Cardiology Practice Questions

Q: Which of the following conditions is least likely to present with pulmonary plethora?

Ebstein anomaly. ***Ebstein anomaly*** - Ebstein anomaly is characterized by **apical displacement of the tricuspid valve leaflets**, leading to a large atrialized right ventricle and severe tricuspid regurgitation. - This typically results in **right-to-left shunting** through a patent foramen ovale or atrial septal defect, causing **cyanosis and reduced pulmonary blood flow** (pulmonary oligemia), rather than plethora. *Hypoplastic left heart syndrome* - Hypoplastic left heart syndrome (HLHS) involves **underdevelopment of the left side of the heart**, including the left ventricle, mitral valve, aortic valve, and aorta. - In HLHS, pulmonary venous return shunts from the left atrium to the right atrium via a patent foramen ovale, and systemic blood flow is maintained by a patent ductus arteriosus, resulting in **increased pulmonary blood flow (pulmonary plethora)**. *Double outlet right ventricle* - In double outlet right ventricle (DORV), both the **aorta and pulmonary artery arise primarily from the right ventricle**. - The degree of pulmonary plethora depends on the presence and size of a **ventricular septal defect (VSD)** and the relationship of the great arteries to the VSD. Most commonly, it leads to **increased pulmonary blood flow** if the VSD allows for systemic-to-pulmonary shunting. *TGA (Transposition of Great Arteries)* - Transposition of the Great Arteries (TGA) involves the **aorta arising from the right ventricle** and the **pulmonary artery arising from the left ventricle**, creating two parallel circulations. - In d-TGA, if there is a **large VSD** or **patent ductus arteriosus**, there will be mixing of oxygenated blood with deoxygenated blood, often resulting in **increased pulmonary blood flow (pulmonary plethora)** to the systemic circulation.

Q: Most characteristic cardiovascular defect seen in Rubella-

Patent ductus arteriosus. ***Patent ductus arteriosus*** - **Patent ductus arteriosus (PDA)** is the most characteristic cardiovascular defect associated with congenital rubella syndrome [1]. - The rubella virus can interfere with the normal closure of the **ductus arteriosus** during fetal development [1]. *Coarctation of the aorta* - **Coarctation of the aorta** is a narrowing of the aorta and is not typically linked to congenital rubella syndrome [1]. - It is often associated with syndromes like **Turner syndrome** or bicuspid aortic valve, which are not mentioned here [1]. *Ventricular septal defect* - **Ventricular septal defects (VSDs)** are common congenital heart defects, but they are not specifically characteristic of congenital rubella [1]. - VSDs are more frequently associated with conditions like **Down syndrome** or can occur in isolation [1]. *Pulmonary artery stenosis* - While **pulmonary artery stenosis** can occur as a congenital heart defect, it is less commonly the primary cardiovascular manifestation of congenital rubella syndrome. - **Peripheral pulmonary artery stenosis** can be seen in rubella, but PDA is the most characteristic overarching defect [1].

Q: Which of the following congenital anomalies leads to heart failure at birth?

Total anomalous pulmonary venous connection. ***Total anomalous pulmonary venous connection*** - **Obstructed TAPVC** is the classic congenital heart defect causing heart failure **at birth or within hours of life** - In obstructed types (especially **infracardiac** and some **supracardiac with obstruction**), pulmonary venous blood cannot adequately return to the heart, causing severe **pulmonary venous congestion** and **right heart failure** - Presents with **severe cyanosis, respiratory distress, and heart failure immediately at birth** - This is a **neonatal emergency** requiring immediate surgical intervention *Coarctation of aorta* - Typically presents with heart failure at **1-2 weeks of age** when the ductus arteriosus closes - At birth, the patent ductus arteriosus allows blood to bypass the coarctation, so symptoms are minimal - As the PDA closes, **left ventricular afterload increases dramatically**, leading to heart failure - **Critical coarctation** can rarely present earlier, but classically this is NOT "at birth" *Transposition of great arteries* - Presents primarily with **severe cyanosis at birth**, not heart failure - The aorta arises from the right ventricle and pulmonary artery from the left ventricle - Survival depends on mixing through PDA, ASD, or VSD - Heart failure develops later if there is excessive pulmonary blood flow through large shunts *Pulmonary atresia* - Complete obstruction of the pulmonary valve preventing right ventricular outflow - Presents with **severe cyanosis at birth** due to lack of pulmonary blood flow - The primary manifestation is **hypoxemia and cyanosis**, not heart failure - Requires patent ductus arteriosus or collateral circulation for survival

Q: All of the following are characteristic features of Tricuspid Atresia except for -

Split S2. ***Splitting of S2 is present in Tricuspid Atresia*** - In **tricuspid atresia**, the S2 heart sound is typically **single** rather than split because there is no blood flow through the tricuspid valve to the right ventricle, and pulmonary blood flow is often reduced, leading to a diminished or absent P2. - Absence of blood flow to the right ventricle prevents normal mechanisms of S2 splitting [1]. *Left axis deviation* - **Left axis deviation** on an EKG is a common finding in tricuspid atresia due to the **underdevelopment of the right ventricle** and the increased prominence of the left ventricle. - The electrical activity is predominantly directed towards the left side of the heart. *Right ventricular hypoplasia* - **Right ventricular hypoplasia** is a defining characteristic of tricuspid atresia [1], as the absence of the tricuspid valve prevents blood flow into, and thus proper development of, the right ventricle. - The right ventricle can range from a *small, non-functional chamber* to being almost absent. *Decreased pulmonary vascularity* - **Decreased pulmonary vascularity** is observed in tricuspid atresia because the pulmonary blood flow is significantly reduced, usually depending on a **patent ductus arteriosus (PDA)** or a **ventricular septal defect (VSD)** for blood to reach the lungs [1]. - The lack of direct flow from the right atrium to the right ventricle limits the amount of blood ejected into the pulmonary arteries. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Heart, pp. 545-546.

Q: What is the most common cause of isolated congenital heart block in infants?

Maternal autoantibodies (neonatal lupus). ***Maternal autoantibodies (neonatal lupus)*** - **Maternal autoantibodies**, specifically **anti-Ro/SSA** and **anti-La/SSB**, cross the placenta and target the fetal cardiac conduction system, leading to **congenital heart block**. - This is the most common cause of **isolated complete heart block** in infants, often occurring in the absence of other structural congenital heart defects. *Viral myocarditis* - While viral myocarditis can cause **heart block** due to inflammation of the myocardium and conduction system, it is a less common cause of **congenital heart block** and typically presents with other signs of heart failure. - It usually occurs at any age, including infancy, but is not considered the most common cause of congenital heart block, especially when isolated. *Rheumatic fever* - **Rheumatic fever** is an inflammatory disease that can affect the heart, joints, brain, and skin, and typically follows an infection with Group A Streptococcus. - It is **extremely rare** in infants and primarily affects older children and young adults, making it an unlikely cause of heart block in this population. *Surgery for congenital heart disease* - **Surgical repair** of congenital heart defects can result in **iatrogenic heart block** due to damage to the conduction system during the procedure. - However, this is a **post-surgical complication** and not an intrinsic cause of congenital heart block at birth, as implied by the question regarding heart block "in infants with congenital heart disease" before surgical intervention.

Q: Most common conotruncal anomaly

Tetralogy of Fallot. ***Tetralogy of Fallot*** - Tetralogy of Fallot is the **most common conotruncal anomaly** and the **most common cyanotic congenital heart defect**, accounting for approximately 5-7% of all congenital heart diseases. - Its four classic features (ventricular septal defect, pulmonary stenosis, overriding aorta, and right ventricular hypertrophy) all result from an **anterior and cephalad displacement of the conotruncal septum**. - Among the classic conotruncal anomalies (TOF, TGA, Truncus arteriosus, DORV), TOF has the highest prevalence. *TGA* - **Transposition of the Great Arteries (TGA)** is another significant conotruncal anomaly, but it is less common than Tetralogy of Fallot. - It involves an **abnormal septation** and rotation of the great arteries, leading to two parallel circulations. *Truncus arteriosus* - **Truncus arteriosus** is a rare and severe conotruncal anomaly where a single great artery arises from both ventricles, instead of separate aorta and pulmonary arteries. - This condition involves a failure of the **truncal ridges to fuse** and form a septum. *Double outlet right ventricle* - **Double outlet right ventricle (DORV)** is a complex anomaly where both great arteries (aorta and pulmonary artery) arise entirely or predominantly from the right ventricle. - This condition is less common than Tetralogy of Fallot and has a **wide spectrum of anatomical variations**.

Q: Most common cardiac defect in Turner syndrome

Coarctation of aorta. ***Coarctation of aorta*** - **Coarctation of the aorta** is the most frequent cardiac defect found in individuals with **Turner syndrome**, occurring in approximately 10-20% of cases [1]. - This congenital narrowing of the aorta typically presents with **hypertension in the upper extremities** and diminished or absent pulses in the lower extremities [1]. *VSD* - **Ventricular septal defects (VSDs)** are common congenital heart defects but are not the *most common* defect associated with Turner syndrome. - VSDs involve a hole in the wall separating the two lower chambers of the heart, resulting in a **left-to-right shunt**. *ASD* - **Atrial septal defects (ASDs)** are relatively common congenital heart defects but are less frequent in Turner syndrome compared to coarctation of the aorta [2]. - An ASD involves a hole in the wall separating the two upper chambers of the heart, leading to a **left-to-right shunt**. *TOF* - **Tetralogy of Fallot (TOF)** is a complex congenital heart defect involving four specific abnormalities, but it is **rarely associated with Turner syndrome**. - TOF typically presents with **cyanosis** and can be diagnosed by an abnormal heart murmur and characteristic findings on echocardiography.

Q: Most common type of TAPVC is -

Supracardiac. ***Supracardiac*** - This is the **most common type** of Total Anomalous Pulmonary Venous Connection (TAPVC), accounting for about 50% of cases. - Pulmonary veins drain into a **common vertical vein** that ascends to connect with the **innominate vein** or superior vena cava. *Cardiac* - In this type, the pulmonary veins drain directly into the **right atrium** or a coronary sinus. - It is relatively less common than the supracardiac type. *Infracardiac* - This is the **least common** and most severe type, where the pulmonary veins drain below the diaphragm, typically into the portal vein, ductus venosus, or inferior vena cava. - It is often associated with **pulmonary venous obstruction**, leading to cyanosis and pulmonary hypertension. *Multiple* - While it is possible to have anomalous drainage sites, **multiple sites** draining into different systemic veins are less common than a single primary site for TAPVC. - TAPVC is typically classified into specific anatomic types rather than 'multiple' as a primary category.

Question 1

Which of the following conditions is least likely to present with pulmonary plethora?

Accepted Answer

Ebstein anomaly

Answer

Hypoplastic left heart syndrome

Answer

Double outlet right ventricle

Answer

TGA (Transposition of Great Arteries)

Question 2

Most characteristic cardiovascular defect seen in Rubella-

Accepted Answer

Patent ductus arteriosus

Answer

Coarctation of the aorta

Answer

Ventricular septal defect

Answer

Pulmonary artery stenosis

Question 3

Which of the following congenital anomalies leads to heart failure at birth?

Accepted Answer

Total anomalous pulmonary venous connection

Answer

Transposition of great arteries

Answer

Pulmonary atresia

Answer

Coarctation of aorta

Question 4

All of the following are characteristic features of Tricuspid Atresia except for -

Accepted Answer

Split S2

Answer

Decreased pulmonary vascularity

Answer

Left axis deviation

Answer

Right ventricular hypoplasia

Question 5

What is the most common cause of isolated congenital heart block in infants?

Accepted Answer

Maternal autoantibodies (neonatal lupus)

Answer

Viral myocarditis

Answer

Rheumatic fever

Answer

Surgery for congenital heart disease

Question 6

Most common conotruncal anomaly

Accepted Answer

Tetralogy of Fallot

Answer

TGA

Answer

Truncus arteriosus

Answer

Double outlet right ventricle

Question 7

What are the potential clinical consequences of a large patent ductus arteriosus (PDA)?

Accepted Answer

All of the listed complications are potential consequences of PDA, depending on the clinical scenario.

Answer

Endocarditis

Answer

Eisenmenger syndrome

Answer

Congestive heart failure (CHF)

Question 8

Most common cardiac defect in Turner syndrome

Accepted Answer

Coarctation of aorta

Answer

VSD

Answer

ASD

Answer

TOF

Question 9

An 11-year-old child with a history of streptococcal pharyngitis presents you with fever and arthralgia. There is no past history of rheumatic heart disease or features of carditis or valvular disease. How often is 600,000 IU of benzathine penicillin recommended for prophylaxis of rheumatic heart disease?

Accepted Answer

Once in three weeks for 5 years or till the age of 18, whichever is longer

Answer

Immediately

Answer

Thrice weekly lifelong

Answer

Once in three weeks for 10 years or till the age of 25, whichever is longer

Question 10

Most common type of TAPVC is -

Accepted Answer

Supracardiac

Answer

Cardiac

Answer

Infracardiac

Answer

Multiple

Cardiology — MCQs

Cardiology — MCQs

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