Cardiology Practice Questions

Q: A 5-year-old boy presents with difficulty in breathing and fatigue. On examination, a systolic murmur is heard at the left sternal border, and the chest X-ray shows a boot-shaped heart. What is the most likely diagnosis?

Tetralogy of Fallot. ***Tetralogy of Fallot*** - The combination of **difficulty in breathing**, **fatigue**, a **systolic murmur at the left sternal border**, and a **boot-shaped heart on chest X-ray** is highly characteristic of Tetralogy of Fallot. - The "boot-shaped heart" (or *coeur en sabot*) on X-ray is due to **right ventricular hypertrophy** and an upturned cardiac apex, a hallmark of this condition. *Ventricular Septal Defect* - While a **VSD** can cause a **systolic murmur** and difficulty breathing, it typically does not present with a **boot-shaped heart** on chest X-ray. - The murmur is usually **holosystolic** and loudest at the lower left sternal border, but the specific X-ray finding points away from an isolated VSD. *Atrial Septal Defect* - An **ASD** usually presents with a **fixed split second heart sound** and a **systolic ejection murmur** at the upper left sternal border due to increased flow across the pulmonary valve, not necessarily a prominent systolic murmur at the left sternal border. - It does not cause a **boot-shaped heart** on chest X-ray. *Patent Ductus Arteriosus* - A **PDA** typically presents with a **continuous "machinery" murmur** loudest below the left clavicle and bounding peripheral pulses. - While it can cause heart failure symptoms, it does not lead to a **boot-shaped heart** on chest X-ray.

Q: A 10-year-old with short stature and a webbed neck is likely to have which heart defect?

Coarctation of Aorta. ***Coarctation of Aorta*** - **Coarctation of the aorta** is a common cardiovascular anomaly associated with Turner syndrome, which presents with **short stature** and a **webbed neck**. - Other classic features of Turner syndrome include **gonadal dysgenesis**, **lymphedema**, and **bicuspid aortic valve** (the most common cardiac defect in Turner syndrome, often co-existing with coarctation). - Turner syndrome occurs in females with 45,X karyotype. *VSD* - **Ventricular septal defects (VSDs)** are the most common congenital heart defects overall but are not specifically associated with the constellation of findings seen in Turner syndrome. - VSDs typically present with a **holosystolic murmur** and signs of heart failure or pulmonary hypertension depending on the size. *ASD* - **Atrial septal defects (ASDs)** can occur in various genetic syndromes, but they are not as strongly linked to the specific phenotypic features of **short stature** and **webbed neck** as coarctation is with Turner syndrome. - ASDs are often characterized by a **fixed, wide splitting of S2** and a pulmonary flow murmur. *Pulmonary Stenosis* - **Pulmonary stenosis** is the most common cardiac defect in Noonan syndrome, which also presents with **short stature** and **webbed neck**, similar to Turner syndrome. - However, Noonan syndrome occurs in **both males and females** with a **normal karyotype**, whereas Turner syndrome is **female-only with 45,X karyotype**. - The clinical context of a 10-year-old (sex not specified, but Turner syndrome phenotype described) makes coarctation more characteristic of Turner syndrome. - Pulmonary stenosis manifests with a **systolic ejection murmur** best heard at the upper left sternal border.

Q: A 4-year-old presents with 'blue spells' and a boot-shaped heart on chest X-ray. Which congenital heart defect does this indicate?

Tetralogy of Fallot. ***Tetralogy of Fallot*** - The combination of **'blue spells' (cyanotic spells)** and a **boot-shaped heart (coeur en sabot)** on chest X-ray are classic signs of Tetralogy of Fallot [2]. - This condition involves four key defects: **ventricular septal defect**, **pulmonary stenosis**, **overriding aorta**, and **right ventricular hypertrophy** [1]. *Ventricular septal defect* - While a component of Tetralogy of Fallot, an isolated **VSD** primarily causes a left-to-right shunt and typically does not lead to severe cyanosis or a boot-shaped heart. - Symptoms usually include a loud **holosystolic murmur** and signs of heart failure rather than 'blue spells'. *Aortic stenosis* - This defect involves a **narrowing of the aortic valve**, obstructing blood flow from the left ventricle. - It usually presents with symptoms like **chest pain**, **syncope**, or **shortness of breath** on exertion, and does not cause cyanosis or a boot-shaped heart. *Patent ductus arteriosus* - A **PDA** is an open connection between the aorta and pulmonary artery, leading to a left-to-right shunt after birth. - It typically causes a **continuous murmur** and can lead to pulmonary hypertension or heart failure, but not cyanotic spells or a boot-shaped heart.

Q: Most characteristic cardiovascular defect seen in Rubella-

Patent ductus arteriosus. ***Patent ductus arteriosus*** - **Patent ductus arteriosus (PDA)** is the most characteristic cardiovascular defect associated with congenital rubella syndrome [1]. - The rubella virus can interfere with the normal closure of the **ductus arteriosus** during fetal development [1]. *Coarctation of the aorta* - **Coarctation of the aorta** is a narrowing of the aorta and is not typically linked to congenital rubella syndrome [1]. - It is often associated with syndromes like **Turner syndrome** or bicuspid aortic valve, which are not mentioned here [1]. *Ventricular septal defect* - **Ventricular septal defects (VSDs)** are common congenital heart defects, but they are not specifically characteristic of congenital rubella [1]. - VSDs are more frequently associated with conditions like **Down syndrome** or can occur in isolation [1]. *Pulmonary artery stenosis* - While **pulmonary artery stenosis** can occur as a congenital heart defect, it is less commonly the primary cardiovascular manifestation of congenital rubella syndrome. - **Peripheral pulmonary artery stenosis** can be seen in rubella, but PDA is the most characteristic overarching defect [1].

Q: Which of the following conditions is least likely to present with pulmonary plethora?

Ebstein anomaly. ***Ebstein anomaly*** - Ebstein anomaly is characterized by **apical displacement of the tricuspid valve leaflets**, leading to a large atrialized right ventricle and severe tricuspid regurgitation. - This typically results in **right-to-left shunting** through a patent foramen ovale or atrial septal defect, causing **cyanosis and reduced pulmonary blood flow** (pulmonary oligemia), rather than plethora. *Hypoplastic left heart syndrome* - Hypoplastic left heart syndrome (HLHS) involves **underdevelopment of the left side of the heart**, including the left ventricle, mitral valve, aortic valve, and aorta. - In HLHS, pulmonary venous return shunts from the left atrium to the right atrium via a patent foramen ovale, and systemic blood flow is maintained by a patent ductus arteriosus, resulting in **increased pulmonary blood flow (pulmonary plethora)**. *Double outlet right ventricle* - In double outlet right ventricle (DORV), both the **aorta and pulmonary artery arise primarily from the right ventricle**. - The degree of pulmonary plethora depends on the presence and size of a **ventricular septal defect (VSD)** and the relationship of the great arteries to the VSD. Most commonly, it leads to **increased pulmonary blood flow** if the VSD allows for systemic-to-pulmonary shunting. *TGA (Transposition of Great Arteries)* - Transposition of the Great Arteries (TGA) involves the **aorta arising from the right ventricle** and the **pulmonary artery arising from the left ventricle**, creating two parallel circulations. - In d-TGA, if there is a **large VSD** or **patent ductus arteriosus**, there will be mixing of oxygenated blood with deoxygenated blood, often resulting in **increased pulmonary blood flow (pulmonary plethora)** to the systemic circulation.

Q: Which of the following congenital anomalies leads to heart failure at birth?

Total anomalous pulmonary venous connection. ***Total anomalous pulmonary venous connection*** - **Obstructed TAPVC** is the classic congenital heart defect causing heart failure **at birth or within hours of life** - In obstructed types (especially **infracardiac** and some **supracardiac with obstruction**), pulmonary venous blood cannot adequately return to the heart, causing severe **pulmonary venous congestion** and **right heart failure** - Presents with **severe cyanosis, respiratory distress, and heart failure immediately at birth** - This is a **neonatal emergency** requiring immediate surgical intervention *Coarctation of aorta* - Typically presents with heart failure at **1-2 weeks of age** when the ductus arteriosus closes - At birth, the patent ductus arteriosus allows blood to bypass the coarctation, so symptoms are minimal - As the PDA closes, **left ventricular afterload increases dramatically**, leading to heart failure - **Critical coarctation** can rarely present earlier, but classically this is NOT "at birth" *Transposition of great arteries* - Presents primarily with **severe cyanosis at birth**, not heart failure - The aorta arises from the right ventricle and pulmonary artery from the left ventricle - Survival depends on mixing through PDA, ASD, or VSD - Heart failure develops later if there is excessive pulmonary blood flow through large shunts *Pulmonary atresia* - Complete obstruction of the pulmonary valve preventing right ventricular outflow - Presents with **severe cyanosis at birth** due to lack of pulmonary blood flow - The primary manifestation is **hypoxemia and cyanosis**, not heart failure - Requires patent ductus arteriosus or collateral circulation for survival

Q: All of the following are characteristic features of Tricuspid Atresia except for -

Split S2. ***Splitting of S2 is present in Tricuspid Atresia*** - In **tricuspid atresia**, the S2 heart sound is typically **single** rather than split because there is no blood flow through the tricuspid valve to the right ventricle, and pulmonary blood flow is often reduced, leading to a diminished or absent P2. - Absence of blood flow to the right ventricle prevents normal mechanisms of S2 splitting [1]. *Left axis deviation* - **Left axis deviation** on an EKG is a common finding in tricuspid atresia due to the **underdevelopment of the right ventricle** and the increased prominence of the left ventricle. - The electrical activity is predominantly directed towards the left side of the heart. *Right ventricular hypoplasia* - **Right ventricular hypoplasia** is a defining characteristic of tricuspid atresia [1], as the absence of the tricuspid valve prevents blood flow into, and thus proper development of, the right ventricle. - The right ventricle can range from a *small, non-functional chamber* to being almost absent. *Decreased pulmonary vascularity* - **Decreased pulmonary vascularity** is observed in tricuspid atresia because the pulmonary blood flow is significantly reduced, usually depending on a **patent ductus arteriosus (PDA)** or a **ventricular septal defect (VSD)** for blood to reach the lungs [1]. - The lack of direct flow from the right atrium to the right ventricle limits the amount of blood ejected into the pulmonary arteries. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Heart, pp. 545-546.

Q: What is the most common cause of isolated congenital heart block in infants?

Maternal autoantibodies (neonatal lupus). ***Maternal autoantibodies (neonatal lupus)*** - **Maternal autoantibodies**, specifically **anti-Ro/SSA** and **anti-La/SSB**, cross the placenta and target the fetal cardiac conduction system, leading to **congenital heart block**. - This is the most common cause of **isolated complete heart block** in infants, often occurring in the absence of other structural congenital heart defects. *Viral myocarditis* - While viral myocarditis can cause **heart block** due to inflammation of the myocardium and conduction system, it is a less common cause of **congenital heart block** and typically presents with other signs of heart failure. - It usually occurs at any age, including infancy, but is not considered the most common cause of congenital heart block, especially when isolated. *Rheumatic fever* - **Rheumatic fever** is an inflammatory disease that can affect the heart, joints, brain, and skin, and typically follows an infection with Group A Streptococcus. - It is **extremely rare** in infants and primarily affects older children and young adults, making it an unlikely cause of heart block in this population. *Surgery for congenital heart disease* - **Surgical repair** of congenital heart defects can result in **iatrogenic heart block** due to damage to the conduction system during the procedure. - However, this is a **post-surgical complication** and not an intrinsic cause of congenital heart block at birth, as implied by the question regarding heart block "in infants with congenital heart disease" before surgical intervention.

Question 1

A 5-year-old boy presents with difficulty in breathing and fatigue. On examination, a systolic murmur is heard at the left sternal border, and the chest X-ray shows a boot-shaped heart. What is the most likely diagnosis?

Accepted Answer

Tetralogy of Fallot

Answer

Ventricular Septal Defect

Answer

Atrial Septal Defect

Answer

Patent Ductus Arteriosus

Question 2

A 10-year-old with short stature and a webbed neck is likely to have which heart defect?

Accepted Answer

Coarctation of Aorta

Answer

VSD

Answer

ASD

Answer

Pulmonary Stenosis

Question 3

A 4-year-old presents with 'blue spells' and a boot-shaped heart on chest X-ray. Which congenital heart defect does this indicate?

Accepted Answer

Tetralogy of Fallot

Answer

Ventricular septal defect

Answer

Aortic stenosis

Answer

Patent ductus arteriosus

Question 4

Which imaging modality is essential for diagnosing Tetralogy of Fallot and planning surgical intervention in infants?

Accepted Answer

Echocardiography

Answer

Chest X-ray

Answer

CT scan

Answer

MRI

Question 5

Most characteristic cardiovascular defect seen in Rubella-

Accepted Answer

Patent ductus arteriosus

Answer

Coarctation of the aorta

Answer

Ventricular septal defect

Answer

Pulmonary artery stenosis

Question 6

Which of the following conditions is least likely to present with pulmonary plethora?

Accepted Answer

Ebstein anomaly

Answer

Hypoplastic left heart syndrome

Answer

Double outlet right ventricle

Answer

TGA (Transposition of Great Arteries)

Question 7

Which of the following congenital anomalies leads to heart failure at birth?

Accepted Answer

Total anomalous pulmonary venous connection

Answer

Transposition of great arteries

Answer

Pulmonary atresia

Answer

Coarctation of aorta

Question 8

All of the following are characteristic features of Tricuspid Atresia except for -

Accepted Answer

Split S2

Answer

Decreased pulmonary vascularity

Answer

Left axis deviation

Answer

Right ventricular hypoplasia

Question 9

What are the potential clinical consequences of a large patent ductus arteriosus (PDA)?

Accepted Answer

All of the listed complications are potential consequences of PDA, depending on the clinical scenario.

Answer

Endocarditis

Answer

Eisenmenger syndrome

Answer

Congestive heart failure (CHF)

Question 10

What is the most common cause of isolated congenital heart block in infants?

Accepted Answer

Maternal autoantibodies (neonatal lupus)

Answer

Viral myocarditis

Answer

Rheumatic fever

Answer

Surgery for congenital heart disease

Cardiology — MCQs

Cardiology — MCQs

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