Cardac Surgery MCO

1. Whch s not true of cardopumonary resusctaton (CPR)?

A. Cosed chest massage s as ehectve as open chest massage.
B. The success rate for out-of-hospta resusctaton may be as hgh as 30% to 60%.
C. The most common cause of sudden death s schemc heart dsease.
D. Standard chest massage generay provdes ess than 15% of norma coronary and cerebra bood
ow.
Answer: A
DISCUSSION: Cosed chest massage s not as ehectve as open-chest massage n normazng bood
pressure or perfuson of vta organs, and cosed chest massage does generay dever 5% to 15%
of norma coronary and cerebra bood ow. The success rate for out-of-hospta resusctaton has
been as hgh as 30% to 60% when communtes are prepared to nsttute CPR eary after a cardac
arrest. Ischemc heart dsease s the most common cause of sudden death.
2. Whch maneuver generay s not performed eary before chest compresson n basc fe support
outsde the hospta? A. Ca for hep.
B. Obtan arway.
C. Eectrca cardoverson.
D. Ventaton.Answer: C
DISCUSSION: Basc fe support does nvove cang for hep, obtanng an arway, and begnnng
ventaton before startng chest compresson. Eectrca cardoverson requres speca equpment
and traned personne and thus s part of advanced cardac fe support.
3. Whch treatment woud be east ehectve for asystoe? A. Externa
pacemaker.
B. Intravenous epnephrne, 10 m. of 1:10,000.
C. Intravenous cacum guconate, 10 m. of 10% souton.
D. Intravenous atropne, 0.5 mg.Answer: C
DISCUSSION: Recommended treatment for asystoe s admnstraton of atropne. If atropne s
unsuccessfu epnephrne s gven. Utmatey cardac pacng s necessary f atropne and
epnephrne do not estabsh an adequate heart rate. Cacum has no cear roe n treatng asystoe.
4. The most mportant factor that nuences the outcome of penetratng cardac n|ures s:
A. Commnuted tear of a snge chamber.
B. Mutpe-chamber n|ures.
C. Coronary artery n|ury.
D. Tangenta n|ures.Answer: C
DISCUSSION: Mutpe studes n the terature conrm that n|ures to the coronary arteres are the
most mportant factor n determnng outcome after a penetratng cardac n|ury. Tangenta n|ures
are the east serous. In|ury to a snge chamber-even f commnuted-or to mutpe chambers s
ess key to be fata than are n|ures that nvove a ma|or coronary artery.
5. The most usefu ncson n the operatng room for patents wth penetratng cardac n|ury s:
A. Left anteror thoracotomy.
B. Rght anteror thoracotomy.
C. Batera anteror thoracotomy.
D. Medan sternotomy.
E. Subxyphod.Answer: D
DISCUSSION: The subxyphod ncson s usefu for determnng f there s bood n the percardum
and f there s an ntracardac n|ury; however, exposure s extremey mted, and dentve repar
can rarey be performed through the ncson. Left (or rght) anteror thoracotomy s easy
performed, especay n the emergency room, and gves adequate exposure to certan areas of the
heart. However, each has sgncant mtatons n exposure. Ether may be extended across the
thoracotomy nto the other sde of the chest, thus producng a batera anteror thoracotomy.
Exposure s exceent through ths ncson, and most n|ures can be satsfactory repared through
ths approach. Most cardac operatons today are performed through medan sternotomy ncsons. If
the patent s n the operatng room, ths ncson s easy performed and aways provdes exceent
exposure for a areas of the heart.
6. In patents who present wth a penetratng chest n|ury, n|ury to the heart s most key when
the foowng physca sgn(s) s/are present: A. Hypotenson.
B. Dstended neck vens.
C. Decreased heart sound.
D. A of the above.Answer: D
DISCUSSION: Hypotenson, ncreased venous pressure (dstended neck vens), and decreased heart
sounds make up the cassc Beck's trad assocated wth cardac tamponade. If these three ndngs
are present n a person who has a penetratng chest wound, ntracardac n|ury s amost certan
and operatve nterventon s mandatory.
7. Whch of the foowng woud be an acceptabe method of repar for a neonate wth symptomatc
soated coarctaton of the aorta? A. Resecton wth end-to-end anastomoss.
B. Prosthetc patch aortopasty.
C. Subcavan ap aortopasty.D.
Prosthetc tube graft repar. Answer: AC
DISCUSSION: The most commony used methods for coarctaton repar are resecton wth
anastomoss and subcavan ap aortopasty. Both have been shown to provde adequate reef of
the obstructon wth acceptabe rates of restenoss. The choce of repar depends on the patent's
anatomy and the surgeon's experence. Patch aortopasty was used frequenty n the past; however,
because of concern over restenoss and aneurysm formaton t s no onger commony performed.
Prosthetc tube graft repar s avoded except n some compex cases and some cases of
recoarctaton.
8. Whch of the foowng consttutes a true vascuar rng? A. Pumonary
artery sng.
B. Doube aortc arch.
C. Anomaous orgn of rght subcavan artery from the descendng aorta.
D. Cervca aortc arch.Answer: B
DISCUSSION: Ony the doube aortc arch secondary to persstence of the rght and eft fourth aortc
arches forms a true vascuar rng. Pumonary artery sng may cause symptoms that are due to
compresson of the trachea, and an anomaous rght subcavan may cause dysphaga, but these
anomaes do not consttute compete rngs. Cervca aortc arch, whch s thought to be secondary
to persstence of the thrd aortc arch, s not a compete rng and usuay s asymptomatc.
9. Whch of the foowng may be physca examnaton ndngs n a young adut wth coarctaton of
the aorta?
A. Posteror systoc murmur between the scapuas.
B. Dmnshed femora puses.
C. Eevated bood pressure n eft arm as compared wth rght arm.
D. Perphera cyanoss.Answer: ABC
DISCUSSION: A systoc murmur that radates posterory s characterstc of coarctaton of the aorta.
Coarctaton produces obstructon to aortc ow, and thus the femora puse has a dmnshed
voume wth deayed upstroke. Hypertenson n coarctaton s mutfactora, but the most mportant
factors are dmnshed rena ow (snge cp, snge kdney-Godbatt mode) and mechanca
factors. If the rght subcavan artery s anomaous and arses dsta to the coarctaton, bood
pressure may be greater n the eft arm than n the rght. Isoated coarctaton does not produce
cyanoss.
10. In a premature nfant wth hyane membrane dsease and nabty to be weaned from
mechanca ventaton, whch of the foowng woud suggest hemodynamcay sgncant patent
ductus arterosus (PDA)? A. Contnuous murmur.
B. Hyperactve precordum wth boundng perphera puses.
C. |aundce.
D. Dmnshed femora puses.Answer: AB
DISCUSSION: PDA causes a eft-to-rght shunt that produces eft ventrcuar voume overoad.
Physca ndngs ncude evdence of hyperdynamc crcuaton wth a promnent apca mpuse and
boundng perphera puses. The cassc murmur of PDA s a contnuous or mechanca murmur
heard over the precordum and radatng to the meda thrd of the cavce. Dmnshed femora
puses are not seen wth soated PDA and woud suggest other anomaes. PDA may resut n
hepatomegay but does not cause |aundce.
11. In an nfant wth suspected PDA, whch of the foowng woud be the optma method of
conrmng the dagnoss? A. Chest m.
B. Cardac catheterzaton.
C. Retrograde aortography va an umbca artery catheter.
D. Two-dmensona echocardography wth contnuous-wave and coor-ow Dopper echocardography.
Answer: D
DISCUSSION: Echocardography s the best method for conrmng the dagnoss of a PDA. Two-
dmensona echocardography can demonstrate PDA and excude assocated anomaes. Dopper
echocardography can demonstrate the shunt, determne drecton of shuntng, and provde an
estmate of shunt magntude. The chest m s not partcuary hepfu and may be norma or show
cardomegay wth pumonary congeston. In genera, cardac catheterzaton shoud be reserved for
oder patents and those wth suspected assocated anomaes or pumonary hypertenson.
12. Whch of the foowng are potenta compcatons of untreated coarctaton of the aorta?
A. Endocardts.
B. Pumonary vascuar dsease.
C. Cerebrovascuar accdent.D. Congestve heart faure. Answer: ACD
DISCUSSION: Coarctaton of the aorta produces an obstructon to bood ow and hypertenson,
turbuent ow, and ncreased eft ventrcuar afteroad. There s an ncreased ncdence of coronary
artery dsease. Pror to the ntroducton of ehectve technques for reef of coarctaton, the most
common causes of death were endocardts, aortc rupture, congestve heart faure, and
cerebrovascuar accdent. Pumonary vascuar dsease does not occur wth soated coarctaton.
13. The atra septa defect (ASD) most commony assocated wth parta anomaous pumonary
venous return (PAPVR) s: A. Secundum defect.
B. Snus venosus defect.
C. Ostum prmum defect.
D. Compete atroventrcuar (AV) cana defect.
E. Coronary snus defect.Answer: B
DISCUSSION: Athough parta anomaous return of the pumonary vens can occur wth any of the
ASDs sted, t s partcuary common wth snus venosus defects and s consdered by many to be
part of ths eson. The most common anomay s dranage of the rght superor pumonary ven to
the atera aspect of the superor vena cava.
14. The drecton of an ntracardac shunt at the atra eve s controed by:
A. The sze of the defect
B. The compance of the rght and eft ventrces.
C. The systemc oxygen saturaton.
D. Rght atra pressure.
E. The presence or absence of an assocated ventrcuar septa defect (VSD).
Answer: B
DISCUSSION: The drecton of an ntracardac shunt s governed by the compance of the
downstream chambers. For an atra eve shunt, the compance of the rght and eft ventrces and
ther abty to dstend wth ncreased voume durng dastoc ng dctates the drecton of the
shunt ow. Snce the rght ventrce s usuay a more compant-and therefore more dstensbe-
chamber than the eft ventrce, ow across an ASD occurs from eft to rght across the open
trcuspd vave durng dastoe. The sze of an ASD does not correspond to the degree of shunt as
ong as the defect s arge enough to be unrestrctve to ow. A arge shunt can occur through a
reatvey sma defect f the ventrcuar compance s favorabe.
15. The ASD most commony assocated wth mtra nsumcency s:
A. Secundum defect
B. Snus venosus defect
C. Ostum prmum defect.D. Coronary snus defect. Answer: C
DISCUSSION: Ostum prmum defects, or "parta" AV cana defects, are commony assocated wth a
"ceft" of the anteror eaet of the mtra vave. Dependng on the deformty of the mtra vave,
these defects can be accompaned by varabe degrees of mtra nsumcency. Ths ceft of the mtra
vave needs to be repared at the same tme that the defect s cosed. Athough other types of ASDs
can be assocated wth mtra nsumcency, ths s not as common. When mtra stenoss exsts wth
a secundum ASD the condton s often referred to as Lutembacher's syndrome.
16. An eectrocardogram (ECG) n a patent wth a systoc e|ecton murmur that shows an
ncompete bunde branch bock n the precorda ead s most consstent wth:
A. A secundum ASD.
B. A snus venosus ASD wth PAPVR.
C. An ostum prmum ASD.
D. A compete AV cana defect.
Answer: A
DISCUSSION: Many patents wth secundum ASDs have an ncompete bunde branch bock on ther
ECG. Ths s n contradstncton to patents wth ostum prmum defects, who often have a eft axs
devaton. Athough the ECG s not pathognomonc of the defect, the ndngs are sometmes hepfu
aong wth other cnca and dagnostc nformaton toward eucdatng the nature of the defect.
17. ASDs can a be cosed wth a percarda or prosthetc patch. Whch of the foowng ASDs
can aso be safey cosed prmary wthout the use of a patch? A. Secundum ASD.
B. Snus venosus ASD wth PAPVR.
C. An ostum prmum ASD.
D. A compete AV cana defect.Answer: A
DISCUSSION: Secundum ASDs can frequenty be cosed prmary, athough the use of a prosthetc
or percarda patch s ndcated for arge defects. The other types of ASDs are more safey cosed
wth a patch.
18. Obstructon to pumonary venous return s assocated wth whch of the foowng anomaes?
A. Parta anomaous pumonary venous connecton (PAPVC) to the superor vena cava.
B. Infracardac (Type III) tota anomaous pumonary venous connecton (TAPVC).
C. Pumonary ven stenoss.
D. Cor tratratum.
E. Supracardac (Type I) TAPVC.Answer: BCDE
DISCUSSION: Obstructon to pumonary venous return s the most mportant factor ahectng
crcuatory functon when pumonary venous anomaes exst. Ths obstructon s most prevaent and
severe n patents wth nfracardac TAPVC, but t aso occurs n as many as 50% of patents wth
supracardac TAPVC and 20% of patents wth ntracardac TAPVC to the coronary snus. Obstructon
to pumonary venous return s aso the prmary pathophysoogc ehect of both pumonary ven
stenoss and cor tratratum. Obstructon, however, s rare wth parta anomaous pumonary
venous connecton, especay wth the common form of PAPVC to the superor vena cava.
19. Postoperatve compcatons assocated wth repar of TAPVC ncude: A. Compete
heart bock.
B. Acute pumonary hypertensve crss.
C. Peura ehusons.
D. Pumonary venous obstructon.Answer: BD
DISCUSSION: In the eary postoperatve perod after repar of obstructed forms of TAPVC, acute
epsodes of pumonary hypertenson may deveop as a response to stress. To mnmze ths
potentay fata compcaton, nfants are kept anesthetzed wth fentany and pancuronum for at
east 48 hours. Resdua or recurrent pumonary venous obstructon occurs n ony 5% to 10% of
patents after TAPVC repar, but f dented t requres eary reoperaton. Reoperaton s usuay
successfu f the obstructon s at the eve of the anastomoss. Unfortunatey, n some cases, the
obstructon s n the pumonary vens and surgca reef s ess successfu. Athough compete heart
bock and peura ehusons can occur after any cardac operaton, they rarey occur after TAPVC
repar.
20. Whch of the foowng statements about VSDs s/are correct?
A. Permembranous esons are ocated n the regon of the membranous porton of the
nterventrcuar septum near the anterosepta commssure of the trcuspd vave. B. Muscuar VSDs
are hoes n the nterventrcuar septum that are bordered by musce on three sdes and by the
pumonary and the aortc vave annuus superory. C. VSD, n ts soated form, s the most
commony recognzed congenta heart defect.
D. The conducton bunde runs aong the posteronferor rm of a permembranous VSD.
Answer: ACD
DISCUSSION: Permembranous VSDs occupy the area of the membranous porton of the
nterventrcuar septum ad|acent to the anterosepta commssure of the trcuspd vave. Often a
remnant of the membranous porton of the nterventrcuar septum (the membranous ap) s eft
hangng on the posteronferor rm of the defect. The annuus of the trcuspd and aortc vaves often
form a part of the rm of the defect, but n some patents they are separated from the VSD by a thn
rm of musce tssue that protects the conducton bunde. Muscuar VSDs have excusvey muscuar
rms on a four sdes. VSDs n the outet septum that extend to the annuuses of the aortc and
pumonary vaves are caed douby commtted or |uxta-artera defects. Isoated VSDs occur at an
approxmate rate of 2 per 1000 ve brths and represent 30% to 40% of a congenta heart
maformatons at brth. The conducton bunde n patents wth permembranous VSDs does run
aong the posteronferor rm of the defect on the eft ventrcuar sde. Sutures used for repar of a
permembranous VSD shoud be paced we away from ths area to avod the creaton of surgcay
nduced compete heart bock.
21. Whch of the foowng statements about VSDs s/are true?
A. When coarctaton of the aorta s assocated wth VSD, t most commony occurs n nfants wth
arge esons who have to undergo repar before age 3 months.
B. In some patents wth VSD, aortc vave ncompetence deveops over tme and progresses.
C. In the Unted States douby commtted or |uxta-artera VSDs are most commony assocated
wth aortc nsumcency.
D. PDA s present n approxmatey one fourth of nfants wth a VSD and concomtant congestve
heart faure. Answer: ABD
DISCUSSION: VSD n combnaton wth severe coarctaton of the aorta occurs n approxmatey 17%
of patents. Ths combnaton s more common among nfants wth arge VSDs undergong operaton
before age 3 months. Aortc vave ncompetence does deveop over tme n some patents wth VSD,
presumaby as a resut of progressve proapse of the rght aortc cusp through the defect. In the
Unted States two thrds of patents wth VSD and aortc nsumcency have permembranous esons
and one thrd have a douby commtted or |uxta-artera eson. In |apan, however, the reverse s
true: two thrds have douby commtted or |uxta-artera esons and one thrd have
permembranous esons. A moderate- or arge-szed PDA s assocated wth VSD n approxmatey
6% of patents of a ages; however, n nfants wth VSD and concomtant congestve heart faure,
PDA s present n approxmatey 25%.
22. Whch of the foowng statements about VSD s/are correct?
A. A arge VSD s approxmatey the sze of the pumonary vave orce or arger.
B. Large VSDs assocated wth hgh pumonary bood ow resut n an enarged eft atrum on chest x-
ray.
C. Patents wth sma (restrctve) VSDs tend to have norma rght ventrcuar and pumonary artera
pressures wth norma pumonary vascuar resstance and no evdence of pumonary vascuar
dsease.
D. A pumonary vascuar resstance greater than 10 to 12 unts per sq. m. s consdered a
contrandcaton to operaton. Answer: BCD
DISCUSSION: A arge VSD s approxmatey the sze of the aortc vave orce or arger and causes
systemc rght ventrcuar systoc pressures. In the absence of rght ventrcuar outow tract
obstructon, the pumonary artery systoc pressure w aso be systemc n the presence of a arge
VSD. Large VSDs assocated wth a hgh pumonary bood ow do resut n an enarged eft atrum
because of ncreased pumonary venous return. When marked enargement of the eft atrum s
present n a patent suspected of havng a VSD, the presence of coexstng mtra vave
regurgtaton shoud aso be consdered. Patents wth sma VSDs do have norma rght ventrcuar
and pumonary artera pressures. There s ony a sght eevaton of pumonary bood ow reatve
to the systemc ow, and the pumonary vascuar resstance s norma wthout evdence of
pumonary vascuar dsease. At any age, the presence of pumonary vascuar dsease so severe that
the pumonary vascuar resstance s xed and greater than 10 to 12 unts per sq. m. s consdered
a contrandcaton to operaton.
23. Whch of the foowng statements about VSDs s/are correct?
A. Spontaneous cosure of VSDs occurs n 25% to 50% of patents durng chdhood. B. Tachypnea
and faure to thrve are symptoms frequenty assocated wth arge
VSDs.
C. Patents wth norma pumonary vascuar resstance and eft-to-rght shuntng across the VSD
have Esenmenger's compex.
D. Patents wth a arge VSD and ow pumonary vascuar resstance can present wth a
mddastoc murmur at the apex. Answer: ABD
DISCUSSION: Spontaneous and compete cosure of VSDs, even arge ones, has been estmated to
occur n 25% to 50% of patents durng chdhood. The probabty of eventua spontaneous cosure
s nversey reated to the age at whch the patent s observed. Tachypnea, poor feedng, growth
faure, recurrent respratory nfectons, exercse ntoerance, and severe cardac faure may
deveop n patents wth arge VSDs. Patents wth Esenmenger's compex are cyanotc,
poycythemc, and severey mted n ther exercse toerance, owng to markedy eevated
pumonary vascuar resstance assocated wth a predomnanty rght-to-eft shunt across the VSD. A
mddastoc murmur can be present at the apex n patents wth a arge VSD assocated wth ow
pumonary vascuar resstance. Ths ndcates hgh pumonary bood ow wth a arge ow across
the mtra vave nto the eft ventrce.
24. Whch of the foowng s/are true of the surgca treatment of VSDs?
A. A rght ventrcuar approach s empoyed for the repar of most permembranous
VSDs.
B. Intracardac repar s advsabe for patents wth ntractabe symptoms and for asymptomatc
nfants wth evdence of ncreasng pumonary vascuar resstance. C. Compete heart bock s a
common compcaton.
D. Hospta mortaty after repar of VSD n nfants approaches 20%. Answer: B
DISCUSSION: The rght atra approach s preferred for the repar of most permembranous VSDs.
Prompt ntracardac repar s ndcated for nfants wth arge defects, arge shunts, and pumonary
hypertenson who present wth ntractabe eft ventrcuar faure, recurrent pumonary nfectons,
severe growth faure, or evdence of ncreasng pumonary vascuar resstance. In the modern era,
compete heart bock requrng a permanent pacemaker s a very uncommon compcaton of
surgca cosure of a ventrcuar septa defect. Hospta mortaty after cosure of a VSD currenty
approaches zero. Whe n earer years younger age was an ncrementa rsk factor for hospta
death n some surgca experences, ths rsk has been neutrazed durng the past decade.
25. Tetraogy of Faot conssts of a of the foowng features except: A. ASD.
B. VSD.
C. Dextroposton of the aorta.
D. Pumonary stenoss.
E. Rght ventrcuar hypertrophy.Answer: A
DISCUSSION: Athough ASD s a frequent component of tetraogy of Faot, t was not ncuded by
Faot as part of hs cassc tetraogy. Occasonay, the ncuson of an ASD prompts use of the term
pentaogy of Faot. The other four anomaes sted were a mentoned by Faot n hs orgna
descrpton of ths defect.
26. Whch of the foowng has the greatest mpact on the physoogy of tetraogy of
Faot?
A. The sze of the ASD.
B. The sze of the VSD.
C. The degree of pumonary stenoss.D. The amount of aortc overrdng. Answer: C
DISCUSSION: The VSD n tetraogy of Faot s nonrestrctve, and therefore ts sze does not ahect
the degree of shuntng that can occur. Lkewse, an ASD, whch may or may not be a component of
tetraogy of Faot, can provde rght-to-eft shuntng at the atra eve but s not the man
contrbutor to the cyanoss of ths dsease. The degree of rght-to-eft shunt across the VSD s
dctated by the varabe compance of the downstream chambers, and the ncreased resstance
mposed by severe pumonary stenoss creates greater amounts of rght-to-eft shuntng and,
therefore, more ntense cyanoss. The poston of the aorta n reaton to the VSD s not mportant as
ong as no subaortc obstructon exsts.
27. Whch of the foowng anomaes s not assocated wth tetraogy of Faot? A. Absence of the
eft pumonary artery.
B. A rght aortc arch.
C. A retroesophagea subcavan artery.
D. Anomaous orgn of the eft anteror descendng coronary artery from the rght coronary artery.
E. Prmary pumonary hypertenson.Answer: E
DISCUSSION: The rst four defects sted occasonay are assocated wth tetraogy of Faot. A rght
aortc arch s seen n 25% of patents wth that eson. Anomaous coronary arteres or a
retroesophagea subcavan artery are found n as many as 5% to 10% of patents. Absence of a
pumonary artery s unusua but can present n as many as 3% of patents. Pumonary hypertenson
s dstncty unusua wth tetraogy of Faot uness the patent has had excessve pumonary bood
ow from coateras or systemc-to-pumonary artery shunts for a ong tme. It s because these
patents usuay do not have pumonary hypertenson that nfant correcton wth transannuar
patches can be performed wth such great success.
28. Surgca treatment of a patent wth tetraogy of Faot can ncude any of the foowng except:
A. Mantenance of ducta patency wth prostagandns (PGE 1) to provde pumonary bood ow
whe the baby s transferred to an nsttuton equpped to provde more dentve therapy.
B. Bandng of the pumonary artery n an acyanotc patent wth tetraogy of Faot to contro
pumonary bood ow and prevent the deveopment of pumonary hypertenson.
C. Pacement of a subcavan-to-pumonary artery shunt on the sde opposte the aortc arch n a
3-day-od nfant wth severe cyanoss.
D. Cosure of the VSD and transannuar patchng of the rght ventrce onto the manpumonary
artery n a 2-day-od nfant. Answer: B
DISCUSSION: Patents wth tetraogy of Faot who do not appear cyanotc st have md artera
hypoxema by artera bood gas determnaton. Patents wth tetraogy of Faot rarey have
excessve pumonary bood ow, and the deveopment of pumonary hypertenson s not a concern
n ths popuaton. Bandng of the pumonary artery s never a consderaton n patents wth
tetraogy of Faot, snce the predomnant physoogc ehect of the defect resuts from too tte
pumonary bood ow to begn wth. Acyanotc patents wth tetraogy of Faot ("pnk tets") can
usuay be foowed for severa months and ther defects repared eectvey as a rst-stage
procedure (usuay by age 6 months). A of the other therapes are approprate treatment for babes
wth tetraogy of Faot. Prostagandns mantan patency of the ductus arterosus, provdng an
anatomc systemc-to-pumonary artery shunt that sustans pumonary bood ow unt a more
permanent surgca souton can be provded. The advent of prostagandn therapy has enabed
numerous crtcay nfants to become stabzed enough to reach a tertary care nsttuton and
receve proper surgca therapy who mght not otherwse have survved had t not been for the
abty of pumonary bood ow to be mantaned through the reversa of duct cosng. The choce of
paatve shuntng or tota anatomc correcton rests argey wth the experence and sk of the
surgca team and s dctated n part by the anatomy of the pumonary arteres. Ether of these
optons s acceptabe.
29. The predomnant determnant of outcome for patents wth pumonary atresa and an ntact
ventrcuar septum revoves around: A. The sze of the ASD.
B. The baby's age at presentaton.
C. The sze of the rght ventrcuar cavty and trcuspd vave.
D. The presence of a trcuspd-as opposed to a bcuspd-pumonary vave.
E. The eve of hypoxema at presentaton.Answer: C
DISCUSSION: The ong-term outcome for babes wth pumonary atresa and ntact ventrcuar
septum depends on the abty to convert the cardac crcuaton nto a two-ventrce versus one-
ventrce physoogy. Patents wth a good-szed rght ventrce and trcuspd vave can often be
treated wth pumonary vavotomy or rght ventrcuar outow patchng aone and can have a fary
acceptabe outcome. Patents wth a sma rght ventrce that cannot provde adequate pumpng to
the pumonary bed and s often assocated wth a sma trcuspd vave annuus may need to be
staged toward a Fontan procedure-and, consequenty, a ess acceptabe outcome. The sze of an
ASD s not reevant except that n patents wth ths syndrome, the rght sde of the heart w
decompress across the ASD unt antegrade ow can be estabshed. Therefore, an ASD n some
part s an essenta feature of ths eson. The degree of artera hypoxema, the nature of the
pumonary vave, and the patent's age at presentaton may a be factors that reate to cnca
management, but they do not mpy specc consequences wth respect to ong-term outcome.
30. Whch of the foowng statements about doube-outet rght ventrce are true? A. A VSD s
usuay present.
B. In the Taussg-Bng type of doube-outet rght ventrce, the VSD s usuay noncommtted.
C. Patents wth doube-outet rght ventrce and a subaortc VSD usuay have pumonary
stenoss.
D. Patents wth doube-outet rght ventrce wth a subpumonary VSD (Taussg-Bngmaformaton)
tend to mmc patents wth transposton of the great arteres and
VSD n ther presentaton and natura hstory. Answer: ACD
DISCUSSION: A VSD s usuay present n patents wth doube-outet rght ventrce and s the ony
outet from the eft ventrce. Both great arteres may arse totay from the rght ventrce, or one or
both may overe the ventrcuar septum mmedatey above the VSD. To categorze the heart as
havng a doube-outet rght ventrce, more than 50% of each great artery must arse from the rght
ventrce. In the Taussg-Bng type of doube-outet rght ventrce, the VSD s reated to the
pumonary vave annuus and s termed a subpumonary defect. Addtona morphoogc
characterstcs pecuar to ths entty have been descrbed. Most patents wth doube-outet rght
ventrce and a subaortc VSD have concomtant pumonary stenoss that protects the ungs from
pumonary vascuar dsease and aso resuts n a cnca course smar to that of patents wth
tetraogy of Faot. In the absence of pumonary stenoss the presentaton, cnca course, and
natura hstory of the Taussg-Bng maformaton are smar to those of transposton of the great
arteres wth VSD. Cyanoss s present, usuay from brth, snce streamng drects the desaturated
systemc venous return toward the aorta and the oxygenated eft ventrcuar bood toward the
pumonary artery. These patents tend to deveop eary congestve heart faure and can deveop
severe pumonary vascuar dsease eary n fe. They usuay experence symptoms wthn the rst
few months of fe.
31. Whch of the foowng statements about the surgca repar of doube-outet rght ventrce are
true?
A. In doube-outet rght ventrce wth a subaortc or douby commtted VSD, a tunne-type repar
connectng a commtted VSD wth ts respectve great artery s usuay empoyed.
B. Repar of the Taussg-Bng maformaton can be accompshed usng an ntraventrcuar tunne
technque or by performng a straght patch cosure of the
VSD combned wth an artera swtch procedure.
C. The hospta mortaty rate s hghest when a subaortc VSD s present.
D. Some hearts wth doube-outet rght ventrce and a noncommtted VSD must be repared usng a
modcaton of the Fontan procedure. Answer: ABD
DISCUSSION: When the VSD s subaortc or douby commtted, the tunne-type repar connects the
eft ventrce va the VSD and tunne to the aorta. The Taussg-Bng maformaton can be repared
usng an ntraventrcuar tunne technque descrbed by Kawashma. Ths repar can best be
accompshed when the great arteres are n a more or ess sde-by-sde reatonshp wth the aorta
to the rght of the pumonary artery. The nfundbuar septum s generousy resected and the VSD s
connected to the aorta by an ntraventrcuar tunne that runs posteror to the pumonary artery.
The most common approach for the repar of the Taussg-Bng maformaton nvoves patch cosure
of the VSD to the pumonary artery. Ths creates transposton of the great arteres wth an ntact
nterventrcuar septum. An artera swtch procedure then estabshes ventrcuoartera
concordance. Of a the types of doube-outet rght ventrce the hospta mortaty s owest when a
subaortc or douby commtted VSD s present. Doube-outet rght ventrce s assocated wth a
noncommtted VSD n approxmatey 10% of patents n surgca seres. The repar of ths subset of
patents s assocated wth a reatvey hgh mortaty, as compared wth the resuts obtaned after
repar of other forms of doube-outet rght ventrce. At tmes, because of the remote ocaton of the
VSD and because of other compeng anatomc features, compete repar cannot be performed. In
ths case, a modcaton of the Fontan procedure must be empoyed.
32. Management of a patent wth trcuspd atresa wthn the rst month of fe may ncude:
A. Creaton of a systemc artery-to-pumonary artery shunt.
B. Observaton.
C. Creaton of a bdrectona superor cavopumonary anastomoss.
D. Pumonary artery bandng.
E. Fontan procedure.Answer: ABD
DISCUSSION: Inta management of newborn nfants wth trcuspd atresa s determned by the
anatomc and physoogc factors that ahect the baance of pumonary and systemc bood ow.
Infants wth severey mted pumonary bood ow and artera oxygen saturatons of ess than 70%
shoud be stabzed wth PGE 1 to mantan patency of the ductus arterosus unt a systemc-to-
pumonary artery shunt can be performed. Patents wth unobstructed pumonary bood ow may
exhbt ony md cyanoss but suher from sgncant congestve heart faure. Many of these
patents are best managed by pumonary artery bandng to decrease the voume overoad on the
eft ventrce and to prevent the eary deveopment of rreversbe pumonary vascuar dsease.
Some patents wth moderate restrcton of pumonary bood ow may have baanced devery of
bood to the systemc and the pumonary crcuaton. These patents can be carefuy foowed unt
such tme as an mbaance deveops or they become canddates for a bdrectona superor
cavopumonary (Genn) anastomoss or a Fontan procedure. The normay hgh pumonary vascuar
resstance present n the rst month of fe precudes the performance of ether the Genn or the
Fontan procedure n the newborn.
33. Whch of the foowng shoud contrandcate performance of the Fontan procedure?
A. Patent age of 25 years.
B. Severe mtra nsumcency.
C. Left ventrcuar end-dastoc pressure of 18 mm. Hg.
D. Rght pumonary artery stenoss.
E. Pumonary vascuar resstance of 6 Woods unts.Answer: CE
DISCUSSION: Good ventrcuar functon and ow pumonary vascuar resstance are essenta
requrements for a successfu Fontan procedure. The Fontan operaton shoud not be performed
when ventrcuar e|ecton fracton s ess than 30% or ventrcuar end-dastoc pressure s greater
than 15 mm. Hg. Pumonary vascuar resstance n excess of 4 Woods unts shoud aso be
consdered an absoute contrandcaton for Fontan correcton. Age at the tme of Fontan procedure
does not appear to be a ma|or rsk factor, except before age 2 years. Athough patents who have
survved nto the thrd or fourth decade are key to have ventrcuar dysfuncton, a Fontan
procedure can be performed successfuy n these oder patents f ventrcuar functon and
pumonary vascuar resstance meet the above crtera. In patents wth trcuspd atresa a
competent mtra vave s mportant for satsfactory cardac output after the Fontan procedure. The
presence of severe mtra nsumcency, however, shoud not necessary contrandcate the
procedure. In these cases t s recommended that the mtra vave be repared or repaced n
combnaton wth the creaton of a bdrectona superor cavopumonary anastomoss. A competon
Fontan operaton s performed ater. Dstorted or stenosed pumonary arteres are common
sequeae of systemc-to-pumonary artery shunts and may resut n unsatsfactory hgh pumonary
vascuar resstance. In most cases, these stenoses can be repared at the tme of Fontan correcton
or wth a bdrectona superor cavopumonary anastomoss.
34. Inta management of a newborn nfant wth hypopastc eft heart syndrome shoud ncude:
A. Intravenous admnstraton of PGE 1.
B. Suppementa oxygen.
C. Routne ntubaton and mechanca ventaton to acheve a PCO 2 between 30 and
35 mm. Hg.
D. Cardac catheterzaton and baoon atra septostomy. Answer: A
DISCUSSION: Postnata stabzaton of nfants wth hypopastc eft heart syndrome requres patency
of the ductus arterosus and baance of the systemc and the pumonary crcuaton. Because the
ductus s the ony pathway from the rght ventrce to the systemc crcuaton, duct patency must
be mantaned wth ntravenous PGE 1. To mnmze the workoad on the snge ventrce and ensure
adequate devery of oxygen to the tssues, an equa devery of bood to both the ungs and the
body s sought. The norma postnata decrease n pumonary vascuar resstance often resuts n
overperfuson of the pumonary crcuaton and underperfuson of the systemc crcuaton.
Maneuvers that further decrease pumonary vascuar resstance, such as the addton of
suppementa oxygen, owerng the PCO 2 to ess than 35 mm. Hg, or emnatng any resstance at
the atra septum by baoon septostomy ony worsens the mbaance.
35. The performance of a bdrectona superor cavopumonary (Genn) anastomoss as the second
stage n the reconstructve approach to hypopastc eft heart syndrome: A. Provdes eary reef of
voume oad on the snge rght ventrce.
B. Increases perphera oxygen saturatons to greater than 90%.
C. Permts concomtant repar of pumonary artery or aortc arch stenoses.
D. Improves mortaty and morbdty of subsequent Fontan procedure.Answer: ACD
DISCUSSION: After the rst-stage reconstructve (Norwood) procedure, the crcuaton s nherenty
nemcent because of the obgatory recrcuaton of a porton of both saturated and desaturated
bood. Cosure of the artera shunt and creaton of a bdrectona Genn anastomoss emnates ths
nemcent recrcuaton and sgncanty dmnshes the voume oad on the snge rght ventrce.
Dstorted and stenosed centra pumonary arteres or aortc arch obstructons shoud be repared at
the same tme the bdrectona Genn procedure s performed. In amost a seres the mortaty of
the Fontan procedure has decreased snce the adopton of the three-stage approach for hypopastc
eft heart syndrome. Because systemc and pumonary venous bood contnue to mx n the rght
atrum after a bdrectona Genn procedure, cyanoss perssts wth perphera oxygen saturatons
between 75% and 85%.
36. Whch of the foowng statements about truncus arterosus are true? A. Most nfants
survve wthout operatons unt ate chdhood.
B. Most nfants present wth cyanoss.
C. Most nfants present wth congestve heart faure.
D. Repar requres a condut from rght ventrce to pumonary arteres.Answer: BCD
DISCUSSION: Whe an occasona chd survves to age 3 or 4 years, wthout ether paatve or
totay correctve surgca treatment few ve past eary nfancy. The eson s one of excessve
pumonary bood ow because of the orgn of the pumonary arteres from the truncus arterosus;
physoogcay, the pumonary arteres arse drecty from the aorta. Athough the aortc saturaton
can never be 100% because of some eement of bdrectona shuntng at the VSD, the physoogc
manfestatons are congestve heart faure and excessve pumonary bood ow rather than
cyanoss. The congestve heart faure becomes severe as pumonary vascuar resstance drops. If
congestve heart faure ater mproves spontaneousy, t s because of the deveopment of
pumonary vascuar dsease. Compete repar aways requres cosure of the VSD, detachment of the
pumonary arteres from the common trunk, and re-estabshment of an outow tract from the rght
ventrce to the pumonary artery. Ths condut usuay contans a vave and can be ether a
homograft or a synthetc condut contanng a porcne vave.
37. Truncus arterosus s a dagnoss wth anatomc components ncudng: A. VSD.
B. Abnorma orgn of pumonary arteres.
C. Subaortc stenoss.
D. Snge ventrcuar outow vave.Answer: ABD
DISCUSSION: By denton, a VSD s aways present mmedatey beneath the trunca vave. The
pumonary arteres arse abnormay from the snge trunk, whch s due to faed parttonng of the
embryonc conus durng the rst few weeks of feta deveopment. In the casscaton of Coett and
Edwards, Type I truncus arterosus has a snge artera trunk gvng rse to an aorta and a man
pumonary artery; n Type II the rght pumonary arteres arse mmedatey ad|acent to one another
from the dorsa wa of the truncus; n Type III the rght and eft pumonary arteres orgnate from
ether sde of the truncus; and n Type IV the proxma pumonary arteres are absent and pumonary
bood ow s by way of ma|or aortopumonary atresa and s no onger consdered truncus
arterosus. Subaortc stenoss cannot occur n ths anomay. The snge ventrcuar outow vave s
the trunca vave. It may contan from two to sx cusps, but most often there are three and, next
most often, four.
38. Optma treatment for the neonate who presents wth transposton of the great arteres
{S,D,D}* and ntact ventrcuar septum ncudes: A. PGE 1 nfuson to mantan duct patency.
B. Admnstraton of ntravenous ud to ncrease ntravascuar voume.
C. Hyperventaton to decrease pumonary resstance.
D. Oxygen admnstraton to ncrease artera oxygen tenson.
E. Atra baoon septostomy to mprove atra mxng.Answer: ABE
DISCUSSION: Because wth transposton of the great vesses the systemc and the pumonary
crcuatons exst n parae rather than n seres, survva depends on mxng between pumonary
and systemc crcuatons. Intay nfants wth transposton and ntact atra septum survve
because of aortopumonary ow through PDA, whch may be mantaned wth prostagandn
nfusons. Athough ncreased pumonary ow may cause enargement of the eft atrum and
stretchng of the foramen ovae resutng n atra-eve mxng of oxygenated and nonoxygenated
bood, nadequate mxng at the atra eve w resut n margna tssue oxygenaton, whch does
not mprove wth oxygen admnstraton. Atra baoon septotomy resuts n mproved admxture
and oxygen devery n these patents and shoud be performed prompty f perphera acdema and
severe cyanoss are present. Reatve dehydraton may decrease the degree of nteratra shuntng
and voume nfuson often mproves hemodynamcs n nfants. Decreased pumonary vascuar
resstance may ncrease pumonary bood ow at the expense of systemc bood ow and ater the
oadng condtons of the eft ventrce, whch may compcate eary artera repar.
39. Factors that precude the use of a snge-stage artera swtch reconstructon of
dextrotransposton of the great vesses ncude:
A. Age oder than 6 weeks wth a eft ventrcuar pressure of ess than 50% of systemc pressure.
B. Dynamc eft ventrcuar outow tract obstructon.
C. Intramura coronary artery anatomy.
D. Vavar pumonc stenoss.
E. Subpumonary VSD.Answer: AD
DISCUSSION: Snge-stage artera swtch procedure for reconstructon of transposton of the great
vesses, wth or wthout assocated VSD has become the standard of treatment n the ma|orty of
cardac centers. Contrandcatons to artera swtch repar ncude xed types of eft ventrcuar
outow tract obstructon, ncudng vavar pumonc stenoss, whch woud render the systemc
semunar vave stenotc or ncompetent. Anatomc abnormates wthout stenoss, such as a
bcuspd vave, however, are sutabe for surgca correcton. The ocaton of VSD does not ahect
surgca outcome, and most VSDs can be approached adequatey through the rght atrum or the
anteror great vesse. Most dynamc forms of eft ventrcuar outow tract obstructon are often
reeved partay or competey by reagnment of the ventrcuar septum wth the hemodynamc
changes foowng successfu artera swtch repar. When, however, the eft ventrce has not been
prepared to sustan the pressure oad of the systemc crcuaton by the decrease n pumonary
vascuar resstance that occurs n the rst few weeks of fe and when the ventrcuar pressure s
ess than 50% of the systemc ventrcuar pressure, one-stage repar s contrandcated, and staged
repar wth pumonary bandng and shunt foowed by artera swtch must be contempated.
40. Compcatons commony assocated wth the atra (Sennng and Mustard) repars of
transposton of the great arteres ncude: A. Atra arrhythmas.
B. Systemc or pumonary venous obstructon.
C. Rght ventrcuar outow tract obstructon.
D. Systemc ventrcuar faure.
E. Progressve eevaton of pumonary vascuar resstance.Answer: ABD
DISCUSSION: The atra repar of transposton of the great arteres-reroutng systemc and
pumonary venous bood at the atra eve-resuts n the rght ventrce's becomng the systemc
ventrce. Ths resuts n an anatomc rght ventrce wth abnorma geometry sustanng the
afteroad of a more deay suted eft ventrce. Long-term compcatons of ventrcuar dataton, AV
vave regurgtaton, and rght ventrcuar faure have been reported n as many as 10% of patents
many years foowng the atra operaton. The mutpe suture nes n the atrum have been
assocated wth a hgh ncdence of ate atra arrhythmas and a ow ncdence of snus rhythm
foowng the Mustard and Sennng operatons. These compcatons do not appear to be as frequent
wth the artera swtch repar. In addton, the compcated nteratra bames have been assocated
wth pumonary or systemc venous bame obstructon. Because the rght ventrcuar outow tract s
not addressed durng an atra swtch operaton, rght ventrcuar outow tract obstructon s not a
recognzed compcaton foowng the repar. Rght ventrcuar outow tract and supravavar
pumonc stenoss, however, have been reported n patents after the artera swtch repar, owng to
the reconstructon of the rght ventrcuar outow tract n that operaton. Athough progresson of
pumonary artera obstructon has rarey been reported foowng eary repar wth the atra or the
artera swtch procedure, t s an unusua compcaton f operaton s undertaken n nfancy.
Deayed repar beyond age 6 months to 1 year, however, has been assocated wth a hgher
ncdence of progressve deveopment of pumonary vascuar obstructve dsease. The rapdty of
the deveopment of pumonary vascuar dsease s ncreased by the coexstence of a VSD.
41. Crtca aortc stenoss n the neonate s characterzed by whch of the foowng?
A. It s most often due to commssura fuson of a treaet vave.
B. It may be assocated wth coarctaton of the aorta, PDA, and mtra stenoss.
C. It can be managed medcay unt the chd s arge enough to undergo aortc vave repacement.
D. Success of vavotomy s determned by the adequacy of the eft ventrce.
Answer: BD
DISCUSSION: Crtca aortc stenoss n the neonate most often presents n the rst week of fe wth
severe and progressve congestve heart faure and may be assocated wth coarctaton of the
aorta, PDA, and mtra stenoss. The prognoss s poor uness vavotomy can be performed
expedtousy. Medca management cannot stabze these nfants for vave repacement at a ater
age. Infants whose eft ventrce s too sma to sustan the systemc crcuaton are unkey to
survve aortc vavotomy and, thus, shoud be managed as patents wth hypopastc eft heart
syndrome. The aortc vave n neonata aortc stenoss s most commony uncuspd or bcuspd.
42. Surgca management of aortc vave dsease n an oder chd may ncude: A. Enargement
of the aortc annuus.
B. Incson of fused commssures.
C. Inserton of a porcne vave prosthess.
D. Transfer of the pumonary vave to the aortc poston.Answer: ABD
DISCUSSION: The ma|orty of oder chdren wth aortc stenoss and sgncant transvavuar
gradents can be treated successfuy by aortc vavotomy. Ths can be done percutaneousy wth
baoon dataton or surgcay wth drect vsuazaton of the aortc vave and ncson of the fused
commssures. Aortc vave repacement s rarey necessary as a prmary procedure but may be
requred n chdren who deveop progressve aortc nsumcency after a prevous nterventon. When
vave repacement s performed t s desrabe to nsert the argest prosthess possbe, to aow for
growth. Enargement of the aortc annuus s commony performed for ths purpose. If a true vave
prosthess s empoyed, a mechanca vave s preferred. Durabty of xenograft vaves n chdren s
mted owng to eary caccaton and eaet degeneraton. The pumonary autograft technque
may be the best method of aortc vave repacement n chdren. Wth ths operaton the patent's
own pumonary vave s transferred to the aortc poston and a pumonary aograft s nserted to
repace the pumonary vave. Athough the pumonary autograft may not acheve the ong-term
durabty of a mechanca vave, the patent does not face the ong-term compcatons of
thromboembosm and beedng mposed by a mechanca vave and feong antcoaguaton.
43. Whch of the foowng statements about subvavuar aortc stenoss are true? A. Most patents
present n eary nfancy wth severe congestve heart faure.
B. An e|ecton cck s a specc physca sgn of subaortc stenoss.
C. The subaortc membrane s approached surgcay va the aorta and aortc vave.D. A concomtant
septa myectomy decreases the ncdence of recurrent subaortc stenoss.
Answer: CD
DISCUSSION: Subaortc stenoss s rarey encountered n neonates. Most often t s dscovered n an
asymptomatc chd durng a routne physca examnaton. A oud crescendo-decrescendo systoc
murmur wthout an e|ecton cck s usuay noted. The presence of an e|ecton cck s more
consstent wth soated vavuar aortc stenoss. Dscrete subaortc stenoss s approached surgcay
wth cardopumonary bypass, aortc cross-campng, and cardopegc arrest. The aorta s opened
and the aortc vave eaets are retracted, exposng the brous membrane. The brous rng s
carefuy excsed, takng care to avod n|ury to the anteror eaet of the mtra vave and the
penetratng conducton bunde. Once the subaortc membrane s excsed a septa myectomy further
opens the eft ventrcuar outow tract and dmnshes the kehood of recurrent subaortc stenoss.
44. Management of hypertrophc obstructve cardomyopathy may ncude: A.
Propranoo and verapam.
B. Aortc vave repacement.
C. Dua-chamber sequenta pacng.
D. Combned septa myectomy and mtra vave pcaton.Answer: ACD
DISCUSSION: The ma|orty of patents wth hypertrophc obstructve cardomyopathy are treated
medcay wth beta-bockers such as propranoo and cacum channe bockers such as verapam.
Patents whose symptoms do not respond to medca therapy are treated surgcay wth a
transaortc septa myectomy. Recent reports ndcate that smpe pcaton of the anteror eaet of
the mtra vave performed n addton to the septa myectomy further opens the eft ventrcuar
outow tract by emnatng systoc anteror moton of the mtra vave. Aortc vave repacement s
not an approprate treatment for hypertrophc obstructve cardomyopathy. Some patents who are
poor surgca canddates may experence reef of symptoms and eft ventrcuar outow gradents
wth dua-chamber permanent pacng. Approprate pre-exctaton of the ventrcuar septum can
prompt the septum to move away from the eft ventrcuar wa durng systoe and open the outow
tract.
45. Whch of the foowng statements about supravavuar aortc stenoss are true?
A. Surgca repar s ndcated ony when the systoc gradent exceeds 75 mm. Hg.
B. Smpe excson of the supravavuar membrane resuts n satsfactory reef of the stenoss n most
patents.
C. The dhuse form of supravavuar aortc stenoss may cause obstructon to branches of the aortc
arch.
D. Reoperaton after repar of dscrete supravavuar aortc stenoss s rare unessabnormates of the
vave tsef aso exst. Answer: CD
DISCUSSION: Supravavuar aortc stenoss s a progressve dsease and shoud be repared
surgcay f symptoms are present or the systoc gradent exceeds 50 mm. Hg. In addton to
excson of the supravavuar membrane, a patch of dacron or percardum must be paced across
the area of narrowng and down nto at east one of the snuses of Vasava. Reoperaton s rare after
ths procedure uness assocated aortc vave dsease s aso present. In the dhuse form of the
dsease the thckenng of the aortc wa commony resuts n sgncant umna narrowng of the
ascendng aorta and ts ma|or branches.
46. Each year the approxmate number of Amercans who de from compcatons of coronary
artery dsease s: A. 100,000.
B. 250,000.
C. 500,000.
D. 1,000,000.
E. Over 2,000,000.
Answer: C
DISCUSSION: It s estmated that approxmatey 7,000,000 Amercans currenty have symptomatc
coronary artery dsease. Of these some 1,500,000 experence myocarda nfarcton annuay and
approxmatey 500,000 de each year from compcatons.
47. Whch of the foowng arteres s most key to be nvoved wth serous atherosceross?
A. The rght coronary artery.
B. The eft coronary artery.
C. The anteror descendng coronary artery.
D. The crcumex coronary artery.Answer: C
DISCUSSION: In order of frequency, the anteror descendng coronary artery s the most commony
nvoved wth atherosceross, foowed by the rght coronary, the crcumex, and the eft man
coronary artery.
48. Whch of the foowng statements about coateras n the norma coronary crcuaton s true?
A. There s a rch and qute ehectve coatera crcuaton n the coronary artera bed.
B. The coronary artera bed has mnma ehectve coateras.
C. The coronary artera bed s an absoute exampe of anatomc end-arteres.
Answer: B
DISCUSSION: The coatera crcuaton to the heart s reatvey poor. In the human heart there are
few natura coateras of sumcent dameter for devery of a sgncant quantty of bood. Most of
the coateras are approxmatey 200 mm. or smaer, and channes of ths sze cannot conduct
sgncant quanttes of bood for cardac requrements. There s no absoute exampe of anatomc
end-arteres n humans. Whe the magntude of artera coatera crcuaton vares consderaby, a
organs have some coateras.
49. If bood enterng the norma artera crcuaton of the heart s 100% saturated wth oxygen,
oxygen saturaton of bood n the coronary snus can be expected to be approxmatey: A. 75%.
B. 60%.
C. 50%.
D. 35%.
E. Less than 20%.Answer: D
DISCUSSION: The heart has an unusuay hgh rate of oxygen utzaton and consumes
approxmatey two thrds of the oxygen n the artera bood. The oxygen saturaton of the bood n
the coronary snus s usuay about 30% to 35% and vares wth the magntude of cardac dsease.
The body as a whoe extracts approxmatey 25% of the oxygen t receves, thus emphaszng the
great need of the heart for oxygen at rest as we as at exercse.
50. Coronary bypass procedures have been demonstrated to: A.
Reduce the ncdence of myocarda nfarcton.
B. Sgncanty reeves angna symptoms.
C. Statstcay mprove the fe span.
D. Improve the e|ecton fracton of the eft ventrce n many patents n whom t s sgncanty
depressed preoperatvey. Answer: ABCD
DISCUSSION: In a varety of studes, coronary bypass procedures have been demonstrated to
reduce the ncdence of subsequent myocarda nfarcton as we as to reeve sgncanty angna
symptoms. They aso mprove the fe span of most patents as we as the e|ecton fracton of the
eft ventrce n those n whom t was depressed preoperatvey.
51. The foowng patents are best treated wth coronary artery bypass graftng
(CABG):
A. A 60-year-od man wth cass II angna, 75% proxma rght coronary artery eson, and norma
ventrcuar functon.
B. A 60-year-od man wth unstabe angna, three-vesse dsease, and an e|ecton fracton of 35%.
C. A 60-year-od nondabetc man wth cass III angna symptoms and foca dscrete esons n the
md-rght coronary artery and md-eft crcumex artery.
D. A 60-year-od man wth dabetes, cass IV angna, 75% proxma eft anteror descendng and
75% proxma rght coronary artery obstructon, and eft ventrcuar e|ecton fracton of 60%.
Answer: BD
DISCUSSION: CABG has been shown to proong patent survva compared wth medca therapy n
those patents wth eft man occusve dsease and those wth three-vesse or two-vesse dsease
wth proxma eft anteror descendng nvovement n assocaton wth cass III or greater angna
symptoms, mpared e|ecton fracton, or easy nducbe schema wth exercse. Athough
percutaneous transumna coronary angopasty (PTCA) appears to be comparabe to CABG n
nondabetc patents, patents wth dabetes appear to have a sgncant survva advantage when
CABG s used. Smary, patents wth more extensve coronary artery dsease are better treated
wth CABG than wth PTCA.
52. Sterna wound nfectons that spread to the medastnum are assocated wth a mortaty
rate of: A. 60%.
B. 30%.
C. 25%.
D. Less than 15%.Answer: D
DISCUSSION: Athough the mortaty rate foowng sterna nfectons wth medastnts formery was
hgh, t s now greaty reduced. In most seres, medastnts s cured n more than 90% of patents
who are treated aggressvey wth dbrdement and pacement of musce aps or omentum nto the
medastnum to speed wound heang.
53. Peroperatve myocarda nfarcton occurs foowng coronary bypass procedures n
approxmatey: A. 15%.
B. 10%.
C. 7%.
D. Less than 5%.Answer: D
DISCUSSION: Foowng mprovements n myocarda protecton and coronary graftng technques,
peroperatve myocarda nfarcton now occurs n ess that 2% to 4% of patents n most seres.
54. Foowng acute myocarda nfarcton, ventrcuar septa defects occur n: A. 20%.
B. 10%.
C. 15%
D. 2% or ess.Answer: D
DISCUSSION: Postmortem studes ndcate that 8% to 10% of fata cases of myocarda nfarcton are
due to rupture of the heart. In addton, nfarcton of the nterventrcuar septum wth subsequent
formaton of a ventrcuar septa defect occurs n 1% to 2% of patents wth acute myocarda
nfarcton. The usua nterva between the acute nfarcton and septa rupture-4 to 12 days-
correates wth the hstoogc ndng of maxma cardac musce degeneraton.
55. Whch of the foowng cnca characterstcs s/are assocated wth a hgher mortaty after
emergency CABG for faed PTCA? A. Mutvesse dsease.
B. Rescue atherectomy.
C. Cardogenc shock pror to CABG.
D. Prevous bypass surgery.
E. A of the above.Answer: ACD
56. Whch statement(s) about operatve mortaty and peroperatve ncdence of myocarda
nfarcton for eectve CABG (X) versus emergency CABG foowng faed
PTCA (Y) s/are accurate?
A. The operatve mortaty s hgher for Y but the ncdence of peroperatve myocarda nfarcton s
unchanged between X and Y.
B. The operatve mortaty s unchanged between X and Y but the peroperatve ncdence of
myocarda nfarcton s hgher n Y.
C. The operatve mortaty and peroperatve ncdence s hgher n X than n Y.
D. The operatve mortaty and peroperatve ncdence of myocarda nfarcton are no dherent for X
and for Y. Answer: C
57. Whch of the foowng statements about patents treated by pacement of an nterna mammary
artery (IMA) bypass graft at prmary CABG s/are correct?
A. The rsk for morbdty and mortaty from reoperatve coronary bypass graftng sncreased.
B. Left ventrcuar functon s better preserved at the tme of reoperaton.
C. The rsk of sterna wound compcatons s greaty ncreased f the contraatera
IMA s harvested at the tme of reoperaton.
D. A ght camp shoud be apped to the IMA pedce to mt cardac warmng durng cardopegc
arrest at the tme of reoperaton.
E. A functona study demonstratng a arge porton of myocardum at rsk shoud be obtaned before
reoperaton. Answer: BDE
DISCUSSION: Patents who have an ntact IMA graft shoud have severe angna symptoms and a
sgncant porton of myocardum at rsk before reoperatve coronary bypass graftng s consdered.
A functona study may better dene the proporton of myocardum at rsk for schema and
nfarcton. Patents wth an ntact IMA graft are ess key to requre reoperaton, but f stenoss
dsta to the IMA and dsease n other ven grafts have progressed or f a arge porton of
myocardum s at rsk, reoperaton s recommended. The presence of an ntact IMA s not a
contrandcaton to reoperaton; n fact, ths popuaton of patents have better-preserved ventrcuar
functon and are, perhaps, better canddates for reoperaton. Pacement of an IMA graft at the tme
of the rst operaton was crtcay mportant, neutrazng the adverse ehects of eevated serum
choestero, hypertenson, and smokng on reoperaton-free survva. The rsk of damagng an ntact
IMA graft s 3% to 5%. A atera pro|ecton of the IMA at cardac catheterzaton w dene ts course,
partcuary n reaton to the sternum, to aow more carefu sterna re-entry. The IMA shoud be
mnmay dssected and a ght camp apped durng cardopegc arrest to mt cardac warmng
and mprove myocarda protecton. The IMA may be detached and recyced f needed. The use
durng reoperaton of the contraatera IMA does not ncrease the rsk of sterna wound
compcatons.
58. Consderng the resuts of coronary reoperaton n comparson to prmary CABG, choose the
ncorrect statement:
A. Operatve morbdty and mortaty are ncreased over those for prmary CABG.
B. Mortaty most often stems from cardac causes after reoperaton.
C. Survva of patents after hospta dscharge foowng coronary reoperaton s neary equvaent to
survva after prmary CABG.
D. Compared to prmary CABG, return of angna symptoms s deayed after reoperatve
CABG.
E. Myocarda protecton and the rsk of myocarda nfarcton n reoperaton are compcated by
ncreased noncoronary coateras, patent atheroscerotc saphenous ven grafts, and more dhuse
coronary atherosceross. Answer: D
DISCUSSION: The mortaty and morbdty after reoperatve CABG are approxmatey two to three
tmes that of prmary CABG. In contrast to prmary CABG, where the ma|orty of deaths are a resut
of faure of other organ systems, 75% to 85% of deaths after reoperatve CABG are due to cardac
causes. The ncreased rsk of reoperaton resuts from more advanced natve vesse dsease, a
onger cross-camp tme, a onger cross-camp tme per graft, a onger tme to ntate
cardopumonary bypass, and ncreased bood oss. The ncreased frequency of pumonary
compcatons, myocarda nfarcton, neuroogc n|ury, and death, stems from the technca factors
of reoperaton and the characterstcs of the patent popuaton. Technca factors ncude dmcuty
n ndng targets secondary to percarda reacton and more dhusey dseased vesses, the rsks of
n|urng the heart or great vesses on sterna re-entry, ncreased bood oss and rsk of requrng
transfuson, ess avaabe condut for bypass, and greater dmcuty n provdng optma myocarda
protecton. Characterstcs of ths patent popuaton that ncrease rsks ncude advanced age and
dmnshed ventrcuar functon. Whe survva after reoperaton s neary equvaent to that after
prmary CABG, angna symptoms return at twce the frequency n the rst year after operaton (47%
versus 20%) then return at a smar annua rate (2% to 3%).
59. Whch statements are correct comparsons of gated equbrum and nta-transt radonucde
measurements of eft ventrcuar functon?
A. Gated equbrum technques provde more accurate measurements of e|ecton fracton than nta-
transt methods.
B. Left ventrcuar magng tme for a gated equbrum study s at east 10 tmes that of an nta-
transt study.
C. Both technques requre the same radopharmaceutcas.
D. Both technques requre a bous n|ecton.Answer: B
DISCUSSION: Both technques are equay accurate for measurng eft ventrcuar e|ecton fracton.
The eft ventrcuar magng tme for gated equbrum studes s at east 10 tmes that of nta-
transt radonucde angocardography. Inta-transt technques use data from fewer than 10
heartbeats, whereas equbrum studes requre more than 100 heartbeats to acqure data wth
smar nformaton densty. The nta-transt study can be performed wth any radoactve
substance, but the gated equbrum technque requres a radopharmaceutca that remans wthn
the bood poo for magng. The nta-transt radonucde study requres a bous n|ecton, but an
equbrum study can be acqured up to severa hours after n|ecton and must be acqured whe
the tracer s at equbrum.
60. The radonucde varabe that contans the greatest amount of prognostc nformaton
n patents wth coronary artery dsease s: A. Exercse e|ecton fracton.
B. Change n regona wa moton from rest to
exercse.
C. Maxma cardac output durng exercse.D. Change
n heart rate durng exercse. Answer: A
DISCUSSION: The exercse e|ecton fracton s the snge most mportant radonucde varabe
reatng to subsequent cardac death or myocarda nfarcton, and ths snge varabe contans 80%
of the prognostc nformaton n the test.
61. Whch of the foowng statements about eft ventrcuar aneurysm s/are correct?
A. Ventrcuar aneurysms are commony assocated wth systemc artera embozaton.
B. Absent coatera crcuaton n an area of myocardum supped by an acutey occuded artery favors
aneurysm formaton.
C. Posterobasa aneurysms are more common than those ocated n the anteroapca regon.
D. Aneurysm repar can mprove assocated cardac vave dysfuncton.
E. Persstent ST segment eevaton after acute myocarda nfarcton suggests aneurysm formaton.
Answer: BDE
DISCUSSION: The mura thrombus frequenty present on the endocarda surface of an aneurysm s
usuay adherent and rarey embozes. Coatera crcuaton, when present, often prevents
transmura necross foowng artera occuson. Snce the eft anteror descendng coronary artery s
the vesse most commony occuded n patents wth ventrcuar aneurysms, most of the aneurysms
are anteroapca. Improvements n ventrcuar contour and reducton n ventrcuar voume
accompany aneurysm repar. Athough persstent eevaton of ST segments foowng myocarda
nfarcton s very suggestve of aneurysm formaton, the dagnoss shoud be conrmed by more
dentve tests.
62. Whch of the foowng factors does/do not ncrease eary mortaty assocated wth repar of
eft ventrcuar aneurysm? A. Cass IV cardac status.
B. Sze of aneurysm.
C. Presence of eft man coronary dsease.
D. Emergent operaton.
E. Locaton of aneurysm.Answer: BE
DISCUSSION: Cass IV cardac status and emergent operaton both mpy extensve myocarda
damage and n most reported seres are assocated wth ncreased operatve mortaty. Smary,
the presence of sgncant stenoss of the eft man coronary artery ncreases the operatve
mortaty of vrtuay a cardac procedures. On the other hand, nether the sze of the aneurysm nor
ts ocaton ahect eary operatve mortaty, despte the fact that posteror aneurysms are
techncay more dmcut to repar and are much ess common.
63. The most ehectve medca therapy n ameoratng the symptoms of Kawasak's dsease and
preventng the deveopment of gant coronary artery aneurysms s admnstraton of: A.
Antbotcs.
B. Antvra agents.
C. Asprn.
D. Gamma gobun.
E. Gucocortcods.Answer: D
DISCUSSION: Kawasak's dsease s a mutsystemc dsorder of unknown cause and s the eadng
cause of acqured heart dsease n chdren n both |apan and the Unted States. Athough many
cnca aspects of Kawasak's dsease suggest an nfectous agent, the search for a snge agent has
been unsuccessfu; nether antbacteras nor antvras have a roe n the therapy of Kawasak's
dsease. The goa of nta therapy of Kawasak's dsease s the reducton of nammaton, ncudng
coronary and myocarda nammaton. After the dagnoss of Kawasak's dsease s secured,
patents are treated wth ntravenous gamma gobun and arge doses of asprn. Gamma gobun,
2 gm. per kg., s admnstered as a snge nfuson over 12 hours. Treatment wth ntravenous
mmune gobun has been shown to decrease the duraton of fever, to decrease the prevaence of
cardovascuar compcatons, and to prevent the progresson to gant coronary aneurysms. Hgh-
dose asprn therapy contrbutes to the resouton of the acute manfestatons of Kawasak's dsease.
When Kawasak's dsease s dagnosed, chdren are gven a regmen of asprn, 100 mg. per kg. per
day, whch s contnued unt defervescence. Thereafter, they are mantaned on sma doses of
asprn, 3 to 5 mg. per kg. per day, for 8 weeks. The goa of asprn therapy s ameoraton of
symptoms and preventon of the thrombotc and emboc compcatons of Kawasak's dsease.
Asprn does not decrease the rsk of the deveopment of coronary aneurysms. There s no roe for
gucocortcods n the treatment of Kawasak's dsease.
64. Indcatons for surgca nterventon n Kawasak's dsease ncude whch of the foowng?
A. The presence of mutpe coronary artery aneurysms.
B. Myocarda nfarcton and severe eft ventrcuar dysfuncton.
C. The presence of a 5 mm. aneurysm n the rght coronary artery.
D. Progressve stenoss n the eft anteror descendng coronary artery.
E. None of the above.
Answer: D
DISCUSSION: The ndcatons for surgca treatment of Kawasak's dsease ncude:
(1) progressvey stenotc coronary esons demonstrated on coronary arterography, wth no dsta
coronary aneurysms wth stenoss; (2) ocazed aneurysm wth sgncant stenoss n the eft man
coronary artery; (3) sgncant stenoss n two coronary arteres; (4) presence of coatera vesses
arsng from a coronary artery wth a proxma aneurysm; (5) progressve stenoss n the eft anteror
descendng coronary artery; and (6) presence of a eft ventrcuar aneurysm. Advanced thromboss
of coronary aneurysms causng crtca stenoses n mutpe coronary arteres s the most common
ndcaton for surgca nterventon.
65. Whch of the foowng statements about the pathophysoogy of Ebsten's anomay s/are true?
A. The trcuspd vave s usuay nsumcent.
B. Typcay there s a eft-to-rght shunt across the ASD.
C. The redundant anteror eaet of the trcuspd vave may cause obstructon of the rght ventrcuar
outow tract.
D. Pumonary hypertenson s a common ate compcaton.
E. Hgh pumonary vascuar resstance n neonates exacerbates trcuspd regurgtaton and cyanoss.
Answer: ACE
DISCUSSION: Ebsten's anomay s characterzed by downward dspacement of the trcuspd vave
nto the rght ventrcuar cavty. The anteror eaet s arge and "sa-ke," whe the other two
eaets are rudmentary. Athough the trcuspd vave occasonay may be stenotc, t s usuay
regurgtant. The trcuspd regurgtaton and functona rght ventrcuar outow tract obstructon
caused by the arge anteror eaet ead to rght-to-eft shuntng across the ASD. Systemc venous
hypertenson s often present, but pumonary hypertenson amost never occurs wth ths
maformaton. Fnay, neonates that present wth Ebsten's anomay are markedy cyanotc, owng
to ther hgh pumonary vascuar resstance. Ths causes a functona pumonary atresa, whch
ncreases rght-to-eft shuntng across the ASD.
66. In the surgca treatment of Ebsten's anomay, whch of the foowng s/are true?
A. In neonates, the trcuspd vave orce may be oversewn and a systemc-pumonaryshunt created to
provde pumonary bood ow.
B. Technques n repar of the trcuspd vave do not utze pcaton of the atrazed rght ventrce.
C. Cosure of the ASD aone s adequate repar of the maformaton.
D. If trcuspd vave repacement s performed, the vave shoud be sutured above the coronary snus
to avod n|ury to the conducton system.
E. Currenty, mechanca prostheses are recommended for trcuspd vave repacement because the
durabty of boprosthetc vaves n the trcuspd poston s so poor.
Answer: AD
DISCUSSION: In a recent report on the surgca treatment of Ebsten's anomay n neonates, Starnes
descrbed a technque consstng of oversewng the trcuspd vave, atra septectomy, and
pacement of a systemc-pumonary shunt. These patents are then ater staged to a moded
Fontan procedure when they outgrow ther shunts. Repar of the ASD aone was performed eary n
the treatment of Ebsten's anomay and was assocated wth hgh mortaty rates. It s not
consdered an adequate repar. Most technques n trcuspd vave repar for Ebsten's maformaton
utze pcaton of the atrazed rght ventrce n addton to excson of redundant atra tssue. If
trcuspd vave repacement s necessary, current approaches utze boprosthetc vaves because of
ther exceent durabty n the trcuspd poston. Pacement of the vave rng above the coronary
snus has been assocated wth a ower rate of postoperatve heart bock.
67. Whch of the foowng congenta esons of the coronary crcuaton causes a cardac murmur
that s smar to the murmur produced by a PDA?
A. Orgn of the eft coronary artery from the pumonary artery.
B. Orgn of the rght coronary artery from the pumonary artery.
C. Coronary artery stua.
D. Membranous obstructon of the ostum of the eft man coronary artery.Answer: C
DISCUSSION: The ma|or cnca ndng wth a coronary artery stua s a
contnuous murmur over the ste of the abnorma communcaton. Ths murmur may cosey
resembe that of PDA.
68. The congenta coronary eson most key to cause death n nfancy s: A. Coronary
artery stua.
B. Orgn of the eft coronary artery from the pumonary artery.
C. Orgn of the rght coronary artery from the pumonary artery.
D. Congenta coronary aneurysm.Answer: B
DISCUSSION: The prognoss for most patents wth orgn of the eft coronary artery from the
pumonary artery s poor. It has been estmated that 95% of patents wth ths anomay de wthn
the rst year of fe uness surgca therapy s undertaken. Patents whose rght coronary artery
orgnates from the pumonary artery are usuay asymptomatc. Patents wth coronary stuas
occasonay suher congestve heart faure eary. Congenta aneurysms of the coronary arteres are
most often asymptomatc unt compcatons occur, usuay ater n fe.
69. The congenta coronary eson assocated wth mnma or absent cnca manfestatons and
neary norma fe expectancy s:
A. Congenta orgn of both coronary arteres from the pumonary artery.
B. Congenta coronary artery stua.
C. Membranous obstructon of the ostum of the eft man coronary artery.
D. Congenta orgn of the rght coronary artery from the pumonary artery.
Answer: D
DISCUSSION: Cnca manfestatons of congenta orgn of the rght coronary artery from the
pumonary artery are usuay mnma or absent. Ths maformaton s thought to have been
assocated wth death. The odest reported patent wth ths maformaton ded at age 90 years from
unreated probems.
70. Whch of the foowng s/are ndcatons for aortc vave repacement for aortc stenoss?
A. Syncope.
B. Congestve heart faure.
C. Angna.
D. Transvavar gradent of 35 mm. Hg wthout symptoms.Answer: ABC
DISCUSSION: Wth progressve narrowng of the aortc vave area from the norma 3 to 4 sq. cm. to 1
sq. cm., patents become symptomatc. The cassc symptoms produced by aortc stenoss are
syncope, congestve heart faure, and angna. Once symptoms occur, fe expectancy s mted to 2
to 5 years. Therefore, symptomatc aortc stenoss s an ndcaton for aortc vave repacement. The
rsk of death wth asymptomatc aortc stenoss s qute ow, and aortc vave repacement s not
ndcated for asymptomatc patents wth a transvavar gradent ess than 50 mm. Hg.
71. Under whch of the foowng crcumstances s medca management ogca? A. Moderate
aortc nsumcency seen on echocardography wth norma eft ventrcuar end-systoc
dmensons.
B. Moderate to severe aortc nsumcency seen on echocardography wth cardomegay on chest
roentgenography.
C. Moderate aortc nsumcency seen on echocardography wth symptoms of congestve heart faure.
D. Moderate aortc nsumcency wth an end-systoc eft ventrcuar dmenson of
70 mm. as seen on echocardography. Answer: A
DISCUSSION: The eft ventrce s usuay abe to compensate for a ong tme for the ncreased
voume oad mposed by aortc nsumcency. The natura hstory of asymptomatc aortc stenoss s
exceent; 10-year survva for moderate aortc nsumcency managed medcay s as hgh as 85% to
95%. Medca management typcay conssts of duretcs and afteroad reducton; however, once
the compensatory mechansms begn to fa, survva s mted. Haf of patents wth sgns or
symptoms of congestve heart faure de wthn 2 years. Therefore, evdence of eft ventrcuar
daton by echocardography (eft ventrcuar end-systoc dmenson greater than 55 mm.,
cardomegay on chest roentgenography) or symptoms of congestve heart faure are ndcatons
for aortc vave repacement.
72. Whch of the foowng may be ndcatons for operaton for mtra stenoss? A. Systemc
embozaton.
B. Infectve endocardts.
C. Onset of atra braton.
D. Worsenng pumonary hypertenson.Answer: ABCD
DISCUSSION: Athough each s ony a reatve ndcaton for operaton for mtra stenoss, systemc
embozaton, nfectve endocardts, onset of atra braton, and worsenng pumonary
hypertenson may each be an ndcaton for operaton for mtra stenoss. Systemc embozaton,
nfectve endocardts, and onset of atra braton are each compcatons of mtra stenoss that
portend a rsk of further compcaton wth contnued medca therapy. Patents oder than 40 years
wth md cass II congestve heart faure stand to gan symptomatcay from operaton for
sgncant mtra stenoss and do not run excessve rsk of mutpe reoperatve procedures.
73. Whch of the foowng s/are not true?
A. Operaton mproves survva n patents wth severe, symptomatc mtra vave dsease.
B. Left ventrcuar dataton wth cass I or cass II heart faure s an ndcaton for operaton wth
mtra regurgtaton.
C. Trcuspd regurgtaton s most commony caused by abnormates of the eaets themseves.
D. Mtra vave repacement requres resecton of the mtra vave eaets and chordae. Answer: CD
DISCUSSION: Reatve to medca therapy aone, surgca therapy has been shown to mprove
survva n patents wth severe, symptomatc mtra vave dsease. In mtra regurgtaton, eft
ventrcuar dataton s an ndcaton for surgca nterventon regardess of faure symptoms. The
most common cause of trcuspd regurgtaton s trcuspd annuar dataton wthout abnormates
of the eaets themseves. Mtra vave repacement wth preservaton of both eaets or at east the
posteror eaet s we descrbed and s probaby advsabe for most patents to preserve eft
ventrcuar functon and reduce the probabty of ventrcuar-annuar separaton.
74. Whch of the foowng generay are not symptoms of trcuspd vave dsease? A. Pumonary
edema.
B. Hepatc faure.
C. Anasarca.
D. Hoarseness.Answer: AD
DISCUSSION: Hepatc faure and anasarca are ndeed common symptoms of severe, ong-standng
trcuspd vave dsease wth ncreased venous pressure. Pumonary edema s a consequence of eft-
sded heart dsease and does not resut from a trcuspd eson. Smary, hoarseness s most
common after mtra vave dsease wth eft atra enargement and s rarey due to trcuspd vave
dsease aone.
75. Whch of the foowng are reatve ndcatons for mtra vave repacement, as opposed to mtra
vave repar?
A. Extensve eaet caccaton.
B. Mtra regurgtaton.
C. Chorda rupture of the anteror mtra eaet.
D. Sgncant annuar dataton.Answer: A
DISCUSSION: Extensve mtra vave caccaton s a reatve ndcaton for mtra vave
repacement. Mtra regurgtaton or sgncant annuar dataton may, however, be amenabe to
mtra vave repar. Chorda rupture of the anteror eaet s generay reparabe usng chorda
transposton or poytetrauoroethyene (PTFE) chordae.
76. Whch of the foowng are not true?
A. Trcuspd regurgtaton due to annuar dataton aone generay does not requre vave
repacement.
B. Mtra vave repacement wth ether a boprosthess or a mechanca vave requres warfarn
antcoaguaton.
C. Trcuspd vave repacement s generay an ndcaton for usng a tssue vave.
D. Chronc rena faure s a reatve ndcaton for tssue vaves.Answer: B
DISCUSSION: Trcuspd regurgtaton due to annuar dataton aone generay can be treated wth
trcuspd annuopasty or wth correcton of assocated mtra vave dsease. Mtra vave
repacement wth a mechanca vave does requre warfarn antcoaguaton; however, mtra vave
repacement wth a boprosthess may be managed wth asprn aone. Trcuspd vave repacement
s an ndcaton for usng a tssue vave because of the sgncant ncdence of vave thromboss
when a mechanca vave s n the trcuspd poston. Chronc rena faure s a reatve ndcaton for
tssue vaves because vave caccaton s rare and because antcoaguaton of patents on dayss
carres hgh rsks of morbdty and mortaty.
77. Whch of the foowng are reatve ndcatons for mechanca, as opposed to tssue, vave
repacement?
A. Patent younger than 30 years.
B. Young femae patent who desres chdren.
C. An edery patent.
D. Trcuspd vave repacement.
Answer: A
DISCUSSION: Age younger than 30 years s a reatve ndcaton for mechanca vaves because of
an ncreased ncdence of caccaton of tssue vaves n younger persons. A young femae who
desres chdren woud be a reatve contrandcaton to mechanca repacement because of the rsk
of teratogeness and hemorrhage durng pregnancy secondary to warfarn therapy. Advanced age s
a reatve ndcaton for boogc vaves to avod compcatons of antcoaguaton and because the
probabty of reoperaton s ow. Trcuspd vave repacement s a reatve contrandcaton to
mechanca vave repacement, owng to the ncreased ncdence of trcuspd vave thromboss wth
a mechanca prosthess.
78. Whch of the foowng statements are not true?
A. Boprosthetc vaves have a reatvey hgh ncdence of hemoyss.
B. Boprosthetc vaves have a ower ncdence of postoperatve prosthetc vave endocardts.
C. Mechanca vaves deveop structura faure after an average of 7 to 10 years.
D. Mortaty attrbutabe to warfarn therapy approaches 5% per patent-year.Answer: ABCD
DISCUSSION: Boprosthetc vaves have a reatvey ow ncdence of hemoyss. Boprosthetc and
mechanca vaves do not dher sgncanty n the assocated ncdences of postoperatve prosthetc
vave endocardts. Boprosthetc vaves deveop structura faure after an average of 7 to 10 years,
whereas mechanca vaves have a fe span of we beyond 10 years. The mortaty attrbutabe to
warfarn therapy approaches 1% per patent-year.
79. Whch of the foowng are not generay assocated wth mtra stenoss wthout regurgtaton?
A. Pumonary hypertenson.
B. Pumonary edema.
C. Left ventrcuar dataton.
D. An openng snap after the second heart sound.Answer: ABD
DISCUSSION: Pure mtra stenoss wthout regurgtaton may be assocated wth pumonary
hypertenson, pumonary edema, and an openng snap after the second heart sound. Left
ventrcuar dataton woud be rare n pure mtra stenoss and generay occurs wth voume or
pressure overoad of the eft ventrce, as wth mtra regurgtaton.
80. The most common ocaton of accessory pathways n patents wth the
Woh-Parknson-Whte syndrome s the: A. Left
free wa.
B. Rght free wa.
C. Posteror septum.
D. Anteror septum.Answer: A
DISCUSSION: A ma|or pubshed seres of the Woh-Parknson-Whte syndrome ndcate that the
ma|orty of a accessory pathways appear n the eft free wa space. In one seres, approxmatey
60% of a accessory pathways occur n the eft free wa space. In Ebsten's anomay, pathways are
usuay ocated n the posteror septum and/or rght free wa spaces. If these patents are excuded,
approxmatey 70% of pathways occur n the eft free wa space.
81. The anatomc eectrophysoogc bass of AV node re-entry tachycarda s dua AV node
conducton pathways. AV node re-entry tachycarda s most key to occur wth whch of the
foowng eectrophysoogc aberratons?
A. Proxma antegrade bock n the sow conducton pathway.
B. Proxma retrograde bock n the sow conducton pathway.
C. Proxma antegrade bock n the fast conducton pathway.
D. Proxma retrograde bock n the fast conducton pathway.
Answer: C
DISCUSSION: A retrograde conducton bock n ether the sow or fast pathway woud be key to
prevent a re-entrant crcut from deveopng. A proxma antegrade bock n the sow conducton
pathway s extremey unusua because of the short refractory perod of the sow conducton
pathway. The most common conducton bock that occurs n patents wth dua AV node physoogy
s a proxma antegrade conducton bock n the fast pathway because of ts onger refractory
perod. Ths antegrade bock n the fast conducton pathway aows AV conducton to occur va the
sow pathway and to return n retrograde fashon up the fast pathway to estabsh the re-entrant
crcut responsbe for AV node re-entry tachycarda.
82. Match the four surgca procedures that have been deveoped for the treatment of atra
braton wth the ma|or detrmenta sequea(e) of atra braton that each corrects.
A. Hs bunde abaton.
B. Left atra soaton procedure.
C. Corrdor procedure.
D. Maze procedure.
1. Patent's sensaton of rreguar heart rhythm.
2. Hemodynamc compromse because of oss of AV synchrony.
3. Increased vunerabty to thromboembosm.Answer: A-1. B-1,2. C-1. D1,2,3
DISCUSSION: The surgca procedure most commony empoyed for the treatment of atra
braton s catheter abaton of the Hs bunde. The Internatona Catheter Abaton Regstry
reveas that more than 60% of patents who undergo eectve catheter abaton of the bunde of Hs
do so for the treatment of atra braton. Hs bunde abaton s an soaton procedure, n that t
connes the atra braton to the atra and protects the ventrces from the unpeasant sensaton
of an rreguar heartbeat. Because the atra contnue to brate there s no restoraton of AV
synchrony, and therefore there s no mprovement n cardac hemodynamcs. Moreover, the
contnung braton of the eft atrum means that postoperatvey the patent s st at the same
rsk for thromboembosm. Thus, Hs bunde abaton corrects ony one of the three detrmenta
sequeae of atra braton, namey the arrhythma probem.
The eft atra soaton procedure connes atra braton to the eft atrum, aowng the snus
node to drve the remander of the heart n a norma snus rhythm. Thus, t aevates the
unpeasant sensaton of an rreguar heartbeat. In addton, because AV synchrony s re-estabshed
between the rght atrum and rght ventrce, rght-sded cardac output s restored to norma. Ths
means that norma cardac output s devered through the ungs to the eft sde of the heart. In the
presence of a norma eft ventrce the eft-sded cardac output s aso norma, despte the fact that
eft-sded AV synchrony s not present; however, because the eft atrum s aowed to brate, the
vunerabty to thromboembosm remans unchanged postoperatvey.
The corrdor procedure aows the snus node to drve the heart n norma snus rhythm, but because
of the tota soaton of the snoatra and AV nodes from the remander of the atra, the atra may
contnue to brate. Even f they do not, n ehect they are soated from ther respectve ventrces
so that AV synchrony s ost on both sdes of the heart. As a resut, the corrdor procedure aevates
the sensaton of arrhythma but does not restore norma hemodynamcs, nor does t decrease
vunerabty to thromboembosm. The maze procedure abates the re-entrant crcuts responsbe
for atra braton and restores the norma snus rhythm. Thus, t aevates the sensaton of
arrhythma, restores norma hemodynamcs, and aevates the vunerabty to thromboembosm.
83. A of the foowng statements about nonschemc ventrcuar tachyarrhythmas are true except:
A. They usuay occur n the rght ventrce.
B. They are usuay assocated wth a eft bunde branch bock pattern durng the tachycarda.
C. They are usuay more refractory to medca therapy than schemc ventrcuar tachyarrhythmas.
D. They usuay occur as a resut of automatcty rather than re-entry.Answer: D
DISCUSSION: Nonschemc ventrcuar tachyarrhythmas usuay occur n the rght ventrce, and as
a resut the ECG shows a eft bunde branch bock-type pattern durng ventrcuar tachycarda.
These arrhythmas are notorousy refractory to medca therapy and they occur amost excusvey
on a re-entrant bass.
84. Whch of the foowng statements about eft atra myxoma are true?
A. Ths eson, by ste and hstoogy, s the most common prmary cardac tumor.
B. It s best dagnosed by cardac catheterzaton and angography.
C. The symptom compex can mmc coagen vascuar dsease.
D. It has an ntracavtary growth pattern.
E. It has a mutcentrc orgn n the chamber wa.Answer: ACD
DISCUSSION: Eghty per cent of prmary cardac tumors are bengn, and haf of these bengn tumors
are myxomas. Seventy-ve per cent of myxomas arse n the eft atrum n the regon of the fossa
ovas. Echocardography s the technque of choce n the evauaton of ntracardac tumors, and
ndngs suggestve of myxoma occur n 95% of patents examned. Invasve procedures, wth the
attendant rsk of tumor embozaton, are not warranted. Owng to an autommune phenomenon,
eft atra myxomas can present wth systemc consttutona symptoms of fever, maase, weght
oss, poymyosts, and bood dyscrasas that mmc coagen vascuar dsease. Of surgca
sgncance s the fact that most myxomas rarey extend deeper than the endocardum but grow as
poypod, ntracavtary masses. Attachment by a vascuar stak thus aows tumor mobty,
predsposng to embozaton and nterference wth mtra vave competence and causng
characterstc echocardographc ndngs.
85. Whch of the foowng statements about magnant cardac tumors are true? A. Sarcomas
are the most frequent prmary magnancy.
B. Metastatc tumors are usuay asymptomatc.
C. Ad|uvant chemotherapy and rradaton are emcacous n proongng survva.D. Intra-atra
extenson of rena neopasms s a contrandcaton for surgca resecton.
E. Constrctve physoogy s an ndcaton for operaton.
Answer: AB
DISCUSSION: Twenty per cent of prmary cardac tumors are some varant of sarcoma. Precse
hstoogc casscaton s not mperatve, as a have a smar cnca pcture wth rapd systemc
dssemnaton and aggressve oca nvason. In contrast, metastatc tumors cause symptoms n ony
10% of patents. Unfortunatey, most prmary and secondary cardac magnances nfrequenty
respond to systemc chemotherapy or medastna rradaton. Surgca treatment s most successfu
wth rena tumors extendng nto the rght atrum. Sgncant 5-year survva can be acheved wth
concomtant nephrectomy and ntra-atra resecton of the tumor thrombus. Reef of tamponade s
worthwhe; however, extensve decortcaton provdes tte hep.
86. Dsadvantages of temporary pacng through skn eectrodes apped to the anteror
chest wa ncude a of the foowng except: A. Skn burns.
B. Panfu chest wa musce contractons.
C. Ventrcuar braton.
D. Inabty to pace.Answer: C
DISCUSSION: In 1952 Zo rst descrbed successfu pacng through externa meta eectrodes
apped to the anteror chest wa. Cnca experence wth ths technque has shown that t s both
feasbe and fesavng for temporary pacng; however, dsadvantages of the externa pacng
technque ncude skn burns when too tte eectrode |ey s apped, panfu chest wa musce
contractons, and nabty to pace n thck-chested or emphysematous patents. Ventrcuar
braton nduced by externa temporary cardac pacng s exceedngy rare.
87. In aduts the most common cause of acqured compete heart bock s: A. Ischemc
heart dsease.
B. Scerodegeneratve dsease.
C. Traumatc n|ury.
D. Cardomegay.Answer: B
DISCUSSION: Before permanent pacemakers were avaabe, 50% of patents wth compete heart
bock ded wthn 1 year. The most common cause of acqured compete heart bock n aduts s
scerodegeneratve dsease of the cardac skeeton and AV conducton system. Other ess common
causes of compete heart bock ncude schemc heart dsease, cardomyopathc processes, Chagas'
dsease, and traumatc n|ury.
88. The most common ndcaton for permanent pacng s: A.
Compete heart bock.
B. Second-degree AV bock.
C. Chronc bfasccuar bock.
D. Sck snus syndrome.Answer: D
DISCUSSION: Patents wth snus node dysfuncton may deveop a number of arrhythmas, such as
napproprate snus bradycarda, chronotropc ncompetence, snoatra ext bock, and snus arrest.
Ths group of rhythm dsorders typcay occurs n oder patents wth or wthout underyng heart
dsease and s coectvey known as the "sck snus syndrome." In addton, many patents wth sck
snus syndrome have assocated atra tachyarrhythmas, partcuary atra braton. Ths
assocaton of atra tachyarrhythmas n patents wth the sck snus syndrome s caed the
tachycarda-bradycarda (or tachy-brady) syndrome. The most common ndcaton for permanent
pacng occurs n patents wth the sck snus syndrome.
89. Decreasng pacemaker eectrode tp sze resuts n: A. Lower
pacng threshods.
B. Improved eectrogram sensng.
C. Decreased battery fe.D. Less
patent dscomfort. Answer: A
DISCUSSION: Decreasng pacemaker eectrode tp sze resuts n ower pacng threshods, both at
the tme of mpant and subsequenty, because of hgher current densty. However, better sensng
functon s drecty reated to eectrode area and s adversey ahected by sma eectrode sze.
Therefore, a compromse between pacng and sensng emcency s requred. Typca eectrode
surface areas for pacng are between 8 and 10 sq. mm.
90. At the tme of ventrcuar pacemaker mpantaton, ead resstance s determned at a votage
near that of the pacemaker's output. The cacuated resstance at 5 vots shoud range from: A. 10
to 100 ohms.
B. 125 to 250 ohms.
C. 300 to 800 ohms.
D. 1000 to 1500 ohms.Answer: C
DISCUSSION: At the tme of pacemaker mpantaton, n addton to measurng puse amptude
(votage and current) and puse wdth, resstance s aso determned. As descrbed by Ohm's aw,
resstance s cacuated by dvdng votage by current.
Resstance cacuatons are made at a votage near that of the pacemaker's output. The cacuated
resstance at 5 vots shoud range from 300 to 800 ohms. An unsatsfactory ow resstance s
unsatsfactory because current s wasted and battery fe s shortened. Conversey, excessvey hgh
resstance (more than 800 ohms) ncreases battery fe but decreases the current devered to the
heart for pacng.
91. A ventrcuar nhbted-demand pacemaker usng the Intersocety Commsson for
Heart Dsease Resources (ICHD) code s desgnated as: A. DVI.
B. VVI.
C. VOO.D.
VDD.
Answer: B
DISCUSSION: A ventrcuar nhbted-demand pacemaker usng the ICHD code s desgnated as VVI.
As the ICHD code states, the pacemaker senses ntrnsc ventrcuar actvty and s nhbted when
ths actvty exceeds the standby or escape rate of the pacemaker. When the ntrnsc ventrcuar
rate fas beow the escape rate of the puse generator, the pacemaker begns to functon at ts
programmed rate.
92. In rate-moduated pacng, the pacng rate s determned by a physoogc parameter
other than atra rate and s measured by a speca sensor n the pacemaker or pacng
ead. The most commony used physoogc parameter n rate-moduated pacemakers s:
A. OT nterva.
B. Venous bood temperature.
C. Mxed venous oxygen saturaton.
D. Body moton.Answer: D
DISCUSSION: Durng exerton, the requred ncrease n cardac output s obtaned mosty by the
ncrease n paced heart rate, athough ncreased venous ng and mantenance of AV synchrony
are aso mportant contrbutors. The most commony used physoogc parameters n rate-
moduated pacemakers at the present tme are body moton and mnute ventaton. Other
parameters that are ess commony used or under evauaton ncude OT nterva, venous bood
temperature, mxed venous oxygen saturaton, contractty, stroke voume, venous pH, and the
paced depoarzaton gradent.
93. The most common pacng mode used n patents wth symptomatc bradycarda and an
underyng snus rhythm s: A. AAI.
B. DVI.
C. DDD.D.
VVI.
Answer: C
DISCUSSION: "Unversa," or DDD, pacng has been shown to have many benets over other pacng
modates, ncudng the abty to track the ntrnsc snus rate, pace the atrum and ventrce,
mantan atroventrcuar synchrony, and avod the pacemaker syndrome. Recognton of these
benets has steady ncreased the use of DDD pacemakers n the ast decade, and at the present
tme DDD s the most common pacng mode.
94. A transvenous pacemaker generator pocket shoud be paced on the patent's
nondomnant sde over the: A. Anteromeda chest wa.
B. Anteroatera chest wa.
C. Inferomeda chest wa.
D. Inferoatera chest wa.Answer: A
DISCUSSION: Bpoar mpuse generators can be paced ether n the subcutaneous tssue or
beneath the musce. Mgraton of the mpuse generator most commony occurs n nfracavcuar
pacemakers pockets. Mgraton tends to foow the curvature of the chest wa, and the mpuse
generator tends to mgrate ateray. Ths can be prevented by creatng an anteromeda pocket
arge enough to contan the mpuse generator and ead. In susceptbe persons the mpuse
generator can be further secured to the chest wa to prevent mgraton.
95. Pacemaker-medated tachycarda s caused by:
A. Pacemaker nducton of atra braton.
B. Sensng of retrograde atra actvaton.
C. Inapproprate ventrcuar sensng.
D. Lead fracture.Answer: B
DISCUSSION: Pacemaker-medated tachycarda occurs n the settng of ntact ventrcuoatra
conducton. Typcay, premature ventrcuar contractons may be conducted retrogradey through
the AV conducton system and cause retrograde actvaton of the atrum. If ths retrograde atra
actvaton occurs after competon of the programmed pacemaker ventrcuoatra refractory perod,
the atra event s sensed by the DDD pacemaker and evokes a paced ventrcuar event that may
cause further VA conducton. If each ventrcuary paced event resuts n atra actvaton sensed by
the pacemaker, pacemaker-medated tachycarda w be generated.
96. Whch cardovascuar pharmacoogc agents are safe to use durng routne abdomna
surgery n a 75-year-od woman wth documented hypertenson and md coronary artery
dsease? A. Nfedpne.
B. Atenoo.
C. Hydraazne.
D. Captopr.E. Reserpne. Answer: ABD
DISCUSSION: Nfedpne s toerated fary we by edery patents and s safe to use n the
peroperatve perod wth cose hemodynamc montorng. Atenoo s a safe beta-bocker to use
durng the peroperatve perod and provdes protecton from cardac rhythm dsturbances and
rebound hypertenson. Hydraazne, f gven wthout a beta-bocker, often ects reex tachycarda,
whch mts ts usefuness. Captopr s a safe agent that does not appear to nterfere wth the
norma cardovascuar response to anesthesa, and abrupt wthdrawa of ths agent may resut n
severe hypertenson and shoud be avoded. Reserpne s an adrenergc nhbtor that may depress
cardac output and resut n hypotenson, so ts use n the peroperatve settng s mted.
97. Whch notropc drugs are safe for use n edery patents wth md congestve heart faure n
the postoperatve perod? A. Dgtas compounds.
B. Dopamne.
C. Amrnone.
D. Mernone.
E. Dobutamne.Answer: BCDE
DISCUSSION: Dopamne and dobutamne stmuate cardac beta-receptors and are very usefu n
provdng notropc support for patents n the postoperatve perod. Mernone and amrnone are
phosphodesterase nhbtors that have strong notropc ehects whe causng artera and venous
daton. Mernone and amrnone are usefu n patents wth ow cardac output, especay n the
settng of congestve heart faure. Dgtas compounds can be troubesome n the postoperatve
perod owng to the toxc ehects of these agents. Furthermore, peroperatve hypoxa and
hypokaema ncrease myocarda susceptbty to dgtas-nduced ventrcuar arrhythmas.
98. Whch antcoaguaton treatment pan(s) s/are approprate for a 72-year-od man wth a
mechanca heart vave n pace who takes Coumadn (warfarn) and now requres eectve eft coon
resecton?
A. Dscontnuaton of Coumadn therapy on the day of the operaton.
B. Dscontnuaton of Coumadn therapy on the day of the operaton wth repacement of cottng
factors wth fresh frozen pasma (FFP) before the start of the surgca procedure.
C. Dscontnuaton of Coumadn therapy 5 days before operaton wth no further antcoaguaton
therapy before surgery.
D. Dscontnuaton of Coumadn therapy 5 days before operaton wth the nsttuton of ntravenous
heparn as the prothrombn tme normazes.
E. Dscontnuaton of Coumadn therapy 2 days before operaton foowed by arge doses of asprn.
Answer: D
DISCUSSION: Many patents who requre antcoaguaton wth Coumadn for underyng cardac
dsease need to undergo routne genera surgca procedures. The current recommendatons for
patents who have been on ong-term Coumadn therapy s to dscontnue Coumadn 5 days before
an operatve procedure. As the patent's prothrombn tme normazes ntravenous heparn shoud
be started. The patent shoud be mantaned on a therapeutc dose of heparn wth an actvated
parta thrombopastn tme (aPTT) of at east 60 seconds. Heparn shoud then be wthhed
approxmatey 4 to 6 hours before the surgca procedure. The operaton s then performed n a
"heparn wndow," where the eve of antcoaguaton can easy be ttrated or totay reversed wth
protamne f necessary.
99. Whch of the foowng treatment pans s approprate for a 68-year-od patent wth moderate to
severe congestve heart faure foowng a ma|or abdomna surgca procedure?
A. Aggressve use of notropc support wth epnephrne.
B. Aggressve duress wth furosemde and notropc support wth dopamne.
C. Afteroad reducton wth ntroprussde and notropc support wth dopamne.
D. Cose peroperatve montorng and notropc support wth mernone.
E. Intravenous dgtas wth duress usng furosemde as needed.Answer: CD
DISCUSSION: Treatment of congestve heart faure usng epnephrne aone s contrandcated owng
to the profound vasoconstrctve propertes of epnephrne, whch ony exacerbate the heart faure.
Duress wth furosemde and notropc support wth dopamne s acceptabe for patents wth md
congestve heart faure; however, n the postoperatve perod pharmacoogc duress can ead to
profound hypovoema requrng contnuous nvasve hemodynamc montorng. The dea choce for
the postoperatve management of patents wth severe congestve heart faure s afteroad
reducton usng ntroprussde and notropc support wth dopamne. Ths heps to stmuate the
fang heart whe decreasng the afteroad pressure aganst whch the heart must pump. Mernone
s a usefu phosphodesterase nhbtor, whch has been shown to be usefu n the treatment of md
to moderate congestve heart faure. Dgtas aong wth a duretc n the postoperatve perod can
be troubesome owng to the potenta toxcty of dgtas whe the patent has ongong ud and
eectroyte shfts.
100. Whch of the foowng steps s/are approprate for a 65-year-od woman who deveops atra
braton wth assocated md hypotenson and rapd ventrcuar response foowng parta gastrc
resecton?
A. Correcton of eectroytes and bood chemstres.
B. Evauaton for possbe myocarda nfarcton.
C. Treatment wth ntravenous docane.
D. Attempt to mt the ventrcuar response wth dgtas.
E. Immedate cardoverson.Answer: ABD
DISCUSSION: When a patent deveops postoperatve atra braton foowng an extracardac
procedure, correcton of the patent's bood chemstres and eectroytes s essenta. The patent
must aso undergo evauaton for a possbe myocarda nfarcton as the cause of the atra
dysrhythma. The rst rue n treatment s to sow the ventrcuar response and attempt to mt
hemodynamc nstabty. Dgtas s ehectve n sowng down the ventrcuar response and thus
mprovng the hemodynamc status of the patent. Ldocane has tte use n controng atra
dysrhythmas but s very ehectve n decreasng ventrcuar ectopy. Immedate cardoverson s
rarey ndcated for new-onset atra braton. Ony after correcton of a underyng metaboc and
eectroyte defects as we as an attempt at medca converson and ventrcuar rate contro s
cardoverson recommended.
101. The damagng ehects of cardopumonary bypass are, to a arge degree, due to actvaton of
the humora ampcaton system. The humora ampcaton system ncudes whch of the
foowng? A. The coaguaton cascade.
B. The brnoytc cascade.
C. Compement actvaton.
D. A and C.
E. A, B, and C.Answer: E
DISCUSSION: Cardopumonary bypass stmuates a whoe-body nammatory response, and the
concentratons of severa nammatory medators (e.g., compement fracton C5a) have been
assocated wth subsystem dysfuncton foowng cardopumonary bypass. Ths nammatory
response s compex and has severa arms, ncudng the coaguaton, brnoytc, and compement
systems. Smpy bockng one pathway s unkey to competey prevent bypass-nduced n|ury.
102. Adequate ow durng cardopumonary bypass s best ndcated by: A. Systemc
bood pressure of 90/50 mm. Hg.
B. Artera PO 2 of 230 mm. Hg.
C. Mxed venous hemogobn saturaton of 78%.
D. Centra venous pressure of 1 mm. Hg.E. Pasma actate vaue of 6 mg. per d. Answer: C
DISCUSSION: The purpose of cardopumonary bypass s to provde adequate crcuaton of bood to
sustan aerobc metabosm. Oxygen consumpton durng bypass depends on bypass ow unt a
crtca ow s attaned. Wth hgher ows there s no further ncrease n oxygen consumpton (.e.,
oxygen consumpton becomes ow ndependent), and the mxed venous hemogobn saturaton
ncreases. A mxed venous hemogobn saturaton of 78% ndcates that bypass ow s above the
crtca eve and that ow s adequate. The other varabes do not ensure adequate bypass ow.
103. Whch of the foowng does not typcay occur durng the rst few mnutes of cardopumonary
bypass?
A. Interstta ud ncreases.
B. Bood ow becomes nonpusate.
C. Pateet count decreases.
D. Compement s actvated.
E. Systemc vascuar resstance fas.Answer: A
DISCUSSION: Severa events occur durng the rst few mnutes of bypass. The tubng and
oxygenator surfaces are coated by serum protens that n turn actvate pateets. Ths reduces the
pateet count. The roer pump produces nonpusate ow, whch s dherent from the usua
pusate cardac ow. Serum compement s actvated by exposure of bood to the nonphysoogc
surfaces of the pump-oxygenator, and systemc vascuar resstance fas. Interstta ud
accumuates durng bypass; however, ths occurs ater durng bypass.
104. Whch of the foowng are physoogc benets of ntra-aortc baoon
counterpusaton to the schemc ventrce? A. Preoad reducton.
B. Afteroad reducton.
C. Coronary bood ow enhancement.
D. Decreased ventrcuar end-dastoc pressure.Answer: BCD
DISCUSSION: In genera, preoad reates to the voume of bood or ud presented to the eft
ventrce. Athough wa tenson does ncrease wth ncreased voume, Starng propertes are caed
forth for added emcency. Preoad s controed by voume status as we as capacty of the venous
system. The ehects of baoon counterpusaton on cardac preoad are mnma and secondary to
other changes. As the baoon coapses n the aorta, the absence of the baoon voume, or "abyss,"
creates a decrease n ventrcuar afteroad. In ehect ths decreases ventrcuar wa tenson,
reducng myocarda oxygen consumpton sgncanty. Durng counterpusaton, the ntra-aortc
baoon nates n dastoe, eevatng coronary perfuson pressure sgncanty. Maxma coronary
artery perfuson occurs n ths part of the cardac cyce. Thus, schemc ventrces benet especay
from baoon pumpng. The baoon pump does not drecty decrease the eft ventrcuar end-
dastoc pressure. However, n ventrces fang from schema the combnaton of afteroad
reducton and mproved coronary bood ow usuay augments cardac functon, producng
decreased cardac ng pressure or eft ventrcuar end-dastoc pressure.
105. Whch of the foowng are the ma|or ndcatons for nsttutng ntra-aortc baoon pumpng?
A. Medcay refractory angna.
B. Acute papary musce rupture.
C. Left man coronary artery eson.
D. Ventrcuar faure after cardac surgery.
E. PTCA faure.Answer: ABDE
DISCUSSION: Medcay refractory angna s one of the ma|or ndcatons for mpementng the ntra-
aortc baoon pump. When ntravenous ntrogycern becomes nehectve at reevng chest pan or
resuts n eary hypotenson, the baoon pump shoud be used n preparaton for surgca
revascuarzaton or percutaneous angopasty. By reducng eft ventrcuar afteroad, the pump
reduces regurgtaton nto the eft atrum. Thus, baoon counterpusaton s very hepfu for treatng
patents wth acute mtra nsumcency secondary to papary musce rupture. Patents shoud
undergo vave surgca procedures emergenty, as baoon pump support s ony temporzng. The
mere presence of a eft man coronary eson s not an ndcaton for use of the baoon pump. In
former years such pumps were nserted prophyactcay before nducton of anesthesa for coronary
bypass surgery. Newer anesthetc technques have argey obvated ths; however, n the presence
of a eft man eson and medcay refractory angna the baoon pump shoud be used. The baoon
pump s qute ehectve n hepng to wean patents who have postcardotomy eft ventrcuar faure
from cardopumonary bypass. Ths s one of the ma|or uses of ths devce. The Emory Unversty
group was the rst to expound on the emcacy of the baoon pump n stabzng patents foowng
percutaneous angopasty faure. Wth the pump nserted, most patents can be transported to the
operatng room safey, many beng stabe enough to harvest an nterna mammary graft nstead of
havng to defer to the more accessbe but ess preferabe saphenous ven.
106. Whch of the foowng are the most frequent compcatons of ntra-aortc baoon
counterpusaton? A. Stroke.
B. Lmb schema.
C. Arrhythmas.
D. Aortc thromboss.Answer: B
DISCUSSION: Stroke rarey occurs secondary to ntra-aortc baoon pump use. The baoon must be
postoned we beow the aortc arch vesses and never proxma to the eft subcavan artery orgn.
Strokes have been reported from embo beng thrown retrograde from the baoon; however, ths s
very rare. Lmb schema s one of the most frequent compcatons of baoon pumpng. The
combnaton of ofemora atherosceross and catheter umna obstructon may mpede dsta ow.
Ths may requre catheter remova to re-estabsh ow. In 2% to 10% of patents, artera
reconstructon s necessary to repar baoon-reated compcatons. Smaer catheters have heped
prevent mb schema. Arrhythmas n genera are not compcatons of baoon pumpng. In fact,
arrhythmas reated to schema may be controed by the baoon pump. Aortc thromboss can
occur very rarey wth pump use. A more frequent occurrence s dsta embozaton wth mb
schema. Patents shoud be heparnzed whe the baoon catheter s n pace. Foowng cardac
surgery heparnzaton s usuay deayed for 12 to 24 hours.
107. Permanent artca hearts are beng deveoped that are eectrcay powered. Wreess
technques are used to transmt the eectrca energy across the body wa usng the prncpe of: A.
Infrared sensor.
B. Inductve coupng.
C. Thermonc coupng.
D. Hgh-pressure qud chromatography (HPLC).
E. Infrared spectroscopy.Answer: B
DISCUSSION: Eectrca energy can be transmtted across the body wa by tunneng an eectrc
wre; however, experence has shown that nfecton, startng at the skn ne and burrowng deeper
nto the body, w occur over tme. Ths nfecton can be deayed, but not stopped, by the use of a
veour coverng on the wre. Wreess eectrca energy transmsson was rst used n cnca surgery
by W.W.L. Genn n the 1950s for powerng pacemakers. The remarkabe advances n eectroncs
have factated ths technque; however, the pacement of the two cos parae to one another
(wth the skn between), as opposed to nterockng as n an ndustra transformer, reduces the
emcency of transmsson from approxmatey 99% to 70%.
108. The foowng statements about the pneumatc artca heart s/are correct: A. It can support
the crcuaton for over 1 year.
B. It may be compcated by nfecton or thromboembosm.
C. When further deveoped, t w be an dea permanent heart substtute.
D. It s an dea "brdge" for transpantaton.
E. It can be mpanted usng technques smar to those used for heart transpantaton. Answer: ABE
DISCUSSION: The pneumatc artca heart was deveoped as a permanent cardac substtute, but
the need for two tubes to pass through the chest wa and the buky power unt have reegated the
pneumatc heart to short-term use as a brdge to transpantaton. The heart s mpanted usng
smar technques as a heart transpantaton. The presence of foregn surfaces and crevces make
the devce prone to thromboembosm and nfecton. Most surgeons fee that eft ventrcuar support
or bventrcuar assst pumps represent a better opton for those patents wth end-stage congestve
heart faure who requre use of a brdge devce.
109. A cyanotc nfant has echocardographc evdence of a unventrcuar heart (UVH). The
foowng s/are true:
a. The most common form of the dsorder s a doube-net rght ventrce
b. To be cassed as a ventrce, the chamber must receve at east haf of an net vave
c. Ths nfant s a good canddate for a Baock-Taussg shunt
d. Optma correcton of UVH dverts a vena cava bood ow nto the pumonary arteres (Fontan
procedure)
e. In the absence of pumonc stenoss, UVH usuay presents as congestve heart faure
Answer: b, c, d, e
Unventrcuar heart s dened by the connecton of the atra to ony one ventrcuar chamber,
usuay the eft as a doube net eft ventrce. A chamber must receve at east haf of an net vave
to be consdered a ventrce. The presentaton of UVH depends on the pumonary bood ow; f
pumonary stenoss s present there s ncreased cyanoss and the nfant s a canddate for a Baock-
Taussg shunt. In the absence of pumonc stenoss, pumonary ow s excessve and the
presentaton s congestve heart faure. Optma correcton of UVH dverts a vena cava ow nto
the pumonary arteres as the Fontan procedure.
110. A 9-year-od boy wth hypertenson has no papabe femora puses. Coarctaton of the aorta s
suspected. The foowng s/are true:
a. The most common assocated abnormaty s a bcuspd aortc vave
b. Chest radograph s key to show rb notchng
c. The etoogy s fet to be secondary to an nammatory aortts
d. In nfancy, coarctaton may present wth a pnk upper body and cyanotc ower body
e. "Paradoxca hypertenson" seen after operatve repar ndcates resdua stenoss from ncompete
correcton Answer: a, b, d
Coarctaton of the aorta occurs |ust dsta to the orgn of the eft subcavan artery and resuts from
contracton of ectopc tssue from the ductus arterosus. The most common assocated abnormaty
s a bcuspd aortc vave. Extensve coatera deveopment nvoves the mammary and ntercosta
arteres producng rb notchng on the chest radograph. In nfancy, ow to the ower body s from
the ductus arterosus before t coses, producng dherenta cyanoss. The
"paradoxca hypertenson" seen postoperatvey s thought to reate to sympathetc nerve
stmuaton and does not reect an ncompete repar.
111. A 48-year-od woman wth epsodc syncope has echocardographc evdence of a mass n the
eft atrum. The foowng s/are true statement(s):
a. Transsepta puncture shoud be used for dentve dagnoss
b. If ths s a prmary cardac tumor t s most key to be magnant
c. If ths s a myxoma attached to the atra septum, the ad|acent septum shoud be removed wth t
d. In nfancy, the most common cardac tumor s a rhabdomyosarcoma
e. The most common prmary magnant tumor of the heart s angosarcomaAnswer: c, e
Prmary cardac tumors commony arse n the eft atrum and can present wth dyspnea, syncope,
congestve faure and systemc embosm. Transsepta puncture shoud not be used for dagnoss
because of the rsk of embosm. Most prmary cardac tumors are bengn by a 3:1 rato. The most
common magnant tumor s the angosarcoma. Myxoma s the most common bengn tumor, but t
can recur and the ad|acent atra septum shoud be resected wth t. In nfancy, the most common
cardac tumor s a rhabdomyoma.
112. A 2-month-od boy who appeared norma at brth has become cyanotc and s found to have a
systoc e|ecton murmur over the pumonc area and a boot-shaped heart on chest radograph. The
foowng s/are true:
a. Echocardography aone s sumcent to conrm the dagnoss of Tetraogy of
Faot
b. Cyanotc spes may be appropratey treated by propranoo
c. The Baock-Taussg shunt connects the rght ventrce to the pumonary artery
d. Increasng cyanotc spes s the most common ndcaton for operaton
e. Operatve repar of rght ventrcuar outow obstructon s never extended across the pumonc
vave snce ntoerabe pumonary nsumcency woud resut Answer: a, b, d
In ths typca scenaro for Tetraogy of Faot, echocardography can conrm the dagnoss wth no
need for cardac catheterzaton. Cyanotc spes are treated by suppementa oxygen, sedaton wth
morphne and a beta bocker such as propranoo. For paatve ncrease n pumonary bood ow,
the Baock-Taussg shunt s utzed connectng the subcavan artery to the pumonary artery.
Increasng cyanoss and cyanotc spes are the most common ndcaton for operatve repar. To
correct the rght ventrcuar outow obstructon n Tetraogy, a transannuar patch may be requred
extendng nto the pumonary artery. Fortunatey the pumonary vavar nsumcency that resuts s
we toerated n the absence of trcuspd nsumcency or ventrcuar dysfuncton.
113. A 12-year-od boy s found to have an e|ecton systoc murmur over the aortc regon wth a
precorda thr and norma cardac sze on chest radograph. The foowng s/are true:
a. A systoc e|ecton cck woud sgnfy that the stenoss s supravavar
b. In the absence of cardomegay, cardac catheterzaton to measure the pressure gradent s
necessary
c. Deveopment of syncope woud suggest an ntracrana eson
d. In vavar aortc stenoss a pressure gradent of 80 mmHg s an ndcaton for operatve repar
regardess of symptoms
e. In membranous subvavar aortc stenoss a pressure gradent of 40 mmHg s an ndcaton for
operatve repar Answer: d, e
In the patent wth ndngs of aortc stenoss, a systoc e|ecton cck s evdence that the
obstructon s vavuar. Cardac sze does not provde an ndcaton of the severty of the stenoss
and s frequenty norma. The deveopment of angna or syncope reects nadequate cardac output
and sgnes ate-stage dsease. A pressure gradent over 75 mmHg s an ndcaton for operaton n
vavar aortc stenoss even f the patent s asymptomatc whe a esser gradent of 30 mmHg or
more s consdered sumcent for operatve correcton of membranous subvavar stenoss.
114. Wthn 2 hours of brth, a baby gr s obvousy cyanotc and chest radograph shows the heart
to appear ke "an egg on ts sde." The foowng s/are true:
a. The most common cause of cyanoss ths eary s transposton of the great vesses (TGV)
b. If TGV s present, echocardography w show that the posteror vesse eavng the eft ventrce
s a pumonary artery
c. If TGV s conrmed by echocardography, cardac catheterzaton has tte to add
d. The EKG s hepfu n makng the dagnoss of TGV snce t shows reversed domnance of the
ventrces
e. To mprove mxng of pumonary and systemc crcuatons, prostagandn shoud beused to
ncrease pumonary vascuar resstance Answer: a, b
TGV s the most common cause of cyanoss n the rst week of fe, and ths dagnoss can be
conrmed by echocardographc demonstraton of a posteror pumonary artery attached to the eft
ventrce. Cardac catheterzaton s usefu to conrm the anatomy, detect other esons, dene the
coronary anatomy and mprove cardac mxng by baoon atra septostomy. The EKG s not hepfu
n the dagnoss of TGV snce t shows ony norma rght ventrcuar domnance. Prostagandn
mproves the mxng of the crcuaton by openng the ductus arterosus and reducng pumonary
vascuar resstance.
115. A one-year-od boy thought to have Tetraogy of Faot s found on cardac catheterzaton to
have doube-outet rght ventrce (DORV). The foow s/are true:
a. Spontaneous cosure of the VSD s rare
b. Locaton of the VSD has tte ehect on the degree of cyanoss
c. Doube outet eft ventrces do not occur
d. Concdenta aortc stenoss wth DORV s not compatbe wth fe
e. Douby commtted VSD refers to ts reatonshp to the great vessesAnswer: a, e
In DORV, the ocaton of the VSD ahects the drecton of ow of oxygenated bood and thus
determnes the degree of cyanoss. Fortunatey, the VSD rarey coses snce that woud resut n
severe decompensaton or death. Doube outet eft ventrces occur but are ess common than
DORV. A number of other anomaes are assocated wth DORV ncudng both vavar and subvavar
pumonary and aortc stenoss. The VSD may be drected to ether or both great vesses (douby
commtted) or remote from them (noncommtted).
116. A 5-year-od gr s found on routne examnaton to have a pumonc ow murmur, xed
spttng of P2 and a rght ventrcuar ft. The foowng s/are true:
a. Cardac catheterzaton s ndcated f the chest m shows cardomegay
b. Radoogy report of "scmtar syndrome" ndngs on the chest m woud ndcateneed for an
arterogram
c. If the catheterzaton report s "ostum secondum defect," at east one pumonaryven drans
anomaousy
d. Measured pumonary vascuar resstance of 14 Woods unts/m2 wth an ASD mandates eary repar
e. An ASD wth Op/Os of 1.8 can be observed unt symptoms occurAnswer: b
The ndngs suggest an atra septa defect (ASD) that can be conrmed by 2D echocardography
emnatng the need for cardac catheterzaton. The ostum secondum type defect s most
commony found, but t s the snus venosus type that s assocated wth anomaous pumonary
venous dranage. In the scmtar syndrome, the anomaous pumonary ven can be seen on a chest
radograph and, snce these are assocated wth a hypopastc ung that s supped by an
anomaous systemc artery from the aorta, an arterogram s approprate. An ASD wth a sgncant
eft-to-rght shunt as demonstrated by a Op/Os rato n excess of 1.5 shoud be repared. When the
pumonary vascuar resstance s eevated above 10-12 Woods unts/m2 the patent s not a
canddate for repar due to xed pumonary hypertenson.
117. A 2-month-od nfant has EKG evdence of myocarda schema and echocardography
suggests anomaous orgn of the eft coronary artery from the pumonary artery. The foowng
s/are true:
a. Ischema s due to perfuson of the myocardum wth nadequatey oxygenated bood
b. Seectve coronary angography shoud not be attempted because of the rsk of myocarda
nfarcton
c. Conservatve treatment s preferred to aow the coronary artery to grow to a sze that w aow
bypass constructon
d. If the nfant deterorates, gaton of the coronary at ts orgn s a vabe opton
e. The severty of the abnormaty nsures that t w aways be detected n the rst year of fe
Answer: d
Anomaous orgn of the eft coronary artery from the pumonary artery resuts n reverse ow n the
coronary nto the ow-pressure system as a stea from the coronary crcuaton. If coateras from
the rght coronary deveop to aow adequate myocarda perfuson, the dsorder s frequenty not
dagnosed unt ater n fe when a murmur s heard. Seectve coronary arterography s approprate
to dene the anatomy and operatve repar s undertaken prompty. Lgaton of the anomaous
coronary can be fesavng but eaves the chd dependent on a snge vesse and coronary bypass s
preferred.
118. A 2-month-od boy s found to be n congestve heart faure manfested by tachypnea,
tachycarda and daphoress wth poor weght gan. The physca ndngs suggest a ventrcuar
septa defect (VSD). Management shoud ncude:
a. Pumonary artery bandng
b. Urgent cosure f a VSD s found on echocardography
c. Medca treatment ony wth dgtas and duretcs
d. If a VSD s found, repar s unkey to be possbe because of eevated pumonary vascuar
resstance
e. If a restrctve VSD s found, spontaneous cosure s a possbty and operatverepar shoud be
deayed Answer: c, e
Large VSDs present at 6-8 weeks of age when the normay eevated pumonary vascuar resstance
fas, aowng an ncrease n the eft-to-rght shunt. Snce roughy haf of a VSDs undergo
spontaneous cosure, partcuary wth restrctve defects, the nta management s medca. The
dagnoss s conrmed by echocardography and cardac catheterzaton. Advanced pumonary
vascuar changes do not occur usuay unt 2 years of age and bandng s ony rarey ndcated for
paaton for mutpe compex muscuar VSDs.
119. A 1-year-od gr wth dyspnea and poor feedng s found to be n congestve heart faure.
Echocardography shows an atro-ventrcuar septa defect (AVSD). The foowng s/are true:
a. The second heart sound w show xed spttng
b. Despte dagnostc echocardography, cardac catheterzaton s ndcated to assess pumonary
artery resstance
c. Pumonary artery bandng s ndcated to mt pumonary ow and aow the chdto grow
d. AVSD s cassed accordng to the morphoogy of the anteror eaet of the common A-V vave
e. Operatve repar s best performed after 2 years of ageAnswer: a, b, d
AVSD s a defect of endocarda cushon deveopment whch produces morphoogc abnormates of
both AV vaves and both atra and ventrcuar septa. It s usuay cassed accordng to the
morphoogy of the anteror eaet of the AV vave. The pumonary vascuar resstance remans
eevated n nfancy deayng dagnoss and producng xed spttng of the second heart sound.
Cardac catheterzaton s ndcated to assess pumonary vascuar resstance, but pumonary artery
bandng s no onger performed to protect the pumonary bed. Instead, operatve repar s made,
preferaby before the age of 6 months.
120. The chd n the prevous queston undergoes cardac catheterzaton conrmng a VSD wth
Op/Os rato of 2.0 and rght ventrcuar systoc pressure haf of systemc pressure. The foowng
s/are true:
a. If aortc nsumcency s detected, the defect s key to be subpumonc n ocaton
b. Fndng aortc stenoss n addton to the VSD woud be hghy unkey
c. The cath data ndcate a restrctve type of VSD
d. If pumonary vascuar resstance fas wth toazone admnstraton, t s safeto cose the VSD
e. Operatve cosure of VSDs s possbe wthout ventrcuotomyAnswer: a, c, d, e
The ndng of aortc nsumcency n a patent wth VSD suggests proapse of the aortc vave due to
a subpumonc or supracrsta defect. Assocated aortc stenoss, mtra stenoss and coarctaton are
common wth VSDs. The ndng of a moderate eft-to-rght shunt and a rght ventrcuar pressure
we beow systemc eves ndcates a restrctve VSD. If eevated pumonary vascuar resstance s
found, the abty to respond to a vasodator ke toazone ndcates that the resstance s not xed
and operatve repar s possbe. Operatve repar of VSDs s frequenty possbe va atrotomy or
through the pumonary artery.
121. A premature nfant n respratory dstress s found to have a contnuous "machnery" murmur
over the precordum. The foowng s/are true:
a. The most key dagnoss s coarctaton of the aorta
b. If arge pumonary arteres are noted, a patent ductus s key
c. To dscrmnate between a and b, prostagandn admnstraton can be used whch w constrct the
patent ductus arterosus
d. If a ductus f found, operatve repar shoud be deayed unt the respratory symptoms mprove to
reduce mortaty rates
e. Norma ductus cosure depends on ncreased oxygen saturaton n the pumonary artery Answer: b,
e
A contnuous "machnery" murmur s characterstc of patent ductus arterosus typcay seen n the
premature nfant. Norma cosure of the ductus s prompted by a fa n pumonary vascuar
resstance that ncreases the eft-to rght shunt and oxygen eves from the aorta. Indomethacn can
cause ductus cosure by cycooxygenase nhbton whch decreases endogenous prostagandns.
Prostagandn nfuson woud keep the ductus open. Operatve cosure can be done safey n even
the smaest neonates and usuay prompty reeves the respratory dstress.
122. A neonate n congestve heart faure has echocardographc evdence of a snge trunca vesse
from whch the pumonary arteres arse, a VSD and trunca vavar stenoss. The foowng s/are
true:
a. Natura hstory of ths anomay aows ony 20% one-year survva
b. The most key conguraton of the trunca vave s bcuspd
c. Locaton of the pumonary arteres mnmzes the rsk of pumonary vascuar obstructve dsease
(Esenmengers)
d. Repar of the eson requres an extracardac condut
e. Optma tmng of operatve repar s at 6-12 monthsAnswer: a, d
The defect descrbed s truncus arterosus whch carres an 80% one year mortaty rate
uncorrected. The trunca vave s most commony trcuspd (65%) or quadrcuspd (25%); east key
bcuspd (9%). The arge eft-to-rght shunt makes these patents partcuary key to deveop
pumonary vascuar obstructon
(Esenmengers syndrome). Operatve repar requres detachment of the pumonary arteres whch
are reconnected to the rght ventrce by an extracardac condut, and the optma tmng for repar
s wthn the rst 6 months of fe.
123. A neonate n respratory dstress has echocardographc evdence of hypopastc eft heart
syndrome (HLHS). The foowng s/are true:
a. Inta management shoud ncude prostagandn nfuson
b. Ventatory ad|ustment shoud mantan PaCO2 at approxmatey 40 mmHg
c. Survva depends on sustaned patency of the ductus arterosus
d. Cardac transpantaton for HLHS requres ncuson of the donor aortc arch
e. Reconstructon for HLHS converts the pumonary artery nto the man outet for a functona snge
ventrce (Norwood) Answer: a, b, c, d, e
The neonate wth HLHS has a severey underdeveoped eft ventrcuar and aortc arch and s
dependent on patency of the ductus whch s factated by prostagandn nfuson. Ventator
ad|ustment to reduce suppementa oxygen and mantan PCO2 of 40 mmHg avods excessve
pumonary ow. The optons for treatment ncude cardac transpantaton whch requres a donor
aortc arch and reconstructon by the Norwood procedure whch converts the pumonary artery nto
the man outet for a functona snge ventrce.
124. A 52-year-od man wth known aortc stenoss deveops angna pectors and has a snge
epsode of syncope. The foowng s/are true:
a. Onset of angna ndcates concomtant coronary artery dsease ndependent of vavuar eson
b. Percutaneous aortc baoon vavuopasty shoud be consdered snce t has generay favorabe
resuts
c. Patent s not an operatve canddate snce heart faure has not occurred
d. A measured transvavuar pressure gradant > 50 mmHg woud be an operatve ndcaton Answer:
d
The ventrcuar hypertrophy whch accompanes aortc stenoss ncreases oxygen demand whe
mechanca forces ncrease resstance to perfuson, resutng n schema. Ony one haf of these
patents wth angna have coronary artery dsease. Percutaneous baoon vavuopasty of the aortc
vave has hgh compcaton and recurrence rates. Any such patent wth symptoms has an
ndcaton for operatons as woud the patent wth a transvavuar gradant > 50 mmHg.
125. The patent n the prevous queston wth AI progresses to profound heart faure requrng
medca management. The foowng s/are true:
a. Perpera vasdators are contrandcated
b. The nta-aortc baoon pump can be used to mprove cardac output
c. Furosemde and ntrogycern woud be approprate
d. Vave repacement s necessaryAnswer: c, d
Perphera vasodators are key to the treatment of AI favorng perphera bood ow. The ntraaortc
pump s contrandcated because dastoc augmentaton worsens aortc regurgtaton. Both
furosemde and ntrogycern woud be of vaue to treat the faure, but the most ehectve treatment
requres repacement of the vave.
126. A 42-year-od woman has noted progressve exercse ntoerance and fatgabty. Examnaton
dscoses an openng snap n the mtra area suggestve of mtra stenoss. The foowng s/are true:
a. Crtca mtra stenoss s dened as an orce area reduced to 2 cm2
b. Wth a xed mtra orce, the change from snus rhythm to atra braton has tte ehect on
cardac output
c. Mura thromb and thromboembosm are drecty reated to the presence of atra braton
d. Depressed cardac output s usuay due to depressed myocarda contracttyAnswer: c
Norma aduts have a 4-6 cm2 mtra orce and reducton to 2 cm2 s md stenoss whe reducton
to 1 cm2 s consdered crtca mtra stenoss. Even wth a xed orce, the onset of atra braton
reduces cardac output by 20%. Mura thromb and thromboembosm are drecty reated to the
presence of atra braton. Mtra stenoss spares ventrcuar functon, and the oss of cardac
output s from decreased preoad.
127. Concernng vavuar heart dsease, the foowng s/are true:
a. Mtra stenoss s the most common eson
b. Of a cardac vaves, the aortc s the most anteror
c. Stenoss s the most common eson of the aortc vave
d. Rheumatc heart dsease s the most common cause of vave dysfunctonAnswer: c, d
Aortc vavuar stenoss s the most common type of vavuar eson foowed by mtra stenoss.
Anatomcay, the pumonc vave s the most anteror of the cardac vaves. Rheumatc heart
dsease s the most common cause of vave dysfuncton and the most common cause of
mutvavuar dsease.
128. A 47-year-od mae wth fatgue and cardac faure has a hgh-ptched, decrescendo dastoc
murmur aong the eft sterna border and an apca dastoc rumbe. Hs bood pressure s 148/45
mmHg. The foowng s/are true:
a. Chest radograph w show cor bovnum
b. The apca murmur s due to the Gaavardn phenomenon
c. A carotd shudder woud be expected
d. Abdomna exam w show a pusate verAnswer: a
Ths patent wth aortc nsumcency has a voume oadng stran on the heart whch produces cor
bovnum as dramatc enargement. The apca murmur produced by turbuence wth mtra forward
ow mmcs mtra stenoss and s caed an Austn-Gnt murmur. A carotd shudder occurs wth
aortc stenoss and a pusate ver s typca of trcuspd nsumcency.
129. Concernng the adaptaton to cardac vavuar dysfuncton, the foowng s/are true:
a. Severe heart faure s more key from acute than chronc vavuar dysfuncton
b. Vavuar dysfuncton produces both voume and pressure afteroad stress on the heart
c. Eary cardac daton from vave dysfuncton shfts the Frank-Starng curve to depress cardac
output
d. The LaPace aw predcts that wa stress decreases wth ncreasng ventrcuar radus Answer: a, b
Vavuar dysfuncton produces both voume and pressure overoad representng afteroad stress on
the heart. Athough cardac reserves aow for gradua adaptaton to chronc vavuar dysfuncton,
acute dysfuncton s ess we toerated and more key to resut n severe heart faure. The ncrease
n dastoc ng whch ntay dates the heart, shfts the Frank-Starng curve to mprove e|ecton
and cardac output. The LaPace aw predcts that wa stress ncreases wth ncreasng ventrcuar
radus but s nversey reated to wa thckness.
130. A 31-year-od mae drug abuser presents wth fever, chs and mutpe batera ung
abscesses. Rght heart endocardts s suspected. The foowng s/are true:
a. The organsms most key responsbe are gram-negatve and funga
b. The pumonc vave s most key to be ahected
c. A negatve echocardogram s usefu to excude the dagnoss
d. Vave repacement s necessary f the natve vave s excsed to treat nfectonAnswer: a
The typca endocardts n a drug-abuser nvoves funga and gram-negatve organsms whch nfect
the trcuspd rather than the pumonc vave. An echocardogram s usefu to conrm the presence
of vegetatons but t may overook smaer ones so t cannot be used to excude the dagnoss.
Athough vave repacement s usuay preferabe, the nfected trcuspd vave can be excsed
wthout prosthetc repacement.
131. In the nta management of the patent n the prevous queston wth suspected acute MI, the
foowng s/are true:
a. Oxygen and docane shoud be admnstered prophyactcay
b. If chest pan perssts, IV ntrogycern shoud be used to mt nfarct sze
c. Ca-channe bockers are aso of vaue to mt nfarct sze
d. Morphne IV can be used but has no therapeutc ehectAnswer: b
Inta treatment durng an eary evovng MI shoud ncude oxygen, but docane shoud be used
ony f arrhythmas occur. Ntrogycern IV s of vaue to mt nfarct sze but not Ca-channe bockers
whch have no such benet. By decreasng pan and anxety, morphne IV has a sgncant
therapeutc ehect n decreasng myocarda oxygen demand.
132. Concernng the physoogy of the coronary crcuaton, the foowng s/are true:
a. Under crcumstances of ncreased oxygen demand by the myocardum, O2 extracton from artera
bood can ncrease
b. Coronary ow s maxma durng systoe
c. Adenosne s the most mportant metaboc reguator of coronary bood ow
d. Sympathetc nerve stmuaton constrcts coronary arteres despte the need for ncreased cardac
output Answer: c, d
Snce myocardum maxmay extracts O2 from bood at rest, ncreased demand requres ncreased
devery. Systoc pressures compress ntramyocarda vesses, so maxma coronary ow s durng
dastoe. Adenosne, a breakdown product of ATP, s a vasodator and the most mportant metaboc
reguator of coronary bood ow. Athough sympathetc nerves produce coronary vasoconstrcton,
the autoreguatory vasodatory responses to ncreased myocarda demand overwhem that ehect.
133. True statement(s) concernng cardac vascuar anatomy ncude the foowng:
a. In 80%-85% of cases the posteror descendng coronary artery (PDA) arses from the crcumex
coronary artery
b. The PDA gves oh the AV noda artery
c. The great cardac ven ascends aong the rght coronary artery to empty nto the coronary snus
d. Thebesan vens dran from ony eft and rght ventrcesAnswer: b
In 80%-85% of cases the crcumex coronary artery ends wth branches to the eft ventrce whe
the PDA orgnates from the rght coronary n 80%-85% of cases. The PDA gves oh the AV noda
artery and ts occuson can resut n heart bock. The great cardac ven ascends aong the eft
anteror descendng coronary artery and the Thebesan vens dran a 4 chambers.
134. In the medca management of coronary artery dsease, the foowng s/are true:
a. Ntrogycern prmary dates coronary arteroes
b. b-bockng agents act to reduce myocarda O2 demand
c. Ca-channe bockng agents reduce ventrcuar contractty
d. Ca-channe agents shoud not be used f there s an eement of coronary vasospastc dsease
Answer: b, c
Ntrogycern prmary dates venous capactance vesses, but at hgher doses can produce
coronary and systemc artera daton. b-adrenergc bockng agents reduce myocarda O2 demand
by decreasng heart rate and contractty. Ca-channe bockng agents reduce ventrcuar
contractty, produce vasodaton and may protect myocytes. They are partcuary ehectve for
coronary vasospastc dsease.
135. A 67-year-od man wth documented acute MI progresses n 24 hours to cardogenc shock. The
foowng s/are true:
a. The mortaty rate for cardogenc shock after acute MI s ncreased more than 10fod n
comparson to no shock
b. Age, e|ecton fracton, MI sze and prevous MI serve as predctors of cardogenc shock
c. Acute oss of more than 20% of myocardum frequenty resuts n cardogenc shockand death
d. Emergency revascuarzaton s contrandcated for the MI patent n cardogenc shock Answer:
a, b
Cardogenc shock s unusua after acute MI but ncreases the mortaty rate from 4% to 65%. A of
the rsk factors descrbed pus a hstory of dabetes metus can predct cardogenc shock. The
voume of myocardum ost acutey that s assocated wth shock s 40%. Recent studes suggest
that emergency coronary bypass can be used wthn 18 hours of shock to reduce the mortaty rate
to 7%.
136. A 52-year-od man wth chest pan and tachycarda has ECG evdence of an acute MI. The
foowng s/are true:
a. Thromboytc therapy shoud be consdered mmedatey snce the benet s greater the earer t s
gven
b. Of the drugs avaabe, recombnant tPA produces better resuts than SK or APSAC athough t s
more expensve
c. Thromboytc therapy requres catheterzaton for ntracoronary admnstraton
d. Addton of heparn and antpateet drugs produces no ncrementa benetAnswer: a
Thromboytc therapy for acute MI s of sgncant vaue n reducng mortaty wth benet reated to
eary admnstraton. Athough rtPA can produce hgher coronary patency rates, the resuts of
treatment are no better than wth SK or APSAC. Thromboytc drugs were ntay gven
ntracoronary but can be used ehectvey when gven systemcay IV. There s an added benet
from heparn and antpateet drugs to prevent rethromboss.
137. Foowng repar of an abdomna aortc aneurysm, a 66-year-od man deveops severe chest
pan, daphoress, bradycarda and hypotenson. The foowng s/are true:
a. The eectrocardogram s most key to show a promnent O n ead 3 f ths s an MI
b. If O wave s present, the nfarct s subendocarda rather than transmura
c. Creatne knase measurement aone s dagnostc of MI
d. Snce bradycarda rarey occurs wth MI, another dagnoss shoud be consderedAnswer: a
Pan s the most common compant n patents wth myocarda nfarcton athough 20%-25% are
asymptomatc. Inferor MIs nvovng the rght coronary frequenty have parasympathetc actvty
wth bradycarda, hypotenson and a promnent O wave n ead 3. The presence of a O wave
ndcates a transmura MI whch can be conrmed by measurement of the specc soenzyme for
cardac tssue (CK-MB) snce creatne knase can be eevated non-speccay after stroke or
operaton.
138. A 70-year-od woman wth ntractabe angna pectors undergoes cardac catheterzaton for
possbe mechanca nterventon. She prefers PTCA to open correcton. The foowng s/are true:
a. A ong symmetrc eson n the eft man coronary artery woud be approprate for
PTCA
b. Mutpe obstructve esons n the same artery woud be a contrandcaton to
PTCA
c. A foca eson n the eft anteror descendng coronary artery where the vesse s 1 mm n dameter
woud aow PTCA
d. Successfu PTCA for a smpe eson carres a recurrent stenoss rsk of ess than 10%
Answer: b
The dea eson for PTCA s foca symmetrc stenoss n an epcarda vesse. However, t s reatvey
contrandcated for sgncant dsease n the eft man coronary, for mutpe obstructve esons n
the same artery, and for vesses ess than 2 mm n dameter. Restenoss rates of 20% to 40% occur
wthn the rst 4-6 months after successfu daton for smpe esons.
139. A 78-year-od patent who s a canddate for CABG s concerned about the rsks/benets of the
procedure. The foowng s/are true:
a. Operatve mortaty n patents > 70 years s more than doube that of younger patents
b. If the patent s a woman, the rsk s hgher than t woud be for a man
c. A prevous CABG procedure ncreases the compexty and compcaton rate, but does not ater
mortaty rate
d. Resuts are better f there s schemc cardomyopathy than f there s hbernatng myocardum
Answer: a, b
Operatve mortaty for patents > 70 years was 8% n the CASS study as compared to 3% n
younger patents. For reasons not entrey cear, the rsk of CABG s hgher n women than n men.
Reoperatve procedures carry a hgher operatve mortaty due to technca dmcutes, more
advanced dsease, and ess compete
revascuarzaton. Congestve heart faure s a ma|or determnant of poor surgca outcome, but the
resuts are better when there s vabe myocardum (hbernatng) than when there s rreversbe
schemc cardomyopathy.
140. Four days after a transmura MI, a 74-year-od man deveops hypotenson and congestve heart
faure. The foowng s/are true:
a. An ntra-aortc baoon pump shoud be used and cardac catheterzaton performed
b. If the nfarct was posteror, ths s most key due to a ventrcuar septa defect
c. Pumonary wedge pressure tracng of promnent V waves wthout an O2 step-up suggests papary
musce rupture
d. Operatve repar of a post MI VSD shoud be deayed to aow strengthenng of themyocardum to
hod sutures Answer: a, c
Both ventrcuar septa defect (VSD) and ruptured papary musce occur from 3-5 days post-MI and
shoud be managed by ntra-aortc baoon pump, decreasng afteroad and cardac catheterzaton
for dagnoss. A VSD s most key n an edery hypertensve femae who has sustaned an anteror
transmura MI; posteror MIs typcay ead to papary musce rupture whch s dagnosed by
promnent V waves on pumonary wedge pressure tracng. Survva rate for both of these
compcatons s mproved by eary rather than ate repar.
141. A 52-year-od woman wth chest pan s consdered for coronary arterography on the bass of
her rsk factors. The foowng s/are true statement(s):
a. A patents wth typca angna symptoms shoud have coronary arterography
b. Atypca patents wth borderne postve stress tests shoud have arterography
c. Patents who requre vave procedures do not requre arterography
d. Patents n refractory heart faure awatng cardac transpantaton shoud havecoronary
arterography Answer: b
Patents wth typca angna and ECG changes shoud have angography ony f they are refractory to
medca management and/or a canddate for revascuarzaton. Patents wth atypca sgns and
symptoms shoud have angography to conrm or excude the dagnoss. Patents wth vave dsease
and rsk of coronary artery dsease shoud have angography but patents awatng cardac
transpantaton are not canddates for revascuarzaton and do not requre coronary angography.
142. The patent n the prevous queston s found to have dsease unsutabe for PTCA. Concernng
operatve revascuarzaton (CABG) the foowng s/are true:
a. CABG s more ehectve than medca treatment for reevng angna and mprovng physca work
capacty
b. In CABG for unstabe angna, there s no dherence n ate outcome between stabe and unstabe
cohorts
c. For CABG, the most common artera graft s the eft nterna mammary artery
d. Long term patency s mproved when artera grafts are used but there s no dherence n the eary
mortaty rate Answer: a, b, c
Randomzed studes show that CABG s more ehectve than medca therapy for reevng angna,
mprovng physca work capacty and mprovng overa quaty of fe. When CABG s used for
unstabe angna, the nta compcaton and mortaty rates are hgher than for stabe angna, but
the ate outcomes are smar. Use of artera grafts for CABG has ncreased wth the eft nterna
mammary artery used most commony; when at east one mammary artery s used, the eary
mortaty rate s mproved.
143. In the workup of a 45-year-od man wth suspected coronary artery dsease, the foowng s/are
true:
a. Thyrod tests are ncuded to rue out hyperthyrodsm
b. Typcay postve stress ECG woud show eevated ST segments
c. Dpyrdamoe s a usefu ad|unct to thaum scannng as t ncreases coronary perfuson pressure
d. Persstng defects on thaum scan ndcate reversbe myocarda schemaAnswer: a
Dagnostc studes for coronary artery dsease shoud detect rsk factors such as dabetes metus,
hyperpdema and hyperthyrodsm. The stress ECG typcay shows downward sopng ST segment
depresson. Dpyrdamoe s a coronary artery vasodator that reduces systemc and coronary
perfuson pressures. The persstng thaum scan defect reects rreversby scarred myocardum.
144. Foowng successfu thromboytc treatment of the patent n the prevous queston, he
deveops recurrent chest pan n 24 hours. The foowng s/are true:
a. Rethromboss s most key and thromboytc therapy aone shoud be repeated
b. The probem coud have been prevented by eary eectve catheterzaton and PTCA
c. Patent has an ndcaton for catheterzaton and PTCA f snge vesse dsease s found
d. Fndngs of mutvesse dsease at catheterzaton woud ndcate need for operatve bypasses
e. If operatve bypass s deemed necessary, there shoud be a 30-day deay to aow myocarda
heang Answer: c, d
After thromboytc therapy for acute MI, angna recurs n 30%-35% and s an ndcaton for cardac
catheterzaton and mechanca nterventon to prevent nfarct extenson. Prophyactc
catheterzaton, however, has not been found to provde benet. If the ndngs at catheterzaton
show mted dsease treatabe by PTCA, then t shoud be performed. But f mutvesse dsease or
unfavorabe anatomy s found, operatve bypass shoud be carred out eary snce resuts are best
wthn 30 days of the MI.
145. A 59-year-od mae has undergone successfu CABG wth 4 grafts constructed but remans n
ow cardac output (< 2L/mn/m2) postoperatvey. The foowng s/are true:
a. An notropc drug shoud be used ntay to ncrease cardac output
b. If ow cardac output perssts despte optma physoogca and pharmacoogca support, a baoon
pump (IABP) shoud be nserted
c. Decreased cardac ng pressures suggest the possbty of cardac tamponade
d. When IABP s used, the baoon s nated durng dastoeAnswer: b, d
Inta ehorts to mprove cardac output shoud ncude correcton of poor oxygenaton or acdoss
and optmzaton of rhythm, preoad and afteroad before an notropc agent s used. If ow cardac
output perssts despte physoogca and pharmacoogca support, an IABP shoud be nserted. It
mproves coronary artery perfuson by counterpusaton durng dastoe. Cardac tamponade s
heraded by ncreased cardac ng pressures, narrowed puse pressure and pusus paradoxus.
146. A 42-year-od asymptomatc attorney undergoes a routne exercse test whch s reported
postve for myocarda schema. The foowng s/are true:
a. Ths s a rare event snce ess than 5% of patents wth coronary artery dsease
(CAD) are asymptomatc wth exercse
b. Such a patent coud progress to heart faure from schemc cardomyopathy
c. Typca angna pectors s prompty reeved by rest or reaxaton
d. Dyspnea on exerton can represent an angna equvaentAnswer: b, c, d
As many as 25% of CAD patents found by exercse testng are asymptomatc. Progressve coronary
obstructon n these patents can produce heart faure from schemc cardomyopathy. Typca
angna s reeved prompty by rest or reaxaton. Ischemc reductons n ventrcuar contractty and
compance can produce dyspnea on exerton as an angna equvaent.
147. A 52-year-od man deveops postoperatve supraventrcuar tachycarda to a rate of 180/mn.
and hypotenson. The foowng s/are true:
a. Snce a heart rate of 180/mn shoud be toerated at hs age, the hypotenson must have another
cause
b. A vaga maneuver that breaks the tachycarda suggests atra utter as the etoogy
c. Atra overdrve pacng shoud be tred for paroxysma atra tachycarda (PAT)
d. Verapam IV shoud be used for rate contro
e. Cardoverson s preferred for patents on dgoxnAnswer: c, d
A tachyarrhythma over 150 beats/mn can produce hypotenson and myocarda schema and
demands urgent therapy. Vaga maneuvers may break PAT but are not usuay ehectve for atra
utter or braton. Atra overdrve pacng shoud be attempted for PAT or atra utter. Verapam
s the most ehectve approach to rate contro for supraventrcuar arrhythmas, but cardoverson of
patents on dgoxn shoud be undertaken cautousy snce they are prone to ventrcuar tachycarda.
148. A 77-year-od man wth a heaed transmura myocarda nfarcton has a medcay refractory
ventrcuar arrhythma. The foowng s/are true:
a. Drect current catheter endocarda abaton has a hgh kehood of success.
b. If the arrhythma s nducbe at EP study, there s an ndcaton for operatve nterventon.
c. A recent MI woud be a contrandcaton to operaton
d. Ventrcuar faure woud be a contrandcaton to operaton
e. Monomorphc ventrcuar tachycarda s east amenabe to surgca resecton.Answer: b, c, d
After catheter abaton, ony 25% of patents reman free of ventrcuar arrhythma oh of drug
therapy. If the arrhythma s nducbe at EP study and the patent s an acceptabe rsk, wth a
myocarda scar he has an ndcaton for operaton. Both recent MI and ventrcuar faure are
contrandcatons to operaton. Monomorphc ventrcuar tachycarda s the arrhythma most
amenabe to surgca resecton.
149. A 68-year-od man suhers sudden cardac death (SCD) but s resusctated and brought to the
hospta for evauaton and treatment. The foowng s/are true:
a. The most key cause of SCD s ventrcuar arrhythma
b. There s 30-40% chance of recurrent SCD n one year
c. Emprc antarrhythmc drug therapy mproves survva
d. An nducbe ventrcuar tachyarrhythma at EP study carres a favorabe prognoss
e. If a ventrcuar aneurysm s found wth arrhythma, aneurysm resecton s adequate treatment
Answer: a, b
Ventrcuar arrhythmas cause 75% of SCD, whe 25% are due to acute MI. There s a 30-40%
chance of recurrent SCD n one year. An nducbe ventrcuar tachyarrhythma carres a poor
prognoss wth < 50% ve year survva from SCD uness t can be aboshed. Emprc antarrhythmc
drug therapy does not mprove survva. Aneurysmectomy aone s not adequate therapy for
arrhythmas assocated wth aneurysms snce the arrhythma usuay orgnates n ad|acent
mechancay stressed myocardum.
150. The foowng s/are true concernng the anatomy of the conducton system:
a. There s no speca conducton path from the snoatra (SA) to the atroventrcuar (AV) node
b. The bood suppy to the AV node s from the anteror descendng coronary artery
c. The ony norma muscuar connecton between atra and ventrces s the bunde of
Hs
d. The aortomtra contnuty s the ony area where supraventrcuar accessory pathways cannot occur
e. The snus node artery arses from the rght or crcumex coronary arteryAnswer: a, c, d, e
The SA node s ocated at the |uncton of the superor vena cava and the rght atra appendage and
receves ts bood suppy from the rght or crcumex coronary artery. There s no speca conducton
path between SA and AV nodes. The bunde of Hs s the ony norma atroventrcuar musce
connecton but abnorma pathways can occur anywhere except the area known as the aortomtra
contnuty. The bood suppy to the AV node s from the posteror descendng coronary artery.
151. The foowng s/are true concernng the physoogy of arrhythmas:
a. A physca or eectrca stmuus causes sodum fast channes and cacum sow channes to open
b. Durng the ehectve refractory perod, ony the sow cacum channes are cosed
c. Rapd repoarzaton foows potassum egress from the ce
d. Extraceuar hypokaema ncreases sodum channe sze ncreasng automatcty
e. Catechoamnes ncrease outward potassum ow from myocytesAnswer: a, c, d
Physca or eectrca stmu cause sodum fast channes and cacum sow channes to open. Durng
the ehectve refractory perod, both sow cacum channes and fast sodum channes are cosed and
the myocardum cannot be excted. Then potassum channes reopen, aowng potassum out, and
rapd repoarzaton occurs. Extraceuar hypokaema ncreases transmembrane potassum
gradent and sodum channe sze ncreasng automatcty. Catechoamnes decrease outward
potassum ow from myocytes enhancng automatcty.
152. A 72-year-od man has had severa epsodes of ventrcuar tachycarda and s a canddate for
eectrophysoogca (EP) study. The foowng s/are true:
a. The goa of the EP study s ether sustaned or non-sustaned ventrcuar tachycarda
b. Patents wth ess than 5 repettve compexes n response to stmuaton are consdered
nonnducbe
c. An nduced reentry from ventrcuar stmuaton s not necessary pathoogca
d. Mcroreentry arrhythmas are typca after myocarda nfarcton
e. Macroreentry arrhythmas are typca of myocarda schemaAnswer: a, b
For arrhythmas of ventrcuar orgn, the EP study goa s ether sustaned or nonsustaned
ventrcuar tachycarda. Patents wth ess than ve repettve compexes n response to stmuaton
are consdered nonnducbe. Ventrcuar reentry does not occur n norma myocardum, so a
reentrant arrhythmas are pathoogca. Macroreentry arrhythmas are typca after myocarda
nfarcton, whe mcroreentry arrhythmas are typca of myocarda schema.
153. A 29-year-od mae wth supraventrcuar tachyarrhythmas s suspected to have Woh-
Parknson-Whte (WPW) syndrome. The foowng s/are true:
a. Eectrophysoogc studes (EPS) w requre catheters n or at the rght atrum, Hs bunde, rght
ventrce and coronary snus
b. Pacng for EPS uses stmu twce the dastoc threshod
c. The anomaous conductng bunde (Kent) s found n the rght free wa f the coronary snus
catheter records the earest atra actvty durng recprocatng tachycarda
d. If the atra catheter records the earest actvty durng tachycarda, the bunde of Kent s ocated n
the eft free wa
e. If nether eft or rght bunde-branch bock proong the VA nterva, the anomaous bunde s n the
septum Answer: b, e
For supraventrcuar arrhythmas, EPS requres catheters paced n the rght atrum and ventrce,
coronary snus and Hs bunde. A programmabe stmuator s used for stmu that are twce the
dastoc threshod and 2 msec n duraton. When the coronary snus catheter records the earest
actvty durng recprocatng tachycarda, the bunde of Kent s n the eft free wa whe t s n the
rght free wa f the earest actvty s n the atra catheter. When nether eft or rght bunde-
branch bock proong the VA nterva, the bunde s n the septum.
154. A 62-year-od woman whose arrhythma s nonnducbe at EP study has depressed LV functon
wthout aneurysm. The foowng s/are true:
a. If her arrhythma s ventrcuar tachycarda, she s not a canddate for an Automatc Impantabe
Cardac Debrator (AICD) snce t ony recognzes braton
b. If an AICD s approprate, t ohers a 50% mprovement n mortaty compared to drug therapy
c. Poor ventrcuar functon s a contrandcaton to AICD mpantaton
d. AICD shoud not be used for patents awatng cardac transpantaton
e. AICD can provde anttachycarda pacng as we as debratonAnswer: b, e
The AICD s capabe of recognzng ventrcuar tachycarda as we as braton and can provde
anttachycarda pacng, ow or hgh-energy debraton or some combnaton. It ohers a 50%
mprovement n mortaty wth 95% freedom from SCD at 5 years after mpantaton. Nether poor
ventrcuar functon nor pendng transpantaton are contrandcatons to AICD mpantaton.
155. A 27-year-od surgery resdent has had mutpe epsodes of supraventrcuar tachycarda (SVT)
and on EP study s fet to have WPW syndrome. The foowng s/are true:
a. The pathophysoogy of WPW s a snge bunde of Kent
b. Dangerous ventrcuar responses n WPW are due to the shorter refractory perod of the accessory
pathway
c. Identcaton of the accessory pathway of WPW s an ndcaton for ts nterrupton
d. Approxmatey haf of the patents who have successfu dvson of accessory pathways demonstrate
VA bock postop
e. Both radofrequency catheter and surgca abaton oher exceent resuts wth ow morbdty
Answer: b, d, e
The pathophysoogy of WPW s the Kent bunde of whch 10-20% are mutpe rather than snge.
The shorter refractory perods permt rapd and dangerous ventrcuar responses to atra utter or
braton. In 0.25% of the popuaton, accessory pathways of WPW can be dented, but n the
absence of a hstory of SVT, they have a norma fe expectancy. Approxmatey haf the patents
who have successfu dvson of accessory pathways demonstrate VA bock postop. Both
radofrequency catheter and surgca abaton oher exceent resuts wth ow morbdty and the
catheter technque s ess costy.
156. In the pharmacoogca management of cardac arrhythmas, the foowng s/are true:
a. Membrane-stabzng oca anesthetcs (Cass 1) act va sodum channe bockage
b. Cass 1 drugs aso shorten the refractory perod
c. b-bockng drugs (Cass 2) bock the sympathetc nervous system but not crcuatng
catechoamnes
d. Bretyum and other Cass 3 drugs nhbt potassum nux nto ces
e. Cacum channe bockers (Cass 4) drecty ahect the SA and AV nodesAnswer: a, d, e
Cass 1 drugs are oca anesthetcs that act va sodum channe bockade, and engthen the
refractory perod. Cass 2 b-bockng drugs nhbt both the sympathetc nervous system and
crcuatng catechoamnes. Cass 3 drugs nhbt potassum nux nto ces and Cass 4 drugs ahect
sow channe-dependent pacemaker tssue (SA and AV nodes).