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INTERNAL MEDICINE BOARD
REVIEW – CARDIOLOGY
BY KAIS AL BALBISSI, MD, FACC, FSCAI
I HAVE NO DISCLOSURES
CARDIOLOGY INTERNAL MEDICINE BOARD REVIEW
• Coronary Artery Disease
• Adult Congenital Heart Disease
Internet Source: doccartoon.blogspot.com
Internet Source: doccartoon.blogspot.com
QUESTION 1
A 32 year old female with previous history of SLE, presented to her PCP with recurrent
retrosternal chest pain upon exertion relieved with rest for the past 6 months.
She is a smoker. Her mother died of an MI at an age of 59. Upon P/E, her Pulse
is 88, BP 147/92. BMI 29. No JVD. Clear lungs. RRR, no murmurs. No
peripheral edema. Her ECG revealed NSR, no acute ST changes. Her WBC 9.0,
Hb 11, PLT 200. BUN/Cr 25/1.0. hsCRP 2.0 mg/dl. Troponins are negative.
What would be your next step to evaluate the patient’s chest pain.
A. Treat with a trial of NSAIDs. No further work up needed.
B. Exercise Treadmill Stress Test only
C. Adenosine Nuclear Stress Test
D. Exercise Treadmill Nuclear Stress Test
E. Left Heart Catheterization
QUESTION 2
A 52 year old male with previous history of HTN, presented to his PCP with recurrent
epigastric chest pain upon exertion for the past 2 months. Upon P/E, his Pulse is
72, BP 150/89. No JVD. Clear lungs. RRR, no murmurs. No peripheral edema.
His ECG revealed NSR with an old LBBB. Renal function normal. What would be
your next step to evaluate the patient’s chest pain.
A. Treat with a Trial of PPI. No further work up needed.
B. Exercise Treadmill Stress Test only
C. Adenosine Nuclear Stress Test
D. Exercise Treadmill Nuclear Stress Test
E. Left Heart Catheterization
EPIDEMIOLOGY OF CAD
Incidence in USA (Per Year)
Chest Pain
> 5 million
Non ST Elevation ACS
1.7 million
ST Elevation MI
1.5 million
Death due to STEMI
0.6 million (1/3 deaths)
Epidemiology of ACS
< 65 years
45% of MI
< 40 years
5% of MI
Incidence of MI only slight decrease
Mortality from MI considerable decrease (50%)
PREVENTION OF CAD – RISK FACTORS
Established
Novel Risk Factors
Modifiable
Non Modifiable
High LDL-Cholesterol
Age
Inflammatory markers
Low HDL-Cholesterol
Male Sex
Small Dense LDL
Cigarette Smoking
Family History of Premature CAD
(1st degree < 55 for men, < 65 for
women)
Lipoprotein (a)
Hypertension
Homocysteine
Diabetes
Fibrinogen
Sedentary Life Style
Coronary Artery Ca
Obesity
Metabolic Syndrome
Stress and Depression
Socioeconomic factors
INTERHEART Study, Framingham Heart Study
CHRONIC STABLE ANGINA
O2 Supply
O2 Demand
CHRONIC STABLE ANGINA
Chest Pain
• Retrosternal
Typical
3/3
• On Exertion
Atypical
2/3
• Relieved with Rest or NTG
Non Anginal
1/3
CHRONIC STABLE ANGINA
Low
Typical CP
Atypical CP
Non Anginal CP
Intermediate
High
M
30 - 39
40 - 49
50 - 59
60 - 69
F
30 - 39
40 - 49
50 - 59
60 - 69
M
30 - 39
40 - 49
50 - 59
60 - 69
F
30 - 39
40 - 49
50 - 59
60 - 69
M
30 - 39
40 - 49
50 - 59
60 - 69
F
30 - 39
40 - 49
50 - 59
60 - 69
CHRONIC STABLE ANGINA
CVS Symptoms
Pre-Test Probability
Low
Intermediate
No W/u
ETT only
High
Medical Rx
Exercise Ability, ECG & Comorbidities
ETT MPI
ETT Echo
Vasodilator
MPI
Cardiac Catheterization
Dobutamine
MPI
Dobutamine
Echo
CHRONIC STABLE ANGINA - TREATMENT
Anti-Anginal
B-Blockers
Cardiovascular
Protective
ASA
Revascularization
PCI
•Plavix
Long Acting Nitrates
Statin
CABG
ACEI
Hybrid
Ca Channel Blockers
Ranolazine
CHRONIC STABLE ANGINA – TREATMENT: REVASCULARIZATION
PCI
CABG
 Indications:
 Indications:
 Symptomatic despite optimal
medical therapy
 Medical Therapy limited by adverse
effects of medications
 High-risk findings on noninvasive
imaging
 Relieves Symptoms
 Does not improve Survival
 Does not prevent MI
 Does not improve LV function
 LM
 MV CAD with Proximal LAD or LV
Dysfunction
 Excellent Symptom relief
 Improves Survival
 Does not prevent MI
 Does not decrease V. arrhythmias
 Does not uniformly improve LV
function
High Risk Features on Non Invasive Cardiac Testing:
• Significant ST Depression > 2 mm at low workload
• ST Elevation
• Hypotension
• Transient Ischemic Dilation (TID)
• Lung uptake of Thallium
• Ischemia > 2 vascular distribution
• EF < 35% or Fall in EF with Stress
QUESTION 1
A 32 year old female with previous history of SLE, presented to her PCP with recurrent
retrosternal chest pain upon exertion relieved with rest for the past 6 months.
She is a smoker. Her mother died of an MI at an age of 59. Upon P/E, her Pulse
is 88, BP 147/92. BMI 29. No JVD. Clear lungs. RRR, no murmurs. No
peripheral edema. Her ECG revealed NSR, no acute ST changes. Her WBC 9.0,
Hb 11, PLT 200. BUN/Cr 25/1.0. hsCRP 2.0 mg/dl. Troponins are negative.
What would be your next step to evaluate the patient’s chest pain.
A. Treat with a trial of NSAIDs. No further work up needed.
B. Exercise Treadmill Stress Test only
C. Adenosine Nuclear Stress Test
D. Exercise Treadmill Nuclear Stress Test
E. Left Heart Catheterization
QUESTION 1
A 32 year old female with previous history of SLE, presented to her PCP with recurrent
retrosternal chest pain upon exertion relieved with rest for the past 6 months.
She is a smoker. Her mother died of an MI at an age of 59. Upon P/E, her Pulse
is 88, BP 147/92. BMI 29. No JVD. Clear lungs. RRR, no murmurs. No
peripheral edema. Her ECG revealed NSR, no acute ST changes. Her WBC 9.0,
Hb 11, PLT 200. BUN/Cr 25/1.0. hsCRP 2.0 mg/dl. Troponins are negative.
What would be your next step to evaluate the patient’s chest pain.
A. Treat with a trial of NSAIDs. No further work up needed.
B. Exercise Treadmill Stress Test only
C. Adenosine Nuclear Stress Test
D. Exercise Treadmill Nuclear Stress Test
E. Left Heart Catheterization
QUESTION 2
A 52 year old male with previous history of HTN, presented to his PCP with recurrent
epigastric chest pain upon exertion for the past 2 months. Upon P/E, his Pulse is
72, BP 150/89. No JVD. Clear lungs. RRR, no murmurs. No peripheral edema.
His ECG revealed NSR with an old LBBB. Renal function normal. What would be
your next step to evaluate the patient’s chest pain.
A. Treat with a Trial of PPI. No further work up needed.
B. Exercise Treadmill Stress Test only
C. Adenosine Nuclear Stress Test
D. Exercise Treadmill Nuclear Stress Test
E. Left Heart Catheterization
QUESTION 2
A 52 year old male with previous history of HTN, presented to his PCP with recurrent
epigastric chest pain upon exertion for the past 2 months. Upon P/E, his Pulse is
72, BP 150/89. No JVD. Clear lungs. RRR, no murmurs. No peripheral edema.
His ECG revealed NSR with an old LBBB. Renal function normal. What would be
your next step to evaluate the patient’s chest pain.
A. Treat with a Trial of PPI. No further work up needed.
B. Exercise Treadmill Stress Test only
C. Adenosine Nuclear Stress Test
D. Exercise Treadmill Nuclear Stress Test
E. Left Heart Catheterization
QUESTION 3
A 75 year old male with previous history of HTN, DM, presented to ED with retrosternal chest pain
fluctuating in severity more on exertion in last week but today he had a severe episode which
prompted his visit to ED. He is a smoker. His home meds are Lisinopril, Aspirin and Metformin.
Upon P/E, Pulse is 88, BP 157/92. No JVD. Clear lungs. RRR, no murmurs. No peripheral
edema. ECG shown below. Normal Renal Function. Troponins are negative. The patient chest
pain improved after Morphine, ASA, NTG paste and O2 supplement. What would be your next
step to treat the patient’s chest pain.
A. Schedule patient for Exercise Treadmill Nuclear Stress Test
B. Start patient on B-blockers, provide NTG SL prn and D/C Home.
C. Start patient on B-Blockers and LMWH. Then, Schedule patient for Exercise Stress in am.
D. Start patient on B-Blockers and LMWH. Then, Schedule patient for Regadenosine Stress in am.
E. Start patient on B-Blockers and LMWH. Then, Schedule patient for LHC.
ACUTE CORONARY SYNDROME (ACS)
Acute Coronary
Syndrome
ST Elevation MI
Non ST Elevation
ACS
Unstable
Angina
NSTEMI
NON ST ELEVATION ACS – CLINICAL PRESENTATION
1. Chest Pain
2. ECG
Rest
Worsening
3. Cardiac Biomarkers
New Onset
ACUTE CORONARY SYNDROME
Non ST Elevation ACS – High Risk Features
TIMI Risk Score
TIMI Risk Score
Age ≥ 65
Low
0-2
Recent (≤ 24hr) Severe Angina
Intermediate
3-4
Known CAD (≥ 50% stenosis)
High
5-7
≥ 3 CAD Risk factors
ASA use in past 7 days
ST deviation
Elevated Cardiac markers
NON ST ELEVATION ACS - TREATEMENT
Initial Therapy
• Monitoring
• Analgesia
• O2
• NTG
• Aspirin
• B-Blockers
• Statins
• Anticoagulation
Risk Stratification & Clinical Assessment
Invasive Strategy
May add
• Plavix
• GPIIb/IIIa inhibitor
Coronary
Angiography
+/Revascularization
Conservative Strategy
• Add Plavix
• May add GPIIb/IIIa inhibitor
High Risk Features
No Symptoms
Not Low Risk
Stress test
Low Risk
Stress Test
Low EF ≤ 40%
Preserved EF > 40%
Medical Therapy
Patient not suitable for Invasive Strategy
QUESTION 3
A 75 year old male with previous history of HTN, DM, presented to ED with retrosternal chest pain
fluctuating in severity more on exertion in last week but today he had a severe episode which
prompted his visit to ED. He is a smoker. His home meds are Lisinopril, Aspirin and Metformin.
Upon P/E, Pulse is 88, BP 157/92. No JVD. Clear lungs. RRR, no murmurs. No peripheral
edema. ECG shown below. Normal Renal Function. Troponins are negative. The patient chest
pain improved after Morphine, ASA, NTG paste and O2 supplement. What would be your next
step to treat the patient’s chest pain.
A. Schedule patient for Exercise Treadmill Nuclear Stress Test
B. Start patient on B-blockers, provide NTG SL prn and D/C Home.
C. Start patient on B-Blockers and LMWH. Then, Schedule patient for Exercise Stress in am.
D. Start patient on B-Blockers and LMWH. Then, Schedule patient for Regadenosine Stress in am.
E. Start patient on B-Blockers and LMWH. Then, Schedule patient for LHC.
QUESTION 3
A 75 year old male with previous history of HTN, DM, presented to ED with retrosternal chest pain
fluctuating in severity more on exertion in last week but today he had a severe episode which
prompted his visit to ED. He is a smoker. His home meds are Lisinopril, Aspirin and Metformin.
Upon P/E, Pulse is 88, BP 157/92. No JVD. Clear lungs. RRR, no murmurs. No peripheral
edema. ECG shown below. Normal Renal Function. Troponins are negative. The patient chest
pain improved after Morphine, ASA, NTG paste and O2 supplement. What would be your next
step to treat the patient’s chest pain.
A. Schedule patient for Exercise Treadmill Nuclear Stress Test
B. Start patient on B-blockers, provide NTG SL prn and D/C Home.
C. Start patient on B-Blockers and LMWH. Then, Schedule patient for Exercise Stress in am.
D. Start patient on B-Blockers and LMWH. Then, Schedule patient for Regadenosine Stress in am.
E. Start patient on B-Blockers and LMWH. Then, Schedule patient for LHC.
QUESTION 4
A 78 year old female with previous history of HTN, presented to a Rural Urgent care center with severe
retrosternal chest pain for last 4 hours. Upon P/E, Pulse is 106, BP 103/55. No JVD. Clear lungs. RRR,
no murmurs. No peripheral edema. ECG shown below. Normal Renal Function. Troponins 1st set
negative. The closest hospital is a small community hospital which is 5 min away while the closest
tertiary hospital with a cath lab is 45 min away . What would be your next step be:
A. Start ASA, Morphine, NTG, IV B-Blockers. Administer Lytics and admit to Community hospital CCU.
B. Start ASA, Morphine, NTG, IV B-Blockers. Administer Lytics and Transfer tertiary hospital.
C. Start ASA, Morphine, NTG, IV B-Blockers. Transfer to Tertiary hospital for primary PCI.
D. Start ASA, Morphine, NTG, Heparin. Transfer to Tertiary hospital for primary PCI.
E. Start ASA, Morphine, NTG, IV B-Blockers and Heparin. Transfer to Tertiary hospital for primary PCI.
ST ELEVATION MI
Clinical Presentation:
 Chest Pain
 ECG
 Cardiac Biomarkers
Initiate Medical
therapy
STEMI Time from onset of Symptoms
High Risk Features
Risk of Thrombolytic Therapy
Time to achieve balloon inflation with PCI
ASA
Plavix
B-Blockers
NTG
Anticoagulation
Non PCI Capable
PCI Capable
DTB vs. DTN
Lysis Prefered
Sx < 3 hrs
DTN < DTB by 60 min
Thrombolytic therapy
Primary PCI
Rescue PCI
Long Term Therapy
ASA
Plavix
B-Blockers
ACEI
NTG
Statin
Successful Lysis
Risk Stratification
Clinically Significant Ischemia
EF < 40%
Coronary Angiography +/- Revascularization
COMPLIATIONS OF MI
Complications of Acute MI
 Cardiogenic Shock
 Arrhythmias & Conduction Disturbances
 Cardiogenic Shock
 RV Infarction / Ischemia
 Ischemic MV Regurgitation
 VSD
 LV Free Wall Rupture
NOTES ON CAD
•
•
•
•
•
Non Invasive Testing has lower specificity in Women.
Atypical presentation in women more common
Poorer Prognosis in Women
• Older age at presentation
• Co-morbidities
• Delayed presentation
• Higher bleeding complications
Low Risk Women with Non ST ACS do better with conservative approach
No added benefit with plavix in DM for primary prevention for CAD
QUESTION 4
A 78 year old female with previous history of HTN, presented to a Rural Urgent care center with severe
retrosternal chest pain for last 4 hours. Upon P/E, Pulse is 106, BP 103/55. No JVD. Clear lungs. RRR,
no murmurs. No peripheral edema. ECG shown below. Normal Renal Function. Troponins 1st set
negative. The closest hospital is a small community hospital which is 5 min away while the closest
tertiary hospital with a cath lab is 45 min away . What would be your next step be:
A. Start ASA, Morphine, NTG, IV B-Blockers. Administer Lytics and admit to Community hospital CCU.
B. Start ASA, Morphine, NTG, IV B-Blockers. Administer Lytics and Transfer tertiary hospital.
C. Start ASA, Morphine, NTG, IV B-Blockers. Transfer to Tertiary hospital for primary PCI.
D. Start ASA, Morphine, NTG, Heparin. Transfer to Tertiary hospital for primary PCI.
E. Start ASA, Morphine, NTG, IV B-Blockers and Heparin. Transfer to Tertiary hospital for primary PCI.
QUESTION 4
A 78 year old female with previous history of HTN, presented to a Rural Urgent care center with severe
retrosternal chest pain for last 4 hours. Upon P/E, Pulse is 106, BP 103/55. No JVD. Clear lungs. RRR,
no murmurs. No peripheral edema. ECG shown below. Normal Renal Function. Troponins 1st set
negative. The closest hospital is a small community hospital which is 5 min away while the closest
tertiary hospital with a cath lab is 45 min away . What would be your next step be:
A. Start ASA, Morphine, NTG, IV B-Blockers. Administer Lytics and admit to Community hospital CCU.
B. Start ASA, Morphine, NTG, IV B-Blockers. Administer Lytics and Transfer tertiary hospital.
C. Start ASA, Morphine, NTG, IV B-Blockers. Transfer to Tertiary hospital for primary PCI.
D. Start ASA, Morphine, NTG, Heparin. Transfer to Tertiary hospital for primary PCI.
E. Start ASA, Morphine, NTG, IV B-Blockers and Heparin. Transfer to Tertiary hospital for primary PCI.
Internet Source: manymeanderingthoughts.blog.com
QUESTION 9
Which of the following is NOT correctly paired?
Syndrome
Associated Congenital Hear Disease
A.
Noonan Syndrome
Pulmonary Stenosis
B.
Williams Syndrome
Subvalvular Aortic Stenosis
C.
Downs Syndrome
ASD Primum
D.
Turner Syndrome
Coarctation of Aorta (COA)
E.
Maternal Rubella
Patent Ductus Arteriosus (PDA)
QUESTION 10
Which one of the following does not correlate with worse prognosis post congenital
heart disease corrective surgery?
A. ASD repair after age of 40
B. Small residual VSD post TOF repair
C. RV enlargement post TOF repair
D. Persistent HTN post COA patch repair
E. Moderate Pulmonary insufficiency post TOF repair
F. QRS duration > 180 ms in a patient post TOF repair
CONGENITAL HEART DISEASE
•
Pathology
•
Associated Syndromes or Anomalies
•
Presentation especially in Adulthood
•
Treatment
• How?
• When?
•
Complications post Treatment
PATENT FORAMEN OVALE (PFO)
25% of population
Diagnosis: Echocardiography
Associated with Atrial Septal Aneurysms
Treatment:
• Antiplatelet
Indications for Closure:
• Recurrent Cryptogenic Stroke
• Cyanosis with TR / Pulmonary HTN
• Decompression Sickness
• Orthodeoxia – Platypnena
PFO & Migraines
ATRIAL SEPTAL DEFECT (ASD)
Types of ASD
1. Secundum ASD (75%)
2. Primum ASD (Endocardial Cushion Defect)
3. Sinus Venousus ASD
4. Coronary Sinus ASD
Note:
• Down Syndrome
• Holt-Oram Syndrome
(Hand-Heart Syndrome)
• Familial Syndrome
with Conduction defect
ATRIAL SEPTAL DEFECT (ASD)
Clinical Presentation:
 Exercise Intolerance
 SOB on Exertion
 CHF
 Palpitations / AF
 CVA (Paradoxical Embolism)
 RV Failure
 Cyanosis
ATRIAL SEPTAL DEFECT (ASD)
Murmur
Fixed Split S2:
RV conduction delay
 Pulmonary flow
delaying PV closure
SEM:  flow across PV
Diastolic Murmur:  flow across TV
Advanced Stages : (Examination will change due to PHT development)
• Accentuation of P2
• SEM  (pulmonary outflow murmur as flow becomes bidirectional)
ATRIAL SEPTAL DEFECT (ASD)
Abnormal CXR
Enlarged PA
 Vascular
Markings
Cardiomegaly
ASD
Diagnosis
 ECG
 RAD in Ostium Secundum
 LAD in Ostium Primum
 RBBB
ATRIAL SEPTAL DEFECT (ASD)
Natural History & Prognosis :
Indications for Repair
Right Sided Volume Overload
Recurrent Paradoxical Emboli
Atrial Arrhythmias
Exercise Intolerance
ATRIAL SEPTAL DEFECT (ASD)
Treatment:
 Timing of Closure Procedure & Survival
Predictors of Good
Long term Survival Post Procedure:
Age < 25 years
PASP < 40 mmHg
No AF
Causes of
Poor Long Term Survival
Late Cardiac Failure
 Risk of CVA
 Risk of AF
ASA for 6 months post patch repair
IE prophylaxis 6 months post repair
VSD - TYPES
Types
 Perimembranous (Most
Common 80%)
 Trabecular (Muscular)
 Inlet
(Endocardial Cushion Defect)
(AV Septal Defect)
 Outlet (Infundibular)
 Supracristal
 Infracristal
VENTRICULAR SEPTAL DEFECT
Degree of VSD
Shunt
Natural History & Clinical Features
Restrictive
< 1.5
Murmur, IE, AI
Mod. Restrictive
1.5 – 2.0
Dyspnea, A.Fib, LVHF Later in Life
Non – Restricitive
> 2.0
LVHF Early in Life
Eisenmenger
< 1.0
Cyanosis, PHTN, Poor Prognosis
VENTRICULAR SEPTAL DEFECT TREATMENT
Indication for Intervention
 Significant VSD
 Qp/Qs > 2.0/1.0 (Class I) and >1.5/1.0 (Class IIa)
 PASP > 50 mmHg
 Increased LV and LA Size
 Decreased LV Function
 Absence of Irreversible Pulmonary HTN
 Other Indications:
 AI
 Recurrent IE
 Pediatric Age group with Sig. Symptoms not responding to medical
therapy
PATENT DUCTUS ARTERIOSUS (PDA)
Normally closes
 Functionally within 12-24 hrs
 Complete Anatomic closure with fibrosis in 3 weeks
Usually an isolated anomaly
P/E: Continuous “Machinary” Murmur
at Left Subclavian area
Differential Cyanosis
Associated with:
• Maternal Rubella
• Prematurity
Treatment: LA or LV Enlargement without Pul. HTN
 Surgical
 Catheter closure
Hemodynamics
Left to Right Shunt
 Pulmonary vascular resistance is less than
systemic vascular resistance
 RV Pressure Overload
 LA and LV Volume Overload
Murmur DDx:
• AV fistula
• Ruptured sinus of Valsalva aneurysm
• VSD with aortic regurgitation
PULMONARY STENOSIS
Usually isolated abnormality
Associated Anomalies:
 Noonan Syndrome
 PDA, COA, TOF, TGA, VSD, Bicuspid AV
Hemodynamics: RV Pressure Overload
Diagnosis: Echocardiography
Treatment:
 Indication:
 Asymptomatic & Mean PG > 40 mmHg or Peak PG > 60 mmHg
 Symptomatic & Mean PG > 30 mmHg or Peak PG > 50 mmHg
 Balloon valvuloplasty is procedure of choice
 Expected Complication post balloon:
 Pulmonary Regurgitation
 Recurrence
COARCTATION OF THE AORTA (COA)
Narrowing in Proximal Portion of Thoracic Descending Aorta
Pathological Types:
 Discrete Ridge or Membrane
 Most common type.
 Short narrowing close to
ligamentum arteriosum.
 Cardiac anomalies uncommon.
 Tubular
 Long segment stenosis.
 Cardiac anomalies common
Associated with:
• Bicuspid AV (50%)
• Turner Syndrome
COARCTATION OF THE AORTA (COA)
Diagnosis:
 Physical Examination:
 HTN
 Continuous or Systolic Murmur
 Ejection Systolic Murmur (Associated Bicuspid AV)
 Weak Delayed LE Pulses
 Echocardiography
 CT
 MRI
COARCTATION OF THE AORTA (COA)
Diagnosis:
 CXR:
COARCTATION OF THE AORTA (COA)
Treatment:
 Indication: Peak-Peak Gradient > 20 mmHg
 Surgical Repair:
 Patch Aortoplasty
 Resection of Coarctation and End-end Anastomosis
 Subclavian Flap Repair
 Bypass Tube Grafting
 Percutaneous Balloon & Stent Angioplasty
COARCTATION OF THE AORTA (COA)
Follow up of Repaired COA:
 Persistant Systemic HTN
 B.P. Follow up both resting, ambulatory ± exercise
 Recurrent Coarctation
 By Clinical exam and Echocardiography
 Aortic Aneurysm
 By Clinical exam and MRI (every 1-2 years)
 Premature CAD
 Screening and Treatment of CAD Risk Factors
 SCD
TETRALOGY OF FALLOT (TOF)

Anatomy of TOF
1)
RVOT Obstruction
Outlet VSD
Overridding of Aorta
(50% rule)
RVH
2)
3)
4)
TOF – PATHOPHYSIOLOGY
TOF - ECG
Diagnosis
 ECG
 CXR
TOF – TREATMENT
Treatment:
 Surgical Repair
 Shunt Repair
 Complete Repair
 VSD Patch Closure
 Resection of Subpulmonic Obstruction
 ± Pulmonary valve transannular patch placement
 ± Prosthetic / Homograft placement for PV atresia
TOF – POST REPAIR FOLLOW UP
Main Points in F/u
 Evaluation for Arrhythmias
 Hemodynamically Significant PI
 RV Enlargement and Systolic Dysfunction
Follow up Examination
Evaluated Feature
High Risk Features
QRS Duration
>180 ms
Physical Exam
ECG
Echocardiography
Severe PI
Ambulatory ECG Monitoring
Arrhythmias
VT
RV evaluation by MRI
Size and Function
RV enlargement
CYANOTIC CONGENITAL HEART DISEASE
•
Paradoxical Embolism:
•
Filters on intravenous lines to prevent paradoxical air embolism
•
Aggressive DVT Prophylaxis
•
Hyperviscosity symptoms
• Hydration is crucial
• Phlebotomy is recommended:
•
Hb > 20 g/dL & Hct > 65%
•
Presence of hyperviscosity symptoms
•
No dehydration
• The procedure should be followed by fluid administration and should be performed no
more than two or three times per year.
• Treatment for iron deficiency in a patient who iron deficient with oral iron for a short
time
EISENMENGER SYNDROME
Complications:
Risk Factors for CVA
HTN
AF
H/o Phlebotomy
Microcytosis (Strongest predictor)
May need Phlebotomy
From  RBC Turnover
QUESTION 9
Which of the following is NOT correctly paired?
Syndrome
Associated Congenital Hear Disease
A.
Noonan Syndrome
Pulmonary Stenosis
B.
Williams Syndrome
Subvalvular Aortic Stenosis
C.
Downs Syndrome
ASD Primum
D.
Turner Syndrome
Coarctation of Aorta (COA)
E.
Maternal Rubella
Patent Ductus Arteriosus (PDA)
QUESTION 9
Which of the following is NOT correctly paired?
Syndrome
Associated Congenital Hear Disease
A.
Noonan Syndrome
Pulmonary Stenosis
B.
Williams Syndrome
Subvalvular Aortic Stenosis
C.
Downs Syndrome
ASD Primum
D.
Turner Syndrome
Coarctation of Aorta (COA)
E.
Maternal Rubella
Patent Ductus Arteriosus (PDA)
QUESTION 10
Which one of the following does not correlate with worse prognosis post congenital
heart disease corrective surgery?
A. ASD repair after age of 40
B. Small residual VSD post TOF repair
C. RV enlargement post TOF repair
D. Persistent HTN post COA patch repair
E. Moderate Pulmonary insufficiency post TOF repair
F. QRS duration > 180 ms in a patient post TOF repair
QUESTION 10
Which one of the following does not correlate with worse prognosis post congenital
heart disease corrective surgery?
A. ASD repair after age of 40
B. Small residual VSD post TOF repair
C. RV enlargement post TOF repair
D. Persistent HTN post COA patch repair
E. Moderate Pulmonary insufficiency post TOF repair
F. QRS duration > 180 ms in a patient post TOF repair
Internet Source: www.phdcomics.com
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