CSC Case Studies & Practical Application 2 — Questions and Answers
Question 1: A 58-year-old man presents with exertional chest pain and dyspnea. Echo shows LVEF 35%, moderate MR, and dilated LV. Coronary angiography reveals 3-vessel disease. What is the most appropriate next step?
- Proceed directly to MV repair before revascularization
- Perform CABG with concurrent mitral annuloplasty (Correct answer)
- Initiate medical therapy and reassess in 3 months
- Refer for cardiac transplantation evaluation
Correct answer: Perform CABG with concurrent mitral annuloplasty
In patients with ischemic cardiomyopathy and moderate functional MR, CABG combined with mitral annuloplasty is preferred when revascularization is planned.
Question 2: A 45-year-old woman with known bicuspid aortic valve is found to have an ascending aorta measuring 4.8 cm on surveillance imaging. She is asymptomatic. What is the recommended management?
- Continue surveillance with imaging every 6 months
- Elective surgical repair is indicated at this size for bicuspid AV (Correct answer)
- Wait until aorta reaches 5.5 cm before intervention
- Initiate beta-blocker therapy and reimage in 1 year
Correct answer: Elective surgical repair is indicated at this size for bicuspid AV
Guidelines recommend surgical repair of the ascending aorta at ≥4.5–5.0 cm in patients with bicuspid aortic valve, lower than the threshold for tricuspid valves.
Question 3: A 70-year-old man with hypertension presents with acute-onset tearing back pain. CT shows a Stanford Type B aortic dissection without malperfusion. BP is 160/90 mmHg. What is the initial treatment?
- Emergency open surgical repair
- TEVAR within 24 hours
- IV labetalol to achieve SBP <120 mmHg and HR <60 bpm (Correct answer)
- Urgent cardiac catheterization
Correct answer: IV labetalol to achieve SBP <120 mmHg and HR <60 bpm
Uncomplicated Stanford Type B dissections are managed medically with aggressive blood pressure and heart rate control as the primary intervention.
Question 4: A 62-year-old woman presents with progressive dyspnea. Echo reveals severe aortic stenosis with AVA 0.7 cm², mean gradient 52 mmHg, and LVEF 60%. She has COPD and prior stroke. STS score is 8%. What is preferred treatment?
- Surgical aortic valve replacement (SAVR)
- Balloon aortic valvuloplasty
- TAVR via transfemoral approach (Correct answer)
- Medical management with diuretics
Correct answer: TAVR via transfemoral approach
TAVR is preferred for high-surgical-risk patients with severe symptomatic AS, and transfemoral TAVR is the default approach when anatomy permits.
Question 5: A 55-year-old man with HFrEF (EF 30%) on optimal medical therapy develops symptomatic ventricular tachycardia. He previously declined ICD. Amiodarone has been ineffective. What is the next best step?
- Increase amiodarone dose
- Catheter ablation of VT (Correct answer)
- Lidocaine infusion
- Reassure and observe
Correct answer: Catheter ablation of VT
Catheter ablation is recommended for recurrent, drug-refractory VT in patients with structural heart disease.
Question 6: A 48-year-old competitive athlete presents with syncope during exercise. ECG shows epsilon waves and T-wave inversions in V1–V3. MRI reveals fatty infiltration of the RV free wall. What is the diagnosis and priority management?
- HCM; prescribe beta-blockers and allow return to sport
- ARVC; disqualify from competitive sports and refer for ICD (Correct answer)
- RV myocarditis; hospitalize for IV steroids
- Brugada syndrome; prescribe quinidine
Correct answer: ARVC; disqualify from competitive sports and refer for ICD
Arrhythmogenic right ventricular cardiomyopathy (ARVC) carries high risk of sudden death with exercise; competitive sports are contraindicated and ICD implantation is typically indicated.
Question 7: A 65-year-old woman post-MI 6 weeks ago presents with pleuritic chest pain, friction rub, and new diffuse ST elevation. Echo shows a small pericardial effusion. What is the best treatment?
- Restart anticoagulation at therapeutic levels
- High-dose aspirin and colchicine (Correct answer)
- IV methylprednisolone
- Pericardiocentesis
Correct answer: High-dose aspirin and colchicine
Dressler syndrome (post-MI pericarditis) is treated with aspirin as the preferred NSAID and colchicine to reduce recurrence risk.
CSC Case Studies & Practical Application 2
A 58-year-old man presents with exertional chest pain and dyspnea.
Echo shows LVEF 35%, moderate MR, and dilated LV.
Coronary angiography reveals 3-vessel disease.
What is the most appropriate next step?