Congenital Heart Diseases: Acyanotic — MCQs
Commonest congenital heart disease is:
Which of the following is a manifestation of Tetralogy of Fallot?
A 29-day-old child presents with features of congestive cardiac failure and left ventricular hypertrophy. Auscultation shows a short systolic murmur. The most likely diagnosis is:
Which of the following murmurs increase with a Valsalva maneuver?
Which of the following cyanotic congenital heart disease is associated with increased risk of chest infections?
Which among the following is a sure sign of heart failure in an infant with congenital heart disease?
A 6-year-old with congenital heart disease presents with fever, new-onset murmur, and petechiae. Blood cultures are pending, but initial Gram stain shows Gram-positive cocci. What is the most appropriate initial intervention?
Congenital cyanotic heart disease with pulmonary oligemia is seen with –
Commonest type of congenital cyanotic heart disease is -
Which of the following congenital heart diseases is MOST OFTEN associated with decreased pulmonary blood flow?
Congenital Heart Diseases: Acyanotic Indian Medical PG Practice Questions and MCQs
Question 1: Commonest congenital heart disease is:
- A. Patent ductus arteriosus
- B. Atrial septal defect
- C. Ventricular septal defect (Correct Answer)
- D. Mitral valve prolapse
Explanation: ***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.
Question 2: Which of the following is a manifestation of Tetralogy of Fallot?
- A. Left axis deviation
- B. VSD (Correct Answer)
- C. Left ventricular hypertrophy
- D. All of the options
Explanation: **VSD** - A **ventricular septal defect (VSD)** is one of the four cardinal defects comprising Tetralogy of Fallot, allowing for communication between the right and left ventricles [1]. - The size of the VSD is typically large, leading to equalization of pressures between the two ventricles [1]. *Left axis deviation* - **Left axis deviation** is not a typical electrocardiographic finding in Tetralogy of Fallot; instead, right axis deviation is more common due to **right ventricular hypertrophy** [1]. - It is more characteristic of conditions like **left anterior fascicular block** or chronic left ventricular overload. *Left ventricular hypertrophy* - **Left ventricular hypertrophy** is not a characteristic feature of Tetralogy of Fallot; rather, **right ventricular hypertrophy** is a diagnostic component due to the obstruction of the right ventricular outflow tract [1]. - While the left ventricle may be affected by volume changes, it does not typically undergo hypertrophy in Tetralogy of Fallot. *All of the options* - This option is incorrect because, as explained, **left axis deviation** and **left ventricular hypertrophy** are not characteristic manifestations of Tetralogy of Fallot. - Only a **VSD** is one of the core defects in this complex congenital heart condition [1].
Question 3: A 29-day-old child presents with features of congestive cardiac failure and left ventricular hypertrophy. Auscultation shows a short systolic murmur. The most likely diagnosis is:
- A. Rheumatic fever
- B. Transposition of great arteries
- C. Tetralogy of Fallot
- D. Ventricular septal defect (Correct Answer)
Explanation: ***Ventricular septal defect*** - A **ventricular septal defect (VSD)** causes a left-to-right shunt, leading to increased pulmonary blood flow and can result in **congestive cardiac failure** and **left ventricular hypertrophy** as pulmonary vascular resistance drops in the first few weeks of life. - Large VSDs typically present with a **holosystolic murmur** best heard at the left lower sternal border; however, in the early neonatal period or with muscular VSDs, the murmur may be **shorter and less prominent** as pulmonary resistance is still relatively elevated. - Among the given options, VSD is the **most likely acyanotic heart defect** to present with CHF and LVH in this age group. *Rheumatic fever* - **Rheumatic fever** is an inflammatory disease following **Group A Streptococcal pharyngitis**, typically occurring in children **over 3 years of age**. - It is **extremely rare in infants** and would not explain CHF and LVH in a 29-day-old neonate. *Transposition of great arteries* - **Transposition of the great arteries (TGA)** is a cyanotic congenital heart defect where the aorta arises from the right ventricle and the pulmonary artery from the left ventricle. - Infants with TGA present with **severe cyanosis within hours to days of birth**, not primarily CHF. - The murmur is often **absent or soft** unless there is an associated VSD or PDA. *Tetralogy of Fallot* - **Tetralogy of Fallot (ToF)** is a cyanotic heart disease with four components: VSD, pulmonary stenosis, overriding aorta, and **right ventricular hypertrophy** (not left). - Infants present with **cyanosis** (not CHF) and a **loud systolic ejection murmur** at the left upper sternal border due to pulmonary stenosis. - The pathophysiology leads to **RVH, not LVH**, making this inconsistent with the clinical findings.
Question 4: Which of the following murmurs increase with a Valsalva maneuver?
- A. MR
- B. VSD
- C. AS
- D. Hypertrophic cardiomyopathy (Correct Answer)
Explanation: ***Hypertrophic cardiomyopathy*** - The Valsalva maneuver decreases **preload**, leading to a reduction in left ventricular volume and an **increased outflow tract obstruction**. - This increased obstruction accentuates the murmur of hypertrophic cardiomyopathy, making it louder. *MR* - Mitral regurgitation (MR) murmur typically **decreases** or remains unchanged with the Valsalva maneuver due to reduced **venous return** and thus reduced left ventricular preload. - A decrease in preload lessens the volume of blood being regurgitated from the left ventricle into the left atrium. *VSD* - The murmur of a ventricular septal defect (VSD) usually **decreases** during the Valsalva maneuver because of the reduction in **venous return** and consequent decrease in left-to-right shunting. - Decreased systemic vascular resistance relative to pulmonary resistance also plays a role, reducing the pressure gradient for shunting. *AS* - Aortic stenosis (AS) murmur generally **decreases** during the Valsalva maneuver due to decreased **left ventricular volume** and reduced transvalvular flow. - The reduction in preload lessens the blood ejected through the stenotic aortic valve, thereby reducing the intensity of the murmur.
Question 5: Which of the following cyanotic congenital heart disease is associated with increased risk of chest infections?
- A. Tetralogy of Fallot
- B. Truncus arteriosus (Correct Answer)
- C. Tricuspid atresia
- D. None of the options
Explanation: ***Truncus arteriosus*** - This condition involves a single great artery overriding a **ventricular septal defect**, leading to mixed systemic and pulmonary blood flow. - The **unrestricted pulmonary blood flow** results in **pulmonary hypertension** and edema, making the lungs vulnerable to frequent infections. *Tetralogy of Fallot* - Characterized by **reduced pulmonary blood flow** due to **pulmonary stenosis**, which typically protects the lungs from overload. - While patients can experience complications, an increased risk of frequent chest infections due to pulmonary overcirculation is not a primary feature. *Tricuspid atresia* - Involves the absence of the **tricuspid valve**, leading to mixing of blood in the atria and systemic circulation of deoxygenated blood. - Pulmonary blood flow can be reduced or normal, but severe pulmonary overcirculation leading to recurrent chest infections is not a hallmark. *None of the options* - This option is incorrect because **Truncus arteriosus** is indeed strongly associated with an increased risk of chest infections.
Question 6: Which among the following is a sure sign of heart failure in an infant with congenital heart disease?
- A. Pedal oedema
- B. JVP
- C. Liver enlargement (Correct Answer)
- D. Basal crepitations
Explanation: ***Liver enlargement*** - **Hepatomegaly** is a reliable sign of **heart failure in infants** because the infant's liver is very compliant and readily distends with increased systemic venous pressure. - Due to a less developed compensatory mechanism, infants often manifest heart failure with signs related to **systemic congestion**, with liver enlargement being a primary indicator. *Pedal oedema* - **Pedal edema is uncommon in infants** with heart failure compared to adults, as they are often supine and have less hydrostatic pressure effect on their lower extremities. - When present, it might be due to other causes or a sign of very severe, chronic heart failure rather than an early or "sure" sign. *JVP* - **Jugular venous distension (JVD) is difficult to assess accurately in infants** due to their short, fat necks and the difficulty in positioning and visualizing the neck veins. - Therefore, it is generally considered an **unreliable physical sign** for diagnosing heart failure in this age group. *Basal crepitations* - **Basal crepitations (rales)** indicate pulmonary congestion and can be a sign of left-sided heart failure. - However, in infants, these can also be caused by **bronchiolitis**, **pneumonia**, or other respiratory infections, making them a less specific "sure sign" than liver enlargement.
Question 7: A 6-year-old with congenital heart disease presents with fever, new-onset murmur, and petechiae. Blood cultures are pending, but initial Gram stain shows Gram-positive cocci. What is the most appropriate initial intervention?
- A. Schedule for urgent valve replacement
- B. Administer high-dose steroids
- C. Start broad-spectrum antibiotics (Correct Answer)
- D. Wait for susceptibility testing
Explanation: ***Start broad-spectrum antibiotics*** - The presentation of **fever**, **new-onset murmur**, **petechiae**, and **Gram-positive cocci** in a patient with **congenital heart disease** is highly suggestive of **infective endocarditis**. - Prompt initiation of **broad-spectrum antibiotics** is crucial to prevent further damage to the heart valves and systemic complications while awaiting definitive culture results. *Schedule for urgent valve replacement* - **Valve replacement** is a definitive treatment for severe valvular damage but is typically considered after initial medical management has failed or in cases of severe complications like heart failure or recurrent emboli. - It is not the initial intervention for suspected infective endocarditis. *Administer high-dose steroids* - **Steroids** are anti-inflammatory but are not indicated in the treatment of active bacterial infections like endocarditis. - Administering steroids could potentially worsen the infection by suppressing the immune response. *Wait for susceptibility testing* - **Waiting for susceptibility testing** to initiate treatment would delay critical care, allowing the infection to progress and increasing morbidity and mortality. - Initial treatment should be empiric, and antibiotics can be narrowed once susceptibility results are available.
Question 8: Congenital cyanotic heart disease with pulmonary oligemia is seen with –
- A. VSD
- B. Hypoplastic left ventricle
- C. ASD
- D. Tricuspid atresia (Correct Answer)
Explanation: ***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.
Question 9: Commonest type of congenital cyanotic heart disease is -
- A. ASD
- B. TOF (Correct Answer)
- C. PDA
- D. Single ventricle defects
Explanation: ***TOF (Correct Answer)*** - **Tetralogy of Fallot (TOF)** is the **most common cyanotic congenital heart disease**, accounting for approximately 10% of all congenital heart defects. - Characterized by **four main defects**: ventricular septal defect (VSD), pulmonary stenosis, overriding aorta, and right ventricular hypertrophy. - The degree of **pulmonary stenosis** determines the severity of cyanosis and clinical presentation. - Classic presentation includes **cyanotic spells** (Tet spells) and **squatting** behavior in children. *ASD (Incorrect)* - **Atrial Septal Defect (ASD)** is an **acyanotic** congenital heart defect with left-to-right shunting. - Does not cause cyanosis under normal circumstances because oxygenated blood from the left atrium shunts to the right atrium. - Symptoms are usually mild in childhood and may include fatigue or shortness of breath. *PDA (Incorrect)* - **Patent Ductus Arteriosus (PDA)** is generally an **acyanotic** heart defect with left-to-right shunting. - The ductus arteriosus remains open after birth, connecting the aorta to the pulmonary artery. - While it can cause **differential cyanosis** in rare instances of severe pulmonary hypertension with shunt reversal (Eisenmenger syndrome), it is not primarily classified as a cyanotic heart disease. *Single ventricle defects (Incorrect)* - **Single ventricle defects** (e.g., hypoplastic left heart syndrome, tricuspid atresia) are complex **cyanotic** heart defects, but they are **less common than Tetralogy of Fallot**. - These defects involve only one functional ventricle, leading to mixing of oxygenated and deoxygenated blood. - Require staged surgical palliation (e.g., Norwood, Glenn, Fontan procedures).
Question 10: Which of the following congenital heart diseases is MOST OFTEN associated with decreased pulmonary blood flow?
- A. TAPVC
- B. Truncus arteriosus
- C. Ebstein's anomaly
- D. Single ventricle with pulmonary stenosis (Correct Answer)
Explanation: ***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.
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