Cardiology Practice Questions

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?

Parietal lobe. ***Parietal lobe*** - In **cyanotic congenital heart disease** like Tetralogy of Fallot, the **right-to-left shunt** allows bacteria to bypass pulmonary filtration, leading to **hematogenous spread** to the brain. - Brain abscesses in this context typically occur in the **middle cerebral artery (MCA) territory**, specifically at the **gray-white junction** in the **frontal-parietal region**. *Thalamus* - **Thalamic abscesses** are extremely rare and typically occur in **immunocompromised patients** with hematogenous spread from distant infections. - This location is not characteristic of brain abscesses associated with **cyanotic congenital heart disease**. *Temporal lobe* - **Temporal lobe abscesses** are classically associated with complications of **otitis media** or **mastoiditis** through direct extension or venous spread. - This patient's presentation lacks evidence of **ear infection** as the primary source. *Cerebellum* - **Cerebellar abscesses** are typically seen with **otogenic infections** (otitis media/mastoiditis) spreading via the **posterior fossa**. - While possible with hematogenous spread, the **cerebellum** is not the most common site in **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

Q: A child after 4 weeks of age presents with an acyanotic ejection systolic murmur. Which of the following is the most likely cause?

VSD. ***VSD*** - A **ventricular septal defect (VSD)** typically presents with a **pansystolic (holosystolic) murmur** that becomes **audible after 4 weeks of age** when **pulmonary vascular resistance drops**. - It is the **most common acyanotic congenital heart disease** presenting at this age, with blood shunting from left to right ventricle. - The murmur is best heard at the **left lower sternal border** and increases pulmonary blood flow. - Small VSDs become clinically apparent around 4-6 weeks as PVR falls and the shunt increases. *PDA* - A **patent ductus arteriosus (PDA)** presents with a **continuous "machinery" murmur**, not an ejection systolic murmur. - While it's an **acyanotic lesion**, its characteristic continuous quality heard best at the left upper sternal border differentiates it from VSD. *Coarctation of aorta* - **Coarctation of the aorta** presents with a **systolic murmur** heard best over the **back/interscapular area**. - Characterized by **diminished or delayed femoral pulses** and **differential blood pressures** (higher in upper extremities). - May present earlier with heart failure in severe cases, but not typically with prominent murmur at 4 weeks. *TOF* - **Tetralogy of Fallot (TOF)** is a **cyanotic heart disease** due to right-to-left shunting, which contradicts the "acyanotic" presentation in the question. - The murmur is an **ejection systolic murmur** from pulmonary stenosis (RVOT obstruction), but the presence of cyanosis rules it out. - Presents with **cyanotic spells** and progressive cyanosis, not isolated murmur finding.

Q: Tetralogy of Fallot is characterized by following except –

AS. ***AS (Aortic Stenosis)*** - **Aortic stenosis (AS)** is characterized by a **narrowing of the aortic valve**, obstructing blood flow from the left ventricle to the aorta. - This is **NOT a component of Tetralogy of Fallot** and is a separate congenital or acquired cardiac condition. - The four main features of Tetralogy of Fallot are **ventricular septal defect**, **pulmonary stenosis** (typically infundibular), **overriding aorta**, and **right ventricular hypertrophy**. *VSD (Ventricular Septal Defect)* - A **ventricular septal defect (VSD)** is a communication between the right and left ventricles, allowing blood to shunt between chambers. - This is **one of the four essential components** of Tetralogy of Fallot, typically a large, non-restrictive VSD. *Over-riding of aorta* - An **overriding aorta** means the aortic root is positioned directly over the ventricular septal defect, straddling both ventricles instead of arising solely from the left ventricle. - This is a **hallmark feature of Tetralogy of Fallot**, leading to mixing of oxygenated and deoxygenated blood, contributing to cyanosis. *Infundibular constriction* - **Infundibular constriction**, also known as **pulmonary infundibular stenosis**, refers to the narrowing of the muscular outflow tract of the right ventricle (infundibulum) leading to the pulmonary artery. - This **subvalvular pulmonary stenosis** is a **critical component of Tetralogy of Fallot**, contributing to right ventricular hypertrophy, reduced pulmonary blood flow, and right-to-left shunting through the VSD.

Q: A mother brings her 5-year-old boy to see you as a General Physician. On examination, he has red eyes, dry, cracked lips and a rash on his hands and feet. He also has cervical lymphadenopathy. What is the most important investigation to rule out a serious complication of this condition?

Echocardiography. ***Echocardiography*** - The constellation of symptoms (red eyes, cracked lips, rash on hands and feet, cervical lymphadenopathy in a 5-year-old) is highly suggestive of **Kawasaki disease**. - **Coronary artery aneurysms** are the most serious complication of Kawasaki disease, making echocardiography crucial for early detection and management. *Blood pressure* - While important in any pediatric assessment, **blood pressure measurement** is not specific for diagnosing or monitoring the most critical complication of Kawasaki disease. - Hypertensive or hypotensive episodes are not classic features and do not directly assess **coronary artery involvement**. *ECG* - An **ECG** can detect arrhythmias or signs of myocardial ischemia, which might occur with **coronary artery pathology**. - However, it is less sensitive and specific than **echocardiography** for directly visualizing and quantifying **coronary artery aneurysms**. *Blood tests for autoantibodies* - Kawasaki disease is not an autoimmune condition primarily diagnosed by **autoantibodies**; it is a **vasculitis** of unknown etiology. - Blood tests for autoantibodies would not be the most important investigation to rule out its most serious complication.

Q: Commonly associated in tetralogy of Fallot is:

Right sided aortic arch. ***Right sided aortic arch*** - A **right-sided aortic arch** is a known anomaly that frequently coexists with Tetralogy of Fallot, occurring in about 20-25% of cases. - This association is due to disturbances in the normal development of the **aortic arches** during embryonic life. *Coarctation of aorta* - **Coarctation of the aorta** is a narrowing of the aorta, most commonly found in the juxtaductal region. - While it can occur with other congenital heart defects, it is not particularly associated with Tetralogy of Fallot. *Aortopulmonary window* - An **aortopulmonary window** is a rare defect involving a communication between the aorta and the pulmonary artery, distinct from a patent ductus arteriosus. - It results from incomplete fusion of the aorticopulmonary septum and is not a common associated anomaly in Tetralogy of Fallot. *Aberrant right subclavian artery* - An **aberrant right subclavian artery** (also known as *arteria lusoria*) arises from the descending aorta and passes posterior to the esophagus. - While a congenital anomaly of the great vessels, it is not a characteristic or commonly associated finding with Tetralogy of Fallot.

Q: A 4 1/2- year-old girl always had to wear warm socks even is summer season. On physical examination, it was noticed that she had high blood pressure and her femoral pulse was weak as compared to radial and carotid pulse, a chest radiograph showed remarkable notching of ribs along with their lower borders. This was due to:

Coarctation of aorta. ***Coarctation of aorta*** - The combination of **hypertension**, diminished femoral pulses compared to radial/carotid, and **rib notching** on a chest radiograph is pathognomonic for **coarctation of the aorta**. - Rib notching occurs due to the dilation of **intercostal arteries** as they try to bypass the aortic obstruction and supply blood to the lower body. *Takayasu’s arteritis* - This is a form of **large vessel vasculitis** primarily affecting the aorta and its major branches, leading to **pulseless disease** in the upper extremities. - While it can cause hypertension and differential pulses, **rib notching** is not a characteristic feature, and it typically presents in older children or young adults. *Raynaud’s disease* - Characterized by **vasospasm** of the small arteries and arterioles, typically in the fingers and toes, in response to cold or stress. - It causes color changes (pallor, cyanosis, redness) and pain in the digits, but does not involve **hypertension**, **differential pulses**, or **rib notching**. *Femoral artery thrombosis* - This would cause a sudden onset of **pain, pallor, pulselessness, paresthesia, and paralysis** (5 Ps) in the affected limb, primarily affecting one leg. - It would not lead to generalized hypertension or **rib notching**, and the radial/carotid pulses would typically be normal.

Q: Most common cardiac defect seen in Rubella syndrome

PDA. ***Patent Ductus Arteriosus (PDA)*** - **PDA is the most common cardiac defect** associated with congenital rubella syndrome, occurring in 40-60% of cardiac cases. - Rubella virus infection during the **first trimester** causes failure of ductus arteriosus closure after birth. - The classic triad of congenital rubella syndrome includes **cardiac defects (PDA most common), cataracts, and deafness**. - PDA in rubella syndrome may be **isolated or combined** with other cardiac anomalies. *Pulmonary stenosis* - **Peripheral pulmonary artery stenosis (PPS)** is the second most common cardiac defect in rubella syndrome (20-30% of cases). - The option "pulmonary stenosis" typically refers to valvular PS, which is less specific to rubella. - PPS involves **multiple stenoses at branching points** of pulmonary arteries rather than valvular obstruction. *VSD* - **Ventricular Septal Defect** can occur in rubella syndrome but is **less common** than PDA or PPS. - VSD is more frequently associated with other congenital infections and genetic syndromes. *ASD* - **Atrial Septal Defect** is the least common cardiac defect among the listed options in congenital rubella syndrome. - While possible, ASD is not characteristically associated with maternal rubella infection during pregnancy.

Question 1

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 2

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

Parietal lobe

Answer

Cerebellum

Answer

Temporal lobe

Answer

Thalamus

Question 3

Congenital cyanotic heart disease with pulmonary oligemia is seen with –

Accepted Answer

Tricuspid atresia

Answer

VSD

Answer

Hypoplastic left ventricle

Answer

ASD

Question 4

Which of the following is least likely in PDA?

Accepted Answer

CO, wash out

Answer

Bounding pulse

Answer

Pulmonary hemorrhage

Answer

Necrotizing enterocolitis

Question 5

A child after 4 weeks of age presents with an acyanotic ejection systolic murmur. Which of the following is the most likely cause?

Accepted Answer

VSD

Answer

PDA

Answer

Coarctation of aorta

Answer

TOF

Question 6

Tetralogy of Fallot is characterized by following except –

Accepted Answer

AS

Answer

VSD

Answer

Over–riding of aorta

Answer

Infundibular constriction

Question 7

A mother brings her 5-year-old boy to see you as a General Physician. On examination, he has red eyes, dry, cracked lips and a rash on his hands and feet. He also has cervical lymphadenopathy. What is the most important investigation to rule out a serious complication of this condition?

Accepted Answer

Echocardiography

Answer

Blood pressure

Answer

ECG

Answer

Blood tests for autoantibodies

Question 8

Commonly associated in tetralogy of Fallot is:

Accepted Answer

Right sided aortic arch

Answer

Coarctation of aorta

Answer

Aortopulmonary window

Answer

Aberrant right subclavian artery

Question 9

A 4 1/2- year-old girl always had to wear warm socks even is summer season. On physical examination, it was noticed that she had high blood pressure and her femoral pulse was weak as compared to radial and carotid pulse, a chest radiograph showed remarkable notching of ribs along with their lower borders. This was due to:

Accepted Answer

Coarctation of aorta

Answer

Takayasu’s arteritis

Answer

Raynaud’s disease

Answer

Femoral artery thrombosis

Question 10

Most common cardiac defect seen in Rubella syndrome

Accepted Answer

PDA

Answer

VSD

Answer

ASD

Answer

Pulmonary stenosis

Cardiology — MCQs

Cardiology — MCQs

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