Cardiac Surgery and Cardiology MCQs

Short Cases

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You are assisting the cardiac surgeon with a valve case (see below). After going on
bypass, the following valve pathology is visualized. In severe cases of this
pathology, patients often present with what facial feature?

a. Cyanosis
b. Head bobbing
c. Malar flush
d. Xanthelasma
e. Engorged facial veins
f. Eyelid twitch
g. Lip pursing
Answer C
1. The image shows the typical 'fish mouth' appearance of mitral valve stenosis. The cause of
mitral stenosis in most cases is rheumatic fever.
2. Symptoms of mitral stenosis correlate poorly with disease severity because the disease often
progresses slowly, and patients unconsciously reduce their activity.
3. Many patients are asymptomatic until they become pregnant or AF develops. Initial symptoms
are usually those of heart failure (eg, exertional dyspnea, orthopnea, paroxysmal nocturnal
dyspnea, fatigue).
4. The classic facial appearance in mitral stenosis, a plum-colored malar flush, occurs only when
cardiac output is low and pulmonary hypertension is severe; cause is cutaneous vasodilation and
chronic hypoxemia.
Q1. A young person is in the clinic for a routine work related
physical exam. He is asymptomatic and the physical is
unremarkable. Which of the following may explain this ECG?
a. Diabetes
b. Surreptitious ingestion of illicit
drugs
c. Use of anabolic steroids
d. Highly conditioned athlete
e. Bad genes
Q2. Auscultation in patients with this
arrhythmia will usually reveal?
a. Faint diastolic murmur
b. S3
c. Ejection click
d. Soft S1
e. Right ventricular heave
1d,2a
• First-degree atrioventricular block (AV block) is a disease of the electrical conduction
system of the heart in which electrical impulses conduct from the cardiac atria to
the ventricles through the atrioventricular node (AV node) more slowly than
normal. First degree AV block does not generally cause any symptoms.
• It is diagnosed using an electrocardiogram, and is defined as a PR interval greater
than 200 milliseconds. First degree AV block affects 0.65-1.1% of the population
with 0.13 new cases per 1000 persons each year.
• The most common causes of first-degree heart block are AV nodal disease,
enhanced vagal tone (for example in athletes), myocarditis, acute myocardial
infarction (especially acute inferior MI), electrolyte disturbances and medication.
• Patients with first-degree AV block may have a short, soft, blowing, diastolic murmur
heard at the cardiac apex. This diastolic murmur is not caused by diastolic mitral
regurgitation, because it reaches its peak before the onset of regurgitation.
A 30 yo patient with a history of a history of prolonged sore throat as a child now
presents with a murmur. He has been dyspneic and lacks exercise endurance for at
least 6 months. The cardiologist feels that he may have a heart problem because of
his old throat infection. If the infection affected the 2nd most common valve, where
on the chest would you best auscultate this pathology?

A
B
C
D
E
a
• The valves most affected by rheumatic fever, in order, are the mitral, aortic, tricuspid,
and pulmonary valves. In most cases, the mitral valve is involved with 1 or more of the
other 3. In acute disease, small thrombi form along the lines of valve closure. In
chronic disease, there is thickening and fibrosis of the valve resulting in stenosis, or less
commonly, regurgitation.
• Rheumatic heart disease is currently an uncommon cause of aortic stenosis, occurring
less frequently in developed countries than senile degenerative calcific aortic valve
disease, and degenerative bicuspid valve disease. Most patients have concomitant
mitral valve disease.
• Rheumatic heart disease is also an infrequent cause of aortic insufficiency in developed
countries, less common than aortic root disease and endocarditis, depending on the
patient population.
The precise use of a Swan Ganz catheter requires
measurement of the wedge pressure (????) at:

A. End expiration
B. End inspiration
C. Mid inspiration
D. Onset of inspiration
a
• The wedge pressure should be measured at end-expiration and in several
different segments of the pulmonary vasculature. LVEDP should be obtained if
there is any doubt about the accuracy of the wedge pressure tracing or if the
results are unexpected in a given patient.
• To minimize the effect of the respiratory cycle on intrathoracic pressures,
measurements are obtained at end-expiration, when intrathoracic pressure is
closest to zero.
A patient with long standing atrial fibrillation undergoes an ECHO
which reveals a blood clot in the left atrium. In general where in the
left atrium does the clot usually develop in these patients?
A
B
C
D
E
F
a
• The left atrial appendage is a small sac located in the top left chamber of the
heart known as the left atrium. In a properly functioning heart, each time the
heart contracts with a heartbeat, the blood in the left atrium and left atrial
appendage is squeezed out into the bottom left chamber, known as the left
ventricle. In patients with atrial fibrillation, the left atrial appendage does not
function properly and blood stays longer and blood clots can be formed in the
appendage, which can lead to stroke.
Q1. Following a triple vessel bypass, the patient presents with dyspnea on
POD 1. The drainage from the chest tubes has been minimal. His CXR
from POD1 is shown. You immediately suspect?

a. Heart failure
b. Consolidation
c. Atelectasis
d. Pleural effusion
e. Diaphragm palsy
f. Pericardial effusion
From the previous case, what study will you order to confirm the diagnosis?

a. ECHO
b. Nerve conduction study
c. Arterial blood gas
d. Ultrasound
e. Chest aspiration
f. EMG
1e,2d
• The most common diagnosed cause of paralyzed diaphragm is a malignancy (ie,
metastatic lung cancer) lesion leading to nerve compression (approximately 30% of
patients).
• If malignancy is not the cause, many times the etiology cannot be determined.
• Other causes in the differential include blunt cervical trauma, surgical trauma (mainly
thoracic),
• M-mode ultrasonography is a relatively simple and accurate test for diagnosing paralysis
of the diaphragm in the adult population and it can be performed at the bedside.
• The paralyzed side shows no active caudal movement of the diaphragm with inspiration
and abnormal paradoxical movement (ie, cranial movement on inspiration), particularly
with the sniff test.
A 40-year old is stabbed in the mid chest. In the ED his BP is 75/50, P
120, RR 22 and T 98.4. His heart sounds are muffled. A CXR is
obtained. In general in this condition, what is the minimal amount of
fluid collection before it can be visualized on a plain x-ray imaging?

a. 10 ml
b. 250 ml
c. 50 ml
d. 1000 ml
e. 500 ml
Answer B
1. Asymptomatic effusions are typically first detected by radiography performed for
other reasons. A minimum of about 250 mL of fluid collection is required for
detection through radiography that augments the cardiac silhouette.
2. Increased pericardial fluid can be hydropericardium (transudate), true pericardial
effusion (exudates), pyopericardium (if purulent), hemopericardium (in presence of
blood), or mixtures of the above.
3. A rapidly accumulating effusion, such as that associated with hemopericardium
due to trauma, may result in tamponade with collection of as little as 100-200 mL
of fluid, while a more gradual accumulation of fluid may allow for compensatory
stretching of the pericardium and may not show tamponade, despite collection of
fluid even in excess of 1500 mL.
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