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Pediatric Cardiology - Full Q&A Based on Nelson Pediatrics

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Q1. Radiology finding of "Snowman sign" is seen in?

• This is distinct from "coeur en sabot" (boot-shaped heart) seen in Tetralogy of Fallot
• Increased pulmonary vascular markings are present
• CXR also shows right axis deviation and RVH on ECG

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Q2. Which organism when cultured from blood is NOT suggestive of infective endocarditis?

• Streptococcus viridans - most common overall causative organism
• Staphylococcus aureus - most common in IV drug users and healthcare-associated
• HACEK group (Haemophilus, Aggregatibacter, Cardiobacterium, Eikenella, Kingella) - included in Duke criteria as typical organisms

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Q3. Which of the following does NOT comprise a MAJOR Jones Criteria?

• Fever
• Elevated ESR / CRP
• Prolonged PR interval (1st degree AV block) - this is a MINOR criterion

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Q4. At what age does an infant with large VSD begin manifesting symptoms of CHF?

• At birth, pulmonary vascular resistance (PVR) is still high (equal to systemic)
• Left-to-right shunting is minimal initially
• As PVR normally decreases over the first 4-8 weeks of life, the L→R shunt increases
• By 4-8 weeks (approximately 1 month), PVR has fallen enough to cause significant shunting, pulmonary overcirculation, and symptoms of CHF: poor feeding, failure to thrive, tachypnea, recurrent respiratory infections

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Q5. Not related to Coarctation of Aorta - "Snowman sign"

• Coarctation of Aorta findings on CXR: "Figure of 3 sign" (indentation at the coarctation site on aortic knob), rib notching (from collateral intercostal arteries, seen after age 5)
• Snowman sign = TAPVR (supracardiac type)
• Other coarctation signs: bounding pulses in arms, weak/absent femoral pulses, differential BP in arms vs legs

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Q6. NOT a major criterion to diagnose Rheumatic Fever - Arthralgia

• Arthralgia (joint pain without swelling/heat/redness) = Minor criterion
• Polyarthritis (objective joint inflammation) = Major criterion
• This distinction is important: once carditis is present and arthritis is classified as major, arthralgia counts only as minor

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Q7. Side effects of Propranolol

• CNS effects: fatigue, depression, sleep disturbances, impaired school performance/cognitive function - this is the clinically significant pediatric concern
• Bronchospasm (contraindicated in asthma)
• Bradycardia, hypotension
• Hypoglycemia (not hyperglycemia)
• Masking of hypoglycemic symptoms
• Cold extremities

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Q8. The intensity of murmur where a thrill can be palpated?

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Q9. What valves are involved in Rheumatic Heart Disease?

• Mitral valve is the most frequently affected (mitral regurgitation acutely; mitral stenosis chronically)
• Aortic valve second most common
• Combined mitral + aortic involvement is common
• Tricuspid - rarely affected alone
• Pulmonary valve - almost never
• Carey Coombs murmur (mid-diastolic) is heard during acute rheumatic carditis due to mitral valve involvement

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Q10. Most common CHD in males?

• TGA has a strong male predominance (male:female ratio ~3:1 to 4:1)
• ASD is more common in females (female:female ratio ~2:1)
• PDA is more common in females
• VSD is roughly equal

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Q11. Carey Coombs Murmur - associated with?

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Q12. Sinus Bradycardia in Neonates is diagnosed at a sinus rate of?

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Q13. Which drug taken by mother is LEAST likely to cause a cardiologic defect in the child?

• Phenytoin: Risk of CHD (VSD, pulmonary stenosis, aortic stenosis) - Fetal Hydantoin syndrome
• Valproic acid: Risk of CHD (VSD, ASD), neural tube defects
• Captopril (ACE inhibitor): Fetotoxic in 2nd/3rd trimester - renal dysgenesis, oligohydramnios; also risk of CHD in 1st trimester

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Q14. Lower border of normal pulse rate (for children)?

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Q15. Most common benign tumor of the heart?

• Rhabdomyoma = most common pediatric cardiac tumor (associated with tuberous sclerosis, often regresses spontaneously)
• Myxoma = most common adult cardiac tumor (usually left atrial)
• Fibroma = 2nd most common pediatric cardiac tumor
• Hemangioma = rare

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Q16. Widely split S2 is seen in?

• In ASD, there is increased RV volume load, causing delayed pulmonic valve closure
• The split is fixed and wide - it does not vary with respiration (pathognomonic of ASD)
• Normal S2 splitting varies with inspiration
• This fixed, wide split S2 is the classic auscultatory finding of ASD

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Q17. Normal blood pressure of a neonate?

• At term neonate: SBP ~60-90 mmHg, DBP ~30-60 mmHg
• Rule of thumb: SBP in neonate ≈ gestational age + 30 mmHg (for preterm)
• The Harriet Lane Handbook table confirms: Normal BP <90th percentile for age/sex/height

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Q18. Infective Endocarditis Prophylactic Antibiotic Regimen?

• Standard regimen: Amoxicillin 50 mg/kg (max 2g) orally 30-60 min before dental procedure
• If penicillin allergic: Clindamycin or Azithromycin/Clarithromycin
• Prophylaxis indicated for: unrepaired cyanotic CHD, prosthetic valves, previous IE, cardiac transplant with valve disease
• NOT indicated for most simple CHD after complete repair

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Q19. Most common valve affected in Rheumatic Fever?

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Q20. Radiologic finding of "Coeur en Sabot" is seen in?

• The boot shape results from RVH (upturned apex) + absent/small main pulmonary artery segment (concave pulmonary bay)
• Seen in Tetralogy of Fallot
• CXR also shows decreased pulmonary vascular markings
• Right-sided aortic arch in ~25% of TOF cases

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Q21. Most common complication of Infective Endocarditis?

• CHF is the most common and most serious complication (~50-60% of cases)
• Results from valvular destruction (regurgitation)
• Other complications: systemic emboli (stroke), mycotic aneurysm, metastatic abscess, renal failure, arrhythmias

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Q22. Most common pediatric cardiac tumor?

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Q23. Characteristic physical finding in ASD?

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Q24. What is FALSE about Coarctation of Aorta?

• True: Femoral pulses are weak or absent (blood flow reduced to lower body)
• True: Bounding pulses in arms (high pressure proximal to coarctation)
• True: Blood pressure higher in arms than legs (radiofemoral delay and differential)
• TRUE: Femoral pulses appear LATER than radial (radio-femoral delay), or are absent
• FALSE: Femoral pulse will be EARLIER than radial - this is WRONG. In CoA, the femoral pulse comes AFTER (delayed) compared to radial, or is absent.

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Q25. What NOT to give for Tet Spell in TOF?

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Q26. Holosystolic murmur seen in the following EXCEPT?

• Holosystolic (pansystolic) murmurs = occur throughout systole, from S1 to S2
• Causes: Mitral regurgitation, Tricuspid regurgitation, VSD
• Aortic regurgitation = DIASTOLIC murmur (early diastolic, decrescendo)
• Pulmonic regurgitation = DIASTOLIC murmur
• So both aortic and pulmonic regurgitation are NOT holosystolic

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Q27. Most common cause of death from cardiac defects in the first month of life?

• HLHS is the most common cause of cardiac death in the first week of life
• It accounts for ~25% of all cardiac deaths in the first year
• Babies appear well at birth (PDA keeps them alive), then deteriorate rapidly as the ductus closes (usually by 1-2 days)
• D-TGA without lesions is serious but less uniformly fatal without surgery
• HLHS without surgery (Norwood procedure) is universally fatal

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Q28. Not part of TOF - LVH

1. Pulmonary stenosis (RVOT obstruction)
2. Right ventricular hypertrophy (RVH)
3. Overiding aorta
4. VEntricular septal defect

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Q29. Classic continuous murmur is seen in?

• PDA produces a continuous "machinery" murmur heard best at left infraclavicular area/upper left sternal border
• It is continuous because there is always a pressure gradient between aorta and pulmonary artery (both in systole AND diastole)
• ASD and VSD produce systolic murmurs, not continuous
• Bounding peripheral pulses and wide pulse pressure are also characteristic of PDA

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Q30. Hypertension in children is defined as?

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Q31. Which organism causes Rheumatic Fever?

• Rheumatic fever follows Group A beta-hemolytic Streptococcus (S. pyogenes) pharyngitis (upper respiratory tract)
• Streptococcal skin infections (impetigo) do NOT cause RF - only throat infections
• The M protein of GAS triggers autoimmune cross-reactivity with cardiac tissue (molecular mimicry)

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Q32. Surgical repair of VSD at time of diagnosis is considered in?

• Small/restrictive VSD: High chance of spontaneous closure, manage conservatively
• Large/non-restrictive VSD: No restriction to flow, equal LV/RV pressures, causes pulmonary hypertension - surgery indicated promptly, often before 6 months to prevent Eisenmenger syndrome
• Small supracristal VSD: Early surgery recommended due to risk of aortic regurgitation
• Hemodynamically significant VSD: Symptoms of CHF despite medical therapy → surgical repair

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Q33. Which Hepatitis causes Viral Myocarditis (in Asia)?

• Hepatitis C virus is the most significant hepatitis virus associated with viral myocarditis
• In Asia, Hepatitis B is highly prevalent but HCV has stronger association with myocarditis
• Coxsackievirus B remains the overall most common cause of viral myocarditis globally
• Hepatitis C can cause dilated cardiomyopathy through direct myocardial infection

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Q34. Afterload reducers are NOT indicated in children with heart failure secondary to?

• Afterload reducers (ACE inhibitors, vasodilators) work by reducing systemic vascular resistance
• They are beneficial in: Aortic insufficiency (reduces regurgitant fraction), Mitral insufficiency (reduces regurgitant volume), Cardiomyopathy (reduces wall stress)
• Contraindicated in Aortic Stenosis: In fixed obstruction (AS), the heart cannot increase CO to compensate for vasodilation → severe hypotension and cardiovascular collapse. The obstruction is fixed; reducing afterload peripherally does not help and is dangerous.

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Q35. Earliest sign of CHF on Chest X-ray?

1. Pulmonary vascular redistribution (cephalization - blood vessels prominent in upper lobes) - earliest
2. Cardiomegaly (increased heart size)
3. Interstitial edema (Kerley B lines)
4. Alveolar/pulmonary edema (bat-wing pattern)

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Q36. CHD with decreased pulmonary markings treated with?

• Decreased pulmonary markings = reduced pulmonary blood flow = ductal-dependent pulmonary circulation
• Examples: Pulmonary atresia, critical pulmonary stenosis, TOF (severe), tricuspid atresia
• PGE1 keeps the ductus arteriosus open to maintain pulmonary blood flow
• Digoxin treats heart failure (not useful here), Indomethacin CLOSES the ductus (opposite of what's needed), Epinephrine is for resuscitation

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Q37. Diastolic dysfunction with normal systolic function = ?

• Restrictive cardiomyopathy: Stiff, non-compliant ventricular walls → impaired filling (diastolic dysfunction) but preserved systolic function (EF normal)
• Causes in children: infiltrative (amyloid), storage diseases, post-radiation
• Distinguishes from: Dilated CM (systolic dysfunction) and Hypertrophic CM (can have both)

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Q38. Which is NOT a side effect of ACE inhibitors?

• Renal toxicity (renal failure) - YES, especially in bilateral renal artery stenosis
• Hypotension - YES, first-dose effect
• Hyperkalemia (NOT hypokalemia) - ACE inhibitors reduce aldosterone → potassium retention
• Dry cough (from bradykinin accumulation)
• Angioedema

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Q39. In pediatric patients, cardiac output is primarily increased by?

• Cardiac Output = Heart Rate × Stroke Volume
• In infants/children, the ventricle is less compliant and has limited ability to increase stroke volume
• Therefore, CO is primarily rate-dependent in pediatric patients
• This is why bradycardia is so poorly tolerated in children
• Adults can increase CO via either mechanism; children depend more on rate

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Q40. A 4-year-old, 7 days fever, murmur - which test CONFIRMS diagnosis of Infective Endocarditis?

• The scenario describes probable infective endocarditis (fever + new cardiac murmur)
• Per Duke Criteria, positive blood cultures are a major criterion and the gold standard for diagnosis
• Blood cultures should be drawn before antibiotics (3 sets from different sites)
• Echocardiogram (not listed) is the other major criterion
• ESR/CBC show non-specific inflammation
• CXR shows cardiac size but doesn't confirm IE

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Q41. Risk of infective endocarditis in children with cyanotic CHD - increased by?

• Poor dental hygiene leads to bacteremia with oral organisms (Streptococcus viridans) - the most common cause of IE
• Dental procedures and daily activities (chewing, brushing) cause transient bacteremia
• This is why antibiotic prophylaxis is given before dental procedures for high-risk cardiac patients
• MMR, RSV, diarrhea do not cause IE

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Q42. A 1-year-old, poor feeding, recurrent respiratory infections, weight 6kg, O2 sat 98%, continuous "machinery" murmur at left 2nd intercostal space - Diagnosis?

• Continuous machinery murmur at left upper sternal border/infraclavicular area = PDA
• O2 sat 98% = no cyanosis (left-to-right shunt, acyanotic)
• Symptoms: poor feeding, failure to thrive, recurrent RTIs = large PDA with CHF
• Bounding peripheral pulses would also be expected
• ASD gives a systolic ejection murmur with fixed split S2
• VSD gives a holosystolic murmur
• Pulmonary stenosis gives a systolic ejection murmur

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Summary Table