1) Freddie Fox is a devious fellow!! He has stolen the labels to Dr. Smith’s picture of the cardiac cycle!!

Can you help Dr. Smith fix his picture before he gives his lecture to the second year students??

Please label the picture with the following:

"a" ......for atrial systole (atrial "kick") "MVO" ........for mitral valve opening

"v" ......for the "v wave" "MVC".........for mitral valve closure

"S1".....for the first heart sound "AVO" ........for aortic valve opening

"S2".....for the second heart sound "AVC".........for aortic valve closure

2) Freddie Fox is at it again!! Now he has taken the legend to the three pressure-volume relationships shown below!!

Please match each of the three labeled diagrams with their corresponding legends, by filling in A, B, or C.
 
 

3) Left ventricular compliance is defined as:

a)      P__
         V
 

b)     V__
         P

c)    D P__
       D V

d)    D V__
       D P

e)    D P__
       D t

Answer:  D
 
 

4) Left ventricular preload is defined as:

a) The amount of volume filling the left ventricle

b) The LV wall tension during systole

c) The diastolic wall radius of the LV

d) The LV wall tension during diastole

e) The sum of rapid ventricular filling and the left atrial "kick"

Answer D

5) In response to an excessive hemodynamic burden, the heart uses all of the following compensatory mechanisms to maintain cardiac output, except:

a) Myocardial hypertrophy

b) Decreased venous return

c) The Frank-Starling mechanism

d) Increased catecholamine release from adrenergic nerves and the adrenal medulla

Answer: B

For this page, please choose the one best answer to each question.

A sixty-five year old male presents to the emergency room two hours after the onset of substernal chest pressure. On physical examination, he is hypotensive (blood pressure: 80/50 mm Hg.) and has jugular venous distention. EKG reveals an acute inferior infarction pattern.

6) Each of the following, may be contributing to this patient’s hypotension, except:

a) sinus tachycardia

b) decreased LV stroke volume

c) right ventricular infarction

d) third degree heart block

e) decreased LV preload

Answer:  A

7) Therapy to treat the hypotension might include all the following, except:

a) an intra-aortic balloon pump

b) intravenous inotropic agents

c) infusion of fluids (i.e. saline solution)

d) intravenous nitroglycerine infusion

e) elevating the patient’s legs

Answer: D

8) The next EKG taken on the patient reveals the following rhythm:
 
 
 
 

Please identify the underlying rhythm and name the abnormality:
 
  ________________________________________________________________

9) A patient with an acute anterior MI develops signs and symptoms of congestive heart failure 12 hours after hospitalization. A Swan-Ganz catheter is placed, and the following curve is constructed:
 
 

__________________________________________________________

For each statement, please indicate if it is True or False.

__T______ 1. Concentric left ventricular hypertrophy results from chronic pressure

overload.

___T_____ 2. Aortic insufficiency causes eccentric left ventricular hypertrophy.

___T_____ 3. Hypertension causes serial replication of sarcomeres.

___T_____ 4. The presence of left ventricular hypertrophy denotes a worse

outcome in a hypertensive patient.

___T_____ 5. As many as 40% of patients with "CHF" may have normal left

ventricular systolic function.

___T_____ 6. Afterload reducing agents may be harmful in some patients with

diastolic dysfunction.

___F_____ 7. The heart is usually enlarged in diastolic dysfunction.

___F_____ 8. Inotropic agents are usually indicated for the treatment of

diastolic dysfunction.
 
 

For the following questions, please choose the one best answer.

With the use of a Doppler flow probe all of the following statements are true except:

a) Cardiac output can be estimated

b) Direction of blood flow can be determined

c) Intracardiac structures can be resolved

d) Pressure gradients across valves can be estimated

e) Mitral valve area can be estimated.

Answer:  C

In patients with dilated cardiomyopathy one may find any of the following except:

a) Pulsus alternans

b) Pulsus paradoxus

c) Cardiomegaly

d) Increased left ventricular end diastolic volume

e) Decreased ejection fraction

Answer: B

For the following questions, please choose the one best answer.

Radionuclide imaging can be helpful to evaluate all of following conditions except:

a) Constrictive pericarditis

b) Atrial septal defect

c) Decreased left ventricular ejection fraction

d) Regional myocardial perfusion abnormalities

e) Regional myocardial contraction abnormalities

Answer: A

What is the approximate incidence of congenital heart disease in the United States?

a) 0.2%

b) 1.0%

c) 2.0%

d) 3.0%

e) 5.0%
 
 

For this question, please circle each correct answer. More than one may be correct.

Of the following, which are NOT determinants of the size and direction of shunted blood flow at any abnormal communication within the heart and/or circulatory system?

a) Age of patient

b) Location of defect

c) Size of defect

d) Blood viscosity (as determined by hematocrit)

e) Balance of relative downstream resistance
 
 
 
 

Name the three shunt pathways that are instrumental in the fetal circulation.
 
 

____________________________________
 
 

____________________________________
 
 

____________________________________
 
 

Match the action potential Phase number to the description of the physiologic event in a ventricular muscle or Purkinje cell.

Phase 0 _____ a. Resting state, » -90 mV

Phase 1 _____ b. Repolarization, relying mainly on K+ efflux

Phase 2 ______ c. Returns membrane potential to 0 mV, possibly

from movement of CI ions

Phase 3 _____ d. Rapid Na+ influx

Phase 4 _____ e. Plateau phase, mediated by slow Ca+ channels
 
 

Match the ECG wave, interval, or segment with the appropriate description:

P wave __I___ a. Useful for measuring heart rate

QRS complex __E___ b. Elevation is consistent with acute injury of

myocardial infarction; depression suggests

ischemia

T wave __F___ c. Need to be corrected for heart rate in order to

measure; if prolonged may predispose to a type of

ventricular tachycardia

R prime wave __H___ d. If prolonged, indicates bundle branch block

PR interval __G___ e. Ventricular depolarization

RR interval __A___ f. Ventricular repolarization

QRS duration __D___ g. Encompasses atrial depolarization, normal

conduction delay in AV node, and passage of

impulse through bundle of His and bundle

branches to ventricle

QT interval __C___ h. Second positive deflection of depolarization; seen

with right bundle branch block

ST segment __B___ i. Atrial depolarization

For each statement, please indicate if it is True or False.

___F_____ 1. In Wolff-Parkinson-White, in which there is a bypass tract from atria to

ventricles, the PR interval is lengthened.

___T_____ 2. Re-entry requires two pathways that have different conduction properties.

___F_____ 3. Adequate cardiac output is usually maintained during ventricular

fibrillation.

___T_____ 4. 2° AV block, Mobitz Type II, can be dangerous and lead to sudden

complete heart block.

___T_____ 5. Death of cardiac muscle produces Q waves on the electrocardiogram.

___F_____ 6. Atrial fibrillation is usually a regular rhythm.

___F_____ 7. An R’ depolarization wave is present in left bundle branch block.

___T_____ 8. A prolonged QT interval can predispose to a Torsades de Pointes

rhythm.

___T_____ 9. In atrial flutter, the P waves are often seen to have a "saw-tooth"

pattern appearance.

___T_____ 10. In complete heart block, A-V dissociation can be seen.
 
 
 
 

The primary pathophysiologic abnormality of different valvular, congenital and cardiomyopathic lesions can be expressed in terms of ventricular volume and/or pressure overload. What is the primary overload pattern (LVVO, RVVO, LVPO, RVPO) for each of the following lesions:

Answers

a) Mitral stenosis ___________________RVPO

b) Chronic aortic regurgitation ___________________LVVO

c) Atrial septal defect with left-to-right shunting ___________________RVVO

d) Hypertrophic obstructive cardiomyopathy (HOCM) ___________________LVPO

e) Severe tricuspid regurgitation ___________________RVVO

f) Congenital VSD with right-to-left shunting ___________________RVVO

g) Dilated, congestive cardiomyopathy ___________________LVVO

Draw the pressure that would be recorded from the tip of an intracardiac catheter as it is withdrawn from the apex of the left ventricle to the aortic arch in each of the following patients.

a) Hypertrophic obstructive cardiomyopathy

b) Valvular aortic stenosis

c) Supravalvular aortic stenosis

d) Combined lesions of A & B

e) Combined lesions of B & C

a)
 
 
 
 
 
 
 
 
 
 

LV Apex Aortic arch

LV Apex Aortic arch
 
 

LV Apex Aortic arch
 
 
 
 
 
 

LV Apex Aortic arch

LV Apex Aortic arch
 
 
 
 
 
 
 

Describe the effect of the following maneuvers or interventions on the intensity of the murmur as detected by bedside auscultation for each of the conditions described below.

You are asked to see three patients in consultation. Each has been told he/she has valvular heart disease as determined by a cardiac catheterization performed at a distant hospital. Each patient has a copy of his/her catheterization report. Based on the information provided, what primary valvular abnormality best explains the findings for each patient?
 

	Patient A	Patient B	Patient C
Ao LV LA (WEDGE)     PAP RV RA     Murmurs LV ejection fraction	120/80 120/18 a=18, v=16, mean=16 36/16 36/5 a=7, v=5 mean=5 Systolic 36%	120/80 120/12 a=12, v=62 mean=26 62/26 62/5 a=7, v=5 mean=5 Systolic 84%	120/80 120/6 a=26, v=22 mean=21 75/32 75/14 a=14, v=24 mean=16 Diastolic 58%

Patient A: ______CHRONIC MITRAL REGURGITATION____________________________

Patient B: _______ACUTE MITRAL REGURGITATION___________________________

Patient C: _______MITRAL STENOSIS ___________________________
 
 

Which patient’s condition is the most acute (i.e. recent, not chronic)?____B_________

What other valve lesion is present in one of these patients? Which patient?

______TRICUSPID REGURGITATION, PATIENT C_______________________

_____________________________
 
 

The hemodynamic hallmark of valvular stenosis is the pressure gradient across the valve. Severe valvular aortic stenosis is characterized by resting gradients five to ten times greater than that observed with severe mitral stenosis (50-100 mm Hg vs 10-15 mm Hg.) Describe two or three reasons why the gradient in aortic stenosis is so much greater.

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________
 
 

Patients with mitral regurgitation can have varying degrees of left atrial pressure elevation. What are the factors which determine the effect of mitral regurgitation on left atrial pressure?

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

Match the diagnosis to the description:

A. Restrictive cardiomyopathy

B. Hypertrophic cardiomyopathy

C. Congestive cardiomyopathy

D. Constrictive pericarditis

Chest pain

_____________________________________________________________________

_____________________________________________________________________
 
 

Dyspnea

_____________________________________________________________________

_____________________________________________________________________
 
 

Syncope

_____________________________________________________________________

_____________________________________________________________________
 

What is the mechanism of mitral regurgitation in congestive cardiomyopathy?

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

The patient whose cardiac catheterization pressure tracing is shown above, would be expected to have:

High systemic venous pressure True False   ---  True

Kussmaul’s sign True False   --  False

Pulsus paradoxus greater than 10 mm Hg True False   --  True
 
 

Please provide a brief explanation for the mechanism of pulsus paradoxus and Kussmaul’s sign.

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________