CSC Cardiac Subspecialty Certification 4 — Questions and Answers
Question 1: A patient with mitral stenosis has a mitral valve area of 0.9 cm² and mean gradient of 12 mmHg at rest. She is in sinus rhythm with no significant mitral regurgitation. Which intervention is MOST appropriate?
- Mitral valve replacement with mechanical prosthesis
- Percutaneous mitral balloon commissurotomy (PMBC) (Correct answer)
- Medical management with beta-blockers only
- Surgical mitral valve repair
Correct answer: Percutaneous mitral balloon commissurotomy (PMBC)
PMBC is the preferred intervention for severe symptomatic mitral stenosis with favorable valve morphology (Wilkins score ≤8) and no significant MR or LA thrombus.
Question 2: Which blood pressure goal is recommended during the first 24 hours in a patient with acute aortic dissection (Type A) awaiting surgical repair?
- SBP <100 mmHg and HR <60 bpm
- SBP <120 mmHg and HR <60 bpm (Correct answer)
- SBP <140 mmHg and HR <80 bpm
- MAP >70 mmHg regardless of heart rate
Correct answer: SBP <120 mmHg and HR <60 bpm
Target SBP <120 mmHg and HR <60 bpm with IV beta-blockers (e.g., esmolol, labetalol) to reduce aortic wall stress before urgent surgical repair.
Question 3: A 45-year-old with no cardiac history has a resting 12-lead ECG showing ST segment elevation in V1–V2 with a right bundle branch block pattern. He denies symptoms. Which condition should be PRIMARILY suspected?
- Anterior STEMI
- Brugada syndrome (Correct answer)
- Arrhythmogenic right ventricular cardiomyopathy
- Hyperkalemia
Correct answer: Brugada syndrome
Spontaneous Type 1 Brugada pattern (coved ST elevation ≥2 mm in V1–V2 with RBBB morphology) in an asymptomatic patient is diagnostic of Brugada syndrome.
Question 4: In a patient with long QT syndrome type 2 (LQT2), which environmental trigger is MOST likely to provoke a potentially fatal arrhythmia?
- Exercise or swimming
- Auditory stimuli (e.g., loud sounds, alarm clocks) (Correct answer)
- Sleep or rest
- Emotional stress during competition
Correct answer: Auditory stimuli (e.g., loud sounds, alarm clocks)
LQT2 is caused by HERG (IKr) channel mutations and arrhythmias are most commonly triggered by auditory stimuli, particularly sudden loud noises.
Question 5: A patient on warfarin for mechanical aortic valve (INR 2.8) needs urgent non-cardiac surgery. Which bridging strategy is MOST appropriate?
- Stop warfarin; no bridging needed for aortic mechanical valve
- Stop warfarin; bridge with IV unfractionated heparin (Correct answer)
- Continue warfarin at full dose throughout perioperative period
- Stop warfarin; bridge with aspirin 325 mg only
Correct answer: Stop warfarin; bridge with IV unfractionated heparin
Mechanical heart valves carry high thromboembolic risk; IV unfractionated heparin bridging is recommended when warfarin must be stopped for urgent surgery.
Question 6: Which finding on right heart catheterization is MOST consistent with a large ventricular septal defect (VSD) with left-to-right shunt?
- Step-up in oxygen saturation from right atrium to right ventricle (Correct answer)
- Step-up in oxygen saturation from superior vena cava to pulmonary artery
- Step-down in oxygen saturation from right atrium to right ventricle
- Elevated pulmonary capillary wedge pressure only
Correct answer: Step-up in oxygen saturation from right atrium to right ventricle
A significant oxygen saturation step-up (≥5–7%) from the right atrium to right ventricle indicates a left-to-right shunt at the ventricular level (VSD).
Question 7: A patient with chronic kidney disease (eGFR 25 mL/min) requires coronary angiography. Which strategy BEST reduces risk of contrast-induced nephropathy?
- Pretreatment with N-acetylcysteine and sodium bicarbonate
- Iso-osmolar or low-osmolar contrast with IV saline hydration before and after (Correct answer)
- Limiting procedure but using high-dose contrast for complete evaluation
- Pretreatment with furosemide to force diuresis
Correct answer: Iso-osmolar or low-osmolar contrast with IV saline hydration before and after
Use of low- or iso-osmolar contrast with adequate IV isotonic saline hydration remains the best-supported strategy to prevent contrast nephropathy.
CSC Cardiac Subspecialty Certification 4
A patient with mitral stenosis has a mitral valve area of 0.9 cm² and mean gradient of 12 mmHg at rest.
She is in sinus rhythm with no significant mitral regurgitation.
Which intervention is MOST appropriate?