Question 1:
A 26 year old female presents with a pulmonary flow murmur and a fixed split of her second heart sound. ECG reveals RBBB. She has become progressively short of breath. A heart catheterisation study is performed and the following values are obtained
Mixed venous saturations 65%
Right atrium 80%
Right ventricle 80%
Pulmonary artery 80%
Pulmonary vein 95%
Aorta 95%
What is the correct assessment of the following values
(A) Ventricular septal defect, shunt fraction Qp:Qs 2:1
(B) Atrial septal defect, shunt fraction Qp:Qs 2:1
(C) Atrial septal defect, shunt fraction Qp:Qs 1:2
(D) Patent Ductus Arteriosus, shunt fraction Qp:Qs 1:2
(E) Cor-triatorium, shunt fraction 1:2
B: Oxygenation step occurs in the right atrium from mixed venous saturations. Shunt fraction calculated using (Ao - Mv)/(Pv - Pa) = (95 - 65)/(95 - 80) = 30/15 = 2:1 - PEP lecture series 2014
Question 2
What is the most common type of atrial septal defect?
(A) Sinus venosus
(B) Osmium primum
(C) Osmium secundum
(D) Osmium triatorium
(E) Coronary sinus
C: Majority are females. If <5mm without RV/ RA overload can then be followed-up. Only osmium second defects can be closed percutaneously.
Question 3
A 25 year old patient arrives from Malawi short of breath of the airplane. She is 21 weeks pregnant. She has plethoric facies, a diastolic rumbling murmur with an audible opening snap. Her neck veins are elevated and there are crackles bi-laterally. Her pulse is 128 and regular. What should be the most appropriate management in this patient with regards to the likely diagnosis
(A) Pulmonary embolus, therefore CTPA and start LMWH, transitioning to UFH prior to elective delivery
(B) Pulmonary embolus, therefore CTPA and start UFH with a bridge to warfarin once patient is therapeutic
(C) Mitral stenosis with acute pulmonary oedema secondary to raised cardiac output, organise urgent ECHO to quantify severity, give IV frusemide and beta-blocker to reduce flow and increase diastolic filling time (decrease peak trans-mitral gradient)
(D) Mitral stenosis with acute pulmonary oedema secondary to raised cardiac output, organise urgent ECHO to evaluate every and gauge the nature of the valvular apparatus and arrange O/T for urgent balloon valvotomy
(E) Mitral regurgitation, therefore mitral valve repair is imperative and O/T should be arranged urgently
C: Trial medical therapy in patient who is pregnant with likely rheumatic origin mitral stenosis, if this fails proceed to surgical management. Need to reduce flow and diastolic filling time.
Question 4
A 68 year old female presents to the cardiology out-patient department referred by his GP for investigation of an ejection systolic murmur radiating to the carotids. The ECHO shows a valve area of <1 cm squared. Left ventricular ejection fraction as estimated by Simpsons method shows LVEF 30%. What is the next most appropriate step?
(A) This patient may have low flow low gradient aortic stenosis and therefore requires a dobutamine stress study. If the valve area improves then one can be confident that this is not severe aortic stenosis
(B) She has echocardiographic severe aortic stenosis and should be followed up closely
(C) This patient may have low flow low gradient aortic stenosis and therefore requires an adrenaline stress study to determine symptomatic improvement
(D) She has echocardiographic severe aortic stenosis and should be urgently referred to a cardiothoracic surgeon for AVR
(E) She has echocardiographic severe aortic stenosis. She is not a surgical candidate and should be referred for a TAVI procedure
Question 5
With regards to the trans-catheter aortic valve implantation (TAVI) procedure, what is FALSE
(A) It is a reliable option for non-surgical candidates, with lower mortality compared to standard medical treatment, less cardiac symptoms but more vascular events and major strokes
(B) It should NOT be utilised in patients with asymptomatic severe aortic stenosis
(C) In operable candidates, surgical aortic valve replacement is favoured over TAVI as surgery favours a mortality benefit over TAVI
(D) There is no reduction in symptoms when TAVI is compared to surgery in operable candidates
(E) There was no improvement in valve haemodynamics with TAVI compared to surgery in operable candidates
C: Partner Trial (Kodali SK et al., N Engl J Med 2012 May 3;336(18): 1686-95. It is not becoming validated for patients with severe aortic stenosis and intermediate surgical risk. "Transcatheter aortic-valve replacement (TAVR) is noninferior to surgery in terms of early and midterm mortality and is likely to be superior if the patient has vascular anatomy and vessels that are healthy enough to be treated with the use of a transfemoral approach. A rather small trial involving 280 patients, the Nordic Aortic Valve Intervention (NOTION) trial, also showed the noninferiority of TAVR" N Engl J Med 2016; 374:1682-1683
Question 6
A 63 year old female who has a prosthetic mitral valve for primary mitral regurgitation is having a pelvic ultrasound and is concerned about her risk of bacterial endocarditis as she has read it on the internet. The gynecology team consult the cardiology team for advice on the prophylaxis of infective endocarditis. What is the most appropriate management for this patient?
(A) Amoxicillin
(B) Clindamycin
(C) Metronidazole
(D) Do nothing, no prophylaxis required
(E) Flucloxacillin
D: Should she have a respiratory or dental procedure, or a procedure that requires incision through infected skin, then the guidelines suggest that patients with a prosthetic valve, congenital heart disease that is un-repaired, or congenital heart disease that has been repaired within the last 6 months, or patients undergoing cardiac transplant with valvular disease should have IE prophlaxis. Regimes include a single dose 30 - 60 mins pre-op of 2g amoxicillin or 600mg clindamicin. PEP 2015
Question 7
What is the most common valvular pathology?
(A) aortic stenosis
(B) Mitral regurgitation
(C) Mitral valve prolapse
(D) aortic regurgitation
(E) Mitral stenosis
C: MVP is the most common valvular disorder in the United States, occurring in 2% to 3% of the general population. There is a similar prevalence in men and women, with a greater risk of complications in men N Engl J Med. 1999, 341: 1-7
A 26 year old female presents with a pulmonary flow murmur and a fixed split of her second heart sound. ECG reveals RBBB. She has become progressively short of breath. A heart catheterisation study is performed and the following values are obtained
Mixed venous saturations 65%
Right atrium 80%
Right ventricle 80%
Pulmonary artery 80%
Pulmonary vein 95%
Aorta 95%
What is the correct assessment of the following values
(A) Ventricular septal defect, shunt fraction Qp:Qs 2:1
(B) Atrial septal defect, shunt fraction Qp:Qs 2:1
(C) Atrial septal defect, shunt fraction Qp:Qs 1:2
(D) Patent Ductus Arteriosus, shunt fraction Qp:Qs 1:2
(E) Cor-triatorium, shunt fraction 1:2
B: Oxygenation step occurs in the right atrium from mixed venous saturations. Shunt fraction calculated using (Ao - Mv)/(Pv - Pa) = (95 - 65)/(95 - 80) = 30/15 = 2:1 - PEP lecture series 2014
Question 2
What is the most common type of atrial septal defect?
(A) Sinus venosus
(B) Osmium primum
(C) Osmium secundum
(D) Osmium triatorium
(E) Coronary sinus
C: Majority are females. If <5mm without RV/ RA overload can then be followed-up. Only osmium second defects can be closed percutaneously.
Question 3
A 25 year old patient arrives from Malawi short of breath of the airplane. She is 21 weeks pregnant. She has plethoric facies, a diastolic rumbling murmur with an audible opening snap. Her neck veins are elevated and there are crackles bi-laterally. Her pulse is 128 and regular. What should be the most appropriate management in this patient with regards to the likely diagnosis
(A) Pulmonary embolus, therefore CTPA and start LMWH, transitioning to UFH prior to elective delivery
(B) Pulmonary embolus, therefore CTPA and start UFH with a bridge to warfarin once patient is therapeutic
(C) Mitral stenosis with acute pulmonary oedema secondary to raised cardiac output, organise urgent ECHO to quantify severity, give IV frusemide and beta-blocker to reduce flow and increase diastolic filling time (decrease peak trans-mitral gradient)
(D) Mitral stenosis with acute pulmonary oedema secondary to raised cardiac output, organise urgent ECHO to evaluate every and gauge the nature of the valvular apparatus and arrange O/T for urgent balloon valvotomy
(E) Mitral regurgitation, therefore mitral valve repair is imperative and O/T should be arranged urgently
C: Trial medical therapy in patient who is pregnant with likely rheumatic origin mitral stenosis, if this fails proceed to surgical management. Need to reduce flow and diastolic filling time.
Question 4
A 68 year old female presents to the cardiology out-patient department referred by his GP for investigation of an ejection systolic murmur radiating to the carotids. The ECHO shows a valve area of <1 cm squared. Left ventricular ejection fraction as estimated by Simpsons method shows LVEF 30%. What is the next most appropriate step?
(A) This patient may have low flow low gradient aortic stenosis and therefore requires a dobutamine stress study. If the valve area improves then one can be confident that this is not severe aortic stenosis
(B) She has echocardiographic severe aortic stenosis and should be followed up closely
(C) This patient may have low flow low gradient aortic stenosis and therefore requires an adrenaline stress study to determine symptomatic improvement
(D) She has echocardiographic severe aortic stenosis and should be urgently referred to a cardiothoracic surgeon for AVR
(E) She has echocardiographic severe aortic stenosis. She is not a surgical candidate and should be referred for a TAVI procedure
Question 5
With regards to the trans-catheter aortic valve implantation (TAVI) procedure, what is FALSE
(A) It is a reliable option for non-surgical candidates, with lower mortality compared to standard medical treatment, less cardiac symptoms but more vascular events and major strokes
(B) It should NOT be utilised in patients with asymptomatic severe aortic stenosis
(C) In operable candidates, surgical aortic valve replacement is favoured over TAVI as surgery favours a mortality benefit over TAVI
(D) There is no reduction in symptoms when TAVI is compared to surgery in operable candidates
(E) There was no improvement in valve haemodynamics with TAVI compared to surgery in operable candidates
C: Partner Trial (Kodali SK et al., N Engl J Med 2012 May 3;336(18): 1686-95. It is not becoming validated for patients with severe aortic stenosis and intermediate surgical risk. "Transcatheter aortic-valve replacement (TAVR) is noninferior to surgery in terms of early and midterm mortality and is likely to be superior if the patient has vascular anatomy and vessels that are healthy enough to be treated with the use of a transfemoral approach. A rather small trial involving 280 patients, the Nordic Aortic Valve Intervention (NOTION) trial, also showed the noninferiority of TAVR" N Engl J Med 2016; 374:1682-1683
Question 6
A 63 year old female who has a prosthetic mitral valve for primary mitral regurgitation is having a pelvic ultrasound and is concerned about her risk of bacterial endocarditis as she has read it on the internet. The gynecology team consult the cardiology team for advice on the prophylaxis of infective endocarditis. What is the most appropriate management for this patient?
(A) Amoxicillin
(B) Clindamycin
(C) Metronidazole
(D) Do nothing, no prophylaxis required
(E) Flucloxacillin
D: Should she have a respiratory or dental procedure, or a procedure that requires incision through infected skin, then the guidelines suggest that patients with a prosthetic valve, congenital heart disease that is un-repaired, or congenital heart disease that has been repaired within the last 6 months, or patients undergoing cardiac transplant with valvular disease should have IE prophlaxis. Regimes include a single dose 30 - 60 mins pre-op of 2g amoxicillin or 600mg clindamicin. PEP 2015
Question 7
What is the most common valvular pathology?
(A) aortic stenosis
(B) Mitral regurgitation
(C) Mitral valve prolapse
(D) aortic regurgitation
(E) Mitral stenosis
C: MVP is the most common valvular disorder in the United States, occurring in 2% to 3% of the general population. There is a similar prevalence in men and women, with a greater risk of complications in men N Engl J Med. 1999, 341: 1-7
