continuous "machinery" murmur**. *Acyanotic congenital heart disease* ✓ - **TRUE statement**: PDA is classified as an **acyanotic congenital heart disease** because the shunt is typically left-to-right, meaning oxygenated blood recirculates to the lungs. - Cyanosis (bluish discoloration of the skin) only occurs in rare instances of **Eisenmenger syndrome**, where severe pulmonary hypertension reverses the shunt to right-to-left.

Q: Which of the following is the most common type of congenital cardiac cyanotic anomaly?

Tetralogy of Fallot. ***Tetralogy of Fallot*** - It is the **most common cyanotic heart disease** contributing to approximately 5-7% of all congenital heart defects and about 50% of all cyanotic CHD. - It consists of four main defects: **ventricular septal defect (VSD)**, **pulmonary stenosis**, **overriding aorta**, and **right ventricular hypertrophy**. *Transposition of great vessels* - This is the **second most common cyanotic congenital heart disease** where the aorta arises from the right ventricle and the pulmonary artery from the left ventricle. - It requires a coexisting defect (like a VSD or PDA) for survival as it creates two separate circulatory systems. *TAPVC* - **Total anomalous pulmonary venous connection (TAPVC)** is a rare cyanotic heart defect where all four pulmonary veins connect to the systemic venous circulation instead of the left atrium. - While serious, it is considerably less common than Tetralogy of Fallot. *Ebstein's anomaly* - This is a rare congenital heart defect involving the **tricuspid valve**, which is displaced downwards into the right ventricle. - It is characterized by variable degrees of cyanosis and right heart failure, but is much less frequent than Tetralogy of Fallot.

Q: A 2-week-old baby is irritable and feeding poorly. On physical examination, the infant is irritable, diaphoretic, tachypneic and tachycardic. There is circumoral cyanosis, which is not alleviated by nasal oxygen. A systolic thrill and holosystolic murmur are heard along the left sternal border. An echocardiogram reveals a heart defect in which a single arterial trunk overrides a ventricular septal defect. What is the appropriate diagnosis?

Truncus arteriosus. ***Truncus arteriosus*** - The description of the **aorta and pulmonary artery forming a single vessel that overrides a ventricular septal defect** is the hallmark of truncus arteriosus. - The infant's symptoms of **irritability, poor feeding, diaphoresis, tachypnea, tachycardia, and circumoral cyanosis not alleviated by oxygen** are consistent with significant **cyanotic congenital heart disease** like truncus arteriosus, which often presents in early infancy with congestive heart failure and cyanosis. *Coarctation of aorta, preductal* - This condition involves a **narrowing of the aorta**, typically presenting with **differential pulses** (stronger in upper extremities, weaker in lower) and a **systolic murmur** heard best over the back or left axilla, which are not described. - While it can manifest with heart failure symptoms, the echocardiogram finding of a single overriding vessel contradicts this diagnosis. *Patent ductus arteriosus* - A PDA typically presents with a **continuous "machinery" murmur** loudest in the left infraclavicular area and may lead to heart failure symptoms but often with subtle or no cyanosis (unless severe pulmonary hypertension develops). - The echocardiogram finding of a single great artery overriding a VSD is not characteristic of PDA. *Atrial septal defect* - An ASD is typically associated with a **fixed, wide splitting of the second heart sound** and a **systolic ejection murmur** at the upper left sternal border due to increased pulmonary blood flow, and often remains asymptomatic in infancy. - Cyanosis is rare, and the specific echocardiographic finding of a single great artery is not seen with an isolated ASD.

Q: True about VSD are all except -

Reverse splitting of S2. ***Reverse splitting of S2*** - **Reverse splitting of S2** occurs when the aortic valve closes *after* the pulmonic valve, typically seen in conditions like **aortic stenosis** or **left bundle branch block**. [2] - In VSD, the increased flow through the pulmonary circulation typically causes a **widened and fixed splitting of S2**, rather than reverse splitting, due to delayed pulmonic valve closure and earlier aortic valve closure. *Left to right shunt* - A **ventricular septal defect (VSD)** creates an opening between the left and right ventricles, leading to blood flowing from the higher pressure left ventricle to the lower pressure right ventricle. [1] - This **left-to-right shunt** is the hallmark hemodynamic feature of a VSD in the absence of pulmonary hypertension. [1] *Pansystolic murmur* - The continuous flow of blood across the VSD during systole produces a characteristic **pansystolic (holosystolic) murmur** that starts with S1 and extends to S2. [3] - This murmur is typically heard best at the **left lower sternal border**. [3] *Left atrial hypertrophy* - A significant left-to-right shunt in VSD increases blood flow into the pulmonary circulation, which then returns to the left atrium through the pulmonary veins. - The increased volume load on the left atrium can lead to **left atrial dilatation and hypertrophy** over time. [1]

Q: Which of the following congenital heart diseases is MOST OFTEN associated with decreased pulmonary blood flow?

Single ventricle with pulmonary stenosis. ***Single ventricle with pulmonary stenosis*** - The combination of a **single ventricle (functional or anatomic)** and **pulmonary stenosis** **MOST CONSISTENTLY** causes severely decreased pulmonary blood flow. - This anatomical arrangement creates an **obligatory shunt** (usually a VSD or PDA) to allow for some mixing of systemic and pulmonary venous return, but the stenotic pulmonary outflow tract significantly limits the total volume reaching the lungs. - This is a **classic cyanotic lesion with consistently decreased pulmonary blood flow**. *TAPVC* - **Total anomalous pulmonary venous connection (TAPVC)** is associated with **increased pulmonary blood flow** because all pulmonary venous return eventually shunts from the systemic circulation back to the pulmonary circulation, causing recirculation. - This condition leads to right heart dilation and pulmonary hypertension due to the excessive volume load on the pulmonary circuit. *Truncus arteriosus* - **Truncus arteriosus** is characterized by a single great artery overriding a large ventricular septal defect, leading to a **left-to-right shunt** and **increased pulmonary blood flow** and pressure. - Both systemic and pulmonary circulations receive blood from the single truncal artery, but pulmonary vascular resistance is usually lower, causing significant shunt to the lungs. *Ebstein's anomaly* - **Ebstein's anomaly** involves **tricuspid valve displacement** into the right ventricle causing functional RV hypoplasia and tricuspid regurgitation. - While it **CAN cause decreased pulmonary blood flow** when severe (with right-to-left shunt across an ASD), the severity is **highly variable** - mild cases may have normal or only slightly reduced pulmonary blood flow. - Unlike single ventricle with pulmonary stenosis, Ebstein's anomaly does **NOT consistently** present with severely decreased pulmonary blood flow.

Q: A 9 year old boy with Fallot's tetralogy, had high grade fever followed by focal seizure 2 days prior to hospital admission. His blood counts were increased and predominantly polymorphs. CT scan of the head showed a focal lesion suggestive of an abscess. Where would be the commonest location of brain abscess in this patient?

Cerebellum. **Cerebellum** - In patients with **cyanotic congenital heart disease** like Fallot's tetralogy, brain abscesses are typically supplied by the **posterior circulation**, making the **cerebellum** the most common location. [1] - The **right-to-left shunt** allows bacteria to bypass pulmonary filtration and directly enter systemic circulation, increasing the risk of infection in the brain, predominantly in areas supplied by the vertebral and basilar arteries. [1], [3] *Parietal lobe* - While brain abscesses can occur in the parietal lobe, it is more commonly associated with spread from a **frontal or sphenoid sinusitis** or direct trauma, not typically from cyanotic heart disease. - Abscesses in the parietal lobe are more often seen in **immunocompromised patients** or those with endocarditis causing septic emboli. [2] *Temporal lobe* - Temporal lobe abscesses are frequently a complication of **otitis media** or **mastoiditis**, with infection spreading directly or via venous drainage. - This patient's presentation does not suggest an ear infection as the primary source. *Thalamus* - Thalamic abscesses are rare and usually occur as a result of **hematogenous spread** from distant infections, particularly in immunocompromised individuals. - While possible, they are not the most common location for brain abscesses in patients with cyanotic congenital heart disease.

Q: Congenital cyanotic heart disease with pulmonary oligemia is seen with –

Tricuspid atresia. ***Tricuspid atresia*** - **Tricuspid atresia** is a **cyanotic congenital heart disease** where the tricuspid valve is absent, preventing blood flow from the right atrium to the right ventricle, leading to **pulmonary hypoperfusion** or **oligemia**. - Systemic venous return must shunt across an **atrial septal defect (ASD)** or **patent foramen ovale (PFO)** to the left atrium, mixing with oxygenated blood, resulting in cyanosis. - Chest X-ray characteristically shows **decreased pulmonary vascular markings** (oligemia). *VSD* - A **Ventricular Septal Defect (VSD)** typically causes a **left-to-right shunt**, leading to **pulmonary plethora (increased pulmonary blood flow)**, not oligemia. - While large VSDs can eventually lead to Eisenmenger syndrome with cyanosis, the initial presentation is usually characterized by increased pulmonary flow. *Hypoplastic left ventricle* - **Hypoplastic left heart syndrome (HLHS)** is a **cyanotic** condition, but it results in **pulmonary plethora (increased pulmonary blood flow)**, not oligemia. - All systemic venous return flows to the right ventricle, which pumps to both the pulmonary arteries (normal pathway) and to the systemic circulation via a **patent ductus arteriosus (PDA)**, resulting in normal or increased pulmonary blood flow. - The primary issue is a severely underdeveloped left side of the heart, which does not lead to pulmonary oligemia. *ASD* - An **Atrial Septal Defect (ASD)** usually causes a **left-to-right shunt**, leading to **pulmonary plethora (increased pulmonary blood flow)** and is typically an **acyanotic** heart condition. - Cyanosis only develops late if pulmonary hypertension leads to shunt reversal (Eisenmenger syndrome), which is not the primary presentation.

Q: Which of the following is least likely in PDA?

CO, wash out. ***CO₂ washout*** - **CO₂ washout** is not a recognized clinical complication or standard finding associated with PDA - While PDA causes **pulmonary overcirculation**, this does not translate into a clinically significant "CO₂ washout" phenomenon - The other options represent well-established associations with hemodynamically significant PDA - This is the **least likely** finding in PDA *Bounding pulse* - **Classic finding** in PDA due to left-to-right shunt from aorta to pulmonary artery - Results in **wide pulse pressure** as diastolic pressure drops (blood "runs off" into pulmonary circulation) - Creates characteristic **water-hammer** or **bounding peripheral pulses** *Pulmonary hemorrhage* - Well-recognized complication of hemodynamically significant PDA, especially in **premature infants** - **Increased pulmonary blood flow and pressure** from left-to-right shunt leads to pulmonary edema and capillary damage - Fragile pulmonary vasculature in preterm infants predisposes to **hemorrhage** *Necrotizing enterocolitis* - **Significant association** between PDA and NEC in premature infants - Mechanism: **Diastolic steal** phenomenon causes mesenteric hypoperfusion - The left-to-right shunt diverts blood flow during diastole, leading to **gut ischemia** - PDA is a recognized **risk factor** for NEC development

Question 1

Most common cardiac anomaly in Turner syndrome: CMC (Vellore) 07; CMC (Ludhiana) 13; UPSC 14

Accepted Answer

Bicuspid aortic valve

Answer

Bifurcation of aorta

Answer

Coarctation of aorta

Answer

Aortic stenosis

Question 2

PDA true is all except -

Accepted Answer

More common in term baby

Answer

More common in preterm baby

Answer

Left to right shunt

Answer

Acyanotic congenital heart disease

Question 3

A 2-month-old infant is brought to the clinic because of poor feeding, sweating, and difficulty breathing. The parents state that she was doing very well, and has actually been a "very easy going baby", until about a week ago. They assumed that she was developing a "cold", but it has not passed, and the symptoms have been worsening. Cardiac examination reveals a loud, harsh systolic murmur with a thrill that is heard best at the left sternal border. The most likely underlying abnormality is

Accepted Answer

ventricular septal defect

Answer

aortic stenosis

Answer

atrial septal defect

Answer

patent ductus arteriosus

Question 4

Which of the following is the most common type of congenital cardiac cyanotic anomaly?

Accepted Answer

Tetralogy of Fallot

Answer

Transposition of great vessels

Answer

TAPVC

Answer

Ebstein's anomaly

Question 5

A 2-week-old baby is irritable and feeding poorly. On physical examination, the infant is irritable, diaphoretic, tachypneic and tachycardic. There is circumoral cyanosis, which is not alleviated by nasal oxygen. A systolic thrill and holosystolic murmur are heard along the left sternal border. An echocardiogram reveals a heart defect in which a single arterial trunk overrides a ventricular septal defect. What is the appropriate diagnosis?

Accepted Answer

Truncus arteriosus

Answer

Coarctation of aorta, preductal

Answer

Patent ductus arteriosus

Answer

Atrial septal defect

Question 6

True about VSD are all except -

Accepted Answer

Reverse splitting of S2

Answer

Left to right shunt

Answer

Pansystolic murmur

Answer

Left atrial hypertrophy

Question 7

Which of the following congenital heart diseases is MOST OFTEN associated with decreased pulmonary blood flow?

Accepted Answer

Single ventricle with pulmonary stenosis

Answer

TAPVC

Answer

Truncus arteriosus

Answer

Ebstein's anomaly

Question 8

A 9 year old boy with Fallot's tetralogy, had high grade fever followed by focal seizure 2 days prior to hospital admission. His blood counts were increased and predominantly polymorphs. CT scan of the head showed a focal lesion suggestive of an abscess. Where would be the commonest location of brain abscess in this patient?

Accepted Answer

Cerebellum

Answer

Parietal lobe

Answer

Temporal lobe

Answer

Thalamus

Question 9

Congenital cyanotic heart disease with pulmonary oligemia is seen with –

Accepted Answer

Tricuspid atresia

Answer

VSD

Answer

Hypoplastic left ventricle

Answer

ASD

Question 10

Which of the following is least likely in PDA?

Accepted Answer

CO, wash out

Answer

Bounding pulse

Answer

Pulmonary hemorrhage

Answer

Necrotizing enterocolitis

Cardiology — MCQs

Cardiology — MCQs

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