Cardiology- Clinical Exam

Question 1

In a normal heart, increased splitting of S2 occurs in:

Answer 1

Inspiration
During inspiration, negative intrathoracic pressure causes increased venous return to the right heart, with increased right ventricular filling and therefore a relative delay in closing of the pulmonary valve after systole

Question 2

Wide split S2 occurs in:

Answer 2

Wide split S2 occurs in:
ASD (fixed)- Right volume overload, so RV needs to stay open longer to expel all blood
Pulmunary stenosis - needs to stay longer open to push blood through narrow opening
Ebstein anomaly - R volume overload
RBBB- R side takes longer to depolarise, so contracts after left side, so pulmunary valve stays open longer

Question 3

Narrow split S2 occurs in:

Answer 3

Pulmunary HTN (as pulmonary valve closes earlier due to high pulmonary resistance.
also pulm HTN causes LOUD S2

Question 4

Single S2 occurs when:

Answer 4

a) If one of the semilunar valves is missing, as in pulmonary or aortic valve atresia, severe stenosis, truncus arteriosus, tricuspid atresia, hypoplastic left heart
b) If both valves close simultaneously as in double outlet single ventricle or in large VSD with equal ventricular pressures
c) In pulmonary hypertension with equal right and left ventricular pressures- Eisenmenger syndrome
d) If vessels are abnormally positioned- L transposition great arteries

Question 5

Paradoxical splitting of S2 (P2 before A2) occurs in:

Answer 5

severe aortic stenosis
left bundle branch block

Question 6

Parasternal heave

Answer 6

A parasternal heave is detected by placing the heel of the hand over the left parasternal region. In the presence of a heave the heel of the hand is lifted off the chest wall with each systole.

A parasternal heave is caused by RIGHT VENTRICULAR HYPERTROPHY
Eg ASD
Pulmonary regurg following repair of ToF

Question 7

Thrill

Answer 7

A thrill is A palpable, and therefore loud, murmur, and has the same diagnostic significance as the murmur itself. Most thrills are more easily palpable when the patient is sitting up and holding his breath in full expiration.
Palpate in the suprasternal and supraclavicular regions

Suprasternal thrill - aortic stenosis
Upper right sternal border- aortic stenosis
Upper left sternal border- pulmonary stenosis
Left lower sternal border- VSD
Carotid arteries- aortic stenosis or CoA

Feel 3 locations:
https://www.youtube.com/watch?v=pcACFYqdOtY

Question 8

Palpable pulmunary valve closure (P2) is felt in:

Answer 8

Palpation with the fingers over the pulmonary area may reveal the palpable tap of pulmonary valve closure due to PULMUNARY HYPERTENSION

Question 9

Heart sounds

Answer 9

The first heart sound (S1) represents closure of the atrioventricular (mitral and tricuspid) valves as the ventricular pressures exceed atrial pressures at the beginning of systole . S1 is normally a single sound because mitral and tricuspid valve closure occurs almost simultaneously. Clinically, S1 corresponds to the pulse.

The second heart sound (S2) represents closure of the semilunar (aortic and pulmonary) valves . S2 is normally split because the aortic valve (A2) closes before the pulmonary valve (P2). The closing pressure (the diastolic arterial pressure) on the left is 80 mmHg as compared to only 10 mmHg on the right. This higher closing pressure leads to earlier closure of the aortic valve. In addition, the more muscular and stiff “less compliant” left ventricle (LV) empties earlier than the right ventricle.
The venous return to the right ventricle (RV) increases during inspiration due to negative intrathoracic pressure and P2 is even more delayed, so it is normal for the split of the second heart sound to widen during inspiration and to narrow during expiration.

The third heart sound (S3) is due to rapid ventricular filling- can be normal in children or a sign of heart failure (MR, VSD, dilated cardiomyopathy)
just after S2
* listen in left lateral position, apex of heart, with bell as it is in diastole*

The fourth heart sound (S4) is an abnormal late diastolic sound caused by forcible atrial contraction in the presence of decreased left ventricular compliance/stiff ventricle eg LVH.
** just before S1 in late diastole**
**listen in left lateral position **

The A2 sound is normally much louder than the P2 due to higher pressures in the left side of the heart; thus, A2 radiates to all cardiac listening posts (loudest at the right upper sternal border), and P2 is usually only heard at the left upper sternal border. Therefore, the A2 sound is the main component of S2

***CLINICAL PEARL: A split S2 is best heard at the pulmonic valve listening post, as P2 is much softer than A2.

***The S2 heart sound intensity decreases with worsening aortic stenosis due to immobile leaflets. In severe aortic stenosis, the A2 component may not be audible at all.

Question 10

Cardiac cycle

Answer 10

Isovolumetric ventricular contraction (a-b): This phase marks the beginning of systole and starts with the appearance of the QRS complex on the EKG and the closure of the AV valves at point (a). With all valves closed, the ventricle generates positive pressure without any change in its volume (isovolumetric) to overcome the semilunar valves resistance that open at point (b). This phase usually lasts for 6% of the cardiac cycle.
Rapid ejection (b-c): As the semilunar valves open at point (b), there is a rapid ejection of blood due to increased ventricular contractility. The arterial pressure increases until reaching its maximum at point (c). This phase usually lasts for 13% of the cardiac cycle.
Reduced ejection (c-d): This phase marks the beginning of ventricular repolarization as depicted by the onset of the T wave on the EKG. Repolarization leads to a rapid decline in ventricular pressures and hence the reduced rate of ejection. However, some forward flow of blood continues secondary to remnant kinetic energy from the previous phase. This phase usually lasts for 15% of the cardiac cycle.
Isovolumetric relaxation (d-e): When the ventricular pressures drop below the diastolic aortic and pulmonary pressures (80 mmHg and 10 mmHg respectively), the aortic and pulmonary valves close producing the second heart sound (point d). This marks the beginning of diastole. The ventricles generate negative pressure without changing their volume (isovolumetric) so that the ventricular pressure becomes lower than the atrial pressure. This phase usually lasts for 8% of the cardiac cycle.
Ventricular filling (e-a): As the AV valves open at point (e), ventricular filling starts. The initial rapid filling is mainly augmented by ventricular suction which results from ventricular untwisting and the return of each ventricular muscle fiber to its slack length. The ventricular pressure gradually increases until it equals the atrial pressure and the AV valves close (point a). This phase usually lasts for 44% of the cardiac cycle.
Atrial contraction: Finally, near the end of ventricular diastole, the atrial contraction contributes about 10% of the ventricular filling volume. This is represented by the P wave on the EKG of the following cycle. This phase usually lasts for 14% of the cardiac cycle.

Question 11

Bruits

Answer 11

Auscultate over the carotid arteries, abdominal aorta, renal arteries, and femoral arteries to detect bruits, which are vascular murmurs caused by turbulent, nonlaminar blood flow in a vessel.

Causes of bruits:
AV fistulae
Arteriovenous malformations
Aneurysms
Vascular stenosis
Hyperdynamic circulation E.g., pregnancy, fever, anemia, hyperthyroidism
May occur physiologically in adolescents

Question 12

Apex beat

Answer 12

From birth to age 3 years the apex beat is located in the 4th intercostal space
With increasing age gradually moves into the 5th space, mid clavicular line

Question 13

T21 common cardiac conditions

Answer 13

AVSD
VSD
TOF

Combo of AVSD + TOF almost diagnostic of T21 (would have superior axis, shunt murmur RVH on ECG)

Superior axis of AVSD remains post operatively, so should be seen in exam on ECG

Question 14

Williams syndrome common cardiac conditions

Answer 14

Supravalvar aortic stenosis
Pulmunary stenosis (at any level)

Renal artery stenosis, coronary artery stenosis
HTN

Question 15

DiGeorge common cardiac conditions

Answer 15

Conotruncal defects:

TOF
Pulmunary atresia + VSD
Truncus arteriosis
Interrupted aortic arch
+/-VSD

Question 16

Turners syndrome common cardiac conditions

Question 17

Scoliosis is more common after

Answer 17

Thoracotomy
Sternotomy
due to disruption of the chest wall

Question 18

Noonans common ECG finding

Answer 18

Superior axis (regardless of their cardiac condition)

Question 19

Noonans syndrome common cardiac conditions

Answer 19

Pulmunary stenosis or branch pulmunary stenosis
Hypertrophic obstructive cardiomyopathy (left sided murmur from outflow tract obstruction with right sided voltages on ECG)
ASD

Superior axis on ECG (regardless of cardiac anomalies)

Question 20

Alagille syndrome common cardiac conditions

Answer 20

Pulmunary stenosis or branch pulmunary stenosis
VSD

Question 21

Holt Oram Syndrome

Answer 21

ASD
VSD

Question 22

Marfan syndrome

Answer 22

Aortic root dilatation (+/- regurgitation)
Mitral valve prolapse

Question 23

Lesions in which you would not see a chest scar in an exam

Answer 23

Simple lesions: ASD, VSD, PDA, valvular lesions (but may have scars in groin from cardiac catheterisation)
Complex unrepairable lesions- usually accompanied by cyanosis and likely to have groin scars from cardiac catheterisation

Question 24

Lateral thoracotomy

Answer 24

Left:
PDA ligation
Aortic coarctation/interrupted aortic arch
Left BT shunt (rare)
PA band (usually done from the front not the side)
Left lobectomy/pneumonectomy

Right:
Right BT shunt (more common)
Tracheo oesophageal fistula, oesophageal atresia
Right lobectomy/pneumonectomy

Question 25

Median sternotomy

Answer 25

repair of complex cardiac lesions ASD/VSD/AVSD Some valvular lesions Most CoA (some done via lateral approach) PA band (rarely done via lateral approach)

Question 26

(modified) Balock - Thomas-Taussig (BT) shunt

Answer 26

Gore tex shunt between subclavian artery and ipsilateral pulmunary artery - usually on right side Aim: provide adequate pulmunary blood flow (but not excessive- we dont want pulmunary overcirculation--> pulmunary oedema! need to ensure the shunt is not too large for the patient to prevent this) - aiming balanced circulation with spO2 75-85% Qp:Qs 1:1 Uses: tetralogy of fallot, pulmunary atresia, tricuspid atresia, part of Norwood procedure in HLHS repair Usually temporary shunt until definitive repair *** continuous murmur present- absence + worsening cyanosis means shunt obstruction***

Question 27

Pulmunary artery band

Answer 27

reduces pulmunary overcirculation and therefore limits development of pulmunary HTN in L--> R shunts Gives PS murmur used in large VSD, AVSD, truncus

Question 28

Surgery to repair HLHS

Answer 28

1. Norwood procedure (newborn): ***aim: RV to pump to body rather than lungs Pulmunary flow provided by shunt** - atrial septostomy - reconstruction of aortic arch (enlargement) to join to the origin of the pulmonary artery (so the right ventricle pumps blood to the body) - closure of PDA - BT shunt to supply pulmonary blood flow (aorta to pulmonary artery)/ Sano shunt (RV to pulmonary artery) 2. Glenn procedure (3-4 months): sends blood from upper body directly to the lungs - SVC is disconnected from the heart and connected to the pulmonary artery - Removal of shunt (if previously had Norwood procedure) - Arterial septectomy 3. Fontan procedure (3-4 years): all venous return from the body flows directly to the lungs - IVC is disconnected from heart and connected to the pulmonary artery using a conduit - Fenstration (hole) between this conduit and right atrium allows some blood flow back to heart but prevents too much flow to the lungs initially ** first procedure changes according to single ventricle physiology, but second and third stages are the same for all single ventricle pathways **first procedure is always arterial shunt to supply pulmunary blood flow ** child is BLUE until the Fontan procedure, only after this is completed do they become pink. Repercussions for neurodevelopment from chronic hypxia (ADHD, autism, inability to focus, learning difficulties, speech delay, behavioral disturbances)

Question 29

Loud S2

Answer 29

increased pulm blood flow (eg asd, vsd, pda) or pulmunary HTN

Question 30

Absent S2 in

Answer 30

TOF PS Fontan

Question 31

ASD murmur

Answer 31

ESM murmur heard over pulmunary area Diastolic murmur heard over tricuspid area (relative MS) Fixed split S2 https://www.youtube.com/watch?v=W8gg2S-mvSQ ECG: superior or left axis in primum asd/ right axis in secundum, complete or incomplete RBBB

Question 32

VSD murmur

Answer 32

Systolic murmur (pansystolic or short systolic)

Question 33

PDA murmur

Question 34

Aortic stenosis

Answer 34

Harsh ejection systolic murmur heard loudest over the aortic area (RUSB) Radiates to the carotid arteries Loudest on expiration and when the patient is sitting forwards Other clinical features of aortic stenosis may include: Slow rising pulse with narrow pulse pressure Non-displaced, heaving apex beat (if present indicates left ventricular hypertrophy) Reduced or absent S2 (a sign of moderate-severe aortic stenosis) Reverse splitting of S2: aortic valve closes after pulmonary valve (due to the longer time required for blood to exit the left ventricle) DDx: hypertrophic cardiomyopathy (accentuates with Valsalva) Pulmunary stenosis

Question 35

Aortic regurgitation murmur

Answer 35

Diastolic murmur Right upper sternal border

Question 36

Pulmunary stenosis murmur

Answer 36

Ejection systolic murmur radiating to the back Wide split S2 If severe- hepatomegaly and CCF

Question 37

Pulmunary regurgitation murmur

Question 38

Mitral stenosis murmur

Answer 38

Diastolic 5th intercostal space MCL May have opening snap after S2 (slightly prior to diastolic murmur )- sudden opening of mitral valve Causes: rheumatic heart disease Relative stenosis in VSD Use bell of steth

Question 39

Mitral regurgitation murmur

Answer 39

Pansystolic Loudest at apex Radiate to axillae

Question 40

Tricuspid stenosis murmur

Answer 40

Diastolic LLSE

Question 41

Tricuspid regurgitation murmur

Answer 41

Pansystolic LLSE

Question 42

Split S2 best heard in ...

Answer 42

pulmunary area

Question 43

Ejection click

Answer 43

Heard in systole over aortic or pulmunary areas aortic click best heard at a[ex and may be only finding of bicuspid aortic valve Due to aortic or pulmunary stenosis (BICUSPID AORTIC VALVE) Followed by ESM of aortic or pulmunary stenosis

Question 44

Causes pansystolic murmur

Answer 44

MR/TR VSD

Question 46

Bounding pulses seen in

Answer 46

Sig aortic runoff eg PDA Aortic regurgitation Truncus arteriosus

Question 47

Low volume leg pulses compared to arm seen in

Answer 47

CoA

Question 48

Tapping apex beat

Answer 48

Palpable s1 Mitral stenosis

Question 49

Pressure loaded apex beat Vs Volume loaded apex beat

Answer 49

Localised and forceful Vs Diffuse and slow rising

Question 50

Coarctation of aorta

Answer 50

Systolic murmur loudest in LUSE, left infraclavicular area and the back below scapula ---> blood pressure difference between uppper and lower extremities 20 mmHg with HTN of upper limbs (must do 4 limb BP) --> A systolic ejection click and systolic ejection murmur in the left upper sternal border is often found with a bicuspid aortic valve (often coexists with CoA) --> diminished or delayed femoral pulses compared to radial pulses —> radio radial delay --> ECG: LVH (increased voltages in lateral precordial leads); echo: LVH + narrowing of the aortic arch ---> main association with Turners syndrome --> treated with stent/balloon angioplasty but not complete cure and recoarctation is common

Question 51

Syndromes associated with HTN

Answer 51

Turners Williams NF-1

Question 52

Cardiac Short Case

Answer 52

Say pertinent positive and negative findings as you go Sit patient to 45 degrees for JVP and chest exam, flat for abdominal exam General inspection - well or unwell - colour, pink or cyanosed - increased resp effort; as for vitals - growth and nutritional status; height and wight - oxygen, medical aids - dysmorphism Hands - clubbing, cyanosis, anomalies (syndromic) - pulse: rate, rhythm (even sinus arrhythmia), character, radioradial and radiofemoral delay Face - dysmorphism - conjunctival pallor - dentition - uvula (LD syndrome) - high arch palate - central cyanosis (under the tongue- ensure good lighting) Neck - JVP (only in older kids after 4 years) - not big deal if dont do - carotid pulse (only do in older kid) Chest - scars, chest deformities (and back, axillae) - position of apex beat (exclude dextrcardia!) - active or quiet precordium - heaves or thrills - suprasternal thrill (LVOTO/AS- but this doesnt make it 4/6 unlike other thrills) - listen to back for crackles "S1 and S2 were normal" "there was a single S2" "S2 physiologically split" "fixed split S2" "S2 was loud" "no added sounds" or "ejection clic, mid systolic click, S3, S4 " or if you dont hear a click, if your differential includes something that would give a click, say you would expect to hear this Murmurs - intensity (/6 if systolic, /4 if diastolic) - ejection, pan/holo, mid (small vsd would give you short murmur not pansystolic) - systolic vs diastolic - location where loudest (RUSE, LUSE, LLSB, apex) - radiation (axillae, neck, back) Feel suprasternal notch Sit forward for diastolic mumrus or innocent murmurs Always listen left lateral decubitus position (MR which is often hard to head) Abdomen - scars - hepato/splenomegaly Legs - femoral and pedal pulses (pedal if struggling to feel femorals- would effectively exclude CoA) - lower limb BP - muscle mass - oedema (rare in kids in HF, much more common in adults) Ask for CXR + ECG **remember PS/PR murmur "to fro murmur" LUSE from conduit ** **unlikely to have PDA wth continuous murmur as this is an indication for closure***

Question 53

Common cardiology short cases

Answer 53

Simple cases: * Bicuspid valve with AS +/- AR * PS * PPS * PDA * Unrepaired ASD and VSD Complex: * TGA – sp arterial switch with branch PS * Sp transannular patch repair TOF * Sp COA with clow acceleration through aorta * Sp RV-PA condiut * interstage single ventricle disease

Question 54

Bell of stethescope

Answer 54

mitral murmurs of apex

Question 55

HOCM

Answer 55

Murmur: LVOTO--> ESM crescendo decrescendo Heard between apex and LLSE Radiates to suprasternal notch NOT CAROTIDS Louder with Valsalva (decreased preload), quieter with squatting (increased preload) Holosystolic murmur at the apex and axilla (mitral regurgitation) ECG: -> LVH criteria -> deep anterior lateral TWI -> dagger-like (deep narrow) Q waves in infero-lateral leads

Question 56

AVSD

Answer 56

can be either pink or blue child with sternotomy residual murmurs (pansystolic, LLSE) will be heard post op as valves abnormal and cant be fixed if unbalanced--> univentricular circulation (often cant proceed to fontan due to elevated pulmunary pressures so remain cyanotic and are palliative) association with T21 ECG: superior axis (which persists even after surgery)

Question 57

Murmur LUSE differentials

Answer 57

RVOTO-Pulmunary stenosis (valvular (has a click), subvalvular, supravalvular (thrill in suprasternal notch or Pulmunary area) ASD Pulmunary flow murmur Aortic stenosis CoA PDA TAPVR/PAPVR

Question 58

Murmur LLSE differentials

Answer 58

VSD (early systolic if muscular, pansystolic if perimembranous) HOCM Tricuspid regurgitation ToF (VSD) Stills murmur (loudest lying down)

Question 59

Murmur mitral area differentials

Answer 59

Mitral regurgitation Mitral stenosis [ aortic stenosis murmur may be loudest at the apex but doesnt radiate to the axilla]

Question 60

Murmur RUSE

Answer 60

LVOT eg aortic stenosis which could be valvular subvalvular or supravalvular i cant hear a click suggestive of vavlular obstruction DDX PS (ESM at ULSE with radiation to back, soft P2, wide split S2)

Question 61

Cyanonosis with continous murmur

Answer 61

MAPCAS (major aortopulmunary collateral arteries with PA + VSD BT shunt

Question 62

Mitral regurgitation murmur ddx

Answer 62

Pansystolic murmur apex --> L) axilla No scar: - rheumatic heart disease , post IE - congenital: partial AVSD , MV cleft Scar: - rheumatic heart disease , post IE - congenital: AVSD, congenital MS, post ALCAPA

Question 63

Murmur LUSE ddx

Answer 63

Murmurs in LUSE (no scar) RVOT which could be: - PS (valvular, subvalvular, supravalvular) - Branch PS (radiates to back) - Pum flow murmur (soft murmur, increased with anemia or fever) - ASD (soft murmur- secundum or primum) - LVOT Murmurs LUSE (+ scar): - Severe/critical PS post valvotomy - TOF (residual PS) - PA + VSD - TGA (if doing Rastelli for PA and VSD) - Truncus arteriosus - Post Ross procedure (for critical AS)- would see LVH on ECG - All the above except PS and TOF would be due to RV-PA conduit= ES murmur or to fro murmur - If no RBBB- all the ones associated with VSD (eg TGA, truncus, TOF) are much less likely Pulmunary atresia + VSD: BT shunt until 2-3 years of age then definitive repair PA + intact VS= BT shunt=>univentricular pathway

Question 64

Cyanotic child with median sternotomy ddx

Answer 64

Univentricular circulation with staged palliative procedures Which is most commonly HLHS Other differentials include: -Hypoplastic R heart syndrome -Unbalanced AVSD -PA with intact ventricular septum -Double inlet left ventricle -Severe Ebstein anomaly

Question 65

Complications congenital heart disease

Answer 65

Delayed puberty Poor growth Protein losing enteropathy (fontan) Congestive heart failure Renal impairment Arrythmias, heart block Need for pacing CNS complications: - stroke -cerebral abscesses Operative: - RLN palsy - Horners syndrome

Question 66

narrow egg on a string appearance w increased pulmunary blood flow on CXR

Answer 66

transposition great arteries

Question 67

snowman sign with increased pulmunary blood flow on CXR

Answer 67

Supracardiac TAPVR

Question 68

causes cyanotic child with median sternotomy and murmur

Answer 68

complex congenital heart disease with palliative surgery and residual disease eg univentricular circulation could be post norwood (shunt in situ) or post glenn (usually no murmur but may be murmur from MAPCAS)

Question 69

DDX LLSE without scar

Answer 69

- VSD (pansystolic) - AVSD (pansystolic) - Mitral regurg (pansystolic)- radiates to apex, displaced apex - Tricuspid regurg (pansystolic)- hepatomegaly, raised JVP - HOCM (ESM) - Stills (louder lying down, very quiet or absent when sitting up) - Aortic regurg (diastolic)

Question 70

Murmurs in LUSE (no scar)

Answer 70

RVOT which could be: - PS (valvular, subvalvular, supravalvular) - Branch PS (radiates to back) - Pulm flow murmur (soft murmur, increased with anemia or fever) - ASD (soft murmur- secundum or primum) LVOT

Question 71

Murmurs LUSE (+ scar):

Answer 71

RVOT: - PS (valvular, subvalvular, supravalvular) - TOF (residual PS) - PA + VSD - TGA (if doing Rastelli for PA and VSD) - Truncus - Ross procedure (for severe AS)- would see LVH on ECG - All the above except PS and TOF would be due to RV-PA conduit= ES murmur or to fro murmur - If no RBBB- rules out all the ones association with VSD (eg TGA, truncus, TOF)

Question 72

Ejection systolic murmurs in RUSE (no scar)

Answer 72

LVOT - AS (valvular, subvalvular, supravalvular)- radiates to carotids HOCM- radiates to suprasternal notch, louder with Valsalva

Question 73

Ejection click at RUSE:

Answer 73

Bicuspid aortic valve

Question 74

Cyanotic child with median sternotomy:

Answer 74

- Univentricular circulation with staged palliative procedures Which is most commonly HLHS Other differentials include: Tricuspid atresia Unbalanced AVSD PA with intact ventricular septum Double inlet left ventricle Double outlet rV Severe Ebstein anomaly "This could be due to a univentricular circulation with staged procedures, including…. Given that they are still cyanotic and their age, I would assume that they have completed two stages, and may be awaiting fontan repair OR have had a fenestrated Fontan (if child is >4 years) "

Question 75

Continuous murmur:

Answer 75

PDA (unwell! Collapsing pulse/bounding pulse- wont be in the exam) BT shunt (most common) - will either see lateral thoracotomy or median sternotomy Venous hum Mapcas (likely cyanotic child) AV fistula

Question 76

Ebsteins anomaly

Answer 76

Cyanotic or acyanotic if older Single ventricular pathology Scar CXR: huge heart ECG: superior axis, WPW , RBBB (and associated wide split S2), first degree heart block

Question 77

Differentiating LVOTO

Answer 77

supravalvular AS has a thrill (and may be associated with Williams syndrome) valvular AS has a click and thrill Subvalvular AS has neither a click or a thrill

Question 78

Diastolic murmur LUSE

Answer 78

pulmunary regurgitation often post repair of TOF

Question 79

VSD murmur is louder in

Answer 79

small defects

Question 80

Increased pulmunary vascularity seen in

Answer 80

Truncus TAPVD TGA

Question 81

Reduced pulmunary vascularity seen in

Answer 81

PA + intact ventricular septum Tricuspid atresia Ebsteins anomaly TOF Critical PS

Question 82

RBBB occurs in

Answer 82

Post VSD repair ASD

Question 83

Causes RAH

Answer 83

Tricuspid atresia Hypoplastic right heart Ebsteins anomaly Pulmunary atresia Looks like peaked p waves on ECG

Question 84

Causes LAH

Answer 84

Mitral valve disease Cardiomyopathy HTN Any large L--> R shunt Looks like wide bifid p waves on ECG

Question 85

Deep, narrow (“dagger-like”) Q waves in lateral (I, aVL, V5-6) +/- inferior (II, III, aVF) leads indicate

Answer 85

HOCM Would also see LVH with this