Valvular Heart Disease — MCQs

10 questions

Investigation of choice for valvular heart disease-

All are radiological features of mitral stenosis except:

A 40-year-old woman who had several episodes of rheumatic fever as a child, is currently afebrile and feels well, and has come to a hospital for monitoring echocardiography. Which of the following findings would most likely be seen in this patient's mitral valve?

For pericardial calcifications, which is the best investigation?

Which X-ray finding is more characteristic of ASD compared to VSD?

Hockey stick appearance on echo is a feature of.

Fish mouth appearance of valve in RHD is due to-

Contraceptive of choice in a woman with Rheumatic heart disease.

Flask shaped heart is seen in –

Q10

Boot shape of heart in TOF is due to:

Valvular Heart Disease Indian Medical PG Practice Questions and MCQs

Question 1: Investigation of choice for valvular heart disease-

A. Nuclear Cardiac imaging
B. Precordial Doppler
C. 2 D- Echocardiography (Correct Answer)
D. MRI

Explanation: ***2 D- Echocardiography*** - **Transthoracic echocardiography (TTE)** is the initial and most common investigation for valvular heart disease due to its non-invasiveness, accessibility, and ability to visualize valve morphology and function in real-time [1]. - It provides critical information on valve structure, leaflet motion, chamber dimensions, ventricular function, and pressure gradients, allowing diagnosis and assessment of severity [2]. *Nuclear Cardiac imaging* - Primarily used for assessing **myocardial perfusion** and viability, rather than direct visualization of valve structure and function. - While it can indirectly assess the impact of valvular disease on ventricular function, it does not provide detailed information about the valves themselves. *Precordial Doppler* - **Doppler echocardiography** is a component of a full echocardiogram, used to quantify blood flow velocities and pressure gradients across valves [1]. - However, "precordial Doppler" is not a standalone comprehensive investigation for valvular disease; it must be combined with 2D imaging for a complete assessment. *MRI* - **Cardiac MRI (CMR)** offers excellent anatomical detail and precise quantification of ventricular volumes and function, and can assess valvular regurgitation. - It is often used as a complementary study in specific cases, particularly for complex congenital heart disease or when echocardiography is inconclusive, but it is not the primary or initial investigation due to cost and accessibility.

Question 2: All are radiological features of mitral stenosis except:

A. Straight left border of heart
B. Lifting of left bronchus
C. Pulmonary hemosiderosis
D. Oligemia of upper lung fields (Correct Answer)

Explanation: ***Oligemia of upper lung fields*** - This is **NOT a feature of mitral stenosis** and is therefore the correct answer to this EXCEPT question. - Mitral stenosis causes **cephalization of pulmonary blood flow** (also called upper lobe blood diversion), which means **increased vascularity** in the upper lung fields, not oligemia (decreased blood flow). - Due to pulmonary venous hypertension, there is redistribution of blood flow from the lower lobes to the upper lobes, making the upper lobe vessels appear **more prominent**, not oligemic. - **Oligemia** (reduced blood flow) is the opposite of what occurs in mitral stenosis. *Straight left border of heart* - This is a **characteristic feature** of mitral stenosis. - Results from enlargement of the **left atrial appendage**, which straightens the normally concave left heart border. - Creates a distinctive silhouette on PA chest X-ray due to left atrial pressure overload. *Pulmonary hemosiderosis* - This is a **feature of chronic severe mitral stenosis**. - Occurs due to recurrent microhemorrhages from chronically congested pulmonary capillaries. - Hemosiderin-laden macrophages (heart failure cells) accumulate in the alveoli. - May present as fine reticulonodular opacities on chest X-ray. *Lifting of left bronchus* - This is a **classic feature** of mitral stenosis with significant left atrial enlargement. - The enlarged left atrium pushes the **left main bronchus** upward, best seen on lateral chest X-ray. - The angle between the main bronchi increases (normally 60-70°, may exceed 90° in severe cases).

Question 3: A 40-year-old woman who had several episodes of rheumatic fever as a child, is currently afebrile and feels well, and has come to a hospital for monitoring echocardiography. Which of the following findings would most likely be seen in this patient's mitral valve?

A. Ballooning of valve leaflets
B. Fibrous bridging between thickened, calcified leaflets (Correct Answer)
C. Irregular beads of calcification in annulus
D. Large bulky vegetation with adjacent leaflet perforation

Explanation: A history of **rheumatic fever** typically leads to **chronic rheumatic heart disease**, resulting in **thickening and fibrosis of the mitral valve** [1]. The presence of **fibrous bridging** is characteristic of rheumatic valve disease, indicating scarring and adhesion of leaflets [1]. *Irregular beads of calcification in annulus* - This finding is more suggestive of **degenerative calcific changes** rather than changes due to rheumatic heart disease. - In rheumatic fever, the mitral valve typically shows **thickened leaflets** rather than calcification at the annulus [1]. *Large bulky vegetation with adjacent leaflet perforation* - This is indicative of **infective endocarditis**, not rheumatic heart disease, which would not present with bulky vegetations [2]. - Rheumatic heart disease leads to **structural valve dysfunction** without the presence of vegetations [2]. *Ballooning of valve leaflets* - Ballooning (or myxomatous degeneration) is associated with **mitral valve prolapse**, not rheumatic heart disease. - In rheumatic fever, the leaflets are usually **thickened and fused**, rather than ballooned or prolapsed [1].

Question 4: For pericardial calcifications, which is the best investigation?

A. Ultrasound
B. CT scan (Correct Answer)
C. MRI
D. Transesophageal echocardiography

Explanation: ***Correct: CT scan*** - **CT scans** are highly sensitive and specific for detecting **pericardial calcifications** due to their excellent spatial resolution and ability to measure calcium density (Hounsfield units). - They provide detailed anatomical information about the **pericardium** and can accurately map the extent, location, and thickness of calcified areas. - **CT is the gold standard** for detecting and quantifying pericardial calcification, particularly in constrictive pericarditis. *Incorrect: Ultrasound* - While ultrasound (echocardiography) can visualize the pericardium and may detect calcifications, its ability to definitively identify and characterize **calcifications** is limited compared to CT. - **Acoustic shadowing** from calcifications can obscure underlying structures, making a precise assessment challenging. - Useful for detecting pericardial effusion and thickening, but not optimal for calcification assessment. *Incorrect: MRI* - **MRI excels** in visualizing soft tissues, pericardial inflammation, and fluid collections, but it is **poor at detecting calcium**. - Calcifications typically appear as signal voids (black) on MRI, making it difficult to differentiate them from other structures, air, or motion artifacts. - MRI is valuable for assessing pericardial inflammation and constriction but not the preferred method for calcification. *Incorrect: Transesophageal echocardiography* - TEE offers high-resolution images of cardiac structures and is primarily used for assessing valve function, intracardiac masses, endocarditis, and aortic pathology. - Its utility in detecting and characterizing **pericardial calcifications** is limited compared to CT, especially for diffuse or subtle calcifications. - The pericardium is not optimally visualized with TEE compared to transthoracic echocardiography.

Question 5: Which X-ray finding is more characteristic of ASD compared to VSD?

A. Normal LA (Correct Answer)
B. Enlarged LA
C. Aortic shadow
D. Pulmonary Congestion

Explanation: ***Normal LA*** - In an uncomplicated **atrial septal defect (ASD)**, blood shunts from the left atrium to the right atrium, decompressing the left atrium. - This decompression results in a **normal-sized left atrium** on chest X-ray, distinguishing it from conditions with **left ventricular overload**. *Enlarged LA* - An **enlarged left atrium (LA)** is more characteristic of conditions causing **left-sided volume or pressure overload**, such as **ventricular septal defect (VSD)** with significant left-to-right shunt. - In VSD, blood shunts from the left ventricle to the right ventricle, increasing **pulmonary blood flow** and pressure, ultimately leading to LA enlargement. *Aortic shadow* - The **aortic shadow** on X-ray reflects the size and position of the aorta, and while some cardiac conditions can affect it, changes in its size are not a primary distinguishing feature between ASD and VSD. - A subtle **aortic knuckle** may be seen, but it does not differentiate the two defects. *Pulmonary Congestion* - While both ASD and VSD can cause increased **pulmonary blood flow**, **pulmonary congestion** (interstitial or alveolar edema) is more likely to be prominent in a **large VSD** due to the higher pressure shunt. - ASD typically leads to **pulmonary arterial hypertension** over time, but less frank congestion unless there's associated left-sided heart failure.

Question 6: Hockey stick appearance on echo is a feature of.

A. Mitral stenosis (Correct Answer)
B. Mitral incompetence
C. Aortic stenosis
D. Aortic regurgitation

Explanation: ***Mitral stenosis*** - The **"hockey stick" appearance** on echocardiography refers to the characteristic **doming of the anterior mitral leaflet** during diastole, which is a hallmark of mitral stenosis. - This doming is due to the stenotic mitral valve opening incompletely, with the tip of the leaflet bending forward while its base remains tethered [1]. *Mitral incompetence* - **Mitral incompetence (regurgitation)** is characterized by **incomplete closure** of the mitral valve leaflets, leading to backward blood flow into the left atrium during systole. - This condition does not typically present with a "hockey stick" appearance; instead, it is often seen with **leaflet prolapse** or inadequate coaptation [1]. *Aortic stenosis* - **Aortic stenosis** involves the **narrowing of the aortic valve**, impeding blood flow from the left ventricle to the aorta. - Its echocardiographic features include **thickened, calcified aortic valve leaflets** with reduced excursion, not a "hockey stick" appearance. *Aortic regurgitation* - **Aortic regurgitation** is the backward flow of blood from the aorta into the left ventricle during diastole due to **incomplete closure of the aortic valve** [2]. - While it can manifest with various echocardiographic signs like **diastolic flow reversal** in the aorta, the "hockey stick" sign is not associated with this condition [2].

Question 7: Fish mouth appearance of valve in RHD is due to-

A. Rupture of valve
B. Calcification & fibrosis (Correct Answer)
C. Hypertrophy of ventricular wall
D. None of the options

Explanation: ***Calcification & fibrosis*** - The **fish mouth appearance** of the valve in rheumatic heart disease (RHD) is primarily due to **calcification and fibrosis** of the mitral valve [1]. - This results in **narrowing of the valve orifice**, which mimics the shape of a fish mouth during diastole [1]. *Rupture of valve* - Rupture of the valve typically leads to **acute severe valvular insufficiency** and does not explain the **gradual narrowing** characteristic of the fish mouth appearance. - It would generally be associated with **acute symptoms** rather than the chronic changes seen in RHD. *None of the above* - This option is incorrect as the fish mouth appearance is well-defined by **calcification and fibrosis**, making it a specific feature of RHD. - It also disregards the specific etiology associated with the valvular deformity in RHD. *Hypertrophy of ventricular wall* - While hypertrophy of the ventricular wall can occur in RHD due to increased workload, it does not directly lead to the **valvular deformity** known as fish mouth appearance. - This hypertrophy affects the **myocardium**, not the structure of the valves themselves which are primarily affected by fibrosis and calcification. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Heart, pp. 566-567.

Question 8: Contraceptive of choice in a woman with Rheumatic heart disease.

A. Progesterone only pills
B. IUCD (Correct Answer)
C. Condom with spermicidal jelly
D. OCPs

Explanation: ***IUCD*** - **Intrauterine contraceptive devices (IUCDs)** are highly effective and do not involve systemic hormones, making them safe for women with **rheumatic heart disease**. - Both copper and hormonal IUCDs can be used, as they pose no additional risk of **thromboembolism** or worsen cardiac function. *Progesterone only pills* - While generally safer than combined oral contraceptives for women with cardiac issues, **progesterone-only pills** still carry a slight risk of **thrombosis**, especially in women with certain heart conditions. - Their effectiveness can be slightly lower than IUCDs, and adherence to strict daily timing is crucial for optimal contraception. *Condom with spermicidal jelly* - **Condoms with spermicidal jelly** are a barrier method and do not pose any direct risk to a woman with rheumatic heart disease. - However, they have a significantly **higher failure rate** compared to highly effective methods like IUCDs, making them less ideal as a primary contraceptive for a condition where pregnancy could be high-risk. *OCPs* - **Combined oral contraceptive pills (OCPs)** containing both estrogen and progestin are generally **contraindicated** in women with rheumatic heart disease, particularly those with valvular lesions or a history of **embolism**. - Estrogen increases the risk of **thromboembolic events**, which can be dangerous for individuals with compromised cardiac function.

Question 9: Flask shaped heart is seen in –

A. Pericardial effusion (Correct Answer)
B. TOF
C. Ebstein anomaly
D. TAPVC

Explanation: ***Pericardial effusion*** - A **"flask-shaped"** or **"water bottle-shaped" heart** on chest X-ray is a classic finding in significant pericardial effusion. - This appearance results from the accumulation of a large amount of fluid in the **pericardial sac**, which causes the cardiac silhouette to enlarge symmetrically and assume a globular shape. *TOF (Tetralogy of Fallot)* - TOF typically presents with a **"boot-shaped" heart** (coeur en sabot) on chest X-ray due to right ventricular hypertrophy and a concave pulmonary artery segment. - This morphology is distinctly different from the flask-shaped appearance of pericardial effusion. *Ebstein anomaly* - Ebstein anomaly is characterized by apical displacement of the tricuspid valve, leading to **massive right atrial enlargement**. - On chest X-ray, this often results in a **markedly enlarged oval-shaped heart**, which can be quite massive but does not typically have the distinct flask/water bottle shape. *TAPVC (Total Anomalous Pulmonary Venous Connection)* - TAPVC can present with different X-ray findings depending on the type, but a classic finding for the supracardiac type is a **"snowman" or "figure-of-8" heart** in children. - This appearance is due to the dilated superior vena cava and anomalous veins draining to it, not a flask shape.

Question 10: Boot shape of heart in TOF is due to:

A. Right ventricular hypertrophy (Correct Answer)
B. Enlargement of the left atrium
C. Enlargement of the right atrium
D. Hypertrophy of both ventricles

Explanation: ***Right ventricular hypertrophy*** - The characteristic **boot-shaped heart (coeur en sabot)** seen in Tetralogy of Fallot (TOF) on a chest X-ray is primarily due to **right ventricular hypertrophy** and the small pulmonary artery. - The hypertrophied right ventricle lifts the cardiac apex, while the concavity in the area of the pulmonary artery (due to **pulmonary stenosis**) gives the heart its distinctive shape. *Enlargement of the left atrium* - Left atrial enlargement is not a feature of **Tetralogy of Fallot**; in fact, chronic pulmonary outflow obstruction often leads to a relatively normal or small left atrium. - This condition involves right-sided heart abnormalities, and left atrial enlargement would suggest increased left-sided pressures, which are not typical for TOF. *Enlargement of the right atrium* - While right atrial enlargement can occur in severe cases of TOF due to increased resistance to blood flow, it is **right ventricular hypertrophy** that is the primary determinant of the classic boot-shaped cardiac silhouette. - Right atrial enlargement alone does not create the specific "boot" appearance which is largely due to the ventricular contour. *Hypertrophy of both ventricles* - In Tetralogy of Fallot, the primary ventricular abnormality is **right ventricular hypertrophy**, driven by the need to pump blood through a stenosed pulmonary artery. - The left ventricle typically maintains a normal size and function, as it primarily pumps into the systemic circulation and is not directly affected by the primary defects in the same way as the right ventricle.

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