Valvular Heart Disease and Infective Endocarditis MCQs

Medicine · 82 free questions with answers & explanations.

1. A 70-year-old man presents with progressively worsening exertional dyspnea, angina, and two syncopal episodes. On examination, there is a harsh crescendo-decrescendo systolic murmur radiating to the carotids, with a slow rising carotid pulse (pulsus parvus et tardus). Echo shows calcified aortic valve with mean gradient 55 mmHg and AVA 0.7 cm². What is the most appropriate next step?
2. A 35-year-old IV drug user presents with 2 weeks of high-grade fever, chills, and pleuritic chest pain. Blood cultures grow Staphylococcus aureus (MSSA). Echo shows a 1.2 cm mobile vegetation on the tricuspid valve with moderate tricuspid regurgitation, and small septic pulmonary emboli on CT. Which antibiotic regimen is most appropriate?
3. A 68-year-old man presents with dyspnea on minimal exertion, angina, and near-syncope. Echocardiogram reveals severe aortic stenosis: valve area 0.7 cm², mean gradient 55 mmHg, peak velocity 4.8 m/s. LVEF is 35%. He is high surgical risk (STS score 8%). Which intervention is recommended?
4. A 35-year-old IV drug user presents with fever (39.5°C), new-onset tricuspid regurgitation murmur, and bilateral pulmonary nodular opacities on CXR. Blood cultures grow Staphylococcus aureus (MSSA). TEE confirms a large mobile vegetation on the tricuspid valve. He has no prosthetic valve and no prior endocarditis. What is the most appropriate antibiotic regimen?
5. A 30-year-old woman with rheumatic mitral stenosis (MVA 1.0 cm²) presents with NYHA Class III dyspnoea during pregnancy (28 weeks). Echo shows mitral valve score (Wilkins) of 6/16, no significant MR, no left atrial thrombus. What is the intervention of choice?
6. Duke criteria for infective endocarditis: a patient has persistently positive blood cultures with Streptococcus bovis (S. gallolyticus) and a new oscillating intracardiac mass on echocardiography. Which additional investigation is now strongly recommended in this specific organism?
7. A 65-year-old man with severe aortic stenosis (AVA 0.7 cm², mean gradient 52 mmHg, peak velocity 4.8 m/s) is referred for intervention. He is high surgical risk (STS score 8%). Which of the following most accurately reflects the current ACC/AHA 2021 VHD guideline recommendations?
8. A 35-year-old IV drug user presents with fever, bacteraemia, and multiple septic pulmonary emboli on CT chest. Echocardiography shows a tricuspid valve vegetation. Blood cultures grow Staphylococcus aureus. Which modified Duke criterion is fulfilled by the positive blood culture and echocardiogram finding?
9. A 45-year-old woman with severe mitral stenosis (MVA 0.8 cm²) is in sinus rhythm, has no LA thrombus, no MR, and minimal valvular calcification. She develops exertional dyspnoea (NYHA class III). The MOST appropriate intervention is:
10. Modified Duke criteria for infective endocarditis (IE) require how many criteria for a 'definite' clinical diagnosis, and which finding constitutes a SINGLE major criterion?
11. A 70-year-old man with severe symptomatic aortic stenosis (valve area 0.7 cm², mean gradient 52 mmHg) is referred for TAVI (TAVR). The PARTNER 3 and Evolut Low Risk trials demonstrated TAVR was non-inferior to surgical AVR for which patient population?
12. Duke criteria for infective endocarditis require 2 major, 1 major + 3 minor, or 5 minor criteria for 'definite' clinical diagnosis. Which pathological finding is a major criterion even without positive blood cultures?
13. In rheumatic heart disease, the most common valve lesion in adults from recurrent rheumatic fever is mitral stenosis. The pathognomonic histological finding of active rheumatic carditis is:
14. A 72-year-old man has severe symptomatic aortic stenosis (AVA 0.7 cm², mean gradient 48 mmHg) with LVEF of 30%. He is a high surgical risk patient (STS score 9%). According to ACC/AHA 2021 valve guidelines, the preferred intervention is:
15. The Duke criteria for diagnosis of infective endocarditis require 2 major, 1 major + 3 minor, or 5 minor criteria. Which of the following correctly represents a MAJOR criterion?
16. A 68-year-old man with severe calcific aortic stenosis (valve area 0.7 cm², mean gradient 52 mmHg, LVEF 60%) is symptomatic with exertional angina. His STS score is 8% (high surgical risk). According to AHA/ACC 2021 valve guidelines, the preferred treatment is:
17. A 35-year-old IV drug user presents with fever, new tricuspid regurgitation murmur, and multiple septic pulmonary emboli on CT. Blood cultures grow Staphylococcus aureus (MSSA). According to ESC/AHA endocarditis guidelines, the standard antibiotic regimen for right-sided native valve infective endocarditis due to MSSA in IV drug users is:
18. A 72-year-old man with severe aortic stenosis (AVA 0.6 cm², mean gradient 55 mmHg) and EF of 25% presents for evaluation. His STS surgical mortality risk score is 12%. He has severe COPD and peripheral vascular disease. Which intervention is most appropriate according to ACC/AHA 2021 guidelines?
19. A 45-year-old injection drug user presents with fever, bacteremia, and new regurgitant murmur. Blood cultures grow methicillin-resistant Staphylococcus aureus (MRSA). TTE shows a 1.2 cm vegetation on the tricuspid valve with moderate regurgitation. He has no signs of systemic embolism or heart failure. What is the antibiotic of choice and duration?
20. A 68-year-old man has severe aortic stenosis (AVA 0.7 cm², mean gradient 55 mmHg, LVEF 35%). He has NYHA class III symptoms and is deemed high surgical risk (STS score 9%). According to current ACC/AHA 2021 VHD guidelines, the preferred intervention is:
21. A 35-year-old IVDU presents with high fever, septic emboli to lungs, and a new pansystolic murmur at the left sternal edge increasing with inspiration. Blood cultures are positive for Staphylococcus aureus. Modified Duke Criteria are met. Echocardiography shows tricuspid valve vegetation 1.5 cm with severe tricuspid regurgitation. The MOST appropriate antibiotic regimen is:
22. A 70-year-old man with severe symptomatic aortic stenosis (AVA 0.7 cm², mean gradient 52 mmHg, LVEF 55%) is deemed 'intermediate surgical risk' (STS score 5.2%). Per current ACC/AHA 2021 valvular guidelines, what is the preferred treatment?
23. A 40-year-old IV drug user develops fever, new holosystolic murmur at the left sternal border, and multiple septic pulmonary emboli on CT. Blood cultures grow Staphylococcus aureus (MSSA). Echo shows a 15 mm mobile vegetation on the tricuspid valve. What is the treatment of choice for right-sided S. aureus endocarditis in this setting?
24. A 70-year-old man with severe aortic stenosis (AVA 0.7 cm², mean gradient 52 mmHg) has NYHA class III dyspnoea. Echocardiogram shows EF of 35% (severe LV dysfunction). Per current ACC/AHA 2021 guidelines on valvular heart disease, the surgical risk is assessed as high. Which intervention is indicated?
25. A 40-year-old IVDU is admitted with fever, chills, and sepsis. Blood cultures grow Staphylococcus aureus. Transthoracic echo is non-diagnostic. Transoesophageal echo (TOE) reveals a 15 mm mobile vegetation on the tricuspid valve. Duke criteria are met. Per modified Duke criteria, this constitutes:
26. In the Duke criteria for infective endocarditis (IE), positive blood cultures with typical organisms (S. aureus, viridans streptococci, HACEK) on separate occasions represent a MAJOR criterion. Which modified Duke minor criterion was added to improve sensitivity for S. bovis group bacteraemia?
27. In severe aortic stenosis, which haemodynamic parameter is used to distinguish 'truly severe' low-flow, low-gradient AS with reduced EF (paradoxical low-flow) from pseudo-severe AS?
28. According to ACC/AHA 2021 guidelines, the preferred anticoagulation for a patient with a mechanical mitral valve prosthesis is:
29. A 75-year-old man has severe aortic stenosis (aortic valve area 0.72 cm², mean gradient 52 mmHg) with an LVEF of 62% and is symptomatic with exertional dyspnoea. He has multiple comorbidities including COPD and prior CABG. His STS surgical mortality risk is 9%. Which treatment is recommended by current guidelines?
30. The modified Duke criteria for infective endocarditis include 'minor' criteria. A patient has fever of 39.2°C, a new regurgitant murmur, two separate blood cultures positive for Streptococcus viridans, and an echocardiogram showing a mobile vegetation on the mitral valve. How many major Duke criteria are satisfied in this patient?
31. A 72-year-old woman has severe aortic stenosis (aortic valve area 0.7 cm², mean gradient 52 mmHg, peak velocity 4.8 m/s) with EF 38% and is NYHA class III. Society of Thoracic Surgeons predicted risk of mortality (STS-PROM) is 7.2%. She has no significant vascular or technical contraindications to TAVR. Which statement best reflects current AHA/ACC 2021 guidelines?
32. A 35-year-old IV drug user presents with fever, new aortic regurgitation (diastolic murmur), splenomegaly, splinter haemorrhages, and vegetation on the aortic valve on TTE. Blood cultures grow Staphylococcus aureus. He has a new first-degree AV block with PR interval 280 ms on ECG. Why does the new PR prolongation change management urgently?
33. A 32-year-old IV drug user develops fever, new tricuspid regurgitation murmur, and septic pulmonary emboli. Blood cultures grow Staphylococcus aureus (MRSA). Which therapy is indicated?
34. A 70-year-old man with severe aortic stenosis (AVA 0.7 cm², mean gradient 55 mmHg, LVEF 35%) is assessed for intervention. He has a REDO cardiac surgery history making reoperation high-risk. STS score is 8.2%. Which procedure is recommended per AHA/ACC 2021 guidelines?
35. A 65-year-old man with severe symptomatic aortic stenosis (aortic valve area 0.7 cm², mean gradient 52 mmHg, LVEF 55%) is deemed intermediate surgical risk (STS score 5%). According to current ACC/AHA 2021 VHD guidelines, which intervention is preferred?
36. A 35-year-old IV drug user presents with fever, new murmur, and positive blood cultures for Staphylococcus aureus. Echocardiogram shows 1.5 cm vegetation on the tricuspid valve. Which Duke criterion does a positive blood culture for S. aureus from 2 separate samples satisfy?
37. A 72-year-old man has severe aortic stenosis (AVA 0.7 cm², peak velocity 4.8 m/s, mean gradient 52 mmHg) and is symptomatic (NYHA class II dyspnea). Echocardiogram shows LVEF 55%. STS predicted surgical mortality risk is 7.2%. According to current ACC/AHA 2021 valvular heart disease guidelines, the preferred intervention is:
38. A 55-year-old man with a prosthetic mitral valve presents with fever, new regurgitant murmur, and positive blood cultures for Enterococcus faecalis (penicillin MIC 0.5 μg/mL, vancomycin MIC 1 μg/mL, streptomycin high-level resistance present). According to current ESC 2023 IE guidelines, the preferred treatment regimen is:
39. A 68-year-old woman with severe aortic stenosis (mean gradient 58 mmHg, AVA 0.7 cm², LVEF 55%) is referred for definitive therapy. She has COPD GOLD Grade 3, prior stroke with mild residual deficit, and porcelain aorta on CT. STS predicted risk of mortality for SAVR is 9.2%. What is the preferred valve replacement strategy per current ACC/AHA 2021 guidelines?
40. A 35-year-old intravenous drug user develops fever, chills, and a new murmur of tricuspid regurgitation. Blood cultures grow Staphylococcus aureus. Echocardiography confirms vegetation on the tricuspid valve. He has no left-sided vegetations. Duke criteria — major: 2 positive blood cultures for S. aureus, new valvular regurgitation. The diagnosis is definite IE. Per current guidelines, what is the MINIMUM duration of IV antibiotic therapy?
41. A 30-year-old intravenous drug user presents with fever (39.4°C), new regurgitant murmur, and multiple septic pulmonary emboli on CT chest. Blood cultures grow Staphylococcus aureus (MSSA). TEE shows a 1.2 cm vegetation on the tricuspid valve. The most appropriate antibiotic regimen is:
42. A 70-year-old woman with severe symptomatic aortic stenosis (valve area 0.7 cm², mean gradient 52 mmHg) has LVEF 35% and STS surgical risk score of 8.5%. She has a hostile chest and severe COPD. The most appropriate intervention is:
43. A 72-year-old man with severe symptomatic aortic stenosis (valve area 0.7 cm², mean gradient 55 mmHg, EF 55%) has a Society of Thoracic Surgeons (STS) predicted operative mortality of 4.5% (intermediate surgical risk). What does the evidence from PARTNER 2 and SURTAVI trials support regarding TAVR vs. SAVR for this patient?
44. A 35-year-old intravenous drug user presents with 2 weeks of high fever, new murmur, and multiple septic pulmonary emboli on CT chest. Blood cultures grow Staphylococcus aureus. Echocardiography confirms a 1.5 cm vegetation on the tricuspid valve with severe TR. He has no left-sided valve involvement. What is the recommended antibiotic regimen duration for right-sided S. aureus endocarditis in PWID?
45. A 65-year-old man with severe aortic stenosis (AVA 0.7 cm², mean gradient 52 mmHg) and EF of 35% is considered for intervention. He has multiple comorbidities with an STS surgical risk score of 9%. Per the 2021 ACC/AHA guidelines, the preferred intervention is:
46. The Duke criteria for infective endocarditis include which of the following as a MAJOR criterion?
47. A 65-year-old man has severe aortic stenosis (AVA 0.7 cm², mean gradient 52 mmHg, LVEF 35%). He has severe COPD (FEV1 35% predicted) and prior coronary artery bypass graft surgery. The STS operative mortality score is 12%. The MOST appropriate intervention is:
48. In infective endocarditis (IE) due to viridans streptococcus with MIC ≤ 0.125 mg/L (highly susceptible), the recommended antibiotic regimen for a patient with normal renal function and no penicillin allergy is:
49. Duke's modified criteria for infective endocarditis (IE) require a definite diagnosis based on which combination of major and minor criteria?
50. Transcatheter aortic valve replacement (TAVR) — per ACC/AHA 2021 guidelines, TAVR is now recommended over surgical AVR (SAVR) for which patient group?
51. A 70-year-old man with severe calcific aortic stenosis (AVA 0.7 cm², mean gradient 55 mmHg) is symptomatic with exertional dyspnea but has preserved LVEF of 60%. STS-PROM score is 8%. According to current ACC/AHA guidelines, the recommended intervention is:
52. A 40-year-old IV drug user presents with fever, tricuspid regurgitation murmur, and multiple pulmonary nodular infiltrates. Blood cultures grow Staphylococcus aureus (MSSA). This is right-sided infective endocarditis. The preferred antibiotic regimen is:
53. A 55-year-old woman with a prosthetic mechanical mitral valve develops fever and bacteremia. Transoesophageal echocardiogram shows a 12 mm vegetation on the atrial face of the prosthesis with new severe paravalvular regurgitation. The MOST important indication for urgent surgery in prosthetic valve endocarditis is:
54. A 72-year-old man has aortic stenosis with valve area 0.7 cm², mean gradient 62 mmHg, and LVEF 35%. He has NYHA Class III symptoms. STS score is 8% (high surgical risk). Which treatment modality is most appropriate?
55. A 32-year-old IV drug user presents with fever, bacteremia, and tricuspid regurgitation on echo with vegetations. Blood cultures grow methicillin-sensitive Staphylococcus aureus (MSSA). What is the antibiotic of choice and minimum treatment duration?
56. A 30-year-old woman is found to have severe rheumatic mitral stenosis: MVA 0.8 cm², mean gradient 18 mmHg, valve score 6/16 (Wilkins), no MR, no left atrial thrombus on TOE, and NYHA class III symptoms. Pulmonary artery systolic pressure is 58 mmHg. Which intervention is the treatment of choice?
57. A 65-year-old man with prosthetic aortic valve replacement (mechanical, 2 years ago) on warfarin presents with fever, malaise and a new regurgitant murmur. Blood cultures grow Staphylococcus aureus. TOE shows 12 mm mobile vegetation on the prosthetic valve with moderate perivalvular abscess. Which criterion determines the need for urgent surgical intervention in prosthetic valve endocarditis?
58. A 70-year-old man with severe aortic stenosis (valve area 0.7 cm², mean gradient 52 mmHg, LVEF 55%) is evaluated for intervention. He has moderate COPD, previous CABG 7 years ago, and STS operative mortality risk score of 6.2%. Which intervention is preferred per ACC/AHA 2021 guidelines?
59. A 45-year-old intravenous drug user presents with fever, new murmur, and embolic phenomena. Blood cultures grow Staphylococcus aureus (MRSA). TTE shows a 1.5 cm vegetation on the tricuspid valve with moderate regurgitation. Which antibiotic regimen is appropriate?
60. A 70-year-old man has severe symptomatic aortic stenosis (valve area 0.8 cm², mean gradient 55 mmHg) and ejection fraction of 65%. He has prior CABG and a porcelain aorta. STS score is 8%. Per ACC/AHA 2021 valve guidelines, the preferred intervention is:
61. A 35-year-old intravenous drug user presents with fever (38.8°C), a new pansystolic murmur heard best at the left sternal border that increases on inspiration, and septic pulmonary emboli on CT chest. Three blood cultures grow Staphylococcus aureus. Echocardiography reveals a 12 mm vegetation on the tricuspid valve. The appropriate empirical antibiotic regimen is:
62. A 28-year-old IV drug user presents with fever (39.8°C), new regurgitant murmur, and septic pulmonary emboli. Blood cultures grow Staphylococcus aureus (MSSA). Duke criteria confirm infective endocarditis. What is the MOST appropriate antibiotic regimen?
63. A 72-year-old woman with severe symptomatic calcific aortic stenosis (AVA 0.6 cm², mean gradient 52 mmHg) has an EuroSCORE II of 8% and is considered intermediate surgical risk. She has no history of coronary artery disease. Which intervention is preferred per 2021 ESC/EACTS valve guidelines?
64. A 68-year-old man with severe aortic stenosis (mean gradient 52 mmHg, AVA 0.75 cm², LVEF 30%) is deemed high surgical risk (STS score 8%). Which intervention is indicated and what trial supports it?
65. A 35-year-old intravenous drug user presents with fever, chills, and a new murmur of tricuspid regurgitation. Three sets of blood cultures grow Staphylococcus aureus (MSSA). Echocardiogram confirms a 1.5 cm vegetation on the tricuspid valve. Which antibiotic regimen is recommended?
66. A patient meets Duke criteria for definite infective endocarditis. Echocardiography shows severe aortic regurgitation with a 12 mm vegetation and new PR interval prolongation on ECG. What does the PR prolongation signify and what action should be taken?
67. A 60-year-old man with severe aortic stenosis (aortic valve area 0.7 cm², mean gradient 52 mmHg) is asymptomatic. His LVEF is 68%. According to current ACC/AHA guidelines, when should intervention be considered?
68. A 35-year-old IV drug user with fever and a new tricuspid regurgitation murmur has blood cultures growing Staphylococcus aureus. Echo shows a 1.2 cm vegetation on the tricuspid valve. No left-sided involvement. According to Duke criteria, how should this be classified?
69. A 68-year-old man with severe symptomatic aortic stenosis (peak gradient 80 mmHg, AVA 0.7 cm², LVEF 55%) has a Society of Thoracic Surgeons (STS) predicted risk of mortality of 8.2%. He is considered intermediate risk. The PARTNER 2 and SURTAVI trials support which intervention?
70. A 38-year-old IV drug user presents with fever, chills, and a new murmur. Blood cultures grow Staphylococcus aureus. Echocardiography shows a large vegetation on the tricuspid valve. He has no prosthetic valve and no previous endocarditis. According to ESC 2023 endocarditis guidelines, the minimum duration of antibiotic therapy for native right-sided S. aureus endocarditis without complications is:
71. A 65-year-old man with severe symptomatic aortic stenosis (valve area 0.7 cm², mean gradient 52 mmHg) is referred for intervention. His STS score is 4.2%, making him intermediate surgical risk. Echocardiography shows preserved LVEF of 58%. According to ACC/AHA 2021 valvular guidelines, which intervention is preferred?
72. A patient with infective endocarditis caused by Staphylococcus aureus on a native mitral valve meets Duke criteria (2 major or 1 major + 3 minor). Which organism-specific finding is an indication for emergency surgery within 24 hours?
73. A 65-year-old man has severe aortic stenosis (valve area 0.7 cm², mean gradient 52 mmHg) and is symptomatic with dyspnea on exertion and syncope. He has previous CABG with a patent LIMA-LAD graft. STS score is 5.2%. According to AHA/ACC 2021 VHD guidelines, what is the preferred intervention?
74. Blood cultures from a patient with suspected infective endocarditis grow viridans streptococci (MIC to penicillin 0.12 mg/L). The patient has no penicillin allergy. What is the preferred antibiotic regimen for native valve endocarditis per ESC 2023 guidelines?
75. A 70-year-old man with severe symptomatic aortic stenosis (valve area 0.7 cm², mean gradient 55 mmHg, EF 35%) is deemed high surgical risk (STS score 8%). Which treatment option offers the best outcomes in this patient?
76. A 35-year-old IV drug user presents with fever, a new regurgitant murmur at the tricuspid area, and multiple septic pulmonary emboli on CT. Blood cultures grow Staphylococcus aureus (MSSA). Echocardiography confirms 1.8 cm tricuspid valve vegetation. Which antibiotic regimen is most appropriate?
77. A 58-year-old asymptomatic man has severe aortic stenosis. Echo shows AVA 0.75 cm², mean gradient 52 mmHg, LVEF 62%, no LV dilation. Per ACC/AHA 2021 VHD guidelines, valve replacement (AVR/TAVR) is indicated when:
78. A 35-year-old intravenous drug user presents with fever, septic pulmonary emboli on CT, and a systolic murmur loudest at the right sternal edge that increases with inspiration. Echo shows a tricuspid valve vegetation. The most common causative organism of right-sided infective endocarditis in IVDU is:
79. A patient with prosthetic aortic valve endocarditis is found to have Staphylococcus lugdunensis growing on blood cultures within 2 months of valve replacement (early prosthetic valve endocarditis). He is hemodynamically stable. The most appropriate management is:
80. A 70-year-old man with severe aortic stenosis (AVA 0.7 cm², peak gradient 68 mmHg) is symptomatic (NYHA III dyspnoea, pre-syncope). His Society of Thoracic Surgeons (STS) predicted operative mortality score is 8%. What is the preferred intervention according to current guidelines?
81. A 34-year-old intravenous drug user presents with fever, new pansystolic murmur loudest at the left sternal edge increasing with inspiration, and multiple pulmonary cavitating infiltrates. Blood cultures grow Staphylococcus aureus (MSSA). What is the most likely affected valve and the empirical antibiotic of choice?
82. According to the 2023 ESC Endocarditis Guidelines, which of the following is an absolute indication for urgent surgical intervention in infective endocarditis?