Cardiothoracic Surgery Practice Questions

Q: A 58-year-old man with coronary artery disease requires CABG. Preoperative angiography shows 90% left main stenosis, 95% proximal LAD stenosis, 80% circumflex stenosis, and chronic total occlusion of the RCA with collaterals. He has diabetes, renal insufficiency (Cr 2.1), and previous stroke. Evaluate the optimal grafting strategy to maximize long-term patency and outcomes.

LIMA to LAD, radial artery to circumflex, vein graft to RCA. ***LIMA to LAD, radial artery to circumflex, vein graft to RCA*** - The **LIMA-to-LAD** graft is the gold standard, providing the best long-term patency and survival outcomes in multi-vessel **CABG**. - Using a **radial artery** for the circumflex system (high-grade stenosis) offers superior patency over vein grafts while avoiding the high risk of **sternal wound infection** associated with **BIMA** in diabetic patients. *Bilateral internal mammary arteries with supplemental vein grafts* - While **BIMA** provides excellent patency, it is associated with a significantly increased risk of **sternal dehiscence** and infection in patients with **Diabetes Mellitus**. - The benefit of a second arterial graft is better achieved with the **radial artery** in this high-risk comorbid profile. *Off-pump CABG with sequential vein grafts only* - **Sequential vein grafts** have lower long-term patency compared to arterial conduits and do not capitalize on the survival benefit of the **LIMA-to-LAD**. - Off-pump surgery might reduce some risks but using only vein grafts is suboptimal for a 58-year-old with **long-term** survival goals. *All saphenous vein grafts to minimize operative time* - **Saphenous vein grafts (SVG)** have much higher failure rates (approx. 50% at 10 years) compared to **internal mammary arteries**. - Minimizing operative time does not justify the poor long-term clinical outcomes and higher **re-intervention rates** associated with an all-SVG strategy. *LIMA to LAD, saphenous vein grafts to remaining vessels* - This is a standard approach, but the addition of a second arterial conduit like the **radial artery** is preferred for younger patients with high-grade stenosis to maximize **patency**. - In the setting of **90% left main** and **80% circumflex** stenosis, the radial artery is more durable than a vein graft for the circumflex target.

Q: A 55-year-old man undergoes esophagectomy for esophageal cancer. On postoperative day 5, he develops fever, tachycardia, and left pleural effusion. Pleural fluid analysis shows turbid fluid with pH 6.8, amylase 2500 U/L (serum amylase 80 U/L), and Gram stain showing mixed flora. Analyze the most likely diagnosis and underlying mechanism.

Anastomotic leak with esophageal-pleural fistula. ***Anastomotic leak with esophageal-pleural fistula*** - The discovery of highly elevated **amylase levels** in the pleural fluid (exceeding serum levels) is a hallmark of **salivary amylase** leakage from the esophagus. - Clinical signs like **fever, tachycardia**, and a **low pH (6.8)** mixed flora effusion on postoperative day 5 are classic for **anastomotic dehiscence** following esophagectomy. *Postoperative atelectasis with parapneumonic effusion* - While **atelectasis** can cause postoperative fever, it typically occurs earlier (POD 1-2) and would not explain the **hyperamylasemia** in the pleural fluid. - Parapneumonic effusions usually show **predominant single organisms** rather than the mixed flora seen in a direct gastrointestinal-pleural communication. *Pulmonary embolism with effusion* - **Pulmonary embolism** can cause tachycardia and pleural effusions, but the effusions are typically **serosanguinous** rather than turbid or infected. - It would not result in such an extreme elevation of **pleural amylase** or the presence of **mixed flora** on Gram stain. *Empyema from aspiration pneumonia* - Aspiration pneumonia usually causes **localized consolidation** and would not explain the leakage of salivary contents into the pleural space directly. - While it can lead to an **empyema**, the isolated elevation of **amylase** 30 times the serum level points specifically to an **esophageal perforation** or leak. *Chylothorax from thoracic duct injury* - **Chylothorax** typically presents with a **milky-white** appearance of pleural fluid due to high **triglyceride** content, not mixed flora bacteria. - It is generally an **insidious, non-inflammatory** process that does not typically present with **low pH** or the high fever associated with a fistula.

Q: A 72-year-old man with severe symptomatic aortic stenosis (valve area 0.6 cm², mean gradient 55 mmHg) has a calculated STS risk score of 8% for surgical AVR. He has severe pulmonary hypertension (PA systolic pressure 65 mmHg), frailty, and porcelain aorta on CT. Apply the most appropriate treatment strategy.

Transcatheter aortic valve replacement (TAVR). ***Transcatheter aortic valve replacement (TAVR)*** - This patient has **high surgical risk** (STS 8%) and specific features like a **porcelain aorta** and **frailty**, which make minimally invasive TAVR the preferred option. - **Porcelain aorta** is a critical indicator for TAVR as it precludes safe cross-clamping during conventional open-heart surgery. *Medical management with careful observation* - **Severe symptomatic** aortic stenosis has a dismal prognosis if left untreated, with a high mortality rate within 2 years of symptom onset. - Medical therapy does not address the underlying **mechanical obstruction** and is reserved only for patients not suitable for any intervention. *Apical-aortic conduit placement* - This is a complex surgical procedure used in very specific cases, but it is generally surpassed by **TAVR** in the current clinical guidelines for high-risk patients. - It involves higher morbidity compared to **percutaneous methods** and is not the primary choice for porcelain aorta management. *Aortic valvuloplasty as definitive treatment* - Balloon valvuloplasty is associated with high **restenosis rates** within 6-12 months and does not provide a durable definitive solution. - It is mainly used as a **bridge to TAVR** or surgery in hemodynamically unstable patients, rather than a final treatment. *Surgical aortic valve replacement via sternotomy* - While standard for low-risk patients, the presence of **severe pulmonary hypertension** and **porcelain aorta** significantly increases the risk of stroke and surgical mortality. - An **STS risk score** of 8% combined with comorbid frailty shifts the balance of benefit toward the less invasive TAVR approach.

Q: A 45-year-old man presents with chest pain and dyspnea. Echocardiography reveals severe aortic regurgitation with a dilated aortic root measuring 5.8 cm. His father died suddenly at age 50. Physical examination shows arm span exceeding height and a high-arched palate. Apply the appropriate surgical intervention.

Valve-sparing aortic root replacement (David procedure). ***Valve-sparing aortic root replacement (David procedure)*** - This patient presents with **Marfan syndrome** (arm span > height, high-arched palate) and significant **aortic root dilatation** (5.8 cm), which necessitates surgical intervention. - The **David procedure** is the preferred choice for young patients when the **aortic valve leaflets** are structurally normal, as it avoids lifelong **anticoagulation** required for mechanical valves. *Ross procedure (pulmonary autograft)* - Involves replacing the aortic valve with the patient's own **pulmonary valve** and is typically reserved for children or young adults with isolated **aortic valve disease**. - It does not address the underlying **aortic root pathology** seen in connective tissue disorders like **Marfan syndrome**. *Transcatheter aortic valve replacement (TAVR)* - This is a minimally invasive procedure primarily indicated for elderly or high-risk surgical patients with **calcific aortic stenosis**. - TAVR is generally contraindicated in patients with **aortic root aneurysms** and severe **aortic regurgitation** due to connective tissue disease. *Aortic valve replacement with mechanical valve only* - Replacing only the valve would not address the **dilated aortic root** (5.8 cm), leaving the patient at high risk for **aortic dissection** or rupture. - In Marfan syndrome, the **aortic sinuses** are diseased and must be addressed surgically when they exceed specific size thresholds. *Bentall procedure (composite graft replacement)* - The **Bentall procedure** involves replacing both the aortic valve and the root with a **composite graft**; it is the standard if the native valve is structurally damaged. - While technically appropriate for root replacement, it is less ideal than the **David procedure** in this scenario as it necessitates permanent **anticoagulation** therapy.

Q: A 58-year-old woman undergoes coronary artery bypass grafting using saphenous vein grafts and the left internal mammary artery. On postoperative day 2, she develops new ST-segment elevation in leads V1-V4 and hypotension. Apply the immediate management for this complication.

Immediate cardiac catheterization. ***Immediate cardiac catheterization*** - This patient presents with signs of **acute graft failure** or native vessel thrombosis post-CABG, necessitating immediate **angiographic evaluation** to identify the site of occlusion. - It allows for both **definitive diagnosis** and potential **percutaneous coronary intervention (PCI)** to restore blood flow to the ischemic myocardium. *Thrombolytic therapy with alteplase* - Fibrinolytics are strictly **contraindicated** in the early postoperative period due to the high risk of **life-threatening hemorrhage** from surgical sites. - **Mechanical revascularization** is preferred over pharmacologic lysis in these clinical scenarios. *Initiate intra-aortic balloon pump support only* - While an **IABP** can provide hemodynamic support and improve coronary perfusion, it is an **adjunct** and does not address the underlying mechanical obstruction. - Management must prioritize **re-establishing vessel patency** rather than just providing circulatory support. *Emergent return to operating room for re-exploration* - **Routine re-operation** without diagnosis is usually reserved for suspected **cardiac tamponade** or massive bleeding. - For suspected ischemia, **cardiac catheterization** is performed first to pinpoint the specific graft or vessel at fault before deciding on surgical revision. *Increase inotropic support and observe* - Increasing inotropes may worsen **myocardial oxygen demand** in the setting of an acute infarct and does nothing to fix the mechanical blockage. - **Observation** is inappropriate when ST-segment elevation and hypotension indicate an evolving, reversible **myocardial infarction**.

Question 1

A 45-year-old man presents with a 3-day history of fever, right upper quadrant pain, and jaundice. He has a history of choledocholithiasis. On examination, temperature is 39.4°C, BP is 85/50 mmHg, HR is 122 bpm, and he is confused. RUQ ultrasound shows a dilated common bile duct of 14 mm with a shadowing calculus. Total bilirubin is 8.2 mg/dL, WBC is 22,000/µL, and alkaline phosphatase is markedly elevated. After initiating IV fluids and broad-spectrum antibiotics, what is the most appropriate next step?

Accepted Answer

Urgent endoscopic retrograde cholangiopancreatography with biliary decompression

Answer

Emergency laparoscopic cholecystectomy with common bile duct exploration

Answer

Percutaneous transhepatic cholangiography and external biliary drainage

Answer

Repeat RUQ ultrasound in 6 hours to reassess ductal dilation after fluid resuscitation

Answer

Continue IV antibiotics for 72 hours and schedule elective ERCP if no improvement

Question 2

A 70-year-old man with severe ischemic cardiomyopathy (EF 25%) has recurrent ventricular tachycardia despite optimal medical therapy and ICD placement. Cardiac MRI shows a large anteroseptal scar with viable myocardium in the lateral and inferior walls. He has three-vessel coronary disease. His daughter is advocating for heart transplantation, but he has multiple comorbidities including obesity (BMI 37) and active tobacco use. Evaluate the management priority and rationale.

Accepted Answer

CABG with surgical ventricular reconstruction and continued medical optimization

Answer

Left ventricular assist device as destination therapy

Answer

Catheter ablation of VT with continued ICD monitoring

Answer

Cardiac resynchronization therapy upgrade and medication adjustment

Answer

List for heart transplantation immediately given severe cardiomyopathy

Question 3

A 49-year-old woman with myasthenia gravis undergoes CT chest showing a 5 cm anterior mediastinal mass with irregular borders. Biopsy confirms thymoma (WHO type B2). She has well-controlled myasthenic symptoms on pyridostigmine. Staging shows no distant metastases, but the mass abuts the pericardium without clear invasion. Evaluate the optimal treatment approach.

Accepted Answer

Thymectomy with possible en bloc pericardial resection, followed by adjuvant radiation

Answer

Increase immunosuppression then delayed surgery in 6 months

Answer

Radiation therapy alone to preserve myasthenia control

Answer

Immediate thymectomy followed by observation

Answer

Neoadjuvant chemotherapy, then thymectomy and adjuvant radiation

Question 4

A 58-year-old man with coronary artery disease requires CABG. Preoperative angiography shows 90% left main stenosis, 95% proximal LAD stenosis, 80% circumflex stenosis, and chronic total occlusion of the RCA with collaterals. He has diabetes, renal insufficiency (Cr 2.1), and previous stroke. Evaluate the optimal grafting strategy to maximize long-term patency and outcomes.

Accepted Answer

LIMA to LAD, radial artery to circumflex, vein graft to RCA

Answer

Bilateral internal mammary arteries with supplemental vein grafts

Answer

Off-pump CABG with sequential vein grafts only

Answer

All saphenous vein grafts to minimize operative time

Answer

LIMA to LAD, saphenous vein grafts to remaining vessels

Question 5

A 62-year-old man develops sudden onset of severe chest and back pain. CT angiography shows a Stanford Type B aortic dissection extending from just distal to the left subclavian artery to the iliac bifurcation. Blood pressure is 165/95 mmHg, heart rate 88/min. He has no evidence of malperfusion, rupture, or refractory pain. Analyze the initial management strategy.

Accepted Answer

Medical management with beta-blockers and blood pressure control

Answer

Fenestration procedure to improve distal perfusion

Answer

Observation in ICU without antihypertensive therapy

Answer

Emergent open surgical repair with graft replacement

Answer

Immediate thoracic endovascular aortic repair (TEVAR)

Question 6

A 68-year-old woman with rheumatic heart disease has severe mitral stenosis (valve area 0.9 cm²) and moderate mitral regurgitation. She is in atrial fibrillation. Echocardiography shows heavily calcified mitral valve leaflets with restricted mobility and moderate subvalvular disease. The left atrium measures 6.2 cm. Analyze the optimal surgical approach.

Accepted Answer

Mitral valve replacement with mechanical valve plus Maze procedure

Answer

Mitral valve repair with annuloplasty

Answer

Medical management with rate control only

Answer

Percutaneous mitral balloon valvuloplasty

Answer

Mitral valve replacement with bioprosthetic valve

Question 7

A 55-year-old man undergoes esophagectomy for esophageal cancer. On postoperative day 5, he develops fever, tachycardia, and left pleural effusion. Pleural fluid analysis shows turbid fluid with pH 6.8, amylase 2500 U/L (serum amylase 80 U/L), and Gram stain showing mixed flora. Analyze the most likely diagnosis and underlying mechanism.

Accepted Answer

Anastomotic leak with esophageal-pleural fistula

Answer

Postoperative atelectasis with parapneumonic effusion

Answer

Pulmonary embolism with effusion

Answer

Empyema from aspiration pneumonia

Answer

Chylothorax from thoracic duct injury

Question 8

A 72-year-old man with severe symptomatic aortic stenosis (valve area 0.6 cm², mean gradient 55 mmHg) has a calculated STS risk score of 8% for surgical AVR. He has severe pulmonary hypertension (PA systolic pressure 65 mmHg), frailty, and porcelain aorta on CT. Apply the most appropriate treatment strategy.

Accepted Answer

Transcatheter aortic valve replacement (TAVR)

Answer

Medical management with careful observation

Answer

Apical-aortic conduit placement

Answer

Aortic valvuloplasty as definitive treatment

Answer

Surgical aortic valve replacement via sternotomy

Question 9

A 45-year-old man presents with chest pain and dyspnea. Echocardiography reveals severe aortic regurgitation with a dilated aortic root measuring 5.8 cm. His father died suddenly at age 50. Physical examination shows arm span exceeding height and a high-arched palate. Apply the appropriate surgical intervention.

Accepted Answer

Valve-sparing aortic root replacement (David procedure)

Answer

Ross procedure (pulmonary autograft)

Answer

Transcatheter aortic valve replacement (TAVR)

Answer

Aortic valve replacement with mechanical valve only

Answer

Bentall procedure (composite graft replacement)

Question 10

A 58-year-old woman undergoes coronary artery bypass grafting using saphenous vein grafts and the left internal mammary artery. On postoperative day 2, she develops new ST-segment elevation in leads V1-V4 and hypotension. Apply the immediate management for this complication.

Accepted Answer

Immediate cardiac catheterization

Answer

Thrombolytic therapy with alteplase

Answer

Initiate intra-aortic balloon pump support only

Answer

Emergent return to operating room for re-exploration

Answer

Increase inotropic support and observe

Cardiothoracic Surgery — MCQs

Cardiothoracic Surgery — MCQs

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