ABTS Congenital Cardiac common mistakes
ABTS Congenital Cardiac · Understand the traps and how to avoid them.
For a neonate with obstructed infracardiac total anomalous pulmonary venous return, selects 'admit, stabilize for 24–48 hours, then semi-elective repair' as the plan.
Applying the habitual 'stabilize the neonate first' script; obstruction, not ductal dependency, drives the physiology, and these infants deteriorate abruptly rather than plateauing.
What to do instead
Classify the lesion as an obstruction-driven emergency: intubate, minimize pulmonary blood flow with sedation and controlled ventilation, correct acidosis, and proceed to urgent repair rather than watchful waiting.
Answers 'biventricular repair' for a neonate with a borderline left ventricle and then stops, without listing the measurements that establish adequacy (mitral valve z-score, LV end-diastolic volume, LV inflow and outflow, RV-to-LV pressure ratio).
The stem names a diagnosis and the candidate anchors on the label instead of the deciding data; ventricular adequacy feels like an impression rather than a decision rule.
What to do instead
Before committing, state the criteria you would use and, if the stem lacks them, name the data you need; treat the biventricular decision as an explicit checklist rather than a gestalt.
Estimates shunt balance and Qp/Qs by clinical impression from the vignette rather than calculating from the oxygen saturations, hemoglobin, and pressures given in the stem.
Under time pressure candidates pattern-match to a familiar case and skip arithmetic they know how to do, then choose an answer that fits the narrative but not the numbers.
What to do instead
Do the computation: Qp/Qs from saturation step-ups, systemic and pulmonary resistance from pressures and flows, then confirm the chosen answer is consistent with the described physiology; if it is not, recheck the arithmetic rather than the physiology.
Treats an echocardiographic gradient as equivalent to a catheterization gradient and commits to a plan from a single modality, ignoring discrepancies between the two studies presented in the stem.
Doppler peak gradient overestimates in high flow and catheter pullback underestimates diffuse disease; candidates default to the last number they read rather than asking which measurement answers the question.
What to do instead
State which modality answers which question-echo for anatomy and valve morphology, catheterization for hemodynamics, resistance, and shunt quantification-and when the two disagree, identify which assumption is being violated before choosing.
In a post-Stage I Norwood patient with saturations of 68% and rising lactate, increases FiO2 to 100% and hyperventilates to a PaCO2 of 28.
Applying an adult or general pediatric ARDS reflex; in a parallel circulation, lowering pulmonary vascular resistance steals systemic flow and worsens the acidosis the maneuver was meant to treat.
What to do instead
Target SpO2 roughly 75–85%, avoid hyperoxia, accept permissive hypercapnia, support systemic vascular resistance and ventricular function, and look for shunt stenosis or a restrictive atrial septum when perfusion is inadequate.
Gives repeated 20 mL/kg crystalloid boluses to a Fontan patient with hypotension and rising lactate.
The default 'hypotension equals hypovolemia' heuristic; candidates forget that pulmonary blood flow is passive and preload cannot be raised by volume alone in this circulation.
What to do instead
Assess for obstruction (conduit, fenestration, pulmonary arteries), reduce pulmonary vascular resistance, use inotropes or vasodilators, and consider fenestration or pacing; volume loading worsens hepatic congestion and effusions.
For an adult with repaired tetralogy of Fallot and severe pulmonary regurgitation, recommends pulmonary valve replacement using the thresholds taught for children without addressing RV volumes, arrhythmia burden, or ACHD-center referral.
Pediatric training habits carry over; the adult congenital evidence base for indication and timing differs, and candidates answer the child's question on an adult's data.
What to do instead
Frame the answer in adult congenital terms: indexed RV end-diastolic volume thresholds, symptoms, RV function, QRS duration and arrhythmia, multidisciplinary ACHD evaluation, and pregnancy considerations where relevant.
Recommends arterial switch for d-transposition without first describing the coronary pattern, and never states what an intramural or single coronary changes about the operation.
Coronary anatomy is treated as a technical detail; stems often omit it and candidates fill the gap with the most common pattern instead of naming the uncertainty.
What to do instead
Make coronary description an explicit step: name the pattern, state the transfer technique and added risk, and note when the finding would alter timing, candidacy, or the choice of operation.
For a scenario describing an intraoperative complication or bad outcome, answers with the ideal technical next step while ignoring that the question asks what should be said to the family.
Candidates read the clinical portion and stop; the professionalism prompt is usually the final clause, and the technical answer is the most available one.
What to do instead
Read the actual question before answering; for disclosure, use a structured approach-express regret, state what happened and why, describe the plan for the patient, and document the conversation.
When a stem describes a system failure such as a delayed OR transfer, unavailable ECMO, or incomplete handoff, chooses 'counsel the individual clinician' or 'report to the board' as the primary action.
Personal blame is the default account of error in training culture, so candidates underuse systems-level interventions even when the stem is constructed around one.
What to do instead
Assign the failure to the system level and choose the intervention that changes the system-standardized handoff, activation protocol, escalation pathway, morbidity and mortality review-reserving individual remediation for true impairment.