Cardiology

Question 1

Midline sternotomy

Answer 1

CABG
Valve replacement
Congenital heart surgery
Aortic root repair

Question 2

Midline sternotomy with leg scar

Answer 2

CABG with venous grafting

Question 3

Tetralogy of fallot

Answer 3

Overiding aorta
VSD
Pulmonary stenosis
Right ventricular hypertrophy

Question 4

Complications of tetralogy of fallot

Answer 4

Pulmonary regurgitation requiring valve replacement
Endocarditis
Coagulopathy
Polycythaemia
Paradoxical embolism
Arrhythmia

Question 5

Midline sterntomy and left thoractomy scar

Answer 5

Tetralogy of fallot repair with shunting
or multiple surgeries eg CABG and separate lung surgery

Question 6

What are different congenital heart diseases

Answer 6

Cyanotic:
Tetralogy of fallot
Transposition of the great vessels
Tricuspid atresia
Truncus arteriosus

Non cyanotic (Although can progress to Eisenmengers with shunt reversal)
VSD
ASD
PDA
Coarctation of the aorta

Question 7

Differentials for systolic murmur

Answer 7

Aortic stenosis
Aortic sclerosis
Mitral regurg
Pulmonary stenosis
ASD, VSD
HOCM

Question 8

Causes of Aortic stenosis

Answer 8

Senile calcification
Biscuspid valve
Rheumatic fever

Question 9

Signs of severe AS
On Exam
On echo
In History

Answer 9

Quiet murmur
Narrow pulse pressure

Valve area <1cm or <0.6 depending on guidelines
Gradient across valve >50

Evidence of heart failure
Symptomatic eg syncope,
Abnormal BP response to exercise

Question 10

Tx options for severe or symptomatic AS

Answer 10

Optimise cardiovascular risks
Ix for co-existent coronary artery disease with angiogram
Valve replacement - bioprosthetic or mechanical
Biosposethetic valves have shorter lifespan but do not require anticoagulation
Mechanical last long but need lifelong anticoagulation
Risk vs benefits. Taking into account patients age, lifestyle etc.
TAVI - older patient, or those not suitable for surgery however cannot have if bad PVD or bad coronary artery disease

Question 11

Complications of TAVI

Answer 11

COMPLICATIONS of TAVI
Pacemaker 10%
Vascular access complication eg stent
Stroke, MR, annular rupture, perforation of apex

Mortality higher on waiting list for TAVI than procedure itself

Question 12

ECG findings with AS

Answer 12

Left ventricular hypertrophy
LBBB
10% of patients who have a TAVI go on to have a pacemaker so important to know about re-existing conduction abnormalities

Question 13

Complications of valve replacement

Answer 13

Immediate- risk of bleeding, infection, damage to local structure (inc conduction issues)
Valve failure
Infective endocarditis
Haemolysis
SE of anticoagulation

Question 14

Mitral regurgitation - causes

Answer 14

MI causing papillary muscle rupture
Infective endocarditis/ Rheumatic fever
Connective tissue diseases - Marfans, RA
PCKD
Inflammatory - Dilated left ventricle / Amyloidosis
Degeneration - Calcification / Fibrosis

Question 15

Tx for MR

Answer 15

If mild to mod- monitor with 2 yearly Echo.
Need to intervene early
Intervention guided by severity, symptoms, pulmonary hypertension and left ventricular function.

Mitral clip
Valve repair
Valve replacement

Question 16

Marfans - underlying pathophysiology

Answer 16

Mutation in the FBN1 gene result in the production of abnormal fibrillin protein.
This causes mechanical instability and loss of elasticity of connective tissues.
This results in aortic dilatation.

Question 17

Managing Marfans

Answer 17

Surveillance of aortic roof size with annual echo
Surgical management of aortic root dilatation (if over 50mm, if FH of dissection and >45mm, if rapidly progressing)
B blockers and angiotensin receptor blocker to slow aortic root dilatation
Valve replacements as required
Genetic counselling
PT/OT

Question 18

Signs on exam of marfans

Answer 18

Tall with long extremities
Arachnodactyly ( can encircle their wrist with their thumb and little finger)
Hyperextendible joints
High arched palate
Pectus carinatum or excavatum
Scoliosis
Aortic regurgitation
Mitral valve prolapse
Coarctation
Inguinal hernia

Question 19

Differentials for Marfans

Answer 19

Homocysteinuria (Similar phenotype, but inherited autosomal recessively, not associated with aortic root disease, but is associated with learning difficulties and recurrent aortic and venous thromembolic events. In addition, lens dislocation tends to be upwards in Marfans but downwards in homocysteinuria.)

Men 2b (Marfanoid body habitus, mucosal neuromas, medullary thyroid cancer, phaeochromocytoma
Ehlers danlos

Question 20

Associated with pulmonary stenosis

Answer 20

o The causes of pulmonary stenosis are primarily congenital causes, which can simply be pulmonary stenosis on its own, or be associated with other congenital conditions:
o Tetralogy of Fallot
o Williams or Noonan syndrome (phenotypical appearance - short stature, webbed neck, widely spread nipples, proptosis, strabismus)

o There are also infective causes:
o Infective endocarditis
o Rheumatic fever
o Carcinoid syndrome ( the secreted mediators cause right- sided heart valve fibrosis causes tricuspid regurgitation and/or pulmonary stenosis)

Question 21

SIgns on exam of PS

Answer 21

Raised JVP with giant A waves
Right parasternal heave
Thrill in the pulmonary area
Ejection systolic murmur loudest in the pulmonary area on inspiration
Radiates to infraclavicular region
Widely split second heart sound
Functional tricuspid regurgitation

Question 22

Ehlers Danlos signs on exam

Answer 22

Fragile skin
Hyperextensible skin
Joint hypermobility
Mitral valve prolapse
Evidence of surgery from aneurysmal rupture or bowel perforation

It is autosomal dominant

Question 24

CAUSES OF MITRAL VALVE PROLAPSE

Answer 24

Marfan syndrome
Ehlers–Danlos syndrome
osteogenesis imperfecta
polycystic kidney disease

Question 25

Causes of restrictive cardiomyopathy

Answer 25

Myocardial - idiopathic - scleroderma - amyloid - Haemachromatosis - glycogen storage disorders - Gauchers Endomyocardial - endomyocardial fibrosis - hyper- eosinophilic syndromes ( inc. lofflers) - carcinoid - malignancy or radiotherapy - toxin related

Question 26

Signs of mitral stenosis on exam

Answer 26

Malar flush Diastolic murmir loudest in mitral area Radiates to axilla Palpable first heart sound Left parasternal heave if pulmonary hypertension present Opening snap of S1, then mid diastolic murmur Tricuspid regurgitation, right ventricular heave and loud p2 if pulmonary hypertension Embolic complications

Question 27

Causes of mitral stenosis

Answer 27

Degeneration Rheumatic fever / IE Congenital

Question 28

Diagnosing rheumatic fever

Answer 28

Evidence of recent group A strep infection - positive throat swab, positive antigen test, raised antibody titre, recent episode of scarlet fever Plus either 2 major criteria or 1 major and 2 minor Major criteria - chorea - erythema marginatum - subcutaneous nodules - polyarthritis - carditis Minor criteria - raised ESR/WCC, arthralgia, previous rheumatic fever, pyrexia, prolonged PR

Question 29

Criteria for diagnosing infective endocarditis

Answer 29

Duke's criteria Major and minor 2 major 1 major and 3 minor 5 minor BC with organisms of IE and echo findings consistent Minor - fever, immunological phenomena, vascular phenomena, risks eg IVDU, BC positive for other organisms

Question 30

Most common organisms in infective endocarditis

Answer 30

Staph aureus Staph epidermis Strep viridans Strep bovis Less commonly - HACEK organisms of fungal organisms

Question 31

Aortic regurgitation

Answer 31

Quinckes signs Collapsing pulse Corrigans sign De mussetts Aortic thrill Diastolic murmur Heard loudest in tricuspid Sat forward in expiration

Question 32

Causes of AR

Answer 32

Degenerative: Bicuspid valves, age and factors like hypertension. Infective: Infective endocarditis, rheumatic fever, tertiary syphilis. Rheumatological: HLA B27 associated arthopathies like ankylosing spondylitis. Connective tissue disorders: Marfans, ehlers danlos, psuedoxanthoma elasticum, osteogenesis imperfecta.

Question 33

HOCM - management

Answer 33

Avoid strenuous exercise, dehydration and vasodilators If symptomatic and LVOT gradient > 30mmHg: - b blocker - Pacemaker - alcohol septal ablation - surgical myomectomy If rhythm disturbance or high risk SCD: - ICD Refractory: Transplant Genetic counselling (autosomal dominant)

Question 34

Absent radial pulse

Answer 34

Iatrogenic - art line, arterial harvesting. Proximal arterial issues Atherosclerosis - smoking, high BMI, high cholesterol, diabetes Vasculitis - takayasu's, giant cell arteritis Subclavian steal syndrome (stenosis or occlusion of subclavian artery proximal to origin of vertebral artery so that bloods diverts up caroitds and back down the vertebral artery to reach remaining vasculature in arm. This diverts blood away from the brain causing neurological symptoms on affect arm – sensory, visual , auditory, olfactory or total collapse. May also be arm claudication on use)

Question 35

HOCM- Mx

Answer 35

Conservative: genetic counselling, lifestyle advice inc avoiding strenuous exercise, referral to support and information networks Medical: beta blockers (to reduce outflow tract gradient), amiodarone (suppress arrythmias) Surgical – alcohol septal ablation, septal myomectomy

Question 36

Poor prognostication in HOCM

Answer 36

Poor prognostic markers: Syncope, FH of sudden cardiac death, poor blood presuure response to exercise, outflow tract gradient >30mmhg at rest, septal wall thickness, certain genetic mutations Inheritance – autosomal dominant or de novo Screening – regular ECG and echo

Question 37

Ix for HOCM

Answer 37

CXR (heart failure), echo (concentric or septal hypertrophy, septal wall thickness, outflow tract gradient, diastolic dysfunction until late stages where systolic too, associated MVP), cardiac MRI (detailed structural information) Special: cardiac catheterisation (gradient), genetic tests (eg beta myosin heavy chains, myosin binding protein C, troponin), endomyocardial biopsy (rule out other causes eg amyloid)