Valvular Heart Diseases — MCQs

10 questions

In rheumatic heart disease, infective endocarditis is detected by echocardiogram and the largest vegetations seen are due to -

Graham Steell murmur is associated with which of the following conditions?

During your preoperative assessment, a 28-year-old woman complains of dyspnea on exertion. Upon auscultation of her heart, you notice a mid-diastolic rumbling murmur. This murmur is most characteristic of which valvular lesion?

A patient with new-onset syncope has a blood pressure of 110/95 mmHg and a harsh systolic ejection murmur at the base, radiating to both carotids. What finding may be revealed upon auscultation of the second heart sound at the base?

Fish mouth appearance of valve in RHD is due to-

Which of the following describes aortic regurgitation murmur?

About carey coombs murmur which is false –

What is the mechanism of aortic regurgitation in a case of VSD?

All of the following are features of a benign heart murmur except which of the following?

Q10

A 38-year-old man presents with pain and shortness of breath. His pulse rate is 85 per minute, blood pressure is 180/80 mmHg, and the cardiac examination reveals an ejection systolic murmur. The ECG shows a LVH pattern and ST depression in the anterior leads. His Troponin T test is positive. Based on these findings, the echocardiogram is likely to reveal which of the following conditions?

Valvular Heart Diseases Indian Medical PG Practice Questions and MCQs

Question 1: In rheumatic heart disease, infective endocarditis is detected by echocardiogram and the largest vegetations seen are due to -

A. Candida albicans
B. Staphylococcus aureus (Correct Answer)
C. Salmonella typhi
D. Streptococcus viridans

Explanation: Staphylococcus aureus - Staphylococcus aureus is well-known for causing aggressive infective endocarditis with large, destructive vegetations due to its virulence factors [1]. - These large vegetations are easily detectable by echocardiogram and are associated with a higher risk of embolic events and valve destruction [1]. Candida albicans - While Candida albicans can cause endocarditis, often in immunocompromised individuals or IV drug users, its vegetations are typically larger and more friable than most bacterial causes but S. aureus still produces larger bacterial vegetations due to its rapid colonization and biofilm formation. - Fungal endocarditis generally has a poorer prognosis and requires prolonged antifungal therapy. Salmonella typhi - Salmonella typhi is a less common cause of infective endocarditis; when it does occur, it is often associated with immunocompromised states or pre-existing cardiac lesions. - The vegetations caused by Salmonella are generally not as large or rapidly destructive as those seen with S. aureus. Streptococcus viridans - Streptococcus viridans is a frequent cause of subacute infective endocarditis, particularly on previously damaged valves [1]. - The vegetations are typically small to medium-sized and less destructive than those caused by S. aureus, leading to more indolent disease [1].

Question 2: Graham Steell murmur is associated with which of the following conditions?

A. Pulmonary Regurgitation (PR) (Correct Answer)
B. Tricuspid Regurgitation (TR)
C. Tricuspid Stenosis (TS)
D. Pulmonary Stenosis (PS)

Explanation: ***Pulmonary Regurgitation (PR)*** - The **Graham Steell murmur** is a high-pitched, decrescendo early diastolic murmur heard best at the left sternal border associated with **pulmonary hypertension**. [1] - It results from dilation of the pulmonary artery due to **elevated pulmonary pressures**, leading to functional pulmonary valve regurgitation. [1] *Tricuspid Regurgitation (TR)* - TR typically presents as a **holosystolic murmur** best heard at the left lower sternal border, often increasing with inspiration (Carvallo's sign). - It is caused by improper coaptation of the tricuspid valve leaflets, often due to **right ventricular dilation**. *Tricuspid Stenosis (TS)* - TS is characterized by a **diastolic rumble** heard best at the lower left sternal border, often with an opening snap. [2] - It is relatively rare and often associated with **rheumatic heart disease**. *Pulmonary Stenosis (PS)* - PS typically produces a **systolic ejection murmur** heard at the upper left sternal border, often radiating to the back. - It is caused by **obstruction to blood flow** from the right ventricle to the pulmonary artery.

Question 3: During your preoperative assessment, a 28-year-old woman complains of dyspnea on exertion. Upon auscultation of her heart, you notice a mid-diastolic rumbling murmur. This murmur is most characteristic of which valvular lesion?

A. Aortic regurgitation
B. Aortic stenosis
C. Mitral stenosis (Correct Answer)
D. Mitral regurgitation

Explanation: ***Mitral stenosis*** - A **mid-diastolic rumbling murmur** is the classic auscultatory finding in **mitral stenosis**, caused by turbulent blood flow across a narrowed mitral valve during ventricular filling [1], [4]. - The associated **dyspnea on exertion** is due to increased left atrial pressure and pulmonary congestion resulting from the stenotic mitral valve [1]. *Aortic regurgitation* - Characterized by a **diastolic decrescendo murmur**, best heard at the left sternal border, not a rumbling mid-diastolic murmur. - Often presents with a **wide pulse pressure** and peripheral signs like head bobbing (De Musset's sign) or pulsating nail beds (Quincke's sign). *Aortic stenosis* - Typically produces a **systolic ejection murmur** that **radiates to the carotids**, best heard at the right upper sternal border. - Main symptoms include **dyspnea**, **angina**, and **syncope** on exertion [2]. *Mitral regurgitation* - Presents with a **holosystolic murmur** that **radiates to the axilla**, indicating continuous backflow of blood into the left atrium during systole. - Can lead to **dyspnea** and **fatigue** due to decreased forward cardiac output and pulmonary congestion [3].

Question 4: A patient with new-onset syncope has a blood pressure of 110/95 mmHg and a harsh systolic ejection murmur at the base, radiating to both carotids. What finding may be revealed upon auscultation of the second heart sound at the base?

A. It is accentuated.
B. It is diminished. (Correct Answer)
C. It is normal in character.
D. It is widely split due to delayed ventricular ejection.

Explanation: ***It is diminished.*** - A **harsh systolic ejection murmur** radiating to the carotids, new-onset syncope, and a narrow pulse pressure (110/95 mmHg) are highly suggestive of **severe aortic stenosis** [1]. - In **severe aortic stenosis**, the aortic valve leaflets are rigid and fail to open properly, causing a significant reduction in the **aortic component of the second heart sound (A2)** due to decreased mobility and calcification [1], [2]. *It is accentuated.* - An **accentuated S2** (specifically A2) would indicate conditions like systemic hypertension or an increased closing pressure of the aortic valve, which is not consistent with severe aortic stenosis. - In **aortic stenosis**, the valve is *stiff* and *calcified*, leading to a weakened rather than an accentuated closing sound [1]. *It is normal in character.* - A **normal S2** would suggest that the aortic valve is functioning adequately or that any stenosis is mild and not significantly impacting valve closure, which contradicts the patient's symptoms and the harsh murmur. - The presence of **syncope** and a **harsh systolic murmur** strongly implies hemodynamically significant valvular disease [1]. *It is widely split due to delayed ventricular ejection.* - A **widely split S2** with delayed ventricular ejection is characteristic of **right bundle branch block** or **pulmonic stenosis**, neither of which fits the clinical picture of a harsh systolic ejection murmur radiating to the carotids. - In severe aortic stenosis, there can be a **paradoxical splitting of S2** (P2 preceding A2) due to prolonged left ventricular ejection time, but a widely split S2 due to delayed right ventricular ejection is incorrect.

Question 5: Fish mouth appearance of valve in RHD is due to-

A. Rupture of valve
B. Calcification & fibrosis (Correct Answer)
C. Hypertrophy of ventricular wall
D. None of the options

Explanation: ***Calcification & fibrosis*** - The **fish mouth appearance** of the valve in rheumatic heart disease (RHD) is primarily due to **calcification and fibrosis** of the mitral valve [1]. - This results in **narrowing of the valve orifice**, which mimics the shape of a fish mouth during diastole [1]. *Rupture of valve* - Rupture of the valve typically leads to **acute severe valvular insufficiency** and does not explain the **gradual narrowing** characteristic of the fish mouth appearance. - It would generally be associated with **acute symptoms** rather than the chronic changes seen in RHD. *None of the above* - This option is incorrect as the fish mouth appearance is well-defined by **calcification and fibrosis**, making it a specific feature of RHD. - It also disregards the specific etiology associated with the valvular deformity in RHD. *Hypertrophy of ventricular wall* - While hypertrophy of the ventricular wall can occur in RHD due to increased workload, it does not directly lead to the **valvular deformity** known as fish mouth appearance. - This hypertrophy affects the **myocardium**, not the structure of the valves themselves which are primarily affected by fibrosis and calcification. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Heart, pp. 566-567.

Question 6: Which of the following describes aortic regurgitation murmur?

A. Ejection systolic murmur
B. Diastolic murmur (Correct Answer)
C. Ventricular contraction
D. Systolic murmur

Explanation: ***Diastolic murmur*** - Aortic regurgitation occurs when the **aortic valve does not close completely**, leading to blood flowing back into the **left ventricle during diastole** [1]. - This backflow of blood during the **relaxation phase** of the heart creates the characteristic diastolic murmur [1]. *Ejection systolic murmur* - This murmur type is typically heard during **systole** and is associated with conditions like **aortic stenosis**, where there is turbulent flow across a narrowed aortic valve during ejection [3]. - It does not describe the sound of blood flowing back into the ventricle during **diastole**, which characterizes aortic regurgitation. *Ventricular contraction* - **Ventricular contraction** occurs during **systole** and is the mechanism by which blood is ejected from the ventricles [2]. - While related to cardiac cycle, it does not directly describe the timing or nature of the murmur caused by aortic regurgitation. *Systolic murmur* - A **systolic murmur** is heard when the ventricles contract, such as in conditions like **aortic stenosis** or **mitral regurgitation** [3]. - Aortic regurgitation is specifically a **diastolic event** as blood leaks back into the left ventricle during ventricular relaxation [1].

Question 7: About carey coombs murmur which is false –

A. Mid-diastolic murmur
B. Can be associated with AR (Correct Answer)
C. Seen in rheumatic fever
D. Low pitched murmur

Explanation: *Carey Coombs murmur can be associated with AR* - The Carey Coombs murmur is caused by inflammation and thickening of the mitral valve in **acute rheumatic fever**, leading to increased flow velocity across the valve during diastole [3]. - It is **not directly associated with aortic regurgitation (AR)**; instead, AR can occur concurrently as part of the overall rheumatic heart disease aetiology, but the murmur itself is mitral in origin [1], [3]. *Mid-diastolic murmur* - The Carey Coombs murmur is indeed a **mid-diastolic murmur**, heard at the apex [2]. - This timing is due to the turbulent flow of blood across the inflamed **mitral valve** during the middle part of ventricular diastole [2]. *Seen in rheumatic fever* - The Carey Coombs murmur is a classic sign specifically associated with **acute rheumatic fever** [3]. - It results from inflammation of the mitral valve causing relative **mitral stenosis** and turbulence during diastole. *Low pitched murmur* - This murmur is typically described as **low-pitched and rumbling**, heard best with the bell of the stethoscope [2]. - Its low pitch is characteristic of turbulent flow caused by relative mitral stenosis [2].

Question 8: What is the mechanism of aortic regurgitation in a case of VSD?

A. Congenital defect
B. Changes in the pressure gradient due to left to right shunt
C. Eisenmengerization
D. Prolapse of right coronary leaflet (Correct Answer)

Explanation: ***Prolapse of right coronary leaflet*** - In certain types of **ventricular septal defects (VSDs)**, particularly infracristal or supracristal defects, the lack of support for the **aortic valve cusps**, especially the right coronary leaflet, can lead to its **prolapse**. - This **prolapse** into the VSD creates an incomplete coaptation of the aortic valve leaflets, resulting in **aortic regurgitation**. *Congenital defect* - While VSD is a **congenital heart defect**, aortic regurgitation itself is not typically a direct, primary congenital defect associated with VSD. - Instead, the VSD indirectly *causes* the aortic regurgitation through secondary mechanisms such as leaflet prolapse or distortion. *Changes in the pressure gradient due to left to right shunt* - A left-to-right shunt causes increased pulmonary blood flow and can lead to **pulmonary hypertension**, but it does not directly explain the mechanism of **aortic valve insufficiency**. - While pressure changes are present, they do not cause the mechanical distortion or prolapse of the aortic valve leaflet that leads to regurgitation. *Eisenmengerization* - **Eisenmenger syndrome** is a late complication of large left-to-right shunts where pulmonary vascular disease leads to **reversal of the shunt (right-to-left)**. - This condition does not directly cause aortic regurgitation but rather primarily affects **pulmonary artery pressure** and flow dynamics.

Question 9: All of the following are features of a benign heart murmur except which of the following?

A. Mid systolic
B. Heard at the left sternal area
C. Soft
D. Radiating to the lower chest (Correct Answer)

Explanation: ***Radiating to the lower chest*** - Benign murmurs are typically **localized** and **do not radiate widely**, especially not to the lower chest. [1] - Radiation suggests a more significant flow disturbance and is often a feature of **pathological murmurs**, indicating conditions like **aortic stenosis** (radiating to the carotids) or **mitral regurgitation** (radiating to the axilla). [1] *Mid systolic* - Many benign murmurs are **mid-systolic**, often referred to as **ejection murmurs**, which are common due to normal blood flow turbulence. [1] - This timing is characteristic of functional murmurs arising from the **right ventricular outflow tract** or **aortic root**. *Heard at the left sternal area* - Benign murmurs are frequently heard at the **left sternal border**, particularly in the **pulmonic area (2nd and 3rd intercostal spaces)**, often due to flow across the pulmonic valve. [1] - This location is common for innocent murmurs, such as a **Still's murmur** in children. *Soft* - Benign murmurs are characterized by being **soft (grade I-II/VI)**, meaning they are barely audible or easily heard but without a thrill. [1] - A **loud murmur (grade III/VI or higher)**, especially with a palpable thrill, is more indicative of a **pathological condition**.

Question 10: A 38-year-old man presents with pain and shortness of breath. His pulse rate is 85 per minute, blood pressure is 180/80 mmHg, and the cardiac examination reveals an ejection systolic murmur. The ECG shows a LVH pattern and ST depression in the anterior leads. His Troponin T test is positive. Based on these findings, the echocardiogram is likely to reveal which of the following conditions?

A. Aortic regurgitation
B. Aortic stenosis (Correct Answer)
C. Mitral regurgitation
D. Mitral valve prolapse

Explanation: Aortic stenosis - The presence of an **ejection systolic murmur** [2], **left ventricular hypertrophy** on ECG [1], and a history of **pain and shortness of breath** are classic signs of aortic stenosis. The **wide pulse pressure** (180/80 mmHg) despite a normal pulse rate suggests increased peripheral resistance, common in advanced aortic stenosis. - **Elevated troponin T** suggests myocardial injury, which can occur due to increased myocardial oxygen demand in the context of severe aortic stenosis and LVH. *Aortic regurgitation* - This condition typically presents with a **diastolic murmur**, not an ejection systolic one [3]. - While it can cause LVH, the hallmark symptom of an **ejection systolic murmur** points away from regurgitation. *Mitral regurgitation* - This condition is characterized by a **holosystolic murmur** best heard at the apex and radiating to the axilla, different from the ejection systolic murmur described [1]. - While it can lead to LVH over time, the clinical presentation and specific murmur type are not consistent with mitral regurgitation. *Mitral valve prolapse* - This condition is often associated with a **mid-systolic click** followed by a late systolic murmur, rather than a clear ejection systolic murmur [4]. - Although it can sometimes cause chest pain, it rarely leads to the degrees of LVH and **troponin elevation** described in this scenario without other contributing factors.

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