1 >>When describing cardiac anatomy, what does the term ‘situs solitus’ refer to? ?
- (A) Normal orientation of the cardiac apex within the thorax, e.g. leftward pointing cardiac apex
- (B) Normal orientation of the cardiac atria, e.g. morphological left atrium on the left and morphological right atrium on the right
- (C) Mirror image of the cardiac structures and abdominal viscera, e.g. left-sided structures on the right and vice versa
- (D) Normal orientation of the cardiac structures but with mirror images of the abdominal viscera
2 >>You are asked to review a 22-year-old male who has presented to the ED with sudden-onset chest pain and breathlessness. He has been diagnosed with a probable acute pulmonary embolism by the emergency team. They have asked for an echocardiogram to look for ‘right heart strain’ as he appears to be mildly compromised and they are considering thrombolysis if he decompensates. Auscultation of the heart sounds has revealed a loud continuous murmur and the CXR shows some pulmonary congestion. What are you likely to see on echocardiography? ?
- (A) A dilated and hyperdynamic RV with evidence of acute TR secondary to raised pulmonary pressure
- (B) A jet of colour flow extending back into the RVOT from the pulmonary artery in the short-axis parasternal view
- (C) A jet of colour extending from the right coronary sinus into the right ventricle
- (D) A jet of colour across the apical interventircular septum in the four-chamber view
3 >>A haematology SHO contacts you regarding a patient with congenital cyanotic heart disease. The patient has trisomy 21 and an unrepaired complete AVSD with Eisenmenger physiology and chronic cyanosis. The patient was seen recently in clinic and was doing reasonably well. The full blood count has been highlighted to the haematology team as the patient has a haemoglobin (Hb) of 27. The haematology records document a previous venesection when the Hb was around the same figure and the patient had developed headaches thought to be due to hyperviscosity. The SHO would like some advice on whether they should arrange for daycase venesection to reduce the risk of hyperviscosity complications and symptoms. What advice should you give? ?
- (A) As the patient is asymptomatic there is no indication for venesection
- (B) Daycase venesection should be arranged with volume replacement based on the Hb to prevent hyperviscosity complications
- (C) The haematocrit (Hct) should be checked; if Hct > 65%, daycase isovolumic venesection is indicated
- (D) The iron status should be checked first; in the presence of iron deficiency this should be treated first, prior to venesection
4 >>You are approached by one of the adult congenital specialist nurses for advice regarding a patient with tetralogy of Fallot (ToF) who has contacted them directly. The patient, who is now 24 years old, had total surgical repair in childhood and has remained well since, but has recently been experiencing palpitations with associated presyncope. The symptoms are transient and there has been no syncope. There are no other relevant symptoms or reduction in exercise capacity. The echocardiogram from clinic a year previously showed moderate�severe PR and moderate RV dilatation. The nurse has performed an ECG which shows SR with first-degree AV block and RBBB (QRS 190 ms). What is the most appropriate advice? ?
- (A) The patient is at risk of malignant arrhythmias and sudden cardiac death; urgent haemodynamic assessment and consideration of an ICD is appropriate
- (B) I t is likely that the patient is experiencing paroxysmal SVTs or symptomatic ectopics; arrange an outpatient 24-hour tape
- (C) I t is common for patients with ToF repair to develop non-sustained RVOT arrhythmias at the site of the surgical scar, and beta-blockers are the initial treatment of choice for symptoms
- (D) I t is possible that the symptoms represent haemodynamic deterioration; an echocardiogram should be arranged to document progression of PR and RV dilatation
5 >>One of the stroke physicians asks your advice regarding a 45-year-old man admitted with a stroke. The patient is overweight with known hypertension and raised lipids. He is a non-smoker. Carotid Doppler scans show no atheroma. The stroke physicians have performed a 24-hour tape which has shown clear runs of asymptomatic paroxysmal AF. They have also requested a bubble contrast echo which has demonstrated complete opacification of the left heart with Valsalva release. The heart is structurally normal apart from moderate LVH and a left atrial area of 30 cm2. The patient is currently on antiplatelet therapy, but they are keen to know what the immediate strategy would be from the cardiac point of view. ?
- (A) There is a large PFO which represents a significant risk factor for recurrent stroke; once the patient has recovered, inpatient transcatheter PFO closure is indicated
- (B) There is clear evidence of paroxysmal AF: in the context of stroke and cardiovascular risk factors, we would recommend anticoagulation once beyond the acute risk of haemorrhagic transformation; no further treatment for the PFO is required whilst on anticoagulation
- (C) The patient is young and should have pulmonary vein isolation and a flutter ablation with transcatheter left atrial appendage closure and PFO closure
- (D) TOE is the next step to confirm the presence and anatomy of the shunt
6 >>One of the medical students asks you what a Fontan operation consists of. What is your answer? ?
- (A) A palliative procedure when a biventricular surgical repair is not possible: the systemic venous blood is directly routed into the pulmonary arteries bypassing the ventricle
- (B) When a biventricular surgical repair is not possible the systemic venous blood is directly routed into the pulmonary arteries bypassing the ventricle; life expectancy is near normal
- (C) I t is a procedure for the treatment of transposition of the great arteries but is no longer performed; the systemic venous blood is routed via baffles to the morphological left ventricle (subpulmonary ventricle) and the pulmonary venous blood is routed to the morphological RV (systemic ventricle)
- (D) I t consists of an SVC-to-PA shunt to increase pulmonary blood flow in congenital cyanotic heart disease when pulmonary flow is low
7 >>You are following up a 33-year-old male in clinic who was referred by the GP for increasing breathlessness and intermittent palpitations. A transthoracic echocardiogram was performed which revealed moderate right heart dilatation but no abnormality of the right-sided valves. Right ventricular systolic pressure was estimated at 30 mmHg. He has no respiratory problems and is a lifelong non-smoker. He is slim with good echocardiogram images, and careful interrogation of the intra-atrial and ventricular septum shows no evidence of a colour flow. What is a likely differential diagnosis? ?
- (A) ASD
- (B) VSD
- (C) PFO
- (D) P rimary respiratory disease with right heart changes
8 >>You are following up a 28-year-old male in clinic who was referred by his GP for increasing breathlessness and intermittent palpitations. He has come back for the result of his TOE which has shown evidence of a superior sinus venosus ASD with normal pulmonary venous drainage and moderate right heart dilatation. He asks you about the likely treatment. ?
- (A) Transcatheter ASD device closure
- (B) Surgical ASD closure
- (C) ACE inhibitor treatment to reduce the shunt and protect the right heart
- (D) Monitoring in clinic for signs of severe right heart dilatation
9 >>Which one of the following patients would you advise to avoid pregnancy? ?
- (A) A 25-year-old with repaired ToF and severe pulmonary regurgitation with a mildly dilated and mildly impaired right ventricle
- (B) A 32-year-old with idiopathic pulmonary arterial hypertension, which has responded well to bosentan, who has a right atrial to right ventricular pressure drop of 45 mmHg
- (C) A 39-year-old patient with moderate mitral regurgitation and good left ventricular function
- (D) An 18-year-old with a single-ventricle circulation and a total cavopulmonary connection operation for tricuspid atresia, normally saturated and with good LV function
10 >>A 36-year-old patient with repaired ToF wishes to become pregnant and asks you about the likelihood of her child being born with a congenital heart defect. She has no family history of congenital heart disease. What is the approximate risk of her child having congenital heart disease? ?
- (A) 1�2%
- (B) 8�10%
- (C) 0.5
- (D) 4�5%
11 >>A GP writes to you to ask which contraceptive is advisable for her 35-year-old patient with a mechanical mitral valve replacement. She has had one child and several miscarriages because of taking warfarin. She does not wish to become pregnant again. What is the best method of contraception for this patient? ?
- (A) Sterilization
- (B) Condoms
- (C) Mirena intra-uterine system
- (D) Depo Provera
12 >>I n current regulations, which of the following drugs is absolutely contraindicated in pregnancy? ?
- (A) Atenolol
- (B) Simvastatin
- (C) Aspirin
- (D) Amlodipine
13 >>A 35-year-old woman with a history of atrioventricular nodal tachycardia presents in premature labour at 36 weeks with a narrow complex tachycardia at 180 bpm (see Figure 5.2). What is the most appropriate drug to use after vagal manoeuvres and adenosine? ?
- (A) Esmolol
- (B) Amiodarone
- (C) Verapamil
- (D) Digoxin
14 >>Which of the following are the first-, second-, and third-line drugs to use in pregnancy-induced hypertension with no other problems? ?
- (A) Methyldopa, labetolol, nifedipine
- (B) Nifedipine, captopril, bendroflumethazide
- (C) Metoprolol, methyldopa, bendroflumethazide
- (D) Enalapril, labetolol, doxazosin
15 >>A 24-year-old woman who has a mechanical mitral valve replacement and requires warfarin 4 mg od comes to your clinic, seeking advice about becoming pregnant. She has heard that warfarin is dangerous in pregnancy. What is the best anticoagulation regime in pregnancy to protect her from valve thrombosis? ?
- (A) Warfarin throughout pregnancy switching to heparin 2�3 weeks before delivery
- (B) L ow molecular weight heparin for weeks 6�12 and warfarin for weeks 12�38, switching to heparin 2 weeks before delivery
- (C) L ow molecular weight heparin throughout with four-weekly monitoring of anti-Xa levels
- (D) L ow molecular weight heparin and aspirin throughout with four-weekly monitoring of anti-Xa levels
16 >>A 25-year old woman who is 35 weeks pregnant is referred to your clinic because of increasing shortness of breath, palpitations on exertion, and a murmur. A soft non-radiating ejection systolic murmur is heard loudest in expiration at the left sternal edge. Pulse is 90 bpm and normal in character. Blood pressure in the right arm is 104/62 mmHg. Non-pitting ankle oedema is present. The ECG shows sinus rhythm with left axis deviation and Q waves in lead III. The ST segments are quite flat inferolaterally with widespread T-wave inversion. There are several premature ventricular complexes. Echocardiography does not show the aortic valve clearly, but peak velocity across the LV outflow tract is 1.8m/s. Which one of the following is the most appropriate next investigation? ?
- (A) Modified Bruce treadmill testing to assess the significance of the likely mild aortic stenosis
- (B) Nothing-all the above are normal findings in pregnancy and the patient should be reassured
- (C) Cardiac magnetic resonance imaging-the patient may have a right ventricular cardiomyopathy
- (D) H olter monitoring to look for arrhythmias
17 >>A 42-year-old woman presents 38 weeks pregnant with her fourth child with a 1 hour history of severe sudden-onset dull central chest pain associated with sweating and dyspnoea. She is diabetic, obese, and a smoker. The ECG shows 4 mm of ST elevation in the anterior leads. What is the ideal management? ?
- (A) U rgent thrombolysis to avoid the radiation risk of coronary angiography to the baby
- (B) P rimary angioplasty optimally with a drug eluting stent
- (C) P rimary angioplasty optimally avoiding a drug eluting stent
- (D) Emergency delivery and subsequent standard primary angioplasty
18 >>A 30-year-old woman presents to the clinic 17 weeks pregnant and becoming increasingly breathless. The LVEDD is 6.1 cm and the EF is estimated at 25%. Which one of the following statements is false? ?
- (A) Termination of pregnancy is justified on medical grounds
- (B) An ACE inhibitor and beta-blocker should be started as soon as possible
- (C) P rescribing a nitrate and hydralazine may cause the symptoms to subside
- (D) The patient should rest and be admitted to hospital for this if necessary