FIP

Question 1

The most and the second most common congenital heart defects in adults respectively are?

Answer 1

Bicuspid aortic valve and ASDs

Question 2

Cardiac auscultation in patients with ASD reveals - heart sounds, murmurs

Answer 2

• Typically- wide and fixed splitting of S2 (with left to right shunt and normal pulmonary aa pressure)
• mid-systolic ejection murmur at the left upper sternal border resulting from increased flow across the pulmonic valve.
• mid diastolic rumble resulting from increased flow across the tricuspid valve

Question 3

What’s AAOCA?
Sxs, dxtic ixs,
How can you differentiate it from brugda syndrome, long QT; Hypertrophic CMP

Answer 3

Anomalous aortic origin of a coronary artery - is one of the causes of SCD in <35 yr
Sxs- exertional angina, lightheadedness, syncope, or SCD without any premonitory sxs.
- resting ECG is typically unremarkable
- echo can sometimes make the dx, but it can also miss or inaccurately characterize AAOCA
- CT coronary angiography or MR angio are the best dxtic tests
- Brugada- cxc ecg findings- right bundle branch block, ST segment elevation in V1-V3
- Long QT- ecg- QTc>450msec in men, >470 in women
- HCMP- evidence of LV hypertrophy on ECG or small LV cavity on echo would be expected

Question 4

Transtuzumab Vs anthracycline associated cardiotoxicities

Answer 4

Transtuzumab, a monoclonal antibody targeting HER2.
- incidence of cardio toxicity is 5% with transtuzumab monotherapy and 25% with combination with anthracyclines or cyclophosphamide.
- transtuzumab- loss of myocardial contractility (myocardial hibernation) —> decreased LVEF => REVERSIBLE (mostly complete recovery of cardiac function after rx discontinuation)
=> cardio toxicity isn’t dose related
=> Rx should be withheld for 4 wks if LVEF decreases by 16% from baseline or by 10-15%from baseline to below the lower limit of normal. Completely discontinued if Pt develops symptomatic heart failure
- Anthracycline- myocyte necrosis, destruction and replacement by fibrous tissue
=> usually IRREVERSIBLE after Rx discontinued
=> toxicity strongly related to cumulative dose

Question 5

Atrial myxomas are?

• clinical features
• diagnosis is made by
• Rx

Answer 5

Are the most common primary cardiac tumors, majority occurring in the left atrium.

• large tumors can present with signs and sxs of MV obstruction (diastolic murmur/tumor plop, rapidly worsening HF, Afib), tumor emboli into the systemic circulation
• echo (transesophageal preferred over transthoracic)
• prompt surgical excision is the typical rx

Question 6

Pt presenting with sudden onset pulmonary edema(SOB, tachycardia, bibasilar crackles, jugular venous distention) hypotension, hyper dynamic precordium with holosystolic murmur (murmur may be absent in 50%), velvety skin with many atrophic scars. CXR- bilateral alveolar infiltrates. ECG- sinus tachycardia with premature ventricular complexes.
The cause of this patient’s condition is?
Ddx

Answer 6

Acute MR secondary to ruptured mitral chordae tendineae.

• acute MR has dramatic presentation due to lack of time for left heart adaptation. It can be secondary to 1) Ruptured mitral chordae tendineae ( which can be 2ndry to MVP, IE, RHD, trauma) 2) Papillary mm rupture due to trauma or MI (complication of MI usually in the first 3 days)
• this patient most likely has MVP associated with CT disease like ehlers- danlos - his skin findings are suggestive.

Question 7

What’s the significance of BNP in HF? What happens with obesity?

Answer 7

BNP<100 is useful in ruling out clinically significant heart failure.
- Obesity lowers BNP levels making the test unreliable in such patients.

Question 8

Which one of the following is a most commonly encountered complication of compartment syndrome?
A. Acute renal failure
B. Microangiopathic hemolytic anemia
C. Paraparesis

Answer 8

ARF!
Arterial n venous occlusion in the extremities results in mm necrosis (rhabdomyolysis). The released myoglobin if degraded n filtered in the kidney.
Heme pigment from myoglobin degradation:
-is directly toxic to proximal tubular cells
-induces vasoconstriction, reducing medullary blood flow
- DIC causing microangiopathic hemolytic anemia can also be a complication of CS but, ARF is more common.

Question 9

The most specific diagnostic finding in cardiac tamponade is?

Answer 9

Echocardiography showing early diastolic collapse of the RV n RA

Question 10

Examination findings that are consistent with severe AS

Answer 10

• a soft, single second heart sound (normally, inspiration pulls blood to the right heart —> delayed closure of pulmonic and earlier closure of the aortic valves. In severe AS, aortic closure is delayed—> no split of A2,P2 during inspiration(simultaneous closure)
• delayed/diminished carotid pulse(parvus et tardus)
• Loud n late-peaking systolic murmur- relatively high LV pressure (attend late in ventricular systole, as it takes time to build that much pressure) is needed to overcome the valvular stenosis

Question 11

ECG findings of MS

Answer 11

• P mitrale-broad,notched P waves
• RV hypertrophy- tall R waves in v1,v2
• atrial tachyarrhythmias

Question 12

In a patient with peripartum CMP, what diagnostic investigation provides the best recurrence/prognostic information during future pregnancy?

Answer 12

Echocardiography
- LV function at dx (LVEF<20%)
- current LV function (persistent LV systolic dysfunction)
Are indicators of poor prognosis/recurrence

Question 13

Bicuspid aortic valve complications?

How should patients be screened for complications?

Answer 13

IE, severe AR or AS, aortic root or ascending aortic dilation, dissection
- they should have a through evaluation with echo, CT or MRI to asses the aortic root or the ascending aorta for dilation.
Follow up echo every 1 to 2 years