Robbin's Qs Flashcards
In the cranial cavity, what vessels are most likely to be invaded by malignant cells within the vascular lumina?
- -Arterioles
- -Capillaries
- -Lymphatics
- -Muscular arteries
- -Veins
–Veins – thin walls relative to diameter, less distinct layers, slow blood flow make them more prone to compression and invasion by malignancies. (route for hematogenous metastases)
–Lymphatics also, but not in cranial cavity
44 y/o woman w/ BP 150/100 has TIA. Labs: normal K, Na, nattriuretic peptide, increased plasma rening activity. Normal urinary Na excretion. What is most likely seen on renal arterial angiography?
- -Arterial dissection
- -AV fistula
- -Berry aneurysm
- -Focal stenosis and dilation
- -Vascularized mass lesion
–Focal stenosis and dilation – Fibromuscular dysplasia (FMD) usually involves renal and carotids.
- -FMD = HTN –> medium/large vessel thickening
- -Renal stenosis –> RAAS activation
Dermal venule w/ endothelial cells is stressed by biogenic amines from mast cells following anaphylaxis. Extravascular fluid compartment increases in size. What is occuring in activated endothelial cells?
- -Cytoplasmic contraction
- -Free radical formation
- -mRNA translation
- -Thromboxane syntehsis
- -VEGF elaboration
–Cytoplasmic contraction
–Anaphylaxis = exudation of intravascular fluid –> edema
73 y/o healthy man has lightheadedness w/ episodes of fainting for 10 days. Exam: BP 135/90 lying down, 100/60 when sitting. Normal electrolytes. What BP regulatory mechanism is altered? --Aldosterone release --CO --Intravascular volume --Renin synthesis --Sympathetic tone --Vasoconstriction
–Intravascular volume
–Fluid loss or decreased fluid intake –> low volume –> orthostatic hypotension
55 y/o woman w/ dull, episodic headaches for past year. Exam: 37C, 166/112, P70, RR14. Lungs clear, HR regular. Abdom ultrasound: left kidney smaller than right. Renal angio: focal stenosis of L renal artery.
What is likely elevated lab finding?
–Plasma renin – 2ndary HTN = stenosis –> low GFR, low afferent arteriole pressure –> Renin release by juxtaglomerular cells –> Angiotension II-induced vasoconstriction –> high TPR –> higher volume
Group of subjects w/ BP between 145/90 and 165/105. They have: increased CO, increased peripheral vascular resistance, normal renal angiogram, normal abdom C, normal serum creatinine and BUN, no meds. What is most likely lab finding? --Decreased urine Na --Elevated plasma renin --Hypokalemia --Increased urine catecholamines --Lack of ACE
–Decreased urine Na – essential HTN = reduced Na homeostasis –> retained Na –> increase intravascular volume –> high CO –> compensation by increasing peripheral vascular resistance –> increased BP
61 y/o woman w/ 2pk/day 40yr smoking Hx has increasing dyspnea for 6 years. Exam: 37.1C, P60, RR18 and labored, BP 130/80, expiratory wheezes bilaterally. CXR: increased lung volume, flattening of diaphragm, greater lucency to all lung fields, pulmonary artery prominence, prominent border on right sie of heart. Blood gas: PO2=80, PCO2=50, pH 7.35. What is likely to be in pulmonary arteries? --Amyloid deposition --Atheromatous plaques --Intimal tears --Medial calcific sclerosis --Necrotizing vasculitis --Phlebothrombosis
–Atheromatous plaques – Obstructive/restrictive lung disease –> high pulm vascular resistance –> pulm HTN –> pulm atherosclerosis
Prevalence of essential HTN has increased for past 10 years to affect 1/4 of adults.
What lifestyle change can be adopted to decrease this?
– Lower dietary salt intake – Essential HTN = Na+ homeostasis dysfunction
45 y/o man w/ poorly controlled HTN of up to 160/90 for 11 years has increased BP up to 250/125 for past 3 months. CXR: prominent border on L side of heart. Creatinine has increased from 1.7 to 3.8. What happened? What vascular lesion is most likely found? --Fibromuscular dysplasia --Granulomatous arteritis --Renal arterial stenosis --Necrotizing arteriolitis --Polyarteritis nodosa
–Malignant HTN superimposed– hyperplastic arteriolosclerosis = arteriole concentric thickening –> luminal narrowing –> fibrinoid necrosis
–Necrotizing arteriolitis
57 y/o woman has mild intermittent right hip pain after falling down stairs. Exam: 3cm contusion over right hip, tender to palpation, full range of motion of right leg. XRay: calcified, medium-sized arterial branches in pelvis.
What is this vascular finding?
–Monckeberg arteriosclerosis = benign process, incidental finding.
–Often at distal extremities, pelvis, thyroid, breast regions
20 year old men and women are assessed for development of atherosclerotic cardiovascular disease. What lab result finding is most likely to indicate the greatest relative risk for development of disease?
- -Anti-proteinase3
- -CRP
- -Cryoglobulin
- -ESR
- -Platelets
–CRP = acuse phase reactant that increases in response to inflammation
–ESR is nonspecific indicator of inflammation
35 y/o woman has angina pectoris for 6mo. Exam: BP 135/85. 5ft 5in, 82kg (BMI29). HbA1C 9%, fasting glucose 143. Coronary angio = 75% narrowing of LAD, 70% narrowing of RCA.
What is her greatest risk factor for atherosclerotic disease?
–Diabetes Mellitus – her HbA1C and glucose suggests hyperglycemia.
In early atheroma develpment, monocytes attach to endothelium, migrate subendothelially, become macrophages and then transform into foam cells
What substance is responsible for macrophage transformation?
–Oxidized LDL – taken up by “scavenger” pathway in macrophages –> transform to foam cells –> form fatty streak.
29 y/o man has angina for past year. Family Hx of CV disease. BP 120/80. Total cholesterol 185, glucose 85.
Mutation in gene encoding for what is most likely in this man’s family?
–Apolipoprotein – Lipoprotein(a) = altered form of LDL cholesterol w/ apoB-100 of LDL linked to apolipoprotein A.
–Increased Lp(a) –> risk for endothelia dysfunction and atherogenesis
–Statin drugs affecting LDL receptor does not affect Lp(a) concentration.
Study of subjects w/ LDL over 160 found to have increased oxidized LDL and decreased arterial lumen size.
What is most likely initial pathologic change arterial narrowing?
–Intimal thickening – initial injury response = intimal thickening w/ neointimal smooth muscle cell proliferation and production of increased intimal ECM
50 y/o man w/ 2yr Hx of angina pectoris during exercise. BP 135/75, HR79 and slightly irregular. Coronary angio: fixed 75% narrowing of LAD. Atherosclerosis risk factors: smoking, HTN, HCL. What is earliest event in atherosclerotic disease?
–Endothelial injury – Atherosclerosis = initial endothelial injury –> subsequent chronic inflammation –> repair of arterial intima
You do an aortic biopsy of a child over the age of 10 and see fatty streaks.
What cells do you find (which is only present early in the pathogenesis of atherosclerotic lesions)?
–T lymphocytes – believed to activate monocytes, endothelial cells, and smooth muscle cells by secreting cytokines.
–Adhere to VCAM-1 on activated endothelial cells and migrated into the vessel wall
Release of groth factors (PDGF, FGF, TNF-a) lead to increased ECM production, causing atheromatous plaque size increase.
Which cells release these growth factors in plaques?
–Smooth muscle – activated platelets, macrophages, and vascular wall cells release growth factors –> smooth muscle cell recruitment –> micration from media to intima –> proliferate –> synthesize ECM
58 y/o woman has chest pain at rest for past year. Pulse 80 and irregular. LAD lumen is markedly narrowd by atheromatous plaque complicated by calcification.
Wat is most likely involved in pathogenesis?
–Elevated platelets
–Low HDL
–Low Lp(a)
–Low plasma homocysteine
–Positive VDRL
–Low HDL – atherogenesis risks = HCL w/ high LDL and low HDL
–VDRL –> syphilis
What kind of plaque alterations is least likely to be associated w/ acute coronary syndromes?
- -Calcium deposition
- -Hemorrhage into plaque substance
- -Intermittent platelet aggregation
- -Thinning of media
- -Ulceration of plaque surface
–Thinning of media – expanding plaque compresses the media –> cause thinning –> weak wall –> predispose to aneurysm formation
59 y/o woman w/ DM2 has an episode of chest pain with exercise. BMI=30, angiography: proximal coronary 70% stenosis. What daily low dose pharmacologic agent is most appropriate for reducing her myocardial infarction risk?
– Aspirin (acetylsalicylic acid) – inhibids COX pathway
84 y/o man w/ long smoking Hx survived a small MI 2 years ago. Now has chest and leg pain on exercise. T37.1, P81, RR15, BP 165/100. Poor peripheral pulses in lower extremities. 7cm pulsating mass in midline lower abdomen. Fasting glucose between 170-200. What vascular lesion does he most likely have? --Aortic dissection --AV fistula --Atherosclerotic aneurysm --Polyarteritis nodosa --Takayasu arteritis --Thromboangiitis obliterans
–Atherosclerotic aneurysm – abdom aneurysm related to underlying aortic atherosclerosis
- -AV fistula = audible bruit on auscultation
- -Takayasu = aortic branches, children
- -Thromboangiitis obliterans = Buerger, smoker, lower extremities
41 y/o man has worsening abdom pain for past week. T36.9, P77, RR16, 140/90. Abdom CT: 6cm diameter enlarged abdom aorta.
What is most likely underlying disease process?
–Diabetes mellitus
–Marfans
–Polyarteritis nodosa
–SLE
–Syphilis
–Diabetes Mellitus – important risk factor for atherosclerosis in younger men/premenopausal woman
- -Marfan = dilated ascending aorta
- -PAN = not aorta
- -SLE = small arteriolar vasculitis
- -Syphilis = thoracic aorta
77 y/o man w/ progressive dementia and gait ataxia for 8 years succumbs to bronchopneumonia. Autopsy: thoracic aorta has dilated root and arch, intimal “tree-bark” appearance. Micro: obliterative endarteritis of vasa vasorum.
What is it?
Syphilitic Aortitis – classic “tree-bark appearance in thoracic aorta and obliterative endarteritis; affect vasa vasorum
–Hx: tabes dorsalis (ataxia), neursyphilis (dementia)
23 y/o man with sudden onset severe, sharp chest pain. T36.9, lungs clear. CXR: widened mediastinum. TEE: dilated aortic root and arch w/ tear in aortic intima 2cm distal to great vessels.
What does he have?
–Marfan syndrome – disruption of medial elastic fibers (cystic medial degeneration) –> weakens aortic media –> risk for dissection
59 y/o man w/ sudden severe chest pain radiating to back. BP 170/110, distant heart sounds. Pulsus paradoxus (abnormally large decrease in SBP during inspiration) observed.
What is it?
–Aortic dissection – sudden tear of proximal aortic intima –> blood enters space between layers –> enters pericardial cavity –> cardiac tamponade
- -blood entering chest cavity –> hemothorax
- -HTN is most common risk factor for dissection
75 y/o man has headaches for past 2 months. T37, P68, RR15, 135/85. Right temporal artery prominent, palpable, and painful to touch. ESR 100, temporal artery biopsy shows grossly thickened and focal microscopic granulomatous inflammation. Responds to corticosteroid therapy.
What is the most likely complication in untreated patients?
– Blindness – Giant cell (temporal) arteritis = large-medium external carotid branches, but also vertebral and ophthalmic arteries.
–associated w/ polymyalgia rheumatica
32 y/o woman has coldness and numbness in arms and decreased right eye vision for 5 months. Afebrile, 100/70, non-palpable radial pulses, strong femoral pulses, decreased sensation and cyanosis in arms, no warmth or swelling. CXR: prominent right side heart border, pulmonary artery prominence. Glucose 74, creatinin 1, cholesterol 165, negative ANA. Stable condition for the next year What is it? --Aortic dissecition --Kawasaki --Microscopic polyangiitis --Syphilis --Takayasu --Thromboangiitis obliterans
–Takayasu arteritis – “pulseless disease”, involves aortic arch
- -Kawasaki = children, acute febrile, coronary arteritis, rash
- -
43 y/o man has malaise, fever, 4kg weight loss over past month. 145/90, mild diffuse abdom pain, no mass or hepatosplenomegaly. BUN 58, creatinin 6.7, Renal angiography: right renal arterial thrombosis, left renal artery and branches narrow w/ focal aneurysmal dilation. During hemodialysis: abdom pain, diarrhea, melena. What is most likely lab finding? --ANA --C-ANCA --HIV --HBsAg --Scl-70 --RPR
–HBsAg – classic Polyarteritis nodosa (PAN) = segmental involvement of medium-sized arteries w/ aneurysmal dilation in renal and mesenteric vascular beds
- -ANA = SLE
- -Scl-70 = scleroderma
- -RPR = syphilis
3 y/o from Osaka japan has fever, rash, swelling of hands and feet for 2 days. T37.8, desquamative skin rash, oral erythema, cervical lymphadenopathy. Improves w/ IVIg therapy.
What is a complication of untreated disease?
–Asthma
–Intracranial hemorrhage
–Glomerulonephritis
–MI
–Pulmonary HTN
–MI – Kawasaki disease = 20% cardiovascular complications (thrombosis, ectasia, coronary aneurysm)
- -Asthma = Churg-Strauss
- -Glomerulonephritis = ANCA associated, SLE
- -Pulmonary HTN = Takayasu
50 y/o man has chronic cough for 18 months. Exam: nasopharyngeal ulcers, diffuse crackles bilat., BUN 75, creatinine 6.7. Urinalysis = 50RBCs/field, RBC casts. C-ANCA (proteinase 3) elevated. CXR: multiple, small, bilateral pulmonary nodules. Biopsy: necrotizing inflammatory processes of small peripheral pulm. arteries and arterioles.
What is it?
–Granulomatosis w/ polyangiitis – ANCA associated vasculitis = hypersensitivy reaction, small-medium vessels
–C-ANCA in 90% of cases
50 y/o man with muscle pain and fever for a month has darker colored urine for 2 weeks. Palpable purpuric lesions on skin. Urinalysis: hematuria, proteinuria. Lab: mixed cryoglobulinemia w/ polyclonal IgG increase, high P-ANCA.
What is most likely finding in skin biopsy?
–Giant cells and macrophages
–Medial fibrinoid necrosis
–Microabscesses
–Mycotic aneurysms
–Perivascular eosinophilic infiltrates
–Medial fibrinoid necrosis – Microscopic polyangiitis = small vessels (capillaries), commonly kidney and lungs
- -Microabscesses = infectious or Buerger disease
- -Perivascular eosinophilic infiltrates = Churg-Strauss
33 y/o man w/ 2pk/day smoking Hx since teenager has painful thromboses of superficial veins of lower legs for 1 month w/ episodes of fingers becoming blue and cold. Next year, he develops ppor healing ulcerations on feet, one toe gangrenous and amputated. Histo: acute chronic vasculitis of medium-sized arteries w/ segmental invovlement.
What is most appropriate treatment?
–Smoking cessation – Buerger disease (Thromboangiitis obliterans = small-medium arteries of extremities, associated w/ smoking. eventually involves peripheral veins and nerves
8 y/o child has abdom pain and dark urine for 10 days. Exam: blotchy purple skin lesions on trunk and extremities. Urinalysis: hematuria, proteinuria. Negative P-ANCA and C-ANCA. SKin biopsy: necrotizing vasculitis of small dermal vessels. Renal biopsy: immune complex deposition in glomeruli w/ IgA-rich immune complexes.
What is it?
–Henoch-Schonlein purpura = in children, IgA nephropathy
35 y/o woman w/ HX of injection drug use has fever for 1 day. T37.6, heart murmur, culture grows S. aureus. Develops severe headache. Head CT: intracranial hemorrhage.
Which vascular complication most likely occurred in her brain?
–Bacillary angiomatosis
–Hyperplastic arteriolosclerosis
–Lymphangitis
–Mycotic aneurysm
–Phlebothrombosis
–Mycotic aneurysm – infectious endocarditis –> vegetation dislodge and embolize –> local arterial destruction
–Bacillary angiomatosis = focal vascular proliferation, skin, immunocompromised, Bartonella
60 y/ woman has paleness on tip of middle finger when driving to work one day associated w/ pain and numbness. Resolves 20min after entering warm office building. What pathologic process? --Calcification --HTN --Thrombosis --Vasculitis --Vasoconstriction
–Vasoconstriction – Raynaud phenomenon = “red, white, and blue” changes, primary exaggerated vasoconstriction
21 y/o woman in 34th wk of pregnancy has itching and burning pain in perianal region for past 4 months. Small amount of bright red blood on toilet paper last week. Which condition is most likely? --Filariasis --Polyarteritis nodosa --External hemorrhoids --Micronodular cirrhosis --Rectal adenocarcinoma
–External hemorrhoids – venous congestion –> dilated hemorrhoidal veins.
–Filarial infections = lymphatics–> lymphadema
69 y/ o woman bedridden from viral pneumonia complicated by baterial pneumonia for past 2 weeks. Exam: swelling, tenderness of right leg, worses when raising or moving leg.
What is it?
–Thrombosis of Deep veins – Phlebothrombosis = venous stasis w/ prolonged immobilization.
54 y/o woman has increasing prominence of dilated superficial veins over both lower legs for past 5 years. T37, P70, RR14, 125/85. No pain, swelling, or tenderness. What is most likely consequence? --Atrophy of lower leg muscles --DIC --Gangrenous necrosis of lower legs --Pulmonary thromboembolism --Stasis dermatitis w/ ulceration
–Stasis dermatitis w/ ulceration – Chronic peripheral venous stasis –> hemosiderin deposition and dermal fribrosis w/ brownish discoleration and skin roughening –> focal ulceration over varicosities
48 y/o woman develops persistent swelling and puffiness in left arm after mastectomy w/ axillary node dissection for breast cancer 1 yr ago. Develops left arm cellulitis 3 months ago. Exam: firm skin and “doughy” underlying soft tissue, not painful or discolored.
What is it?
–Lymphadema – obstruction of lymphatics in axilla –> lymphadema –> cellulitis complication
50 y/o man cuts his right index finger on metal shard while cleaning debris in an irrigation canal. Bleeding stops in 3 min, but 6 hours later, he has pain. T38C, red streaks from right hand to upper arm, arm swollen and tender, tender lumps in right axilla. Cultures grow group A B-hemolytic strep.
What is it?
–Lymphangitis – classic red streaks indicate acute infection draining to axillary lymph nodes
46 y/o man has increasing abdom enlargement over 15 months. Exam: multiple skin lesions on upper chest w/ central pulsatile cores and radius 0.5-1.5cm. Pressing core causes radially arranged array of subcutaneous arterioles to blanch. Glucose 112, creatinine 1.1, total protein 5.8, albumin 3.4. What is likely underlying disease?
- -AIDS
- -Diabetes Mellitus
- -Granulomatosis w/ polyangiitis
- -Marfan syndrome
- -Micronodular cirrhosis
–Micronodular cirrhosis –characteristic spider telangectasias, consequence of chronic alcohol abuse
–Thought to be caused by hyperestrogenism from reduced clearance
21 y/o woman in 3rd trimester has enlarging nodule in mouth for 2 weeks. Exam: 1cm red nodule on left lateral gigiva below first molar. Regresses after delivery.
What is it?
–Capillary hemangioma – pyogenic granuloma
10 y/o boy has 2cm spongy, dull red, circumscribed lesion on upper outer left arm present since infancy w/o change. excised biopsy: dilated, endothelium-lined spaces filled w/ RBCs.
What is it?
–Hemangioma
6 y/o has increasing neck size for past year. Exam: ill-defined, soft mass deforming left side of his neck. Resection of 10cm mass examined: borders not discrete, dilated spaces filled w/ milky fluid, bounded by thin connective tissue walls. Spaces lined by flattened endothelium, surrounded by collagenous tissue and smooth muscle w/ collections of small lymphocytes. What is most likely outcome? --Distant metastases --Local rucurrence --More neoplasms elsewhere --Opportunistic infection --Sarcomatous transformation
–Local recurrence – Cavernous lymphangioma = histologically benign, tend to become large and extend around adjacent structures
35 y/o man w/ HIV for 10 years has multiple reddish, purple, nodular skin lesions that slowly increasing for the past year. What likely played role in development of this?
- -Antiretroviral therapy
- -EBV
- -Hyperlipidemia
- -Mycobacterium avium complex infection
- -Sexual intercourse
–Sexual intercourse – Kaposi sarcoma = caused by HHV8 infection, STD
67 y/o woman w/ glucose intolerance, HTN, central obesity, HCL has increasing dyspnea from worsening CHF. Echo: EF 25%. Stent placed containing Paclitaxel. What long-term complication is prevented by paclitaxel?
–Proliferative restenosis – intimal thickening following angioplasty –> restenosis; paclitaxel limits smooth muscle hyperplasia
–Metabolic syndrome = coronary atherosclerosis risk
82 y/o woman has increasing fatigue for 2 years with paroxysmal dizziness and syncope. Afebrile, Pulse 44, RR 16, 100/65, lungs clear, no murmurs. Echo: normal size heart, normal valve motion, EF 50%. Vagal stimulation slows heart rate and becomes irregular. Abnormality where is most likely?
–SA node – Bradycardia less than 50/min suggests SA disorder
Neonate at newborn checkup has systolic murmur. Echo: muscular defect of intraventricular septum. Checkup 30 years later shows no murmur or flow defect. What kind of cells proliferated leading to disappearance of defect? --Adipocytes --Conduction cells --Endothelial cells --Fibroblasts --Mesothelial cells --Stem cells
–Stem cells – stems cells most active in neonates
- -Adipocytes enlarge with aging
- -Endothelial cells make more coronary collateral channels
- -Fibroblasts produce collagenous scars reducing contractility
66 y/o man has cough and worsening SOB for 3yrs. Dullness to percussion bilat lung bases, poor audible breath sounds, P77, BP110/80, no angina, liver span increased to 14cm, pitting edema to knees, JVD to angle of jaw.
What most likely caused his heart disease?
–Smoking – right-sided CHF –> edema, pleural effusion, hepatic congestion, JVD
–Right side CHF most often follows COPD = cor-pulmonale
62y/o woman has increasing dyspnea for 2 years. Now wakens at night w/ air hunger, cough w/ frothy sputum. Rales (crackles) in all lung fields, PMI strong and displaced laterally. Echo: EF30%, concentric LV wall size. What underlying disease does she have? --Amyloidosis --Cardiomyopathy --HTN --Myocarditis --Pericarditis
–HTN – left-sided CHF –> pulm. congestion and edema.
–Systemic HTN –> high pressure (afterload) –> concentric LVH w/ systolic dysfunction
–Other choices cause diastolic dysfunction
41 y/o woman wakens night w/ air hunger for past year. Sleeps better when sitting in bed. Serum B-type natriuretic peptide > 400 (v high). What cardiac disease best explains this? --Atrial myxoma --Fibrinous pericarditis --Giant cell myocarditis --Libman-Sacks endocarditis --Rheumatic valvulitis
– Rheumatic valvulitis – paroxysmal nocturnal dyspnea = Rheumatic disease affects Aortic or Mitral valves most likely –> L-side CHF –> pulm. edema
- -Myxoma = intermittent obstruction
- -Fibinous pericarditis = chest pain, small amount of fluid
- -Giant cell myocarditis = rare
- -Libman-Sacks = in SLE, not impair valve or ventricular fxn
50 y/o man has increasing abdom discomfort and leg swelling for 2 years. Smoked for 35 years, JVD even when sitting, large tender liver palpable 10cm below costal margin, pitting edema in lower extremities. CXR: bilat. diaphragmatic flattening, pleural effusions, increased lucency of lung. Thoracentesis: 500mL clear fluid w/ few cells.
What is it?
–Chronic bronchitis – Obstructive lung disease (emphysema) –> pulm HTN –> R-side heart failure
Infant has cyanosis during 1st week of life and a heart murmur. Echo: overriding aorta, VSD, r-ventricular thickening, pulm. stenosis. Inherited mutation in what gene? --B-myosin heavy chain (B-MHC) --Fibrillin 1 (FBN1) --KCNQ1 --NOTCH2 --Transthyretin (TTR)
–NOTCH2 – Tetralogy of Fallot
- -B-MHC = hypertrophic cardiomyopathy
- -FBN1 = Marfan
- -KCNQ1 = long QT syndrome
- -TTR = one form of cardiac amyloidosis
Infant from uncomplicated pregnancy is normal at birth, but develops resp. distress at 1 day. Tachypnic, tachycardic, cyanotic, S1 ejection click, split S2 w/ prominent P sound. CXR: normal heart size, prominent hilar vascular markings. Echo: small L atrium, large R atrium, normal ventricles, patent foramen ovale, normal aorta and pulm trunk position.
What congenital heart disease?
–ASD
–Coarctation of aorta, preductal type
–PDA
–Tetralogy of Fallot
–Total anomalous pulmonary venous connection
–Total anomalous pulmonary venous connection – pulmonary veins leading to right atrium instead of left
- -ASD = not enough
- -Coarctation = no cyanosis, preductal form life-threatening
- -PDA = no cyanosis
- -Tetralogy = overriding aorta
77 y/o woman fell and fractured ankle, bedridden for 16 days. Develops sudden chest pain, dyspnea, diaphoresis. L thigh swelling, tenderness. Chest CT: areas of decreased attenuation in right and left pulm arteries. 1 day later: difficulty speaking. MR angiography: L MCA occlusion.
What cardiac abnormality does she have?
–PFO (Patent Foramen Ovale) –DVT –> PE, moves to left heart through shunt –> “paradoxical embolus” –> stroke
5 y/o child not as active as other children. Past 8 months: multiple episodes of resp. difficulty following exertion. T37, P81, RR19, 95/60, loud holosystolic murmur, diffuse crackles bilat., dullness to percussion at bases. CXR: prominent L heart border, pulm. interstitial infiltrates, blunting of costodiaphragmatic recesses. Large VSD seen.
What additional pathologic conditions will he develop?
–Aortic regurg
–Coronary atherosclerosis
–Nonbacterial thrombotic endocarditis
–Pulm HTN
–Restrictive cardiomyopathy
–Pulm HTN – large VSD uncorrected by age 5 –> marked L to R shunting –> pulm HTN (Eisenmenger complex)
–Ventricle chambers undergo hypertrophy and some dilation
3 y/o developing normally has low-pitched cardiac murmur. Echo: present ostium secundum w/ 1cm defect. Which abnormality is most likely? --Cyanosis at rest --L-->R shunt --Mural thrombosis --Pericardial effusion --Pulm HTN
–L–>R shunt – persistent ostium secundum is most common ASD; low atrial pressures = small amount of shunting
2 y/o w/ Staph. epidermidis illness 1 year ago given abx and recovered. Now on exam: harsh, waxing and waning, machinery-like murmur at upper chest. CXR: prominence of pulm. arteries. Echo: normal valves. Normal arterial O2
What congenital heart disease explains these findings?
–Aortic atresia
–Aortic coarctation
–ASD
–PDA
–Tetralogy of Fallot
–PDA – L–>R shunting; can produce significant murmur and predispose to infection; pulm arteries prominence = pulm HTN
- -Atresia = hypoplastic L heart, no survival
- -Coarctation = no shunting, no pulm HTN
- -ASD = no loud murmur
- -Tetralogy = pulm stenosis –> no pulm HTN, R–>L shunt
5 y/o girl below 5percentile in height and weight has easy fatigability since infancy. Cyanotic, T37, P82, RR16, 105/65, pulse ox shows decrease O2 sat. 1 month later: fever, obtundation. Cerebral CT: right parietal, ring-enhancing, 3cm lesion. What congenital heat disease? --ASD --Bicuspid aortic valve --Coarctation of aorta --PDA --Truncus arteriosis --VSD
–Truncus arteriosis – Cyanosis = R–>L shunt
–Cyanotic heart disease most commonly caused by: truncus arteriosis, transposition of great arteries, and tetralogy of Fallot.
Studying tetralogy of Fallot, some have more severe CHF, poor exercise tolerance, and decrease arterial O2 sat.
What predicts worse clinical presentation?
–Degree of pulm. stenosis
–Diameter of tricuspid valve
–Presence of ASD
–Size of VSD
–Thickness of L ventricle
–Degree of pulm. stenosis –mild stenosis –> VSD like symptoms (L–>R shunt, no cyanosis); severe stenosis –> R–>L shunt –> cyanotic heart disease
15 y/o boy complains of leg pain when running more than 300m. T36.8, P76, RR22, 165/90. Radial pulses 4+, dorsalis pedis pulse 1+, ABG shows normal O2. What congenital anomaly most likely?
- -Aortic valve stenosis
- -Coarctation of aorta
- -PDA
- -Transposition of great arteries
- -Tricuspid valve atresia
–Coarctation of aorta – abnormal narrowing of aorta –> large pulse differences in upper vs lower extremities
–Collaterals supplying lower extremities often involve intercostal arteries –> enlarging arteries produce “rib notching” in CXR
Infant develops respiratory distress and cyanosis 1 day after birth. Echo: slitlike L ventricle, small L atrium, atretic aortic and mitral valves. What structure could blood from lungs most likely have reached systemic circulation --Anomalous venous return --Foramen ovale --PDA --Right 4th aortic arch --Truncus arteriosus --VSD
–PDA – infant has hypoplastic L heart syndrome; lung blood –> L atrium –> foramen ovale –> R atrium –> pulm trunk –> PDA –> aorta –> systemic circulation