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Cardiac Surgery: Questions
29
endovascular biopsy of the mass suggested
a diagnosis of cardiac angiosarcoma. Which
of the following statements regarding cardiac angiosarcoma is correct?
A. Cardiac angiosarcomas are the least common primary malignant tumor
of the heart
and pericardium.
B. Cardiac angiosarcomas are slow growing tumors.
C. Cardiac angiosarcomas predominantly affect females.
D. Cardiac angiosarcomas predominantly arise as mural masses in
the right atrium.
E. Cardiac angiosarcomas respond favourably to chemoradiotherapy.
2.8 A 62-year-old female with symptoms suggestive of mitral valve disease had a
transesophageal echocardiogram shown below. Which of the following statements
regarding the pathology shown is correct?
Figure 1.
A. It commonly occurs in infancy.
B. It has a special predilection for older male patients.
C. It predominantly occurs as a familial condition.
D. Its familial form has autosomal dominant inheritance.
E. Its sporadic form has a high recurrence rate after resection.
2.9 Which of the following statements regarding cardiac myxomas is correct?
A. Biatrial myxomas are more common in the sporadic form of the disease.
B. Multicentric myxomas commonly occur in older males.
Shahzad G. Raja
30
C. Multiple myxomas commonly occur in the left atrium.
D. Right atrial myxomas are more likely to have long stalks.
E. Ventricular myxomas commonly occur in children.
2.10 Which of the following statements regarding cardiac myxomas is correct?
A. Histological examination reveals frequent mitoses.
B. Multicentric tumors are more commonly seen in the sporadic form of the disease.
C. Myxomas are of thrombotic origin.
D. Myxomas arise from the endocardium.
E. Myxomas tend to grow into
the surrounding
myocardium.
2.11 Which of the following is the most common mode of presentation of cardiac
myxomas?
A. cardiac rhythm disturbances
B. congestive heart failure
C. embolization
D. fever
E. myalgias
2.12 Which of the following statements regarding cardiac myxomas is correct?
A. Recurrences are more common in younger
patients.
B. Recurrence rate of nonfamilial sporadic myxoma is higher than the familial type.
C. Removal of atrial myxomas carries an operative mortality rate
of 10 -15%.
D. Size of the atrial myxoma is the most important predictor of operative
mortality.
E. Size of the atrial myxoma is the
only reliable factor predicting recurrence.
2.13 Which of the following statements regarding cardiac lipomas is correct?
A. They are fast growing tumors.
B. They are notorious for recurrence.
C. They are predominantly found in younger patients.
D. They have a predilection for female patients.
E. The right atrium and left ventricle are
the sites affected most often.
2.14 Rhabdomyoma is the most frequently occurring cardiac tumor in
children.
Which of the following statements regarding this tumor is correct?
A. It exists as multiple tumors in majority of cases.
B. It is predominatly asymptomatic.
C. It is strongly associated with familial adenomatous polyposis coli.
D. It predominantly occurs in atria.
E. It usually presents in school going children.
2.15 Which of the following statements regarding secondary tumors of the heart is
correct?
A. Bronchogenic carcinoma is the most common tumor giving rise to metastatic deposits
in the heart.
B. Cardiac metastases are almost always solitary.
Cardiac Surgery: Questions
31
C. Cardiac metastases produce clinical symptoms in over 90% of patients.
D. Secondary neoplasms are 20
to 40 times more common than primary cardiac
malignancies.
E. Surgical resection of metastatic tumors is the best therapeutic option.
2.16 Which of the following is a Class I recommendation for aortic valve selection?
A. A bioprosthesis is reasonable for AVR
in patients aged 65 years
or older without risk
factors for
thromboembolism.
B. A bioprosthesis might be considered for AVR in a woman of
childbearing age
C. Aortic valve re-replacement
with a homograft is reasonable for
patients with active
prosthetic
valve endocarditis.
D. A mechanical prosthesis is recommended for AVR in patients with
a mechanical valve
in the mitral or tricuspid position.
E. A mechanical
prosthesis is reasonable for AVR in patients under 65 years
of age who
do not have a contraindication to anticoagulation.
2.17 Which of the following statements regarding cardiac murmurs is correct?
A. A right or left atrial myxoma may cause continuous murmur.
B. Early diastolic murmurs are usually due to mitral or
tricuspid stenosis.
C. Holosystolic (pansystolic) murmurs, often crescendo-decrescendo
in configuration,
occur when blood is ejected across the aortic
or pulmonic outflow tracts.
D. Late systolic murmurs are often due to apical
tethering and malcoaptation of the mitral
leaflets due to anatomic
and functional changes of the annulus and ventricle.
E. Most innocent murmurs that
occur in children and young adults are early systolic
murmurs.
2.18 Which of the following criteria is characteristic of severe aortic stenosis?
A. Jet velocity of 3.5 m/sec.
B. Mean gradient of 35 mmHg.
C. Valve area index less than 0.6 cm
2
per m
2
.
D. Valve area index less than 1.6 cm
2
per m
2
.
E. Valve area of 1.2 cm
2
.
2.19 Which of the following is a Class I indication for aortic valve replacement in
patients with aortic stenosis (AS)?
A. Adults with severe asymptomatic
AS
if there is a high likelihood of rapid progression
(age,
calcification,
and CAD) or if surgery might be delayed at the
time of symptom
onset.
B. Asymptomatic patients with severe
AS and abnormal response to exercise (e.g.,
development of
symptoms or asymptomatic hypotension).
C. Patients undergoing CABG who have mild
AS when there is
evidence, such as
moderate to severe valve
calcification, that
progression may be rapid.
D. Patients with moderate AS undergoing
CABG or surgery on the aorta or other heart
valves.
E. Patients with
severe AS and LV systolic
dysfunction (ejection fraction less
than 0.50).
Shahzad G. Raja
32
2.20 Which of the following statements regarding aortic valve surgery is correct?
A. Aortic regurgitation is the predominant indication for aortic valve replacement.
B. The mortality rates for a combined aortic valve replacement and coronary artery
bypass grafting is 6% to
7%.
C. There is an increase in the implantation of mechanical aortic prosthetic valves in
recent years.
D. The risk of permanent stroke after aortic valve replacement is 5%-8%.
E. The
use of homografts for aortic valve replacement has declined in recent years from
10% to 5%.
2.21 Which of the following statements regarding acute aortic regurgitation is
correct?
A. Acute severe aortic regurgitation (AR) is well-tolerated by patients with pre-existing
pressure overload hypertrophy.
B. Cardiomegaly is a characteristic diagnostic feature of acute AR.
C. In acute severe AR increase in forward stroke volume is the most important
compensatory mechanism.
D. In acute severe AR wide pulse pressure is not seen.
E. Intensity of the first heart sound is increased due to elevated LV diastolic pressure.
2.22 Which of the following statements regarding chronic aortic regurgitation is
correct?
A. Chronic aortic regurgitation (AR) is characterised by a decrease in end-diastolic
volume.
B. Left ventricle (LV) end-diastolic size is the most important determinant of
survival and
postoperative LV function in patients undergoing
aortic valve replacement (AVR) for chronic
AR.
C. LV end-systolic size is the most important determinant of
survival and postoperative
LV function in patients undergoing
AVR for chronic AR.
D. LV responds to the volume load of chronic AR by an increase in filling
pressures.
E. Vasodilator therapy is detrimental in patients with chronic AR.
2.23 Which of the following is a Class I indication for vasodilator therapy in chronic
aortic regurgitation (AR)?
A. Chronic therapy in patients
with severe AR who have symptoms or left ventricular
(LV) dysfunction when surgery
is not recommended because of additional cardiac or
noncardiac
factors.
B. Long-term therapy in
asymptomatic patients with mild to moderate AR and normal LV
systolic function.
C. Long-term therapy
in asymptomatic patients with severe AR who have LV dilatation
but normal systolic function.
D. Long-term therapy in
asymptomatic patients
with LV systolic dysfunction who are
otherwise
candidates for
aortic valve replacement (AVR).
E. Short-term therapy
to improve the hemodynamic profile of patients with severe heart
failure symptoms and severe LV dysfunction before proceeding
with AVR.
Cardiac Surgery: Questions
33
2.24 Which of the following is a Class I indication for aortic valve replacement
(AVR) in chronic aortic regurgitation (AR)?
A. Asymptomatic patients with chronic severe
AR and LV systolic
dysfunction (ejection
fraction 0.50 or less)
at rest.
B. Asymptomatic patients with severe AR
with normal LV systolic function (ejection
fraction greater
than 0.50) but with severe LV dilatation (end-diastolic dimension
greater than
75 mm or end-systolic dimension greater than 55
mm).
C. Asymptomatic patients with severe
AR and normal LV systolic function at rest
(ejection fraction
greater than 0.50) when the degree of LV
dilatation exceeds
an end-diastolic
dimension of 70 mm or end-systolic
dimension
of 50 mm.
D. Asymptomatic
patients with severe
AR and normal LV systolic function at rest
(ejection fraction
greater than 0.50) when there is evidence of declining exercise tolerance, or
abnormal hemodynamic
responses
to exercise.
E. Asymptomatic
patients with severe
AR and normal LV systolic function at rest
(ejection fraction
greater than 0.50) when there is evidence of progressive LV
dilatation.
2.25 Which of the following criteria is characteristic of severe aortic regurgitation?
A. Color Doppler jet width less than 25% of LVOT.
B. Doppler vena contracta width of 0.4 cm.
C. Regurgitant fraction of 45%.
D. Regurgitant orifice area of 0.30 cm
2
.
E. Regurgitant volume of 50 ml per beat.
2.26 Which of the following is a Class I recommendation for patients with bicuspid
aortic valve and dilated ascending aorta?
A. Cardiac magnetic resonance imaging or cardiac computed
tomography
is reasonable in
patients with bicuspid aortic valves
when aortic
root dilatation is detected by
echocardiography
to further quantify
severity of dilatation and involvement of
the ascending
aorta.
B. In patients
with bicuspid valves undergoing AVR because of severe
AS or
AR, repair
of the aortic
root
or replacement of the ascending aorta is indicated if the
diameter
of the aortic
root or ascending aorta is greater than
4.5 cm.
C. It is reasonable to give beta-adrenergic blocking agents to
patients with bicuspid
valves and dilated aortic roots (diameter
greater than 4.0 cm) who are not candidates for
surgical correction
and who do not have moderate to severe AR.
D. Patients with bicuspid aortic valves and dilatation of
the aortic
root or ascending aorta
(diameter greater than 4.0
cm) should
undergo serial evaluation of aortic root/ascending
aorta
size
and morphology by echocardiography, cardiac magnetic
resonance,
or computed
tomography on a 6 monthly basis.
E. Surgery to repair the aortic root or replace
the ascending aorta
is indicated in patients
with bicuspid aortic
valves if the rate of increase in diameter
is 0.3 cm per
year.
2.27 Which of the following is an indication for aortic valve replacement in an
asymptomatic patient with chronic aortic regurgitation?
A. Bicuspid aortic valve with aortic root measuring 40 mm.
B. Left ventricular ejection fraction > 55%.
Shahzad G. Raja
34
C. Left ventricular end-diastolic dimension > 55 mm.
D. Left ventricular end-systolic dimension > 55 mm.
E. Pulmonary artery wedge pressure > 15 with exercise.
2.28 A 42-year-old man with symptomatic aortic stenosis is referred to you for
aortic valve replacement. Which of the following statements regarding aortic valve
replacement is true?
A. A cryopreserved allograft has the greatest freedom from structural deterioration and
reoperation at 10 years compared to other valve options.
B. The Ross procedure is the procedure of choice for patients 25-45 years old.
C. There is a significant difference among the various bioprosthetic valves for rates of
paravalvular leak.
D. There is no significant difference in the incidence of thromboembolism for patients
with prosthetic valve in aortic position when compared with patients with prosthetic valve in
mitral position.
E. There is no significant difference among the various mechanical valves for incidence
of thromboembolism.
2.29 A 58-year-old man with a history of mechanical aortic valve replacement 6
years previously presented with two weeks history of malaise and intermittent fever. On
clinical examination he appeared ill with temperature = 38.8°C, heart rate = 110, BP =
130/55, and respiratory rate = 26 breaths per minute. He had subungual splinter
haemorrhages with a diastolic murmur audible on auscultation of the chest. Blood
cultures grew Staphylococcus epidermidis and IV vancomycin was started. The most
appropriate surgical therapy for this patient is
A. allograft aortic valve/root replacement
B. mechanical aortic valve replacement
C. pulmonary autograft valve/root replacement (Ross procedure)
D. stented bioprosthetic aortic valve replacement
E. stentless bioprosthetic aortic valve replacement
2.30 A 46-year-old woman with atrial fibrillation was investigated and found to have
severe mitral stenosis (MS). Which of the following statements regarding MS is correct?
A. A mitral valve area greater than 1.5 cm
2
usually does not produce symptoms
at rest.
B. In patients with chronic MS there is a marked increase
in pulmonary microvascular
permeability.
C. Severe MS is characterized by mitral valve area
1.0 to 1.5 cm
2
, mean gradient 5 to 10
mm Hg, or pulmonary artery
systolic pressure 30 to 50 mm Hg.
D. The predominant cause of MS is congenital malformations of the mitral valve.
E. The ratio of women to men presenting with isolated MS is 1:1.
2.31 Which of the following statements about the natural history of mitral stenosis
(MS) is correct?
A. MS has a progressive
acceleration in the early years followed by a stable course later
in life.
Cardiac Surgery: Questions
35
B. Serial hemodynamic and Doppler-echocardiographic
studies have reported annual loss
of mitral valve area ranging from 0.5
to 0.9 cm
2
.
C. The 10-year survival of untreated patients
presenting with MS is 50% to 60%,
depending on symptoms at presentation.
D. The mean
age of presentation in developed countries is now in the third to fourth
decade.
E. The
mortality of untreated patients with MS is due to infection in 20%-30% cases.
2.32 Which of the following is a Class I indication for percutaneous mitral balloon
valvotomy?
A. Asymptomatic
patients
with moderate or severe MS and valve morphology that
is
favorable
for percutaneous mitral balloon valvotomy who have
pulmonary
hypertension.
B. Asymptomatic patients with moderate or severe MS and valve
morphology favorable
for percutaneous mitral balloon valvotomy
who have new onset of atrial fibrillation.
C. Patients
with moderate or severe MS who have a nonpliable calcified
valve, are in
NYHA functional class III–IV, and are either
not candidates for surgery or are at high risk for
surgery.
D. Patients with mixed MS and mitral regurgitation.
E. Symptomatic patients (NYHA functional class II, III, or
IV)
with MV area greater than
1.5 cm
2
if there is evidence of
hemodynamically
significant MS based on pulmonary artery
systolic
pressure greater
than 60 mm Hg, pulmonary artery wedge pressure
of 25 mm Hg or
more, or mean MV gradient greater than 15 mm
Hg during exercise.
2.33 Which of the following statements regarding percutaneous mitral balloon
valvotomy is correct?
A. A successful procedure is defined as a mitral valve (MV) area
greater than 0.5 cm
2
and
a decrease in left atrial pressure
to less than 10 mm Hg in the absence of complications.
B. Event-free survival (freedom from death, repeat valvotomy,
or MV replacement)
overall is 50% to 65% over 3 to 7 years.
C. The use of double balloon technique is associated with fewer large atrial septal defects
compared with the Inoue
balloon technique.
D. The immediate results of percutaneous mitral valvotomy are inferior
to those of mitral
commissurotomy.
E. The most
common acute complication reported in large series is embolic events.
2.34 Which of the following statements regarding the pathophysiology and natural
history of mitral valve prolapse (MVP) is correct?
A. Echocardiographic evidence
of thickened MV leaflets (5 mm or greater) is a predictor
of complications related to MVP
B. Familial MVP is transmitted as a recessive trait.
C. MVP is always associated with severe mitral regurgitation.
D. Pulmonic and aortic valve prolapses
occur in 40% of patients with MVP.
E. The age-adjusted survival rate for both men
and women with MVP is less than that of
individuals without
this entity.
Shahzad G. Raja
36
2.35 A 36-year-old patient was diagnosed with infective endocarditis (IE) of the
native aortic valve. A diagnosis of IE is based on the presence of either major or
minor
modified Duke criteria. Which of the following is a major Duke criterion?
A. Blood culture positive for IE
B. Fever, temperature >38°C
C. Major arterial emboli
D. Predisposition, predisposing heart condition, or injection drug use
E. Roth‘s spots
2.36 Which of the following patients should receive endocarditis prophylaxis before
dental procedures?
A. Patients 6 or more months after successful surgical or percutaneous repair of atrial
septal defect, ventricular septal defect, or patent ductus arteriosus.
B. Patients with acquired valvular dysfunction.
C. Patients with aortic valve sclerosis as defined by focal areas of increased echogenicity
and thickening of the leaflets without restriction of motion and a peak velocity less than 2.0 m
per second.
D. Patients with isolated secundum atrial septal defect.
E. Patients with mitral valve prolapse without mitral regurgitation.
2.37 Which of the following statements regarding infective endocarditis is correct?
A. Eighty percent of tricuspid valve
infection is by Streptococcus viridans.
B. Fungal endocarditis is usually associated with manipulation of the genitourinary
or
gastrointestinal tract.
C. In early prosthetic valve endocarditis Staphylococcus epidermidis is the predominant
offending
organism.
D. The HACEK group of organisms cause small vegetations.
E. The majority of cases of endocarditis are caused by Gram positive bacilli.
2.38 Which of the following is the most common predisposing lesion for endocarditis
of the aortic valve?
A. aortic insufficiency
secondary to connective tissue disorders
B. congenital bicuspid valve
C. degenerative calcific aortic stenosis
D. prosthetic valve
E. rheumatic aortic
valve disease
2.39 Which of the following is the most common microorganism responsible for
early prosthetic aortic valve endocarditis?
A. Aspergillus fumigatus
B. Candida albicans
C. HACEK group
D. Staphylococcus epidermidis
E. Streptococcus viridans
Cardiac Surgery: Questions
37
2.40 Which of the following is the most common cause of tricuspid regurgitation?
A. Carcinoid syndrome
B. Functional regurgitation
C. Infective endocarditis
D. Marfan syndrome
E. Rheumatic disease
2.41 A 32-year-old rehabilitated drug addict underwent tricuspid valve replacement
with a bioprosthesis as a second-stage procedure 8 months after tricuspid valve excision
for Staph. aureus endocarditis of tricuspid valve. A bioprosthetic valve in the tricuspid
position
A. has a very low incidence of pannus formation.
B. has superior haemodynamic performance compared to a mechanical prosthseis.
C. most commonly needs replacement due to nonstructural degeneration.
D. offers survival benefit over a mechanical prosthesis.
E. shows extensive structural degenerative changes than in the mitral position.
2.42 Which of the following statements regarding long-term safety and efficacy of
percutaneous coronary intervention (PCI) with stenting and coronary artery bypass
grafting (CABG) for multivessel coronary artery disease is correct?
A. At 5 years, major adverse cardiac
and cerebrovascular event rates are significantly
higher in
the PCI group than in the CABG group.
B. At 5 years, repeat revascularization occurs significantly
more frequently after CABG
compared with PCI with stenting.
C. At 5 years, the cumulative incidence of death is higher after PCI with stenting than
CABG in patients with 2-vessel and 3-vessel disease.
D. At
5 years, the cumulative incidence of death, myocardial infarction (MI), and stroke
is
less in patients randomized to PCI with stenting versus CABG.
E. At 5 years, the cumulative
incidence of death, stroke, or MI in diabetics is higher after
PCI with stenting and CABG.
2.43 Which of the following patients is at an excessive risk when undergoing
reoperative coronary artery bypass grafting?
A. a 62-year-old male with no available saphenous veins to use as conduits
B. a 65-year-old male with patent LIMA to LAD graft
C. a 66-year-old male with previous stenting of right coronary artery
D. a 68-year-old female with previous carotid endarterectomy
E. a 72-year-old male with ejection fraction <30%
2.44 Which of the following is the primary contributing factor to operative mortality
for reoperative coronary artery bypass grafting?
A. Atrial dysrrhythmias
B. Cerebrovascular complications
C. Deep sternal wound infection
D. Renal dysfunction
E. Reoperative CABG less than 1 year after previous operation
Shahzad G. Raja
38
2.45 Which of the following statements regarding ischemic mitral regurgitation is
correct?
A. Acute postinfarct mitral regurgitation is predominantly due to type I dysfunction.
B. Of patients who have cardiac catheterization
within 6 hours of the onset of symptoms
of acute myocardial infarction, 3.4% have ischemic mitral regurgitation.
C. Severe ischemic mitral regurgitation is seen in 3.4% of patients after acute myocardial
infarction.
D. Type IIIa is the more common dysfunction associated with chronic ischemic mitral
regurgitation.
E. Type II dysfunction is characterized by pure annular
dilatation with normal leaflets.
2.46 Which of the following statements regarding the pathophysiology of acute
ischemic mitral regurgitation is correct?
A. Annular dilatation is solely responsible for acute ischemic mitral regurgitation.
B. Papillary muscle rupture occurs in 50% of patients who die after myocardial
infarction.
C. Subvalvular geometric
changes are an important contributor to the pathophysiology of
acute ischemic mitral regurgitation.
D. The posteromedial papillary muscle receives dual supply from the left anterior
descending and
circumflex arteries.
E. The rupture involves
the anterolateral papillary muscle in approximately two-third of
the cases of acute ischemic mitral regurgitation.
2.47 Three weeks after suffering a myocardial infarction a 75-year-old man was
seen in the Emergency department. He had Class II-III heart failure and a systolic
murmur. An echocardiogram revealed moderate-to-severe mitral regurgitation. There
was a 5x5x4 cm fluid-filled extracardiac mass adjacent to the mitral valve and posterior
wall of the left ventricle. This patient needs
A. a CT scan for further evaluation
B. follow-up echo in 3 months
C. medical therapy with diuretics and afterload reduction
D. therapeutic pericardiocentesis
E. urgent patch repair, mitral valve repair and coronary artery bypass grafting
2.48 During cardiopulmonary bypass and open heart surgery high concentrations of
heparin (3
to 4 mg/kg, initial dose) are needed to maintain the fluidity
of blood. Heparin
A. directly inhibits coagulation.
B. -catalyzed antithrombin
inhibits thrombin bound to fibrin.
C. decreases the sensitivity of platelets to soluble agonists.
D. inhibits coagulation
at the end of the cascade.
E. activates binding of platelets to von Willebrand factor.
2.49 Cardiac transplantation is reserved for a select group of patients with
end-stage
heart disease not amenable to optimal medical or surgical therapies.
Prognosis for 1-
year survival without transplantation should be
less than 50%. Prediction of patient