Basic concepts pediatric cardiology Quiz covering congenital heart disease Quiz covering rheumatic heart disease quiz covering bacterial endocarditis

1. Cardiology Quiz
Senior Associate Professor Dr Rajan Duda

2. Quiz

6. Ductus arteriosus

7. Right sided obstruction

10. Inadequate mixing

14. True/False
1 The first heart sound (S1) represents the closure of the
atrioventricular (mitral and tricuspid) valves as the ventricular
pressures exceed atrial pressures at the beginning of systole
2. S1 is normally a single sound because mitral and tricuspid valve
closure occurs almost simultaneously.
3 Clinically S1 corresponds to the pulse. The carotid upstroke
corresponds to ventricular systole

15. Second heart sound True/False
• The second heart sound (S2) represents the closure of the semilunar (aortic and
pulmonary) valves
• S2 is normally split because the aortic valve (A2) closes before the pulmonary
valve (P2).
• The closing pressure (the diastolic arterial pressure) on the left is 80 mmHg as
compared to only 10 mmHg on the right. This higher closing pressure leads to the
earlier closure of the aortic valve.
• In addition, the more muscular and stiff "less compliant" left ventricle (LV)
empties earlier than the right ventricle
• The venous return to the right ventricle (RV) increases during inspiration due to
negative intrathoracic pressure and P2 is even more delayed, so it is normal for
the split of the second heart sound to widen during inspiration and to narrow
during expiration.

16. TRUE/False
• The most common left to right shunts are
• Ventricular septal defects
• Persistent arterial duct
• Tetralogy of Fallot
• Coarctation of aorta

17. Basics :
True/False
• First heart sound is due to :
• Closure of Aortic and pulmonary valves
• Closure of Mitral and tricuspid valves
• Opening of Aortic and pulmonary valves
• Opening of Mitral and tricuspid valves

18. Basics
True/False
• Second heart sound is due to :
• Opening of mitral and tricuspid valve
• Opening of aortic and pulmonary valve
• Closing of mitral and tricuspid valve
• Closing of aortic and pulmonary valve

19. True/False
• The most common Right to left shunt
• Pulmonary stenosis
• Aortic stenosis
• Tetralogy of Fallot
• Atrial septal defect

20. True/False
• If a baby is breathless and has a cardiac lesions, what does it mean.
• Left to right shunt
• Right to left shunt
• Common mixing ( Atrioventricular septal defect )
• Outflow obstruction in a well child
• Outflow obstruction in a sick neonate

21. Answer to previous slide questions
• Right to left shunt : Blue
• Common mixing AVSD Breathless and blue
• Outflow obstruction in a well child ( Asymptomatic with
• a murmur) Pulmonary stenosis 7% , Aortic stenosis 5%
• Outflow obstruction in a sick neonate ( Collapsed with shock)

22. True/False
• The causes of congenital heart diseases are due to
• Maternal disorders . Rubella, Diabetes mellitus
Systemic lupus erythematosus
• Maternal drugs Warfarin, alcohol
• Whole chromosome , point mutations or microdeletions
• Polygenic

23. Fetal circulation

26. True/False
• Some babies with congenital heart disease will rely on blood flow through
the duct ( duct dependent lesions) Their clinical conditions deteriorate
dramatically when the duct close which is usually at 1- 2 days of life.
• Examples of obstructed duct dependent systemic and pulmonary
circulation would be
• Hypoplastic left heart
• Critical aortic valve stenosis
• Critical pulmonary atresia
• Severe coarctation of aorta

27. SBA
• A term baby weight 3.5 kg delivered SVD , Apgar normal, antenatal
uneventful collapsed with shock at 30 minutes of life.
• Pulses are not felt, and echo shows coarctation of aorta .
• It is Sunday and the scenario is in District Hospital. We need to transfer to
Tertiary care Cardiac center. How to keep the systemic circulation intact till
he is transferred to the cardiac center.
• Give IV normal saline
• IV Adrenaline/Dopamine/Nor epinephrine
• IV Albumin
• Prostaglandin infusion

28. True/false
• Congenital heart disease can present with
• Antenatal cardiac ultrasound diagnosis
• Detection of heart murmur
• Heart failure
• Shock
• Cyanosis

29. True/False
• Hallmarks of an innocent ejection murmur are
• Asymptomatic patient
• Diastolic murmur
• Soft blowing murmur
• Left sternal edge
• Parasternal thrill

30. True/false
• Cyanosis is :
• Reduced/Deoxygenated Hemoglobin more than 5 gms %
• Is associate with polycythemia
• Never associated with clubbing
• Is associated with increased risk of cerebrovascular accidents

31. True/False
• In Atrial septal defect the following are :
• Ejection systolic murmur best heard in left lower sternal border due
to increased pulmonary blood flow across the pulmonary valve
• A fixed and widely split second hear sound due to due to right stroke
volume being equal in inspiration and expiration
• With secundum ASD an apical pansystolic murmur due to
atrioventricular valve regurgitation.
• CXR shows increased pulmonary arteries and cardiomegaly

32. ASD
• With septum primum one can get atrioventricular regurgitation .

33. TRUE?FALSE

35. True/False
• In small Ventricular septal defects there is active precordium, lod P2 , soft
murmur , tachypnea and hepatomegaly
In large VSD there is Pansystolic murmur at LSE
In small VSD there is heart failure and needs Diuretics, captopril, calories
and surgery at 3-6 months
IN large VSD there is no failure

36. True/False
• IN PDA there is continuous murmur in lower sternal edge.
• The pulse pressure is decreased causing a collapsed pulse
• In large PDA there will be no symptoms
• In small PDA there will be increased pulmonary blood flow and heart
failure and pulmonary hypertension

37. PDA
• In PDA the murmur is heard best in left infraclavicular region.
• IN PDA the pulse pressure in increased .
• In Large PDA there is failure .

38. TRUE/False
• Right to left shunts presents with cyanosis
• Presents with oxygen saturation less than 85%
• Presents with increased growth
Presents with polycythemia

39. Hyperoxia ( Nitrogen washout ) test
True/False
• Infant is placed in 100% oxygen ( headbox or ventilator) for 10
• Minutes and right radial artery Pa2 from blood gas remains low below
113 mg Hg, it is diagnostic of cyanotic heart disease
• If the PO2 is greater than 150 mm HG it is cyanotic heart disease
• Blood gas analysis are better than pulse oxygen saturation as they are
better in this oxygen saturation ranges

41. Oxygen
dissociation
curve

42. True/false
• In tetralogy of Fallots there is left ventricular hypertrophy and
increased pulmonary blood flow
• Sub pulmonary artery stenosis
• Overriding of pulmonary artery
• Aortic stenosis

43. TOF
• RVH Pulmonic stenosis
• Overriding aorta VSD

44. TOF

46. Explain
• How will you treat it:
• Oxygen
• Morphine
• Knee chest/squatting position
• Propranolol
• Alpha 1 agonist

47. TGA

48. True/False
• What is the anatomical lesions
• For discussion only
• Blue blood is returned to the body and the pink blood is returned to
the lungs.
• Presentation is with cyanosis at birth when duct closes
• Cyanosis will be less severe and delayed if associated left to right
shunt at asd or pda or vsd

49. Common mixing
• If a baby is blue and breathless common problem is due to common
mixing .
• Please give one example of this common mixing condition.

50. AVSD

51. Discussion
• A six-year-old child with VSD comes with fever, pallor, toxic a high-
grade fever and has splenomegaly and has microscopic hematuria .
• What investigations are to be advised
• Treatment
• Complications
• Prognosis

52. Infective endocarditis
• The above signs and symptoms in a patient with underlying CHD following
transient bacteremia should raise the suspicion of IE.
• In the absence of prior antimicrobial therapy, positive blood cultures are
found in >90% of patients.
• Other supporting laboratory evidence includes anemia, leukocytosis with a
left shift, positive rheumatoid factor, hematuria and elevated ESR/CRP.
• The finding of vegetations on echocardiography is confirmatory. However,
since IE is a clinical diagnosis, a negative echocardiogram does not rule out
IE and treatment should not be delayed if there is strong clinical suspicion
of IE. The Duke Criteria helps in making the diagnosis of IE.

53. Infective endocarditis
• Infective endocarditis (IE) is an inflammation of the endothelial lining of the
heart muscle, valves and great vessels. The valves have a particularly high
propensity for infection due to the lack of blood supply and limited access
to immune cells. IE is relatively rare in children. It has an estimated annual
incidence of 3 to 9 cases per 100,000 persons in industrialized countries.
The highest rates are observed among patients with prosthetic valves,
intracardiac devices, unrepaired cyanotic congenital heart diseases, or a
history of infective endocarditis. About 50% of cases of infective
endocarditis develop in patients with no known history of valve disease.
Other risk factors include chronic rheumatic heart disease (which now
accounts for <10% of cases in industrialized countries), age-related
degenerative valvular lesions, hemodialysis, and coexisting conditions such
as diabetes, human immunodeficiency viral infection, and intravenous drug
use

54. IE and Dukes criteria.
• What is Dukes criteria?
• Major and Minor?

55. Duke criteria
• The Duke Criteria for diagnosis of infective endocarditis: Requires 2
major + 1 minor OR 1 major + 3 minor OR 5 minor criteria for
diagnosis

56. Dukes Criteria Major Criteria
•
• Positive blood Cx for IE
• Predisposing heart condition or IV drug use
• Typical micro-organism for IE from 2 separate blood Cx 1
•
•
•
•

57. Minor criteria
• Fever > 38° C
• Evidence of endocardial involvement
• Vascular phenomena (arterial emboli, septic pulmonary infarcts, conjunctival hemorrhage,
intracranial hemorrhage and Janeway lesions)
• Immunologic phenomena (glomerulonephritis, Osler nodes, Roth spots, rheumatoid factor)
• positive blood Cx but not meeting major criteria
•
• Echocardiographic findings consistent with IE but not meeting major criteria

58. What is this ?

59. IE
• Janeway lesions

60. Vascular:
• Janeway lesions are vascular phenomenon

61. What is this ? Immunological or vascular
cause ?

62. IE
• Vascular or immunological reason?
• Roths spots : Immunological

63. What is this ?

64. • Osler's nodes Immunological process

66. What are these features suggestive of ?

67. • Non purulent conjunctivitis
• Lymphadenitis asymmetrical
• Strawberry tongue
• Polymorphous rash

68. Diagnosis Of Kawasaki Disease
• Fever of unknown origin lasting for at least 5 days, in addition to four of the
following criteria:
• Bilateral conjunctivitis which is non-purulent
• Changes of the oral cavity and lips: cracked and erythematous lips,
strawberry tongue
• Changes in the extremities (erythema of the hands and feet, desquamation
of the skin of the fingers and toes in the 2nd and 3rd weeks)
• Polymorphous rash: maculopapular, erythema multiforme-like or
scarlatiniform rash, involving extremities, trunk, and perineal regions
• Cervical lymphadenopathy (> 1.5 cm in diameter) that is commonly
unilateral

69. • Which of the following is a must for the diagnosis for Kawasaki
disease?
• a. Cervical lymphadenopathy > 1.5 cm
• b. Maculopapular rash
• c. Fever > 5 days
• d. Non-exudative conjunctivitis

70. • Must criteria
• Fever for 5 days

71. • Which of the following EKG findings may be commonly found in a
child with rheumatic fever?
• a. Wide QRS interval
• b. Prolonged PR interval
• c. ST-T wave changes
• d. Tall T waves

72. • Prolonged PR interval
• Minor diagnostic criteria for Rh fever

73. • Which of the following phenomenon is a vascular phenomenon seen
in infective endocarditis?
• a. Osler's nodes
• b. Roth spots
• c. Janeway lesions
• d. Glomerulonephritis

74. • Janeway lesion is the only vascular lesion rest are immunological .

75. • A grade 2/6 systolic murmur which is louder in the supine position in
an asymptomatic child is likely to be an innocent murmur?
• True
• False

76. • The classic Stills murmur is heard at the lower left sternal border and
is louder in the supine position
• The correct response: true

77. • Children with left-to-right shunt congenital heart defects are usually
cyanotic.
• True
• False

78. • They may have pulmonary congestion because of the increased flow
through the right heart, but cyanosis does not develop unless
pulmonary hypertension and reversal of the shunt develops.

79. • Infusion of prostaglandin E will lead to closure of a patent ductus
arteriosus
• True
• False

80. • PGE is used to maintain patency of a ductus in congenital heart
defects that are PDA dependent. Indomethacin, a prostaglandin
inhibitor, is used to close the ductus in some premature infants.

81. • A newborn baby did well after birth and was discharged home after 24
hours. Physical exam did not reveal any murmur. At the 2 week well child
check, the physician heard a grade 3/6 holosystolic murmur best heard
over the left mid and lower sternal border. The most likely lesion and the
reason for the delay in hearing the murmur is:
• a. ASD, the murmur was missed in the newborn nursery
• b. ASD, the murmur is now audible as the pulmonary vascular
resistance has dropped and there is a larger pressure gradient across the
ASD
• c. VSD, the murmur was missed in the newborn nursery
• d. VSD, the murmur is now audible as the pulmonary vascular
resistance has dropped and there is a larger pressure gradient across the
VSD

82. • VSD murmurs may not be audible at birth as the PVR is equal to SVR
and the pressure gradient across the VSD is small. As the PVR drops,
the pressure gradient increases and the murmur becomes audible
(hence was audible at 2 weeks of life and not at birth).

83. • 10-year-old child with a small peri-membranous VSD is being followed by a
Pediatric Cardiologist every year. He is completely asymptomatic from a
CVS standpoint. Auscultation is significant for a typical holosystolic murmur
of VSD but no diastolic murmurs are heard. The patient asks you why he
needs to be followed regularly.
• a. To see if the patient has developed pulmonary hypertension
• b. To evaluate for development of congestive heart failure
• c. Because of the concern of possible development of aortic
insufficiency
• d. All of the above
• e. None of the above

84. • Peri-membranous VSDs are close to the aortic valve. In the case of a
small peri-membranous VSD, the turbulent jet (shunt) across the VSD
may cause suction and prolapse of an aortic valve cusp into the
defect. This is known as the Venturi effect. Such prolapse may lead to
aortic insufficiency which is a serious complication.

85. • You are following 2 children who have equal size large muscular VSDs. One
child presents to you at 2 months of age with tachypnea, retractions and
difficulty feeding while the other child has no symptoms. Which child
should you be more concerned about and why?
• a. First child, he is in CHF
• b. Second child though he is asymptomatic because of likelihood
of development of pulmonary hypertension
• c. Both children to the same extent as they both have large VSDs
• d. Neither because VSD is a common CHD with a benign outcome

86. • The expected course of a child with a large VSD is to present in heart
failure as the PVR drops. The typical presentation of CHF is tachypnea,
retractions, sweating and difficulty with feeds. However, when such a
presentation does not occur in the presence of a documented large
VSD, it is a worrisome sign for the presence of pulmonary
hypertension. Hence a high index of suspicion for pulmonary
hypertension should be maintained for the second child.

87. • Where does the systolic murmur of a large ASD originate from?
• a. Turbulence due to the left-to-right shunt across the ASD
• b. Increased blood flow across the pulmonary valve (relative
pulmonic stenosis)
• c. Increased flow across the tricuspid valve (relative tricuspid
stenosis)
• d. A large ASD does not generate a heart murmur

88. • The pressure gradient across the ASD is extremely small. Thus there is
no audible murmur that is heard when blood is shunted across the
ASD. However, the extra blood in the right side of the heart forms the
left-to-right shunt across the ASD which has to flow across the same
size pulmonary valve (relative stenosis) leading to a systolic ejection
murmur typically heard at the left upper sternal border.

89. • A newborn with trisomy 21 was diagnosed with a complete AVSD. The
most characteristic EKG findings are:
• a. RAD, RVH
• b. RAD, LVH
• c. LAD, RVH
• d. LAD, LVH
• e. E. None of the above

90. Rheumatic fever
• Which are jones major criteria :
• Polyarthralgia
• Elevated ESR
• Fever
• Subcutaneous nodules
• Erythema nodosum

91. • Commonest two valves involved in rheumatic fever
• Mitral
• Tricuspid
• Aortic
• Pulmonary

92. Drugs in RHD
• Two Drugs used in Rheumatic heart disease with congestive cardiac
failure to suppress inflammation.
• Steroids
• Aspirin
• Penicillin
• Diuretics

93. • In tetralogy of Fallot (True or false)
• There is decreased pulmonary blood flow
• There is increased pulmonary blood flow
• It is acyanotic heart disease
• It is cyanotic heart disease
• Clubbing is never seen in Tetralogy of Fallot

94. • True or false
• In an examination of a child with heart disease
• We look for
• Dysmorphism
• Cyanosis
• Clubbing
• Murmur
• Apex beat

95. THANKS
• Thank You

96. • Which are the signs of failure in right-sided failure in a twelve-year-
old child
• Hepatomegaly
• Apex down and out (In 6th left intercostal space outside the mid
clavicular line)
• JVP increased
• Pedal edema
• Tachycardia

97. • True /False
• In Kawasaki which is true
• A rash on the main part of the body or in the genital area
• Generalized lymphadenopathy
• Extremely red eyes with a thick purulent discharge
• Red, dry, cracked lips and an extremely red, swollen tongue
• Swollen, red skin on the palms of the hands and the soles of the feet,
with later peeling of skin on fingers and toes

98. • Complications in Kawasaki
• Coronary dilatation or aneurysms
• Increases thrombosis in the dilatation and aneurysm
• Myocardial dysfunction
• Valvular involvement

99. • Treatment of Kawasaki includes
• IV immunoglobulin to lower coronary artery abnormalities
• Aspirin to reduce pain and inflammation
• Low dose aspirin to work as an antiplatelet to prevent blood clots in
case of detected coronary dilatation or aneurysm.
• Immediate vaccination after the disease measles

106. • Commonest cyanotic congenital heart disease in newborn
• Transposition of great vessels
• Tetralogy of Fallot
• Tricuspid atresia
• Hypoplastic left ventricle
• Critical pulmonary artery stenosis

107. • True/false
• Jones criteria
• Pan carditis
• 2. Polyarthritis
• 3. Sydenham chorea
• 4. Erythema nodosum
• 5. Subcutaneous nodules

109. Quiz
• Carnival theme park

110. You

111. Questions on CCF

113. • What are the signs of left-sided failure in an eleven-year-old girl?
• Tachycardia
• Breathlessness
• Paroxysmal nocturnal dyspnea
• Fine crepitations at the lung bases
• Apex inside the mid-clavicular line at the fifth space.