Segunda parte Reflexiones sobre
1. La educación inclusiva en educación superior. Mitos que debemos desterrar
progress (particularly in cases of rheumatic heart disease) after successful mitral valve
replacement.
replacement.
Bonow RO, Carabello BA, Chatterjee K, et al. 2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1998 guidelines for the management of patients with valvular heart disease).
Endorsed by the Society of Cardiovascular Anesthesiologists, Society for
Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 2008;52:e1-142.
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References
Question 48 of 60
A 25-year-old man is seen for outpatient evaluation of CHD. He was known to have a large VSD as a child, and this was never surgically corrected because pulmonary hypertension was evident at the time of discovery. He works full time at a bank. He has slowed down somewhat in recent years, but is still able to do most of what he wants as long as he takes his time. He is not on any medications. Vital signs: pulse 72 bpm and regular; BP 120/80 mm Hg; respirations 16 breaths per minute; pulse oximetry 88%. He has clubbing of both fingers and toes.
Which of the following is the most likely kind of murmur in this patient?
A.Pansystolic murmur maximal at the left lower sternal border.
B.Pansystolic murmur maximal at the second left interspace.
C.High-pitched diastolic murmur.
D.Low-pitched diastolic murmur.
E.Mid- and late systolic murmur maximal at the left lower sternal border.
The correct answer is C. The most likely murmur would be a high-pitched diastolic murmur reflecting pulmonary arterial hypertension and high-pressure pulmonary regurgitation (Graham Steell murmur). Even though a pansystolic murmur maximal at the left lower sternal border is characteristic of a small to moderate VSD, a large VSD does not cause a pansystolic murmur. A pansystolic murmur is rarely if ever heard at the second left interspace, the sole exception probably being severe mitral valve prolapse with posterior leaflet prolapse. A low-pitched diastolic murmur would not fit with what we know about this patient. A mid- and late systolic murmur would also not be expected.
Question 49 of 60
A 20-year-old woman presents during the second trimester of pregnancy with blood pressure of 210/100 mm Hg. She reports that in childhood, she was found to have CoA; however, no interventions were performed and she has had mildly elevated systemic blood pressure prior to conception.
Which of the following statements is true of the patient?
A.Her offspring will have a 50% chance of having congenital heart disease.
B.Her blood pressure will return to normal in the third trimester of pregnancy.
C.An LVOT peak systolic gradient of >30 mm Hg by echocardiography is associated with adverse maternal outcomes.
D.CMR with gadolinium administrated should be performed immediately.
E.Angiotensin-converting enzyme (ACE) inhibition should be started immediately to lessen the afterload on the left ventricle.
The correct answer is C. Unrepaired LVOT obstruction lesions are problematic during pregnancy. In a multicenter study of over 600 pregnancies in women with heart
disease, a LVOT peak systolic gradient of >30 mm Hg by echocardiography was associated with adverse maternal outcomes. Imaging should be done to confirm the diagnosis; however, the contrast agent gadolinium should be avoided in pregnancy due to uncertain effects on the fetus. ACE inhibitors are contraindicated in pregnancy due to the placental transfer and potential teratogenic effects to the unborn child. In the setting of maternal congenital heart disease (CHD), there is an increased chance of offspring affected with CHD. However, the risk does not approach 50%, except in the setting of certain genetic associations (e.g., DiGeorge syndrome).
Siu SC, Sermer M, Colman JM, et al. Prospective multicenter study of pregnancy outcomes in women with heart disease. Circulation 2001;104:515-21.
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References
Question
50 of 60
An 18-year-old man presents for a sports participation physical prior to starting college as a middle-distance runner. He is a scholarship athlete at a Division I school, and has never noticed any exercise limitations. He reports palpitations over the last several years that occur every 1-2 months, last from 10 seconds to 5
minutes, and spontaneously remit. The palpitations are associated with dizziness, but he has not had syncope.
On examination, a faint systolic murmur is heard at the left lower sternal border. A resting ECG and echocardiogram are obtained. The echocardiogram is shown (Figure 1).
Which of the following diagnostic ECG findings is expected?
A.Sinus bradycardia, otherwise normal.
B.Normal sinus rhythm with first-degree AV block.
C.Complete heart block.
D.Right bundle branch block.
E.Pre-excitation.
The correct answer is E. In a patient with Ebstein's anomaly and palpitations consistent with a tachycardia, the most likely cause is an AV re-entrant tachycardia related to a bypass tract which often manifests as pre-excitation on a resting ECG. Although atrial arrhythmias such as atrial flutter or atrial fibrillation occur, those rhythms tend to be seen in patients with more severe disease and heart failure. Severe disease would not be expected in a patient with sufficient cardiopulmonary fitness to be a scholarship track athlete, and the
expected in a patient with sufficient cardiopulmonary fitness to be a scholarship track athlete, and the
echocardiogram shows relatively mild disease. Though the other findings are commonly found in patients with Ebstein's anomaly, none would be expected to be related to symptomatic palpitations.
Question 51 of 60
Some coronary anomalies may not create symptoms, but their course must be appreciated at time of surgical intervention for repair of the heart condition. Which of the following coronary anomalies may directly interfere with a surgical corrective procedure?
A.LAD artery origin from the RCA in tetralogy of Fallot.
B.RCA origin from the anterior cusp in corrected transposition of the great vessels (congenitally corrected transposition).
C.Ectopic origin of the conus artery from a second right cusp ostium in hypertrophic cardiomyopathy.
D.Coronary ectasia in patients undergoing CABG.
E.Anomalous LCX artery from the RCA in patients undergoing atrial septal defect repair.
The correct answer is A. The anomalous origin of the LAD artery from the RCA in tetralogy of Fallot crosses anteriorly to the RV outflow tract in 5-7% of all patients with tetralogy. Surgical patch repair of the RV outflow obstruction in tetralogy of Fallot can, therefore, result in injury to this coronary. When encountered, a conduit over the coronary from the RV to the PA is usually created to prevent coronary injury. The RCA usually arises from the anterior cusp in congenitally corrected transposition. The most common anomaly is the ectopic origin of the conus artery from a second ostium in the right cusp, and it has no significance. Coronary ectasia is common in patients
undergoing CABG and prevents little technical issue. Finally, atrial septal defect repair occurs through an incision in the RA lateral wall, and the location of an anomalous LCX artery does not interfere with the procedure.
Question
52 of 60
A 50-year-old woman presents to the Cardiovascular Medicine Clinic after a recent diagnosis of PE and bilateral calf DVT. She denies any trauma, medical illness, surgery, immobilization, or other precipitating factors preceding her PE and DVTs. She has a history of hyperlipidemia treated with a statin. She is currently taking warfarin and her last international normalized ratio (INR) was 2.3.
She is normotensive in the office with a resting oxygen saturation of 99% on room air. She is obese and has varicose veins with mild pitting edema at the ankles. Her ECG demonstrates sinus rhythm with no
abnormalities. Cardiac biomarkers during her admission were normal. Testing for thrombophilias was conducted during her admission and was unremarkable.
Based on the patient’s history, which of the following is the most appropriate anticoagulation regimen?
A.Oral anticoagulation with warfarin for 6 months with a target INR of 2-3 and then indefinitely with a target INR of 1.5-2.
B.Oral anticoagulation with warfarin for 6 months with a target INR of 2-3.
C.Oral anticoagulation with for 3 months with a target INR of 2-3.
D.LMWH monotherapy via subcutaneous self-injection indefinitely.
E.LMWH via subcutaneous self-injection for 3 months.