Cardiology Practice Questions

Q: Most common cause of Acquired Complete Heart Block in children is

Cardiac Surgery. ***Cardiac Surgery*** - **Cardiac surgery** for congenital heart disease is the **most common cause** of acquired complete heart block in children, occurring in approximately **1-3% of congenital heart surgeries**. - High-risk procedures include **VSD repair**, **AV canal defect repair**, **tetralogy of Fallot correction**, and surgeries involving the **ventricular septum** near the AV node and bundle of His. - The conduction system may be damaged during surgical manipulation, leading to **immediate or delayed post-operative complete heart block**. - If the block persists beyond **7-10 days post-surgery**, permanent pacemaker implantation is typically required. *Myocarditis* - **Myocarditis** can cause varying degrees of AV block, including complete heart block, particularly following **viral infections** (e.g., Coxsackie virus, adenovirus). - However, complete heart block in myocarditis is **less common** than post-surgical cases in the pediatric population. - Most cases of myocarditis-related conduction disturbances are **transient** and resolve with treatment of the underlying inflammation. *Acute Rheumatic Fever* - **Acute Rheumatic Fever (ARF)** typically causes **first-degree AV block** (prolonged PR interval) as part of rheumatic carditis. - Complete heart block is **rare** in ARF; the carditis more commonly leads to **valvular damage** (mitral and aortic regurgitation) rather than complete AV dissociation. *Drug overdose* - Overdose of **cardiac depressants** (beta-blockers, calcium channel blockers, digoxin) can cause complete heart block. - This is an **acute toxicological cause** and relatively uncommon compared to post-surgical heart block in children. - Treatment involves supportive care, antidotes when available, and temporary pacing if needed.

Q: Which of the following is a defining feature of Tetralogy of Fallot?

Ventricular septal defect. ***Ventricular septal defect*** - A **ventricular septal defect (VSD)** is one of the four cardinal features of **Tetralogy of Fallot**, along with pulmonary stenosis, overriding aorta, and right ventricular hypertrophy. - The VSD in Tetralogy of Fallot is typically **large** and **non-restrictive**, allowing a **right-to-left shunt** due to increased right ventricular pressure from pulmonary stenosis, resulting in cyanosis. - Cyanotic spells (tet spells) occur when there is increased right-to-left shunting due to dynamic worsening of RVOT obstruction. *Atrial septal defect* - An **atrial septal defect (ASD)** is a communication between the atria and is not a defining feature of Tetralogy of Fallot. - While ASDs can occur in conjunction with other congenital heart defects, they are not part of the classic tetralogy. *Mitral valve prolapse* - **Mitral valve prolapse** is a condition where the mitral valve leaflets bulge into the left atrium during systole, and it is not a congenital heart defect associated with Tetralogy of Fallot. - It is a common valvular abnormality that usually develops later in life or can be present congenitally but is unrelated to the pathophysiology of Tetralogy of Fallot. *Patent ductus arteriosus* - A **patent ductus arteriosus (PDA)** is a persistent opening between the aorta and pulmonary artery, which normally closes shortly after birth. - While a PDA can be present in some cases of congenital heart disease, it is not one of the four defects that comprise Tetralogy of Fallot.

Q: Which of the following cardiac lesions is least likely to occur in Congenital Rubella syndrome?

ASD. ***ASD*** - While **atrial septal defects (ASDs)** can occur in congenital heart disease, they are **rarely associated with congenital rubella syndrome**. - The classic cardiac defects linked to congenital rubella are related to persistent fetal circulation structures or underdeveloped outflow tracts. *VSD* - **Ventricular septal defects (VSDs)** are among the **most common congenital heart defects** and can be associated with congenital rubella syndrome. - Rubella infection can interfere with septal development, leading to these **shunt lesions**. *Pulmonary Stenosis* - **Pulmonary artery stenosis**, particularly **peripheral pulmonary artery stenosis**, is a **characteristic cardiovascular anomaly** in congenital rubella syndrome. - The rubella virus can affect the development of the pulmonary arteries and valves. *PDA* - **Patent ductus arteriosus (PDA)** is the **most common cardiac lesion** seen in congenital rubella syndrome due to the virus's interference with ductal closure. - The infection leads to abnormal development and persistence of the communication between the aorta and pulmonary artery.

Q: Drug of choice for the treatment of Kawasaki disease is

Intravenous Immunoglobulin. ***Intravenous Immunoglobulin*** - **Intravenous Immunoglobulin (IVIG)**, in combination with aspirin, is the cornerstone of therapy for acute Kawasaki disease. - It works by modulating the immune system and reducing inflammation, thereby preventing serious complications like **coronary artery aneurysms**. *Steroids* - While steroids can reduce inflammation, they are generally considered **second-line therapy** in Kawasaki disease, often used in cases unresponsive to IVIG. - Routine initial use of steroids alone is not the drug of choice due to the proven efficacy of IVIG in preventing **coronary artery pathology**. *Low molecular weight Heparin* - **Low molecular weight heparin** is an anticoagulant used to prevent or treat **thrombosis**. - It is not indicated for the primary treatment of the acute inflammatory phase of Kawasaki disease, though it may be used in specific situations if **coronary artery thrombosis** develops. *Aspirin* - **Aspirin** is an essential part of Kawasaki disease treatment, used initially at high doses for its anti-inflammatory effects and later at low doses for its **antiplatelet properties**. - However, aspirin is always administered **in conjunction with IVIG** as the primary treatment to reduce the risk of coronary artery complications.

Q: An infant previously diagnosed with a large muscular VSD comes to the office with complaints from the mother of fatigue and poor feeding over the past month. You note the child has not gained weight since the previous visit 2 months ago. The child is apathetic, tachypneic, and has wheezes and crackles on lung auscultation. What is the most likely cardiac diagnosis based on this patient's presentation?

Congestive heart failure. ***Congestive heart failure*** - The infant's symptoms of **fatigue**, **poor feeding**, **no weight gain**, **apathy**, **tachypnea**, and **wheezes/crackles** are classic signs of **congestive heart failure** in an infant. - A **large muscular VSD** can lead to significant left-to-right shunting, causing **pulmonary overcirculation** and symptoms of heart failure. *Congenital heart block* - This condition involves an abnormality in the heart's electrical conduction system, leading to a **slow heart rate (bradycardia)**. - While it can cause fatigue, it typically doesn't present with respiratory symptoms like **tachypnea** and **rales** unless profound bradycardia leads to heart failure. *Prolonged QT syndrome* - This is an **electrical disorder** that can cause **arrhythmias** and sudden cardiac death, often presenting with syncope or seizures. - It does not typically manifest with the signs of **pulmonary congestion** (wheezes, crackles) or feeding difficulties seen in this infant. *Hypertrophic cardiomyopathy* - This condition involves thickening of the heart muscle, leading to **outflow obstruction** and diastolic dysfunction. - While it can cause symptoms of poor feeding and fatigue, the prominent respiratory symptoms like **tachypnea** and **crackles** are more indicative of pulmonary venous congestion secondary to a large shunt.

Q: Clinical manifestations of large VSD in children typically appear at:

2 months. ***2 months*** - **Large ventricular septal defects (VSDs)** manifest clinically around **6 to 8 weeks (2 months) of age** because the **pulmonary vascular resistance (PVR)** decreases significantly around this time. - As PVR falls, increased **left-to-right shunting** occurs, leading to pulmonary overcirculation and symptoms like **tachypnea, poor feeding, and growth failure**. *2 days* - At **2 days of age**, PVR is still **elevated**, minimizing **left-to-right shunting** through a VSD, so symptoms are usually absent. - Significant symptoms from large left-to-right shunts due to congenital heart disease are uncommon in the **immediate postnatal period**. *2 weeks* - At **2 weeks of age**, PVR is still **relatively high**, and the decrease is not yet sufficient to cause significant symptomatic **pulmonary overcirculation** from a large VSD. - Clinical manifestations typically become evident when PVR has dropped considerably lower, around the 6-8 week mark. *6 months* - While symptoms would certainly be present at **6 months**, the typical onset of symptoms for a large VSD with significant left-to-right shunting occurs **earlier**, around 2 months of age. - By 6 months, if untreated, infants with large VSDs would likely have well-established signs of **heart failure** and **pulmonary hypertension**.

Q: Tetralogy of Fallot (TOF) includes all of the following components except:

ASD. ***ASD*** - While an **atrial septal defect (ASD)** can be present in some complex congenital heart diseases, it is **not considered a primary component of Tetralogy of Fallot** [1]. - The four classic components of **TOF** are **ventricular septal defect (VSD)**, **pulmonary stenosis**, **overriding aorta**, and **right ventricular hypertrophy (RVH)** [1]. *VSD* - A **ventricular septal defect (VSD)** is a **mandatory component** of Tetralogy of Fallot, allowing for mixing of oxygenated and deoxygenated blood [1]. - It's typically a **large, subaortic defect** that enables the overriding aorta to receive blood from both ventricles [1]. *Pulmonary stenosis* - **Pulmonary stenosis** (obstruction of blood flow from the right ventricle to the pulmonary artery) is a **key component** determining the severity of Tetralogy of Fallot [1]. - The degree of **pulmonary stenosis** dictates the amount of right-to-left shunting and the clinical manifestation of **cyanosis** [1]. *RVH* - **Right ventricular hypertrophy (RVH)** develops as a compensatory mechanism due to the increased workload on the right ventricle from the **pulmonary stenosis** and the **VSD** [1]. - It is a **consequence** of the increased pressure required to eject blood past the stenotic pulmonary valve and into the systemic circulation through the VSD [1].

Q: A one month old infant with a congenital cardiac lesion shows increased sweating during feeding. Which of the following is the sure sign of congestive cardiac failure in this infant?

Liver enlargement. ***Liver enlargement*** - **Hepatomegaly** is a **cardinal sign** of **congestive cardiac failure** in infants due to venous congestion and fluid retention. - The infant's immature lymphatic system and pliable chest wall make other signs less reliable, while the liver quickly reflects increased systemic venous pressure. *JVP* - **Jugular venous pressure (JVP)** is notoriously difficult to assess accurately in infants due to their short necks and poorly developed neck muscles. - Therefore, it is **not a reliable indicator** of congestive cardiac failure in this age group. *Basal crepitations* - **Basal crepitations**, indicating pulmonary edema, can be a sign but are often subtle and can also be present in other respiratory conditions prevalent in infants. - The infant's small lung fields and rapid respiratory rate make the detection of crepitations challenging and less specific than liver enlargement. *Pedal oedema* - **Pedal edema** is less common in infants with congestive heart failure because they tend to retain fluid in the **extracellular space**, leading to generalized edema rather than localized peripheral swelling. - The distribution of fluid retention in infants often manifests as puffiness around the eyes or generalized anasarca rather than prominent pedal edema.

Q: A 3-4 month old baby with heart rate 250/min, QRS complex less than 0.07 sec and no P wave, Diagnosis will be :

SVT. **SVT** - A heart rate of 250/min in a 3-4 month old infant, along with a **narrow QRS complex ( 0.09-0.10 sec in adults, proportionally less in infants) because the impulse originates in the ventricles. - The patient's QRS complex is **narrow (<0.07 sec)**, ruling out typical VT. *PSVT with block* - **Paroxysmal supraventricular tachycardia (PSVT) with block** would still present with a rapid atrial rate, and while there might be block to the ventricles, the dominant rhythm would stem from supraventricular activity causing narrow QRS, but the term "with block" usually implies some degree of AV nodal block which would lead to a ventricular rate slower than the atrial rate, unlike the observed 250/min. - The absence of P waves makes identification of a specific "block" pattern difficult, and the high ventricular rate favors a direct conduction rather than a blocked rhythm limiting ventricular response. *Sinus tachycardia* - **Sinus tachycardia** is usually characterized by discernible **P waves** preceding each QRS complex and a heart rate that typically doesn't exceed 220 bpm in infants unless under extreme physiological stress. - A heart rate of 250/min is generally above the physiological limit for sinus tachycardia in infants, and the **absence of P waves** further distinguishes it from sinus tachycardia.

Q: Ductus dependent blood flow is required for all of these congenital heart diseases except:

Persistent truncus arteriosus. ***Persistent truncus arteriosus*** - In **persistent truncus arteriosus**, there is a single great artery overriding a ventricular septal defect, supplying both systemic and pulmonary circulation. **Ductus arteriosus** closure does not critically compromise blood flow to either system. - Pulmonary blood flow is often increased in truncus arteriosus, so a patent ductus is not necessary for pulmonary circulation, nor is it essential for systemic circulation as the single trunk directly supplies the aorta. *Pulmonary stenosis* - Severe **pulmonary stenosis** in neonates can restrict blood flow to the lungs, making a **patent ductus arteriosus** essential for pulmonary blood flow via a right-to-left shunt if the stenosis is critical. - Without the **ductus arteriosus**, severe hypoxemia and acidosis can develop due to insufficient oxygenation. *Hypoplastic left heart syndrome* - In **hypoplastic left heart syndrome**, the left ventricle and aorta are underdeveloped, making the **ductus arteriosus** crucial for systemic blood flow from the right ventricle. - Its closure would severely impair blood supply to the body, leading to circulatory collapse and death. *TGA with intact ventricular septum* - With **transposition of the great arteries (TGA)** and an **intact ventricular septum**, systemic and pulmonary circulations are parallel rather than in series. - A **patent ductus arteriosus** is necessary to allow mixing of oxygenated and deoxygenated blood to sustain life.

Question 1

Most common cause of Acquired Complete Heart Block in children is

Accepted Answer

Cardiac Surgery

Answer

Acute Rheumatic Fever

Answer

Drug overdose

Answer

Myocarditis

Question 2

Which of the following is a defining feature of Tetralogy of Fallot?

Accepted Answer

Ventricular septal defect

Answer

Atrial septal defect

Answer

Mitral valve prolapse

Answer

Patent ductus arteriosus

Question 3

Which of the following cardiac lesions is least likely to occur in Congenital Rubella syndrome?

Accepted Answer

ASD

Answer

VSD

Answer

Pulmonary Stenosis

Answer

PDA

Question 4

Drug of choice for the treatment of Kawasaki disease is

Accepted Answer

Intravenous Immunoglobulin

Answer

Steroids

Answer

Low molecular weight Heparin

Answer

Aspirin

Question 5

An infant previously diagnosed with a large muscular VSD comes to the office with complaints from the mother of fatigue and poor feeding over the past month. You note the child has not gained weight since the previous visit 2 months ago. The child is apathetic, tachypneic, and has wheezes and crackles on lung auscultation. What is the most likely cardiac diagnosis based on this patient's presentation?

Accepted Answer

Congestive heart failure

Answer

Congenital heart block

Answer

Prolonged QT syndrome

Answer

Hypertrophic cardiomyopathy

Question 6

Clinical manifestations of large VSD in children typically appear at:

Accepted Answer

2 months

Answer

2 days

Answer

2 weeks

Answer

6 months

Question 7

Tetralogy of Fallot (TOF) includes all of the following components except:

Accepted Answer

ASD

Answer

VSD

Answer

Pulmonary stenosis

Answer

RVH

Question 8

A one month old infant with a congenital cardiac lesion shows increased sweating during feeding. Which of the following is the sure sign of congestive cardiac failure in this infant?

Accepted Answer

Liver enlargement

Answer

JVP

Answer

Basal crepitations

Answer

Pedal oedema

Question 9

A 3-4 month old baby with heart rate 250/min, QRS complex less than 0.07 sec and no P wave, Diagnosis will be :

Accepted Answer

SVT

Answer

VT

Answer

PSVT with block

Answer

Sinus tachycardia

Question 10

Ductus dependent blood flow is required for all of these congenital heart diseases except:

Accepted Answer

Persistent truncus arteriosus

Answer

Pulmonary stenosis

Answer

Hypoplastic left heart syndrome

Answer

TGA with intact ventricular septum

Cardiology — MCQs

Cardiology — MCQs

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