Cardiology Practice Questions

Q: One month old baby is referred for failure to thrive. On examination there are features of congestive cardiac failure. Femoral pulses are feeble compared to brachial pulses. The likely diagnosis is

Coarctation of aorta. ***Coarctation of aorta*** - **Coarctation of the aorta** is characterized by a narrowing of the aorta, leading to reduced blood flow to the lower body. This explains the **feeble femoral pulses** compared to the **brachial pulses**. - Presentation in a **one-month-old infant** with **congestive cardiac failure** suggests **critical coarctation** that becomes symptomatic when the **ductus arteriosus closes** (typically in first few weeks of life), suddenly increasing afterload on the left ventricle. - The increased workload on the heart upstream from the coarctation results in signs of **congestive cardiac failure** and contributes to **failure to thrive** in infants. - The **pulse discrepancy** (weak femoral vs normal/bounding brachial) is the **pathognomonic finding** for coarctation. *Congenital aortic stenosis* - **Congenital aortic stenosis** would typically present with a **systolic ejection murmur** and symptoms related to reduced cardiac output, but usually *without* a significant difference in pulse strength between upper and lower extremities. - While it can cause **congestive cardiac failure** and **failure to thrive**, the classic **pulse discrepancy** is absent. *Congenital aorto-iliac disease* - While **aorto-iliac disease** can cause diminished femoral pulses, it is exceedingly **rare as a congenital condition** presenting with heart failure in an infant. - It would typically affect blood supply to the legs more directly, but less likely to cause the global heart failure symptoms seen in this case. *Patent ductus arteriosus* - A **patent ductus arteriosus (PDA)** results in a **continuous murmur** and can cause **congestive cardiac failure** and **failure to thrive** due to left-to-right shunting. - However, PDA typically presents with **bounding pulses** or **widened pulse pressure**, not feeble femoral pulses that differ significantly from brachial pulses.

Q: A neonate is diagnosed with pentalogy of Fallot. She may have the following lesions:

TOF + ASD. ***TOF + ASD*** - The "pentalogy of Fallot" is an atypical variant of the more common **tetralogy of Fallot (TOF)** that includes an additional cardiac anomaly. - The fifth lesion in pentalogy of Fallot is typically an **atrial septal defect (ASD)** or, less commonly, a **patent foramen ovale (PFO)**, adding to the four classic TOF lesions (ventricular septal defect, pulmonary stenosis, overriding aorta, right ventricular hypertrophy). *TOF + COA* - **Coarctation of the aorta (COA)** is a narrowing of the aorta that, when present alongside TOF, does not constitute the pentalogy of Fallot. - While both are congenital heart defects, COA is a distinct lesion not typically included in the definition of pentalogy of Fallot. *TOF + PDA* - A **patent ductus arteriosus (PDA)** is a persistent connection between the aorta and pulmonary artery that usually closes shortly after birth. - While it can coexist with TOF, a PDA is not considered the fifth lesion that defines the pentalogy of Fallot. *TOF + Polysplenia* - **Polysplenia** is a heterotaxy syndrome characterized by multiple small spleens and is associated with complex congenital heart disease, but it is an *extracardiac* anomaly. - The "pentalogy of Fallot" specifically refers to 5 *intracardiac* or *great vessel* abnormalities.

Q: What is the most common congenital heart defect in newborns with Down syndrome?

AV canal defect. ***AV canal defect*** - An **atrioventricular septal defect (AVSD)**, also known as an **AV canal defect**, is the **most common congenital heart defect** in newborns with Down syndrome, accounting for **40-45%** of cardiac defects - This defect involves a **hole in the center of the heart** where the atria and ventricles meet, often affecting both the **mitral and tricuspid valves** (complete AVSD) - The defect results from failure of endocardial cushion development during embryonic life *VSD* - A **ventricular septal defect (VSD)** is the **second most common** CHD in Down syndrome, occurring in approximately **30-35%** of cases - VSDs involve a hole in the **interventricular septum**, leading to left-to-right shunting - While common, it is less frequent than AVSD in this population *ASD* - An **atrial septal defect (ASD)** is also seen in Down syndrome but is **less frequent** than both AVSD and VSD - ASDs are holes in the **interatrial septum**, often leading to volume overload of the right heart - Secundum ASD is the most common type overall, but AVSD remains more prevalent in Down syndrome *Tetralogy of Fallot* - **Tetralogy of Fallot (TOF)** is a complex cyanotic heart defect that can occur in Down syndrome but is **much less common** than AVSD - TOF consists of four components: **VSD, pulmonary stenosis, overriding aorta, and right ventricular hypertrophy** - While TOF is an important differential, it is not the most prevalent defect in this population

Q: Which among the following is a sure sign of heart failure in an infant with congenital heart disease?

Liver enlargement. ***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.

Q: A 2-week-old girl is found to have a harsh murmur along the left sternal border. The parents report that the baby gets "bluish" when she cries or drinks from her bottle. Echocardiogram reveals a congenital heart defect associated with pulmonary stenosis, ventricular septal defect, dextroposition of the aorta, and right ventricular hypertrophy. What is the appropriate diagnosis?

Tetralogy of Fallot. ***Tetralogy of Fallot*** - The combination of **pulmonary stenosis**, **ventricular septal defect**, **dextroposition of the aorta** (overriding aorta), and **right ventricular hypertrophy** is the classic definition of Tetralogy of Fallot. - The "bluish" episodes (cyanosis) when crying or feeding are characteristic of **tet spells**, indicating right-to-left shunting and reduced pulmonary blood flow, exacerbated by activity. *Atrial septal defect* - An ASD primarily involves a **left-to-right shunt** and typically presents with a **fixed, split S2** and a **pulmonic flow murmur**, usually without cyanosis in infancy. - It does not involve the characteristic four defects seen in this patient, particularly the significant pulmonary stenosis and cyanosis. *Coarctation of aorta, postductal* - **Postductal coarctation** typically presents in older children or adults with **hypertension in the upper extremities** and **diminished or absent femoral pulses**, often without cyanosis. - This condition is a narrowing of the aorta **distal to the ductus arteriosus** and does not involve the four specific intracardiac defects described. *Coarctation of aorta, preductal* - **Preductal coarctation** can present in neonates with **heart failure** and **differential cyanosis** (upper body pink, lower body blue), or signs of shock if the ductus arteriosus closes. - This condition involves a narrowing of the aorta **proximal to the ductus arteriosus** and is not characterized by the four specific tetralogy defects.

Q: Tetralogy of Fallot's includes all except -

ASD. ***ASD*** - An **atrial septal defect (ASD)** is not considered one of the four classic components of **Tetralogy of Fallot (TOF)**. - While other cardiac defects can co-exist with TOF, an ASD is not a primary defining feature of the syndrome. - The **four classic components** of TOF are: VSD, pulmonary stenosis, RVH, and **overriding aorta**. *VSD* - A **ventricular septal defect (VSD)** is one of the four essential components of **Tetralogy of Fallot**, allowing communication between the ventricles. - It is typically a large, **malalignment VSD** that is a critical part of the pathophysiology. *Pulmonary stenosis* - **Pulmonary stenosis** (often infundibular, valvular, or supravalvular) is a key defining feature, leading to obstruction of blood flow from the right ventricle to the pulmonary artery. - The degree of pulmonary stenosis determines the severity of the **cyanosis** and clinical presentation. *RVH* - **Right ventricular hypertrophy (RVH)** develops as a compensatory mechanism due to the increased workload on the right ventricle to pump blood across the stenotic pulmonary valve. - This is a direct consequence of the **pulmonary stenosis** and is one of the four classic components of the syndrome.

Q: True about a 1-year-old child with PDA is –

Symptoms similar to aortopulmonary window. ***Symptoms similar to aortopulmonary window*** - Both **patent ductus arteriosus (PDA)** and an **aortopulmonary window** involve a connection between the aorta and pulmonary artery, leading to **left-to-right shunting**. - This shunting results in similar clinical presentations, such as a **continuous murmur**, signs of **pulmonary overcirculation**, and potential for **congestive heart failure** and **pulmonary hypertension**. *Indomethacin may help in closure* - **Indomethacin** is effective in closing a PDA, but primarily in **premature infants** and typically within the first few weeks of life. - In a **1-year-old child**, the ductus arteriosus has become muscularized and fibrotic, making medical closure with indomethacin ineffective. *Chances of spontaneous closure high* - The highest probability of **spontaneous closure** of a PDA occurs within the **first few days to weeks of life**. - By **1 year of age**, spontaneous closure is highly unlikely, and the PDA is generally considered to require intervention if it is hemodynamically significant. *Endocarditis is rare* - While uncommon, **infective endocarditis** is a well-recognized complication of an uncorrected PDA. - The turbulent blood flow through the shunt creates an environment conducive to bacterial adherence and infection at the pulmonary artery end of the ductus. - This makes endocarditis a definite risk rather than a rare occurrence, particularly in untreated cases.

Q: Child with PDA will NOT have:

CO₂ washout. ***CO₂ washout*** - **PDA causes increased pulmonary blood flow** leading to **pulmonary edema** and **CO₂ retention**, not washout - **Left-to-right shunt** results in pulmonary congestion that impairs gas exchange, preventing effective CO₂ elimination *Necrotizing enterocolitis* - **PDA can cause NEC** through **"steal phenomenon"** where blood is diverted from splanchnic circulation to the lungs - **Decreased mesenteric perfusion** in premature infants with significant left-to-right shunt increases NEC risk *Bounding pulses* - **Characteristic finding in PDA** due to **wide pulse pressure** from diastolic run-off - **Systolic hypertension** with **diastolic hypotension** creates the typical bouncing quality of peripheral pulses *Pulmonary hemorrhage* - **Large PDA with significant shunt** increases **pulmonary vascular pressure** and blood volume - **Pulmonary capillary damage** from overcirculation leads to hemorrhage, especially in preterm infants

Q: A patient presents with cyanosis and pulmonary complications. ECG shows left axis deviation. The most likely diagnosis is:

Tricuspid atresia. ***Correct Answer: Tricuspid atresia*** - Patients with **tricuspid atresia** often present with **cyanosis** due to right-to-left shunting across an atrial septal defect, and **pulmonary complications** can arise depending on pulmonary blood flow. - The ECG finding of **left axis deviation (LAD)** is highly characteristic of tricuspid atresia, as the main blood flow from the right atrium to the left atrium through the atrial septal defect leads to increased volume load on the left ventricle and left ventricular dominance. - LAD in a cyanotic neonate is virtually pathognomonic of tricuspid atresia. *Incorrect: TOF (Tetralogy of Fallot)* - While TOF causes **cyanosis** due to a right-to-left shunt, the ECG typically shows **right axis deviation** and **right ventricular hypertrophy**, not left axis deviation. - Pulmonary complications such as "tet spells" are common, but the distinctive ECG pattern (RAD, not LAD) helps differentiate it. *Incorrect: TAPVC (Total Anomalous Pulmonary Venous Connection)* - **TAPVC** presents with **cyanosis** and pulmonary edema or hypertension depending on the degree of obstruction to pulmonary venous return. - The ECG in TAPVC usually shows **right axis deviation** and **right ventricular hypertrophy** due to increased right-sided pressures, not LAD. *Incorrect: VSD (Ventricular Septal Defect)* - Isolated **VSDs** typically cause a **left-to-right shunt**, leading to pulmonary overcirculation and potentially heart failure, but **cyanosis is not a primary symptom** unless Eisenmenger syndrome develops later. - The ECG in VSD often shows **left ventricular hypertrophy** or biventricular hypertrophy depending on the size and duration of the shunt, but **left axis deviation is not a typical isolated finding** in uncomplicated VSD.

Q: Which of the following is a manifestation of Tetralogy of Fallot?

VSD. **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 1

One month old baby is referred for failure to thrive. On examination there are features of congestive cardiac failure. Femoral pulses are feeble compared to brachial pulses. The likely diagnosis is

Accepted Answer

Coarctation of aorta

Answer

Congenital aortic stenosis

Answer

Congenital aorto-iliac disease

Answer

Patent ductus arteriosus

Question 2

A neonate is diagnosed with pentalogy of Fallot. She may have the following lesions:

Accepted Answer

TOF + ASD

Answer

TOF + COA

Answer

TOF + PDA

Answer

TOF + Polysplenia

Question 3

What is the most common congenital heart defect in newborns with Down syndrome?

Accepted Answer

AV canal defect

Answer

Tetralogy of Fallot

Answer

VSD

Answer

ASD

Question 4

Which among the following is a sure sign of heart failure in an infant with congenital heart disease?

Accepted Answer

Liver enlargement

Answer

Pedal oedema

Answer

JVP

Answer

Basal crepitations

Question 5

A 2-week-old girl is found to have a harsh murmur along the left sternal border. The parents report that the baby gets "bluish" when she cries or drinks from her bottle. Echocardiogram reveals a congenital heart defect associated with pulmonary stenosis, ventricular septal defect, dextroposition of the aorta, and right ventricular hypertrophy. What is the appropriate diagnosis?

Accepted Answer

Tetralogy of Fallot

Answer

Atrial septal defect

Answer

Coarctation of aorta, postductal

Answer

Coarctation of aorta, preductal

Question 6

Tetralogy of Fallot's includes all except -

Accepted Answer

ASD

Answer

VSD

Answer

Pulmonary stenosis

Answer

RVH

Question 7

True about a 1-year-old child with PDA is –

Accepted Answer

Symptoms similar to aortopulmonary window

Answer

Indomethacin may help in closure

Answer

Chances of spontaneous closure high

Answer

Endocarditis is rare

Question 8

Child with PDA will NOT have:

Accepted Answer

CO₂ washout

Answer

Necrotizing enterocolitis

Answer

Bounding pulses

Answer

Pulmonary hemorrhage

Question 9

A patient presents with cyanosis and pulmonary complications. ECG shows left axis deviation. The most likely diagnosis is:

Accepted Answer

Tricuspid atresia

Answer

TOF

Answer

TAPVC

Answer

VSD

Question 10

Which of the following is a manifestation of Tetralogy of Fallot?

Accepted Answer

VSD

Answer

Left axis deviation

Answer

Left ventricular hypertrophy

Answer

All of the options

Cardiology — MCQs

Cardiology — MCQs

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