SUR.

TC: SAMPLEX BASED RATIO

QUIZ 2 TCVS

QUIZ # 2
Congenital Heart Diseases, Acquired Heart Diseases / CABG, Valvular Heart Diseases OCT 21 2021

3A – QUIZ 3
QUESTION ANSWER RATIONALE
Questions 1-4: Baby AD 2-week-old baby girl was brought to your clinic because of inability to finish her breast milk feeding without pausing. On interview with the mother, she was born at
only 34 weeks AOG.
1. On examination a machinery murmur was noted on her chest. D Diagnosis of Patent Ductus Arteriosus
What is your next step in this case? ● Physical Examination
A. Do ECG → Continuous machinery murmur: most likely PDA but there are some other rare conditions
B. Observe the baby for a year with this
C. Give Prostaglandin E2 → Widened pulse pressure and hyperactive precordium
D. Request for 2D Echocardiogram → Cyanosis is not present in uncomplicated isolated PDA
● Chest x-ray
→ Increased pulmonary vascularity or cardiomegaly
● 2D Echocardiography
→ LV strain, LA enlargement, RV hypertrophy
● Cardiac catherization
→ Only done if pulmonary hypertension is suspected
SUR.TC.1.04.CONGENITAL HEART DISEASES
2. What is your probable diagnosis? C ● Patent Ductus Arteriosus → History and PE: clubbing, polycythemia,
A. Ventricular septal defect → Continuous machinery murmur: most hemoptysis, brain abscess
B. Tetralogy of Fallot likely PDA but there are some other rare ● Atrial Septal Defect
C. Patent Ductus Arteriosus conditions with this → ASDs result in an increase in pulmonary
D. Atrial Septal Defect → Widened pulse pressure and hyperactive blood flow secondary to left-to-right
precordium shunting
→ Cyanosis is NOT present in uncomplicated → Symptoms include exercise tolerance,
isolated PDA dyspnea on exertion, and fatigue caused
● Ventricular Septal Defect by right heart failure and pulmonary
→ Abnormal communication between the left hypertension
and right ventricles causing the blood to → Auscultation
be shunted ■ Prominent 1st heart sound, fixed
→ Single most common congenital heart splitting of S2
malformation ■ Diastolic murmur over tricuspid valve
→ Holosystolic murmur ■ Systolic murmur over pulmonary valve
● Tetralogy of Fallot ■ If with pulmonary hypertension already,
→ Presents with 4 main lesions: Overriding RV heave and increased intensity of P2
aorta, RVH, VSD, right ventricular outflow heart sound
obstruction
→ Clinical features: cyanosis, hypercyanotic SUR.TC.1.04.CONGENITAL HEART DISEASES
episodes
3. What would be the most appropriate treatment? D Treatment of Patent Ductus Arteriosus
A. Surgery ● The presence of PDA is sufficient indication for closure because of increased mortality and risk
B. Observation for endocarditis.
C. Give Prostaglandin E2 ● For premature infants:
D. Trial of indomethacin → Indomethacin – to promote closure of PDA
→ Ibuprofen
SUR.TC.1.04.CONGENITAL HEART DISEASES

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4. What are the possible consequences of this disease if left D Patent Ductus Arteriosus
untreated? ● If left without ligation – there is an ongoing risk for bacterial endocarditis, heart failure, and
A. Paradoxical embolization development of Eisenmenger’s complex.
B. Heart failure
C. Eisenmeger Syndrome SUR.TC.1.04.CONGENITAL HEART DISEASES
D. All of the above
Other less common intracardiac defects that can result in paradoxical embolism include pulmonary
arteriovenous malformations (PAVMs), arterial septal defect (ASD), ventricular septal defect (VSD),
patent ductus arteriosus (PDA) and Tetralogy of Fallot (TOF).

Cachia, M., Pace Bardon, M., Fsadni, P., & Montefort, S. (2015). Systemic and venous
thromboembolism: think about paradoxical embolism. BMJ case
reports, 2015, bcr2015211174. https://doi.org/10.1136/bcr-2015-211174
Questions 5-7: FC a 2-year-old was brought to your clinic because of circumoral cyanosis. He was born term but was noted to have a bluish hue lips and nails. As grew older, he was noted
to squat often and would have more cyanotic lips whenever he would cry.
5. What would you request to confirm his condition? D Diagnosis of Tetralogy of Fallot
A. Chest X-Ray ● History and PE
B. 12 L ECG → Clubbing
C. Cardiac catheterization → Polycythemia
D. 2D Echo → Hemoptysis
→ Brain abscess
● Imaging Modalities
→ Chest x-ray
■ boot-shaped heart
→ Echocardiography
■ used for confirmation of the diagnosis
■ Demonstrates the position and nature of the VSD
■ Defines the character of the RVOT obstruction
■ Visualizes the branches of the pulmonary arteries and proximal arteries
→ Cardiac Catheterization
■ rarely necessary
■ May lead to RVOT muscle spasm which leads to Tet spells
SUR.TC.1.04.CONGENITAL HEART DISEASES
6. What is the probable diagnosis? B ● Tetralogy of Fallot
A. Eisenmeger Syndrome → Presents with 4 main lesions: Overriding aorta, RVH, VSD, right ventricular outflow
B. Tetralogy of Fallot obstruction
C. Truncus Arteriosus → Clinical features:
D. Total Anomalous Pulmonary venous return ■ Cyanosis
− Caused by R-to-L shunting through the VSD
− Most children present with mild cyanosis at birth
− Varies on the degree of RVOT and the size of the VSD
− Usually becomes significant within the first 6 to 12 months of life, with characteristic “tet
spells” especially when the babies are crying
■ Hypercyanotic episodes
− Periods of extreme ischemia
− Characterized by: sudden episodes of cyanosis (skin, nails, lips) after feeding, crying, or
when the baby is agitated
− Squatting position relieves the cyanosis
● Eisenmenger Syndrome
→ The primary complication associated with an acyanotic heart disease (L-to-R shunt) is the
Eisenmenger’s complex
→ Switching of the shunt flow from a L-to-R shunt to a R-to-L shunt
● Truncus Arteriosus
→ One of the cyanotic heart diseases

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 → Usually presents in the neonatal period with signs and symptoms of congestive heart failure
and cyanosis
→ Presence of a pansystolic murmur at the left sternal border
→ Occasionally, a diastolic murmur in the presence of truncal regurgitation may be appreciated
● Total Anomalous Pulmonary venous return
→ Another cyanotic heart disease
→ History and PE show cyanosis and severe respiratory distress
→ Chest x-ray: normal heart size and generalized pulmonary edema
→ Echocardiography: assesses ventricular septal position which may be leftward secondary to
small LV volumes
SUR.TC.1.04.CONGENITAL HEART DISEASES
7. What is the suggested treatment? C Surgery is the mainstay of therapy. Medical and catheter-based therapy may be used to temporize,
A. Observation until adulthood but TOF is a surgical disease. The principles of surgical correction include patch closure of the VSD
B. Prostaglandin E2 and relief of all levels of the RVOTO and pulmonary artery stenosis. The classic method of TOF repair
C. Surgical correction uses a longitudinal incision through the right ventricular outflow tract; this provides an excellent
D. Blalock Taussig Shunt transventricular view of the VSD, which is closed with a patch. The pulmonary artery, pulmonary
valve, and annulus are incised if stenotic, and then the RVOT is patched.
Sabiston Textbook of Surgery. The Biological Basis of Modern Surgical Practice, 20 th Edition p. 1634
Questions 8-9: ER newborn baby was noted to be extremely cyanotic. Further work-up revealed he has a congenital heart disease Transposition of Great Arteries.
8. In this condition, how is the baby still surviving? D Transposition of Great Arteries
A. Through a Patent Ductus Arteriosus ● Oxygen-poor blood is pumped directly from the heart’s right side to the coronary arteries and the
B. Through a Ventricular Septal Defect aorta. Unable to go the lungs for the oxygen, the blood cannot nourish the heart or body.
C. Through an Atrial Septal Defect ● Oxygen poor blood travels from the right side of the heart to the systemic artery to the aorta
D. All of the above because the aorta is connected to the RV
● Oxygen rich blood from the LV travels to the pulmonary artery (reverse circulation)
● Patient survival is dependent on intracardiac mixing of the blood
● 3 shunts: ASD, VSD, PDA
SUR.TC.1.04.CONGENITAL HEART DISEASES
9. What is the preferred treatment? A Preferred treatment is surgical correction up to 2 months.
A. Surgical correction Remember that the Left ventricle has a thicker mass/muscle than your right ventricle, because it is
B. Palliation subjected to a higher pressure which is the aorta.
C. Observation until adulthood
D. Oxygen supplementation In Congenital Heart Diseases there is Paradigm Shift:
● Congenital heart surgery is constantly evolving
● Early repair is now the goal
SUR.TC.1.04.CONGENITAL HEART DISEASES
10. What are the fetal shunts not present in adults? D Three shunts in Fetal Circulation: FETAL ADULT
A. Ductus Venosus ● Ductus Arteriosus STRUCTURE STRUCTURE
B. Atrial Septal Defect ● Ductus Venosus Foramen ovale Fossa Ovalis
C. Ductus Arteriosus ● Foramen Ovale: patent foramen ovale is the Umbilical vein Ligamentum teres
D. All of the above most common form of an atrial septal defect (intra-abdominal
(ASD) part)
Ductus Venosus Ligamentum Venosum
Adult Derivatives of Fetal Vascular Umbilical Arteries Medial Umbilical
Structures and abdominal ligaments, superior
● Due to the certain changes in the ligaments vesicular artery
cardiovascular system at birth, certain (supplies bladder)
vessels and structures are no longer Ductus Arteriosum Ligamentum arteriosum
required.
● Over a period of months these fetal vessels Circulatory changes at birth. Fetal Circulation. (n.d.).
Retrieved November 20, 2021, from
form nonfunctional ligaments, and fetal http://mcb.berkeley.edu/courses/mcb135e/fetal.html.
structures such as the foramen ovale persist
as anatomic vestiges of the prenatal
circulatory system.

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11. A 65-year-old male was seen in the ER complaining of chest
heaviness accompanied by cold clammy perspiration. ECG
tracing revealed ST Elevation myocardial infarction. The most
helpful diagnostic imaging study is:
A. Transthoracic echocardiography
B. Transesophageal echocardiography
C. Coronary angiography
D. Cardiac MRI
12. The following degree of coronary artery stenosis is considered
abnormal in coronary angiography:
A. 55% of the left anterior descending artery
B. 55% of left main coronary artery
C. 60% of left circumflex artery
D. 65% right coronary artery
13. The graft configurations demonstrated to have the best long-
term patency in CABG:
A. Left internal mammary artery to left anterior descending artery
B. Left internal mammary artery to left circumflex artery
C. Right internal mammary artery to left anterior descending artery
D. Saphenous vein to right coronary artery
14. The following is a correct description of the operational parts of
a cardiopulmonary bypass system:
A. The pump functions as a lungs
B. The venous cannulas bring oxygenated blood to the machine
C. The arterial cannula brings non-oxygenated blood to the body
D. The oxygenator functions as the lungs
15. The pathology of leaflet thickening, calcification and
commissural fusion is consistent with diseased valves found in:
A. Rheumatic mitral stenosis
B. Barlow’s disease
C. Ischemic mitral regurgitation
D. Traumatic Aortic regurgitation
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C The cause of the Myocardial Infarction is the blockage of the coronary arteries; hence it can be
better detected by an angiogram.
Coronary Angiography
● Gold standard for evaluating coronary circulation
● Can delineate the severity and location of each lesion accurately.
SUR.TC.1.07.VALVULAR HEART DISEASES (SUPPLEMENT)
B Coronary Angiography
● The primary diagnostic tool for CAD
● Coronary anatomy and degrees of stenoses are delineated, allowing for planning of surgical
revascularization
SUR.TC.1.05.CARDIOPULMONARY BYPASS
Significant artery occlusion is defined as:
● ± 70% occlusion
● If left main artery is involved, ± 50% occlusion is significant
TCVS QUIZ 2 SAMPLEX RATIO, A2021 (2019)
A ● Left internal mammary artery to the left anterior descending artery
→ Left internal mammary artery is the most popular and most important bypass conduit that is
usually attached to LAD
● Right internal mammary artery to the left anterior descending artery
→ Being used now more than before due to the increase in popularity of multi-arterial CABG
● Saphenous vein to right coronary artery
→ Patency of saphenous vein is not as good as internal mammary artery
SUR.TC.1.05.CARDIOPULMONARY BYPASS p. 3
D ● The oxygenator functions as the lungs
→ Circuits: Venous blood to the oxygenator and returns blood to the circulation
→ Prime: fluid for priming oxygenator and circuits before CPB
● The pump functions as the heart
● The venous cannulas bring deoxygenated blood to the machine
● The arterial cannula brings oxygenated blood to the machine
SUR.TC.1.05.CARDIOPULMONARY BYPASS p. 4
A ● Rheumatic mitral stenosis
→ Fibrosis of the valves results primarily from the endocarditic process
→ Endocardial inflammation and fibrosis progressively lead to
■ Leaflet thickening
■ Calcification
■ Commissural fusion
■ Chordal fusion and shortening
■ Combinations of the above
● Barlow’s disease
→ Characterized by pronounced annular dilatation, bileaflet prolapse and/or billowing, hooding,
and the presence of thick, spongy leaflets due to excessive myxomatous tissue proliferation
with or without calcification
● Ischemic mitral regurgitation
→ Ischemic heart disease is one of the important causes of MR
→ Pathology of MR:
■ Type I MR: valvular insufficiency occurs secondary to annular dilatation or leaflet
perforation, and normal leaflet motion is maintained
■ Type II MR: due to prolapse of often thickened excessive leaflet tissue that gives the valve
“billowing” appearance
■ Type III MR: seen in patients with rheumatic and ischemic heart disease, occurs from
restricted leaflet motion.

16. The choice of mitral valve surgery over balloon valvotomy for
symptomatic severe mitral stenosis is based on presence of:
A. Left atrial thrombus
B. Severe pulmonary hypertension
C. Mild mitral regurgitation
D. Available expert surgeons
17. A 45-year-male with known rheumatic heart disease and
experience exertional dyspnea, has a 2D echo finding of severe
mitral stenosis and mitral regurgitation with severe tricuspid
regurgitation. Best surgical approach would be:
A. Mitral valve repair alone
B. Mitral valve replacement alone
C. Mitral valve repair with tricuspid repair
D. Mitral valve replacement with tricuspid repair
● Traumatic Aortic Regurgitation
→ Although traumatic rupture or avulsion of an aortic cusp is an uncommon cause of acute AR, it
represents the most frequent serious lesion in patients surviving nonpenetrating cardiac
injuries.
→ Retrograde flow of the portion of the stroke volume into the left ventricle during diastole is the
main pathophysiology.
SUR.TC.1.06.VALVULAR HEART DISEASES p.2 and 10
Harisson’s Principles of Internal Medicine, 20th Ed. P. 1809
Melnitchouk SI, Seeburger J, Kaeding AF, Misfeld M, Mohr FW, Borger MA. Barlow's mitral valve disease:
results of conventional and minimally invasive repair approaches. Ann Cardiothorac Surg. 2013;2(6):768-773.
doi:10.3978/j.issn.2225-319X.2013.10.07
A Percutaneous Mitral Balloon Valvotomy
● Done prior to surgery
● Contraindications
→ LA thrombus
→ Severe mitral stenosis
SUR.TC.1.06.VALVULAR HEART DISEASES p.3
D

Schwartz’s Principles of Surgery, 11 th ed., Table 21-9, p. 820

Schwartz’s Principles of Surgery, 11 th ed., Table 21-12 p. 830

18. The following is the most important advantage of a biological C Mechanical Valve Tissue Valve (Biologic)
over a mechanical prosthesis as a cardiac implant: Advantages • Highly durable • Less thrombogenic (may not
A. Less prone to structural failure • Minimized risk for reoperation require anticoagulation therapy)
B. Less chance of reoperation • Preferred if long life expectancy • Less anticoagulation-related
C. May not require anticoagulation therapy and suitable candidates for complications
D. More durable anticoagulation • Good for older patients (>65 y/o)
Disadvantages • Require permanent • More prone to structural failure
anticoagulation (Warfarin) (10-15 years)
• Risk of hemorrhagic complications • Higher chance of reoperation (will
• Lifestyle changes degenerate)
SUR.TC.1.06.VALVULAR HEART DISEASES p.13

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19. A 60-year-old male with exertional dyspnea accompanied by C When you listen to the 2nd RICS, you are listening to the aorta. In contrast, when listening to 2nd
occasional angina has a finding of a harsh crescendo- LICS, you are listening to the pulmonic valve.
decrescendo systolic murmur at the 2nd RICS, radiating to the
carotid arteries. We would first consider: ● Auscultatory findings of aortic stenosis
A. Mitral stenosis → Harsh, crescendo-decrescendo systolic murmur at the 2nd RICS, radiating to the carotid
B. Mitral regurgitation arteries
C. Aortic stenosis → Paradoxical S2 splitting (aortic valve closure may follow pulmonic valve closure)
D. Aortic regurgitation → Prolonged heave (apical impulse)
→ Pulsus parvus et tardus (narrow and sustained peripheral pulses)
● Auscultatory findings of mitral stenosis (triad)
→ Increased first heart sound or loud S1 (mitral valve rapidly closes after diastole)
→ Opening snap (sudden opening of thickened, non-pliable valve with LA contraction)
→ Apical diastolic rumble (murmur due to rapid entry of blood into LV)
● Auscultatory findings of mitral regurgitation
→ Apical holosystolic murmur
→ Forceful apical impulse transmitted to the left axilla or left sternal border
● Auscultatory findings of aortic regurgitation
→ High pitched, decrescendo diastolic murmur heard best at 3rd LICS
→ Associated S3 gallop indicative of late disease
→ Austin-Flint murmur
■ Mid-diastolic apical rumble
■ Simulates mitral stenosis
→ Pulses
■ Widened pulse pressure
■ Corrigan’s or water hammer pulses (bounded pulses quickly collapsing)
■ Pistol shot (appreciated with pulse auscultation)
SUR.TC.1.06.VALVULAR HEART DISEASES
20. The Cox Maze IV is a procedure to for: A Cox Maze IV involves a completion of a maze-like pattern of surgical incisions across the right and
A. Atrial fibrillation left atria that were designed to interrupt the macro entrance circuits thought to be responsible for
B. Left atrial thrombus atrial fibrillation.
C. Mitral valve tumor
D. Tricuspid valve disease SUR.TC.1.06.VALVULAR HEART DISEASES p.14

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SUR.TC.SBR1 Samplex Based Ratio – Quiz 1 7 of 7