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Most likely cause of enlarged cardiac silhouette (cardiomegaly) in a neonate: a. VSD b. ASD c. Ebstein\'s anomaly d. Cor triatriatum e. Tetralogy of Fallot
Answer: Ebstein\'s anomaly Ebstein’s is the downward displacement of the posterior and septal valves of the tricuspid valve, which results in atrialization of the superior portion of the RV. Ebstein’s has extreme enlargement of the RA (essentially tricuspid insuff) and CHF in 50% - per Dahnert – Gautham wondered about CHF fact. a. VSD – usually relatively asymptomatic b. ASD – usually asymptomatic c. Ebsteins anomaly – tricuspid RV and RA dilatation, worse than with ToF d. Cor triatriatum – Usually presents with severe associated anomalies in infants not children; if mild, presents in adulthood e. TOF – presents in the first few years of life with cardiomegaly.
Most common cause of CHF in a neonate: a. Single ventricle b. Hypoplastic left heart c. Tetralogy of Fallot c. ASD
Answer: Hypoplastic left heart syndrome (HLHS) Most common cause of CHF in neonate: 1) HLHS; 2) Coarctation of aorta. HLHS describes a spectrum of cardiac abnormalities characterized by marked hypoplasia of the left ventricle AND ascending aorta. So if the only answer is coarctation of aorta, then that’s a good answer. In fact, some references say coarctation is the most common but if you consider it a syndrome, and the concept of LV outflow obstruction is the key. ASD/VSD does NOT lead to CHF in the first two weeks of life. Because of its small size in HLHS, the left ventricle is incapable of supporting the systemic circulation. There are varying degrees of hypoplasia, atresia and stenosis of the left sided cardiac structures, and often both the aortic and mitral valves are atretic. With aortic atresia, the ascending aorta and transverse arch can be severely hypoplastic, but are usually large enough to supply adequate circulation to the coronary and brachiocephalic vessels with retrograde blood flow from the PDA. A discrete coarctation located at the junction of the ductus arteriosus with the proximal descending aorta occurs in up to 75% of patients with HLHS. Survival is dependent on patency of the ductus arteriosus with right to left shunting to the descending aorta, and an interatrial communication with left to right shunting to maintain the systemic circulation.
What presents as heart failure in a child? a. Tetralogy of Fallot b. Absent pulmonic valve c. Bicuspid aortic valve d. RV muscle band e. Aberrant left coronary artery
Answer: Absent pulmonic valve Absent pulmonic valve – presents with cyanosis and episodes of respiratory distress. Massive regurgitation exists between the pulmonary artery and right ventricle. Associated anomalies include VSD (90%), TOF (50%), and right aortic arch (33%). With a VSD, a large left-to-right shunt develops, which may result in volume overload and congestive heart failure. Radiographs show enlargement of the pulmonary arteries and RV dilatation.
LEAST likely to present with cardiomegaly in a neonate (Neonate with pulmonary edema and large heart. What is least likely cause?): a. Viral myocarditis b. Truncus arteriosus type 2 c. Pericardial effusion d. Obstructive TAPVR e. Anomalous left coronary artery
Answer: Obstructive TAPVR Obstructive TAPVR (or Type III) – The heart size is usually normal, but there is severe interstitial pulmonary edema, thymic atrophy, and depression of the diaphragm. Pericardial effusion is a bit of a trick but I assume they mean enlarged cardiac silhouette. Anomalous left coronary artery - in all of the living patients the CXR revealed cardiomegaly. Type II truncus - only one arterial vessel exits the heart and gives rise to the pulmonary, systemic and coronary arteries; invariably a large VSD present, so that the lesion represents incomplete ventricular and great vessel septation.
CTA of the pulmonary veins is done before treatment of what condition: a. Atrial fibrillation b. PE c. VSD d. Atrial myxoma
Answer: Atrial fibrillation In atrial fibrillation, the arrythmogenic foci are located around the pulmonary veins which can be isolated with RF ablation. To guide the ablation and electroanatomic mapping, various structural imaging techniques have been used consisting of either fluoroscopic angiogram, CT atrial mapping, MR, or combinations of these. Although CT mapping lowers intraprocedural fluoro time, the overall dose is near 20 mSv which is approximately 20 times acceptable background exposure for the general public. The complications of atrial ablation consists of cardiac tamponade, distal infarction from emboli (clot or air), atrial esophageal fistula, pulmonary vein stenosis, phrenic or vagal nerve injury, vascular complications (dissection, hematoma, fistual, pseudoaneurysm), MI, or mitral valve trauma. The procedure uses femoral vein approach with puncture of the atrial septum.
What structure is ablated for resolution of atrial fibrillation? a. Pulmonary veins
Answer: Pulmonary veins Most current treatment approaches for AF aim at ablation around the pulmonary veins (PVs) with or without additional ablation lesion lines. Electrical isolation of the PV from the atrial substrate serves to prevent propagation of arrhythmogenic impulses from the PV to the atria.
What is true of (EKG-gated coronary) CTA: a. Coronary scoring does not require ECG gating b. Multidetector CTA is best performed with retrospective gating c. Arrhythmia improves image quality d. Prospective gating has higher dose than retrospective e. Decreased heart rate reduces the dose
Answer: Multidetector CTA is best performed with retrospective gating Coronary calcium scoring absolutely requires the study to be ECG gated to eliminate motion artifact that limits assessment of the calcium levels within coronary arteries. For ECG gated studies, predictable cardiac rhythm improves image quality, where as tachycardia and arrhythmia degrades image quality. Gating is not needed in electron beam CT. For prospective gating, the present techniques can include dose modulation which will lower patient\'s exposure, particularly during systole whose image data is not used for reconstruction. In addition, no oversampling is typically used during prospective gating acquisition. However, prospective gating technique has been traditionally used with EBCT rather than MDCT. For MDCT, retrospective gating is typically used with oversampling of dataset. This provides better image quality after reconstruction, but increases the dose level. During prospective gating, typically the least motion occurs during diastole (i.e. late in the ECG cycle – 70 to 80% portion - and therefore this period of the ECG cycle is used for imaging. This means that the CT imaging beam is turned on only during this portion of the cycle.This equates to decreased radiation dose. With retrospective gating, scanning is being done during the entire ECG cycle and afterwards (retrospectively) we decide which portions of the ECG cycle generated images to review. Since data is acquired during the entire ECG cycle, it is possible to use this date to get functional data (EF, wall motion, etc.). The optimal imaging heart rate is between 50 and 65 bpm (having longer RR interval). The slower heart rate allows aquisition of diagnostic quality images during diastole, at which time the tube output is optimal for imaging. During systole, the tube output is decreased to lower patient radiation dose. Having slower heart rate allows rapid acquisition, thus decreasing overall exposure time.
What is true of electrocardiographic modulation of the x-ray beam for CTA (retrospected gated coronary CTA)? a. Requires prospective gating b. Longer RR interval results in less radiation dose c. Bradycardia increases radiation dose d. Best done after systole e. Better for arrhythmias
Answer: Longer RR interval results in less radiation dose With current technique using 64 slice MDCT, the optimal imaging heart rate is between 50 and 65 bpm (having longer RR interval). The slower heart rate allows aquisition of diagnostic quality images during diastole, at which time the tube output is optimal for imaging. During systole, the tube output is decreased to lower patient radiation dose. Having slower heart rate allows rapid acquisition, thus decreasing overall exposure time.
What degrades coronary CTA exam accuracy/quality (What lowers sensitivity of coronary CTA)? a. Elevated systolic pressure > 200 b. Elevated diastolic pressure c. Decreased systolic pressure < 90 d. Elevated creatinine > 2 e. Calcium score > 400 f. Heart rate < 65
Answer: Calcium score > 400 Four factors that degrade coronary CTA exam quality: motion artifact, gantry rotation speed, heart rate, and coronary calcification. Agoston score > 1000 lowers the sensitivity from 98 to 71%. .Accuracy begins to decline once there is any coronary calcium at all. However it all depends on the distribution of calcium. Even a low score may make a CTA uninterpretable if the calcium is bunched in the wrong places. There is a new number which may replace the Agatston which measures the total mass of coronary calcium as a more important predictor of coronary events.
40 year old with newly diagnosed aortic stenosis. Most likely diagnosis? a. Bicuspid aortic valve b. Age-related degeneration c. Marfans syndrome d. Cat\'s eye syndrome
Answer: Bicuspid aortic valve Many patients with bicuspid aortic valve remain free of symptoms or problems for many years unless endocarditis occurs or valve calcification develops. Table: Common Reasons of Aortic Stenosis Requiring Surgery Age <70 years (n=324)
What is the most common, characteristic symptom associated with aortic stenosis: a. Left ventricular dilatation b. Angina c. Sinus of valsalva dilatation d. Enlargement of aortic knob e. Bounding pulse f. Palpation of the cardiac pulsation in the left anterior axillary line
Answer: Angina Angina is the earliest manifestation due to inability of heart to increase flow to coronary arteries, and in the case of aortic stenosis has the peculiar feature that patient is more sensitive to vasodilatory effect of nitroglycerin leading to more syncope and hypotension. Angina seen in 30% -40%. Asymptomatic latent period of 10-20 years, then see classic triad of chest pain, heart failure, and syncope. Instead of a bounding pulse, get carotid pulsus parvus et tardus. The ascending aorta dilates (post-stenotic dilatation of ascending aortic arch), not usually the knob. Patients with aortic stenosis will nearly uniformly have LVH from increased end-systolic pressures (this may be the most common finding but not the most common symptom!
LEAST specific finding for traumatic aortic injury: a. Mediastinal hematoma b. Periaortic hematoma (para-aortic fluid) c. Extravasation d. Pseudoaneurysm e. Intimal flap versus What is the LEAST sensitive sign for traumatic aortic injury? a. widened mediastinum b. left apical cap c. depressed L mainstem d. right deviation of NGT
Answer: Mediastinal hematoma, Widened mediastinum (LEAST specific) The direct signs of traumatic aortic injury includes pseudoaneurysm, abnormal aortic contours or abrupt caliber changes, pseudocoarctation, occlusion of a segment of aorta, periaortic hematoma, and an intimal flap. Indirect signs of traumatic aortic injury are mediastinal or retrocrural hematomas. Mediastinal hematoma not in a periaortic location can be caused by mediastinal venous bleeding, esophageal, vertebral, bronchogenic, or pulmonary arterial injury. Absent in 10-15%. If widened mediastinum a choice, would choose this one.
What is left of the native heart in an orthotopic heart transplant: a. Posterior wall of the left atrium b. Aortic valve c. Pulmonary veins d. RA appendage e. Sinuses of valsalva
Answer: Posterior wall of left atrium Following cardiopulmonary bypass, the failing heart is transected from the great vessels and the posterior wall of the LA. Neither the pulmonary veins nor the posterior wall of the LA are transected. Recently, recipient cardiectomy is performed as a two-step procedure. In the first step, the heart is transected at midatrial level, the aorta and pulmonary artery are divided, and the heart is removed. In the second step, the posterior walls of both atria are removed; on the right side, the SVC and IVC are transected at their junction with the right atrium, and on the left side, the left atrium is trimmed, leaving a cuff of tissue around the pulmonary vein orifices. The donor heart left atrium is trimmed, leaving a single orifice where the pulmonary vein entry sites had been, and the right atrium remains intact.
Best modality for detecting vascular calcium (carotid artery calcifications): a. CTA with MIPS b. 2D TOF MR c. 3D TOF MR d. DSA angiography
Answer: CTA with MIPS As we know well, CT is very sensitive to presence of calcium. MR is much less so. Although DSA could potentially detect the secondary effect of vascular calcium, it is not the best modality for vascular calcium detection.
With a pericardial effusion, which of the following has the strongest correlation with pericardial tamponade: a. Size of pericardial effusion b. Enhancement of the pericardium c. Enlargement (diameter) of the SVC d. Enlargement of the pulmonary veins e. Flattening of the RA and RV free walls versus With a pericardial effusion, which is most indicative of hemodynamic compromise? a. flattening of RA, RV b. enhancement of pericardial fluid c. diameter of SVC d. volume of fluid
Answer: Flattening of the RA and RV free walls When the pericardial pressure reaches the right atrial pressure, trivial tampanode is present. Mild tamponade is associated with pericardial pressure equal to that of the left atrial pressure. When the pressure reaches 10-12 mmHg, clinical evidence of cardiac tamponade is noted with abnormal jugular pulse and echocardiography showing concavity of the RA and RV free walls. Specific signs of hemodynamic compromise have included direct evidence of actual elevation in intrapericardial pressures. Diastolic RV outflow collapse and exaggerated right atrial collapse during atrial systole (ventricular diastole) are well validated as signs of elevated intrapericardial pressure. Anatomically and experimentally, the RV outflow tract is the more compressible area of the right ventricle and with significantly elevated intrapericardial pressures tends to collapse. In early diastole, immediately after closing of the pulmonary valve, at the time of opening of the tricuspid valve, the RV outflow tract will paradoxically collapse inward. This is indirect evidence that intrapericardial pressures has exceeded RV diastolic pressures at this timepoint, and hence underlying substrate for tamponade is likely to be present. Collapse of the RV is often best appreciated in the parasternal long and short axis views, but occasionally can be appreciated in the apical four chamber view. When collapse extends from the more compressible outflow tract to the body of the RV, this is evidence that intrapericardial pressure is elevated more substantially.
Most common form of ASD: a. Primum b. Secundum c. Sinus venosus d. Unroofing of the coronary sinus e. Endocardial cushion defect
Answer: Secundum 1. Secundum - most common. 2. Primum - 2nd most common, 50% of Down’s kids (20% of all ASDs) 3. Sinus venosus - 3rd most common, 10% of ASDs. Almost always associated with anomalous connection of the right upper pulmonary vein into SVC. 4. Unroofing of the coronary sinus - 4th most common (1%) 5. Endocardial cushion defect - 5th most common, rare.
10 days s/p MI with transmural delayed enhancement 7 minutes after injection of gadolinium involving the left lateral wall. Corresponds with area of dyskinesis. How do you manage? a. Medical management b. Immediate angioplasty c. Urgent CABG d. Self referral to interventional cardiology e. Stent versus A 10-minute delayed fast spin echo MR sequence demonstrates an area of dyskinesis and delayed enhancement. What is the most appropriate mgmnt? A Medical management B Urgent CABG C Stent D Percutaneous intervention to LAD, RCA, or LCx
Answer: Medical management Delayed transmural or subendocardial enhancement suggests infarcted tissue and improvement in post-cath contractility depends on the degree of transmural enhancement. With no enhancement, there is 78% chance of improvement in contraction. For 1-25% enhancement, 60% chance of improvement; for 26-50% enhancement, 42% chance of improvement. For >50% enhancement, only 10% chance of improvement in contractility was seen. Medical treatment is for nonreversible events. Infarction/scar with delayed hyperenchancement greater than or equal to 50% of the myocardial transmural thickness and dyskinetic, hypokinetic or akinetic wall motion. CABG/Stenting may be used to revascularize reversible events or for ischemic areas detected before an event happens. Infarction/Scar - Dyskinesis with delayed hyperenchancement. Hibernating myocardium or stunned myocardium - Dyskinesis with normal perfusion (can’t tell difference on MRI). On delayed MRI, there is a relatively decreased washout of the gadolinium contrast agent in areas of myocardium that have been replaced by fibrosis or scar. In normal viable myocardium, the gadolinium contrast agent washes out more rapidly than it does from the fibrosis or scar. Since the difference between normal and abnormal myocardium is based on washout kinetics, images that are delayed by 5 to 20 minutes after contrast injection will optimally depict the fibrosis or scar. LGE can also predict the functional recovery after revascularization procedures by directly showing the remaining viable myocardium.
On cardiac MR, a focus of delayed subendocardial enhancement on post-contrast T1 is associated with: a. Ischemia b. Infarct c. Myocarditis d. Neoplasm
Answer: Infarct Regardless, delayed transmural or subendocardial enhancement suggests infarcted tissue and improvement in post-cath contractility depends on the degree of transmural enhancement. Thus, American College of Cardiology Foundation has stated the delayed enhancement MR is indicated in the setting of viability assessment prior to revascularization and necrosis assessment after acute MI. It is important to recognize that delayed myocardial enhancement is not specific for myocardial infarction (both acute and chronic) and can occur in a variety of other disorders, such as inflammatory or infectious diseases of the myocardium, cardiomyopathy, cardiac neoplasms, and congenital or genetic cardiac conditions. Distinguishing acute versus chronic infarction may be difficult with these MR imaging methods. Both acute and chronic infarctions show high signal intensity on delayed enhancement MR images. In general, if the infarction is transmural and chronic, the myocardium will show thinning, whereas the myocardium is normal thickness in acute infarction. However, chronic subendocardial infarction will also frequently have normal thickness of the myocardial wall.
MR delayed-contrast enhancement study utilizing T1 imaging with inversion recovery. The inversion recovery is meant to: a. Null normal myocardium b. Null infarcted myocardium c. Null blood pool d. Null water e. Null fat
Answer: Null blood pool Protocol: image after 10-20 min delay following administration of 0.1 to 0.2 mmol/kg of Gd using an EKG-triggered segmented gradient echo sequence with an inversion pre-pulse that nulls out the normal myocardium. Prior to actual imaging, several inversion times are picked on a single slice through the heart to pick the best inversion time that nulls out the myocardium. Contrast is then given with the heart imaged in the short and long axes. Inversion recovery is used to enhance visualization of the myocardium. IR pulses are used with TIs long enough to null the blood signal reducing intravascular signal giving the black blood images. Two 180° presaturation pulses are used before the SE acquisition is initiated. This results in images on which the blood is truly black termed double inversion recovery (DIR) images. This technique provides superior delineation of the endocardial margin and vessel walls.
What differentiates an angiogenic vessel versus normal vessel? a. Thrombosis b. More layers c. More branches d. More permeable
Answer: More permeable Angiogenic vessel induced by cancer growth is both abnormal in function and structure. With regard to function, they are more permeable to macromolecules. As for structure, they are tortuous, dilated, and have abnormal connectivity (which could potentially represent more branches, though it is universally recognized that the vessels are more permeable, leading to enhancement). The pericytes and basement membranes are aggregated and thickened and at others scattered and thin.
Alcoholic cardiomyopathy is associated with: A Impaired LV systolic function B Impaired RV systolic function C Impaired LV diastolic function D Impaired RV diastolic function E Impaired LV systolic & diastolic function
Answer: Impaired LV systolic & diastolic function Alcoholic cardiomyopathy is a dilated cardiomyopathy which typically has decreased EF, consistent with systolic dysfunction. Diastolic dysfunction is associated with inability of the myocardium to relax during diastole for proper filling of the ventricles. Established alcoholic cardiomyopathy is characterized by pronounced LV dilatation, increased LV mass, thin (or normal) LV walls, diastolic dysfunction (asymptomatic phase) and systolic impairment (symptomatic phase). Early discovery and abstinence from alcohol may reverse pathologic findings.
Most likely diagnosis with dilated left superior intercostal vein: a. Azygous continuation of the IVC b. Subclavian steal c. Left sided SVC d. SVC obstruction e. PAPVR of LUL
Answer: SVC obstruction The left superior intercostal vein can be seen on PA radiograph as a small nipple projecting laterally from the aortic arch. The upper limits of normal was defined as 4.5 mm with average of 2.3 mm and SD of 1.1 mm. Dilated left superior intercostal vein is associated with several abnormalities including absence of the inferior vena cava, hypoplasia of the left innominate vein, congestive failure, portal hypertension, Budd-Chiarl syndrome, superior or inferior vena caval obstruction, mediastinal mass (especially lymphadenopathy and aneurysm of the arch of the aorta). The vein may also dilate with persistent left SVC which is rare at 0.3% of the general population. Given three rare options including azygous continuation of the IVC, left sided SVC, and obstruction of SVC, I would probably choose SVC obstruction given how common catheter related complication, aortic aneurysm, and malignancy are. The LSIV dilates because of communication between the SVC and the azygos-hemiazygos system. It is the remnant of the upper left cardinal vein, and drains into a persistent left SVC when this anomaly is present.
Regarding myocardial ischemia in anomalous origin of the left coronary artery, what is the pathologic mechanism (likely cause of angina)? a) \"steal\" phenomena with retrograde flow in the left coronary artery b) poorly oxygenated blood from the pulmonary vascular system c) congenitally small (left) coronary arteries. d) microocclusions of small perforating branches e) Propensity for atherosclerotic change versus
Answer: Steal phenomena with retrograde flow in the left coronary artery Anomalous origin of the coronary artery from the pulmonary artery (ALCAPA) is one of the most serious congenital coronary artery anomalies. One in 300,000 live births. Most affected patients show symptoms in infancy and early childhood. Approximately 90% of untreated infants die in the 1st year of life, and only a few patients survive to adulthood. In the most common form of this disease, the LCA arises from the pulmonary artery and the RCA arises normally from the aorta (Bland-White-Garland syndrome). Coronary angiography usually helps confirm the diagnosis of ALCAPA and demonstrates collateral circulation between the RCA and LCA and a coronary \"steal\" phenomenon into the pulmonary artery. Treatment of ALCAPA consists of recreation of dual coronary perfusion. In infantile type ALCAPA, either (a) direct reimplantation of anomalous LCA into aorta or (b) creation of an intrapulmonary conduit from left coronary ostia to the aorta (Takeuchi procedure) may be used. In adult type ALCAPA, ligation of the LCA from the pulmonary artery, combined with coronary artery bypass grafting with use of internal mammary artery or the saphenous vein. Mechanism: with postnatal fall in pulmonary arterial pressure, perfusion of LCA drops (ischemic left coronary bed) as flow is preferentially directed towards the lower-resistance pulmonary vascular bed (steal); there may be collateral flow from RCA with flow reversal in LCA. If adequate collateral circulation = lifesaving. If inadequate collateral circulation = myocardial infarction. Large collateral circulation = L-to-R shunt with volume overload of the heart.
What is the most common cardiac manifestation of SLE? a. coronary artery vasculitis/disease b. myocarditis c. valvular disease d. pericarditis e. coronary calcifications
Answer: Pericarditis Most frequently observed complications of SLE are: pericarditis and/or pericardial effusion (39%), arterial hypertension (22%), ischemic heart disease (16%), myocarditis (14%), congestive heart failure (10%), pulmonary hypertension (9%), valvular heart disease (9%), pleural effusion (7%) and cerebrovascular accident (3%).
Drainage of a left sided SVC is most commonly into: a. Coronary sinus b. Pulmonary vein c. IVC d. Right atrium
Answer: Coronary sinus L SVC: persistent left common cardinal vein, usually drains to coronary sinus (90%) (other 10% drain into LA producing small R to L shunt), associated with normal-to-decreased R SVC, minority absent R SVC, majority absent L brachiocephalic vein; incidence 0.2-0.4% all patients, 3-10% congenital heart disease (drain directly into LA-Raghib syndrome with unroofed coronary sinus) . DDx: PAPVR from LUL, prominent L superior intercostal vein.
FMD of the renal arteries treated how? a. Angioplasty b. Self-expandable stent c. Balloon expanding stent
Answer: Angioplasty Angioplasty only. If flow-liming dissection, then stent with bare metal stent (not covered stent). Covered stent graft: use for aneurysm, rupture, fistula rupture. Balloon expandable stent: use in regions of low flexion or body motion (e.g. renals), they have better hoop strength. Self expanding stent: use in regions of high flexion or body motion (eg SFA, carotids).
Which is FALSE regarding fibromuscular dysplasia? a. Involves ICA more often than ECA b. Associated with intracranial saccular aneurysms c. Most often unilateral d. Associated with dissection e. String of pearls appearance
Answer: Most often unilateral (FALSE) FMD: 3:1 F>M, age 30-50, bead on string appearance, mid and distal RAs, 40-70% bilateral; most common type is medial fibroplasia: renal and carotid 25-50 yo females. FMD consists of nonatheromatous fibrous and muscular thickening alternating with dilatations of the arterial wall which produces a “string of pearls” appearance. In the CNS, most commonly involves the internal carotid approximately 2cm from the bifurcation. Multiple vessel involvment is common, bilateral carotid involvement occurs in 60%. Appears to be an association between intracranial aneurysms and FMD. Complications include spontaneous dissection, aneurysm rupture, and HTN.
What is TRUE regarding fibromuscular dysplasia? a. typically unilateral b. may cause saccular intracranial aneurysms of the carotid c. more common in males d. responds poorly to angioplasty
Answer: May cause saccular intracranial aneurysms of the carotid Bilateral involvement in 65% of patients Carotid artery is sometimes involved in FMD, and 25% of carotid FMD have associated intracranial aneurysms. Most common in young to middle aged women. Over 98% respond well to angioplasty.
Which is true about blunt aortic injury? a. Normal contrast enhanced spiral CT has negative predictive value of >98% b. First rib fracture is predictive c. The most common site is aortic root d. Negative CXR rules out aortic injury
Answer: Normal contrast enhanced spiral CT has NPV of >98% First rib fracture is a risk factor but of little predictive value. Most common site of transection is at ligamentum arteriousum/aortic isthmus (90%), aortic root (7-8%) most die at the scene; at diaphragm (2-3%). Fake-outs: Kommerrell, ductus diverticulum.
In coronary CTA, what type of ECG gating is used: a. prospective b. retrospective
Answer: Retrospective Retrospective for coronary CTA. Prospective for coronary calcium. Understand the following statement for all CTA gating questions: Prospective triggering directs the CT scanner to take X-ray scans only at a certain phase of the cardiac cycle. It is usually the diastolic phase because this is when the heart has the least motion. Prospective triggering has the advantage of minimizing X-ray exposure because only the minimum data needed are acquired. However, it depends on a regular heart rate because an arrhythmic heart may confuse ECG trigger. Also, because the motion patterns of the major cardiac arteries differ during the cardiac cycle, prospective triggering may produce images optimized for only some of the arteries. Retrospective gating, the heart is scanned continuously for several cycles, but only scans from a particular phase of the ECG are used for image reconstruction. This improves visualization of the heart but higher dose of X-ray radiation.
Which of the following requires a PDA to survive? a) Hypoplastic left heart syndrome (HLHS) b) Corrected transposition c) Tetralogy of Fallot d) Coarctation e) TAPVR Truncus
Answer: Hypoplastic left heart syndrome (HLHS) a) Shone syndrome = Aortic atresia. See small LV, small LA, small ascd AO. Hemodynamics: RV supplies PA, ductus arteriosis, descending aorta, and ascending aorta/arch via retrograde flow. b) Corrected transposition aka L-trans. c) TOF – PDA masks the neonates’ symptoms, when PDA closes – cyanosis at 3 to 4 months. d) Coarctation – Adult and pedi type exist. Pedi – PDA prevents CHF but not necessary for survival. e) TAPVR – Anamolous connection b/n pulm vessels & systemic veins. Patent foramen ovale necessary for survival. ASD restores oxygenated blood to left side. f) Truncus – Left and right heart already connected at their origin (single outlet of heart).
In total anomalous pulmonary venous return (TAPVR), what forms the upper side of the “snowman”? a. pulmonary artery b. pulmonary vein c. right sided aorta d. vertical vein
Answer: Left vertical vein Type I TAPVR (supracardiac type), the heart has a \"snowman shape.\" The pulmonary veins drain into an enlarged vertical vein (left superior mediastinal border) which in turn drains into the brachiocephalic vein and then to the superior vena cava (right superior mediastinal border). The pulmonary vasculature on CXR is shunt vascularity. TAPVR must also have R to L shunt for survival, obligatory ASD to return blood to the systemic side, all are cyanotic, identical oxygenation in all four chambers.
Most commonly associated with an abdominal aortic stenosis? a. Takayasu\'s arteritis b. PAN c. Buergers d. Giant cell arteritis e. Temporal arteritis
Answer: Takayasu’s arteritis a. Takayasu’s = smooth stenosis of medium/large arteries, can be in multiple locations and have aneurysms, can have aortic occlusion, pulmonary artery involvement is specific; young female. b. not PAN - small to medium sized arteries, necrotizing, results in smooth stenosis with multiple small aneurysms c. not Buerger\'s - also small to medium, stenoses and occlusions of arteries + veins in calves and hands d. Giant cell arteritis = Temporal arteritis - medium/large, alternating segments of smooth narrowing/aneurysmal dilatation, can involve aorta in abdomen rarely, elderly female.
Supply to the posterolateral wall heart (posterolateral hypokinesis, what vessel is affected?) a. Left circumflex artery b. LAD c. Left main coronary artery d. Right coronary artery versus MRI demonstrates akinesia of the posterolateral wall of the LV, this is most likely caused by ischemia in the: a. LAD b. Left Main c. Left Cx RCA
Answer: Right coronary artery R dominance – R main coronary artery supplies PDA and > 1 branch of posterolateral artery (PLA), 85% L dominant – L main coronary artery supplies PDA and PLA, 10% Codominant - R main coronary artery supplies PDA, L main coronary artery supplies PLA, 5% LAD
What is a branch of the LAD? a. Obtuse Marginal b. Acute Marginal c. Conus d. Diagonal e. PDA
Answer: Diagonal The posterior walls are supplied by the left circumflex or the RCA whichever gives rise to the PDA. The LAD provides septal perforators that supply ventricular septum and the diagonals that supply the anterior wall of LV. The left circumflex gives rise to the obtuse marginals which supply the lateral wall of the LV. The RCA gives rise to the acute marginals which supply the RV.
What is a branch of the left circumflex? a) posterolateral branch b) acute marginal c) obtuse marginal
Answer: Obtuse marginal
Septal defect, perfusion is by: a. LAD b. Right coronary c. Circumflex d. Main Left coronary Marginal artery
Answer: LAD
What is the location of the moderator band? a. right ventricle b. right atrium c. left ventricle d. left atrium
Answer: Right ventricle The septomarginal trabecula (or moderator band) is a muscular band of heart tissue found in the right ventricle. It frequently extends from the base of the anterior papillary muscle to the ventricular septum. From its attachments it was thought to prevent overdistension of the ventricle, and was named the \"moderator band\". However, more recent research has indicated that it is more properly considered part of the electrical conduction system of the heart. The moderator band is often used by radiologists to more easily identify the right ventricle in prenatal ultrasound.
Which flow jet is seen in the correct phase of cardiac cycle (During cardiac MR a jet of high velocity flow is seen with): A. Systolic jet with aortic stenosis B. Diastolic jet with mitral insufficiency C. Diastolic jet with pulmonic stenosis D. Systolic jet with tricuspid stenosis E. Diastolic jet with aortic stenosis
Answer: Systolic jet in aortic stenosis (aortic stenosis during systole) Aortic stenosis - systolic flow jet. Aortic regurgitation - early diastolic flow jet posteriorly along anterior mitral leaflet. Mitral stenosis - diastolic flow jet into LV. Mitral regurgitation (acute) - early systolic jet to LA. Mitral insufficiency - systolic jet. Tricuspid regurgitation - systolic jet into RA. Tricuspid stenosis - diastolic jet. Pulmonic stenosis - systolic jet.
To calculate ejection fraction (measure LV function quantitatively), the MRI sequence used is: a. Short axis cine b. Short axis fast spin echo c. Long axis cine d. Long axis spin echo e. Horizontal long axis cine
Answer: Short axis cine In short axis cine, the ventricular volume is calculated in diastole and end systole to determine the EF. The first step in the calculation of ventricular volume is the selection of representative ED and ES cardiac-phase images. Phase images that depict the largest and smallest ventricular volumes or the phase images obtained immediately before mitral valve closure (ie, ED) and opening (ie, ES) are chosen. Next, the RV and LV are traced along the endocardial margin on each section obtained in the selected ED and ES phases from the cardiac apex to the section just prior to one that depicts the mitral and tricuspid valves. The tracings should exclude trabeculations but may include papillary muscles inside the endocardial margin, as long as the procedure is performed in systole and diastole.
With cardiac MR, the best sequence for evaluating EF is: A Cine spin echo B Cine phase contrast C Spoiled gradient echo D First pass imaging
Answer: Spoiled gradient echo Conventional EF calculations done are done with fast gradient echo techniques. SSFP (Steady state free procession) techniques are the newer ways so they may be a better answer (FIESTA, FISP). In these, image contrast is determined by T2/T1 ratio of the tissue. Blood has much higher T2/T1 ratio than the myocardium, thus excellent contrast between blood and myocardium. Visualization of valve leaflets, papillary muscles, and pericardium are also good with this technique as is cardiac functional analysis. Cine phase contrast is a gradient echo pulse sequence in combination with ECG triggering or gating. This technique is used to assess flow volumes and velocity profiles across valves and shunts. Obviously the MR has to be cine (gated). But one also needs good contrast between myocardium and blood. As stated above phase is used for velocity and direction of flow and spin echo doesn’t meet our needs primarily due to long acquisition times. So the two “cine” choices are distractors for anyone looking for the term “cine”. Gradient echo imaging with ECG gating (cine) meets our needs (FLASH, FISP, FIESTA, TrueFISP are giving better myocardial delineation with accuracy).
Interstitial pulmonary edema in 4 day old with normal size heart. What is the most likely diagnosis? (Most common cause of pulmonary edema in a neonate with CHD:) a. Infradiaphragmatic TAPVR b. Single ventricle c. Tetralogy of Fallot d. Transposition of great vessels e. PDA versus In a four day old with pulmonary vascular congestion and a normal heart size, which of the following is likely? a. TAPVR type III (infradiaphragmatic) b. Truncus arteriosus c. Transposition of great arteries d. TAPVR type I (supracardiac)
Answer: Infradiaphragmatic TAPVR (TAPVR type III) Differential diagnosis of a cyanotic infant with pulmonary edema and normal heart size includes: 1) Infradiaphragmatic TAPVR (most common) 2) Cor triatriatum (rare) 3) Atresia of the common pulmonary vein (rare) In infradiaphragmatic TAPVR, veins cross the diaphragm to drain into infradiaphragmatic veins, thus there is a high propensity for stenosis and resultant venous hypertension. 4 Types of TAPVC: 1. Supracardiac connection (50%), most common; infrequently associated with obstruction. 2. Cardiac connection (30%). 3. Infracardiac connection (15%); majority are obstructed. 4. Mixed (5%). Associations: 1. Patent foramen ovale, ASD (necessary to sustain life). 2. Heterotaxy syndrome (asplenia more common). 3. Cat\'s eye syndrome. Clinical: Symptomatology depends on presence or absence of obstruction. If obstructed, pulmonary edema within several days after birth and heart size is normal. If nonobstructed, asymptomatic at birth, but CHF develops during first month. 80% mortality by 1st year. TAPVC causes a complete L-to-R shunt at the atrial level; therefore to sustain life, an obligatory R-to-L shunt must be present. Pulmonary flow is greatly increased, leading to dilatation of RA, RV, and PA. Obstruction has 3 consequences = 1. Pulmonary venous hypertension (PVH) and pulmonary arterial hypertension (PAH). 2. Pulmonary edema. 3. Diminished pulmonary return to the heart, which results in low cardiac output
A neonate with increased pulmonary vascularity may include all of the following EXCEPT: A. Total anomalous pulmonary venous return type III (subdiaphragmatic) B. Tetrology of Fallot C. Hypoplastic left heart syndrome D. Transposition of the great arteries
Answer: Tetrology of Fallot (NOT increased pulmonary vascularity) Cyanotic with increased vascularity: D-TGA, Truncus arteriosus, TAPVR, TA+TGA, Single ventricle, DORV, PA+VSD, Eisenmenger\'s Cyanotic with decreased vascularity: TOF, TA, PAIVS, Ebstein\'s
Location of azygos vein (enters SVC at which location)? a. superior and posterior to RUL bronchus (right main bronchus) b. superior and anterior to RUL bronchus (right main bronchus) versus The azyos vein inserts on the SVC: A) anteriorly and superior to RPA B) anteriorly and inferior to RPA C) posteriorly and inferior to RPA D) posteriorly and superior to RPA
Answer: Superior and posterior to RUL bronchus (superior and posterior to right main bronchus) The azygous vein runs superior and posterior to the RUL bronchus or right main bronchus The azygous vein runs superior and anterior to the right pulmonary artery
What is immediately anterior to LUL bronchus? a. Left pulmonary artery b. Ascending aorta c. Left atrial appendage d. Main pulmonary artery e. Superior pulmonary vein
Answer: Superior pulmonary vein
In coronary CTA, which is used to reduce motion artifact (slow heart rate): a. metoprolol b. benadryl c. versed d. diltiazem
Answer: Metoprolol Metoprolol is used to get heart rate down to 60. Dose: 5 mg IV up to x 3 to achieve a HR < 65 bpm
Coarctation of the aorta is most commonly associated with: a. Bicuspid aortic valve b. ASD c. VSD versus Bicuspid aortic valve is associated with what CHD? a. Tetralogy of Fallot b. Aortic coarctation
Answer: Bicuspid aortic valve is commonly associated with aortic coarctation Aortic coarctation associations include bicuspid aortic valve (in > 50% of cases), coarctation syndrome” = triad of aortic coarctation, PDA, VSD; in Turner syndrome, it’s the most common cardiac abnormality; hypoplasia of the aortic isthmus (“small arch”); Circle of Willis aneurysms (10%), PDA aneurysm, tricuspid atresai, TGV, intracardiac defects. Pathophysiology: Diffuse arteriopathy involving the media of the vessel wall; M > F, more than 2:1 2 types: Infantile = preductal (prox to ductus arteriosus), diffuse; Adult = peri/postductal, short segment, common Clinical findings: 1) blood pressure difference between arms and legs; 2) infantile diffuse type presents as neonatal CHF: 3) adult localized type often asymptomatic, typically presents in young adulthood Hemodynamics: collaterals to the descending aorta; infantile preductal type has R-to-L shunting via PDA or VSD; and adult postdutal type has L-to R shunting through PDA Imaging: MRI is study of choice. Shows site and length of coarctation. Can quantify flow and evaluate collaterals.
Regarding bicuspid aortic valve, all are true EXCEPT: A. Increase incidence of endocarditis compared with the tricuspid valve B. A calcified bicuspid valve is more likely to be stenotic than calcified tricuspid valve C. Has the same incidence of mitral valve disease as a tricuspid aortic valve
Answer: Has the same incidence of mitral valve disease as a tricuspid aortic valve (FALSE) Most common form of aortic stenosis is valvular type (60-70 %). Degeneration of bicuspid valve with calcification is the most common cause of aortic stenosis. Bicuspid valve is also responsible for 50% of aortic valvular bacterial endocarditis. Mitral valve prolapse has an incidence of 2-6 % of general population (Dahnert 293
Which of the following is associated wih aortic coarctation? a. Turner\'s syndrome
Answer: Turner\'s syndrome Bicuspid aortic valve is observed in 85% of patients in Turner\'s syndrome. Coarctation of aorta occurs in 35% of Turner syndrome patients. Most commonly reported cardiac defect in Turner\'s syndrome is left-sided obstructive or hypoplastic defects and VSDs. VSDs associated with coarctation include the perimembranous, muscular or malalignment types. Subvalvar aortic stenosis and a malalignment VSD is particularly common in the critically ill infant with coarctation.
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