281.

Patient prosthesis mismatch is most likely to occur with:

a) Aortic valve replacement

b) Mitral valve replacement
c) Pulmonary valve replacement
d) Tricuspid valve replacement
Correct Answer:
a) Aortic valve replacement

An effective orifice area less than 0.65cm2/m2 (braunwald) for the

aortic valve is taken as patient prosthesis mismatch in case of aortic
valve replacement. Patient prosthesis mismatch is most likely to
occur while replacing aortic valve in aortic stenosis. As the aortic
annulus is not dilated in aortic stenosis, only smaller prosthesis may
be considered at the time of implantation, leading to patient
prosthesis mismatch. In aortic regurgitation, since the annulus is often
dilated, the chance of this occurrence is lesser. Sometimes larger
aortic prosthesis can be used after annulus widening techniques. But
this is not done in most centers due to the potential for added surgical
risk and morbidity with annular widening procedures. It is often said
that aortic valve replacement only converts severe aortic stenosis to
mild aortic stenosis, due to these considerations. Patient prosthesis
mismatch manifests as higher trans aortic gradient soon after surgery.
280.While assessing brachial artery flow mediated
vasodilation, compression to induce ischemia is given:
a) Proximal to the site of measurement, in the arm
b) Distal to the site of measurement, in the fore arm
c) Either in the arm or in the fore arm
d) None of the above
Correct Answer:
c) Either in the arm or in the fore arm
Usually, a segment of brachial artery is measured by ultrasound and
proximal occlusion is applied for a period of 5 minutes followed by
repeat measurements. Alternative method of induction of distal
ischemia, the main vasodilatory stimulus, is by inflating the cuff in the

fore arm
279.Commonest great artery relationship in double outlet right
ventricle (DORV) is:
a) Normally related great arteries(NRGA 3% only)
b) Side by side aorta and pulmonary artery
c) Aorta is anterior and to the left of pulmonary artery
d) None of the above
Correct Answer:
Side by side aorta and pulmonary artery
Side by side relation of great arteries with aorta to the right of the
pulmonary artery is seen in about two thirds of cases of DORV.Both
semilunar valves will be in the same transverse and coronal planes.
278.Glagov phenomenon is:

a) Positive remodeling of the artery

b) Negative remodeling of the artery
c) Dissection of the intima of the artery
d) None of the above
Correct Answer:
c) Positive remodeling of the artery
Glagov phenomenon is the positive remodeling of arteries described
by Seymour Glagov in 1987.
277.What is seen on this chest X-ray?

a) Prosthetic aortic valve

b) Prosthetic pulmonary valve
c) Prosthetic mitral valve
d) Prosthetic tricuspid valve

Correct Answer:
c) Prosthetic mitral valve
Prosthetic mitral valve Starr Edward Prosthesis (SEP). Mitral position
of the prosthesis is identified by the location below the line joining the
left hilum and right cardiophrenic angle. The sewing ring is above and
the cage pointing downwards. There are four struts for a mitral
prosthesis while an aortic prosthesis has only three. The position of
the aortic prosthesis will be above the reference line mentioned above
and the cage will be pointing upwards. A double atrial shadow or
shadow in shadow indicating left atrial enlargement is seen along the
right heart border. At the same time, left atrial appendage shadow is
not prominent on the left border, possibly indicating previous closed
mitral valvotomy with amputation of the left atrial appendage. Sternal
wires used for fixing the sternum after sternotomy are also seen.

276.

This X-ray is suggestive of:

a) Multivalvular heart disease
b) Pericardial effusion
c) Ebsteins anomaly of tricuspid valve
d) None of the above
Correct Answer:
b) Gross enlargement of cardiac outline due to pericardial
effusion
In this case there was underlying severe right ventricular
endomyocardial fibrosis as well.
Differential diagnosis of gross enlaregment of cardiac size on x-ray
include:
1. Large pericardial effusion
2. Ebsteinss anomaly of tricuspid valve
3. Multivalvular heart disease
4. Endomyocardial fibrosis
In pericardial effusion the shadow is globular with no lobulations. In
valvular heart disease different bulges in the cardiac contour will be
seen due to asymmetric enlargement of various cardiac chambers. In
Ebstiens anomaly of tricuspid valve and endomyocardial fibrosis, it is
mainly right atrial enlargement (including atrialized portion of right
ventricle in Ebsteins anomaly)

275.Which of the following is an association of patent foramen

ovale (PFO)?

a. Chiari network
b. Eustachian valve
c. Atrial septal aneurysm
d. All of the above
Correct Answer:
d. All of the above
Common associations of a PFO are the Eustachian valve( It is a
remnant of the embryonic right valve of the sinus venosus ), Chiari
network( It is a remnant of the embryonic right valve of the sinus
venosus ) and an atrial septal aneurysm
274.Which of the following tests can be used to detect right to

left shunting across a patent foramen ovale (PFO)?

a. Saline contrast echocardiography
b. Trans cranial Doppler
c. Ear oximetry
d. All of the above
e. None of the above
Correct Answer:
d. All of the above

Saline contrast echocardiography using agitated saline is used to

detect right to left shunting across a PFO. Trans cranial Doppler can be
used to detect micro bubbles in the middle cerebral artery after
injection of agitated saline into a peripheral vein. Ear oximetry can
detect fluctuations in oxygen saturation due to right to left shunt
across the PFO.
273.Which of the following is not a diagnostic test for carcinoid

syndrome?

a. 24 hour urine 5-HIAA

b. 24 hour urine VMA
c. Chromogranin A
d.

In-pentetreotide scanning

111

Correct Answer:

b. 24 hour urine VMA

Urine VMA (Vanillylmandelic acid) estimation is done for the diagnosis
of pheochromocytomas. 5-H1AA (5-Hydroxy indole acetic acid) and
chromogranin A are used for diagnosis of carcinoid syndrome,
while

111

In-pentetreotide scanning is useful in locating the tumour as

well.
Carcinoid syndrome is usually a manifestation of metastatic carcinoid
tumor. This is because the liver acts as a first filter metabolizing
hormones secreted by the carcinoid tumor draining into the portal
circulation. An exception would be ovarian carcinoid which can drain
into the systemic circulation.
Biochemical markers of carcinoid syndrome
5-HIAA (5-Hydroxy indole acetic acid)
5-HIAA is the metabolite of serotonin released from the carcinoid
tumor. 24 hour urinary 5-HIAA estimation has about 73% sensitivity
and nearly 100% specificity for diagnosis of carcinoid syndrome.
CgA (Chromogranin A)
Chromogranin A (CgA) is seen in the synaptic vesicles storing
serotonin and levels indicate the bulk of the carcinoid tumor. CgA
estimation has around 63% sensitivity and 98% specificity for
diagnosis of carcinoid syndrome.
Imaging studies
111

In-pentetreotide scanning is useful in locating the carcinoid

tumor.

I-MIBG is another radio labelled scan for carcinoid tumors,

123

though less specific. MRI (magnetic resonance imaging), CT

(computerized tomography) and PET (positron emission tomography)
are other modalities useful in assessing the size of the tumor.
272.Rupture of sinus of Valsalva (RSOV) into right sided
cardiac chambers cause left to right shunt. Which RSOVs have
low shunt?
a) RSOV into RVOT
b) RSOV into RA
c) RSOV into PA

d) None of the above

Correct Answer:
a) RSOV into RVOT
RSOV into RVOT (right ventricular outflow tract) has lesser shunt as
the track can get obstructed in systole due to contraction of the tract
in systole and the shunt is mostly in diastole alone. For the same
reason the murmur in RSOV into RVOT, though continuous, has a
characteristic diastolic augmentation. RSOV into RA (right atrium) or
PA (pulmonary artery) have continuous unobstructed flow and hence a
large left to right shunt.