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Thoracic Surgery: Questions
69
3.96 The Medical Research Council Working Group randomized controlled trial
(OEO2) to compare surgical resection with or without preoperative chemotherapy in
esophageal cancer patients showed that
A. event free survival was unaffected by preoperative chemotherapy.
B. overall survival was better in the group that received preoperative chemotherapy.
C. preoperative chemotherapy reduced median survival.
D. there was increased incidence of adverse serious events in the group that received
preoperative chemotherapy.
E. there was no difference in microscopically complete resection in the two groups.
3.97 Atrial arrhythmias are seen commonly after thoracic surgical procedures.
Which of the following statements about atrial fibrillation after esophagectomy is
correct?
A. Advanced age is a predictor of postoperative atrial fibrillation after esophagectomy.
B. Epidural pain management in patients undergoing esophagectomy can potentially
reduce the incidence of postoperative atrial fibrillation by increasing the sympathetic tone.
C. Postoperative atrial fibrillation after esophagectomy is an ―innocent bystander‖.
D. Prophylactic digoxin is effective in reducing postoperative atrial fibrillation after
esophagectomy.
E. The incidence of postoperative atrial fibrillation after esophagectomy is less than 10%.
3.98 Injury to the recurrent laryngeal nerve (RLN) has been reported at varying
rates after transhiatal and transthoracic esophagectomy. Which of the following
statements about RLN injury after esophagectomy is correct?
A. In the majority of the patients the nerve injury is contralateral to the cervical incision.
B. Neoadjuvant chemoradiation increases the rate of RLN injury.
C. RLN injury has minimal impact on the overall postoperative well being of the patient.
D. The incidence of RLN injury appears to be less common after an Ivor-Lewis
esophagectomy.
E. The incidence of RLN injury appears to be less common after transhiatal
esophagectomy.
3.99 Thoracic duct injury and the resultant chylothorax can be an aggravating and
at times difficult problem to take care of following esophagectomy. Chylothorax
A. after esophagectomy even if high output will stop with conservative management.
B. has a reported incidence of >10% after esophagectomy.
C. incidence appears to be higher after transhiatal esophagectomy when compared with
Ivor-Lewis esophagectomy.
D. that fails to resolve with conservative management is best treated with left
thoracotomy with mass ligation of the tissue between the aorta and the spine.
E. that is resistant to all treatment strategies is best treated with thoracic duct
embolization.
3.100 Pulmonary complications are a major source of morbidity and mortality
following esophagectomy. Pulmonary complications
A. after esophagectomy are correlated to preoperative FEV1.
Shahzad G. Raja
70
B. after esophagectomy are more commonly seen in patients who have received
neoadjuvant chemotherapy.
C. after esophagectomy are more commonly seen in patients who require a splenectomy
at the time of esophageal resection.
D. have a reported incidence of 50% after esophagectomy.
E. have been shown to be significantly reduced by postoperative epidural analgesia
compared to intravenous analgesia.
3.101 Compared to transthoracic esophageal resection the incidence of
A. atrial fibrillation is less after transhiatal esophageal resection.
B. chylothorax is more after transhiatal esophageal resection.
C. hoarseness is more after transhiatal esophageal resection.
D. pulmonary complications is more after transhiatal esophageal resection.
E. pulmonary complications is the same after transhiatal esophageal resection.
3.102 Uncertainty about morbidity and mortality; the occurrence, magnitude, and
duration of benefit; and preoperative predictors of benefit from lung-volume reduction
surgery led to the conduct of a federally sponsored, multicenter, randomized clinical
trial, the National Emphysema Treatment Trial (NETT). In NETT
A. overall mortality was more in the medical treatment group.
B. improvement in exercise capacity was similar in the two treatment groups at 24
months.
C. among patients with predominantly upper-lobe emphysema and low exercise capacity,
mortality was lower in the medical-therapy group than in the surgical group.
D. among patients with non-upper-lobe emphysema and high exercise capacity, mortality
was higher in the surgery group than in the medical-therapy group
E. lung-volume-reduction surgery confers an overall survival advantage over medical
therapy.
3.103 A 58-year-old male was diagnosed with a 4 cm non-small cell lung cancer
invading the visceral pleura. According to the seventh edition of TNM classification this
patient has a
A. T1a tumor
B. T1b tumor
C. T2a tumor
D.T2b tumor
E. T3
Chapter IV
Paediatric Cardiothoracic Surgery
4.1 A 16-year-old soccer player during annual physical examination was found to
have an ejection click audible in the aortic area. Echocardiography revealed the
presence of a bicuspid aortic valve (BAV). Which of the following statements regarding
bicuspid aortic valve is correct?
A. Endocarditis is the most frequent complication involving patients with BAV.
B. Fifty percent of patients with BAV will actually develop aortic dissection.
C. It is inherited in an autosomal dominant fashion with reduced penetrance.
D. The most common subtype of BAV involves fusion of right and non-coronary cusps.
E. The prevalence of BAV in the general population is 5%.
4.2 A 19-year-old male was admitted to the hospital after sustaining multiple
injuries, including sternal fracture, in a motor vehicle accident. An admission
echocardiogram revealed a dilated coronary sinus (Figure) with normal right sided
filling pressures, raising the suspicion for the presence of a persistent left sided superior
vena cava (PLSVC). Which of the following statements regarding PLSVC is correct?
A. Drainage of PLSVC into coronary sinus is of no hemodynamic consequence.
B. It is formed as a result of persistence of cephalic portion of left superior cardinal vein.
C. PLSVC is associated with absence of the innominate vein in 95% cases.
D. PLSVC is the most common congenital vascular anomaly.
E. The most common subtype of PLSVC is associated with absent right SVC.
Figure 10.
Shahzad G. Raja
72
4.3 Which of the following statements regarding patent ductus arteriosus (PDA) is
correct?
A. During fetal development, the preponderance
of left ventricular output passes through
the ductus arteriosus
into the descending aorta.
B. Fetal patency of the ductus arteriosus is maintained by high fetal
oxygen tension.
C. Histologically, the constitution of the fetal ductus arteriosus differs from that of the
contiguous main pulmonary artery and descending
aorta.
D. In normal cardiovascular development, the proximal portion of
the left sixth arch
persists as the ductus arteriosus.
E. Premature constriction
or closure of ductus arteriosus may lead to left heart failure
during fetal life.
4.4 Which of the following statement regarding the epidemiology of patent ductus
arteriosus (PDA) is correct?
A. PDA has a predilection for males.
B. PDA is inherited in an autosomal dominant manner.
C. PDA occurs with increased frequency following cytomegalovirus infection during the
first trimester of pregnancy.
D. PDA occurs
with increased frequency in Osler-Rendu-Weber syndrome.
E. PDA occurs with increased frequency in trisomy 21.
4.5 Which of the following is a recognised pathophysiological effect of patent ductus
arteriosus (PDA)?
A. Decreased catecholamine release
B. Decreased diastolic blood pressure
C. Decreased left atrial pressure
D. Decreased myocardial oxygen demand
E. Decreased pulmonary vascular resistance
4.6 In infants with esophageal atresia and tracheoesophageal fistula (TEF) which of
the following statements is true?
A. A circular myotomy should routinely be performed so as to minimize tension on the
anastomosis.
B. Delayed repair with gastric interposition is a reasonable option for most patients.
C. The fistulous tract should be divided flush with the trachea since a small amount of
residual esophageal mucosa will produce excessive tracheal mucous production.
D. Gastrostomy should be performed following repair of the fistula.
E. A retropleural approach to the fistula protects against empyema in the event of an
anastomotic leak.
4.7 Which of the following statements about congenital tracheoesophageal fistula is
true?
A. Abdominal distention secondary to gastric and intestinal distention is uncommon in
neonates with congenital tracheoesophageal fistulae.
B. Esophageal atresia with a proximal tracheoesophageal fistula is the most common type
encountered.
Paediatric Cardiothoracic Surgery: Questions
73
C. Free gastroesophageal reflux resulting in chemical pneumonitis is a rare feature of
congenital tracheoesophageal fistula.
D. Respiratory distress is an early sign of esophageal atresia with a distal
tracheoesophage fistula.
E. The most common presentation is inability to swallow the feeds.
4.8 A child is born with a left-sided aortic arch and a Type I esophageal atresia with
a gap of 6.2 cm between the proximal and the distal esophagus. The
esophagorespiratory fistula arises at the origin of the left main stem bronchus. Initial
Apgar score is 7 and his weight is 7 lbs, 8 oz. Upon assessment, he has no associated
congenital anomalies. Which of the following would be the best course of action?
A. primary repair via a right thoracotomy immediately.
B. primary repair via a right thoracotomy at one week.
C. primary repair via a left thoracotomy at three weeks.
D. primary repair via a right thoractomy at six weeks.
E. colonic interposition at four months.
4.9 A 6-year-old child with recurrent chest infections and failure to thrive was
diagnosed with cystic fibrosis. Which of the following statements regarding cystic
fibrosis is correct?
A. It is an autosomal dominant disease.
B. It is caused
by mutations in the BAC-1 gene.
C. The commonly accepted explanation for airway disease in cystic
fibrosis is the "high
volume" hypothesis.
D. The commonest mutation is the deletion of
phenylalanine at codon 508.
E. The inflammatory response in a patient with cystic fibrosis is 10 times less than a
normal person.
4.10 Which of the following statements regarding the diagnosis of cystic fibrosis is
correct?
A. Patients with the cystic fibrosis have
raised concentrations of potassium and chloride
in the urine.
B. Sweat concentrations of sodium and chloride < 40 mmol/L is diagnostic of cystic
fibrosis in an infant.
C. Sweat concentrations of sodium and chloride > 60 mmol/L is diagnostic of cystic
fibrosis.
D. The optimal diagnostic test for cystic fibrosis is the measurement
of pancreatic juice
electrolyte levels.
E. The optimal diagnostic test for cystic fibrosis is the measurement
of sweat potassium
levels.
4.11 Which of the following statements regarding the development of the lung is
correct?
A. The basic structure of the gas exchange units of the lung appear in the acinar phase.
B. The distal airspaces continue to multiply and differentiate into more complex gas
exchange units during the pseudoglandular phase.
Shahzad G. Raja
74
C. The embryonic phase encompasses development of the conducting airways.
D. The lung begins differentiation in the fourth week of gestation.
E. The lung develops as a dorsal out pouching on the floor of the primitive foregut.
4.12 Which of the following statements regarding the extralobar pulmonary
sequestration (ELS) is correct?
A. ELS are most commonly found on the left side.
B. ELS is a discrete mass of pulmonary parenchyma existing inside the pleural
investment of the lung.
C. ELS in 80% of cases derives its blood supply from the pulmonary artery.
D. ELS in 80% of cases drains by the pulmonary venous system.
E. ELS is related to abnormal expression of the p53 gene.
4.13 An anteroposterior radiograph of the chest of a 3-day-old child with
respiratory distress shows mild hyperexpansion of the left upper lobe. A diagnosis of
congenital lobar emphysema was made. Congenital lobar emphysema
A. is characterised by destruction of alveolar walls with overdistension of alveoli.
B. is caused by extrinsic compression from a vascular anomaly such as an avalvular
pulmonary artery or patent ductus arteriosus.
C. is the most common cause for a congenital lung mass.
D. predominantly affects the lower lobes.
E. presents with cyanosis after birth in 90% of the cases.
4.14 Anteroposterior (AP) and lateral radiographs of the chest in a 14-week-old
female, with cough and wheeze, demonstrated indistinctness of the tracheal air shadow
on the AP view, and anterior bowing of the trachea on the lateral view. CT scan of the
chest showed a midline fluid-attenuation cyst posterior to the trachea. A diagnosis of
bronchogenic cyst was made. Bronchogenic cysts
A. are rarely detected with prenatal sonography.
B. arise from dorsal foregut.
C. in children are predominantly symptomatic.
D. in the mediastinum frequently communicate with the tracheobronchial tree.
E. in two-third of the cases are intraparenchymal.
4.15 A five-year-old child was brought to the Emergency Department by the parents
with symptoms of stridor and dyspnea while lying flat. Clinical examination revealed
cervical as well as bilateral supraclavicular lymphadenopathy. A CT scan of the chest
(Figure) revealed an anterior mediastinal mass. What is the most likely diagnosis?
A. Cystic hygroma
B. Hemangioma
C. Lymphoma
D. Thymoma
E. Teratoma
Paediatric Cardiothoracic Surgery: Questions
75
Figure 11.
4.16 Which of the following statements regarding mediastinal masses in children is
correct?
A. Most children with mediastinal masses are asymptomatic.
B. Neurogenic tumors are the most common mediastinal malignancy in children.
C. Neurogenic tumors are usually located in the anterosuperior mediastinum.
D. Primary mediastinal tumors and cysts are relatively rare in the pediatric population.
E. Teratomas are the most common benign lesions.
4.17 Which of the following statements regarding neurogenic tumors in children is
correct?
A. Ganglioneuromas are composed of both mature and immature Schwann cells.
B. Ganglioneuroblastomas are highly malignant.
C. Neuroblastomas are the most common neurogenic tumors in children.
D. Neurofibromas are well encapsulated.
E. Overall 5-year survival rate for ganglioneuroblastomas is 88%.
4.18 Congenital tracheomalacia is believed to be a consequence of the inadequate
maturity of tracheobronchial cartilage, either from premature delivery or from an
innate immaturity despite normal gestation. Congenital tracheomalacia
A. is associated with the mucopolysaccharidoses, such as Hunter syndrome and Hurler
syndrome.
B. is predominantly seen in females.
C. is most commonly associated with protracted endotracheal intubation.
D. is more common than the acquired form.
E. persists throughout the life of the affected individual.
Shahzad G. Raja
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4.19 Congenital diaphragmatic hernia (CDH) is a relatively common birth defect
associated with high mortality and morbidity. Although the exact aetiology of most cases
of CDH remains unknown, there is a growing body of evidence that genetic factors play
an important role in the development of CDH. CDH
A. most commonly occurs in the anterior retrosternal position.
B. has a high mortality due to associated cardiac defects.
C. is associated with Trisomy 13, 18, and 21 and 45,X aneuploidies.
D. is associated with abnormalities in the vitamin B signalling pathways.
E. has a high recurrence risk in familial cases.
4.20 Numerous techniques for mitral valve reconstruction in children have been
reported. These techniques are not always successful in repairing congenitally
malformed mitral valves necessitating mitral valve replacement (MVR). In children
A. replacement with mechanical prosthesis precludes re-replacement.
B. the incidence of heart block after MVR is 1%.
C. the incidence of prosthetic valve thrombosis, thromboemboli, and anticoagulation-
related bleeding necessitating transfusion is nearly 5%.
D. the most important indication for redo MVR is patient-prosthesis mismatch.
E. xenografts have better durability compared with caged-ball prostheses in mitral
position.
4.21 Ebstein’s anomaly is a complex congenital anomaly with a broad anatomic and
clinical spectrum. Which of the following is a characteristic feature of Ebstein’s
anomaly?
A. delamination of the septal and posterior leaflets
B. dilation of the left atrioventricular junction (true mitral annulus)
C. dilation of the atrialized portion of the right ventricle
D. redundancy, fenestrations, and tethering of the posterior leaflet
E. superior displacement of the functional annulus (septal>posterior>anterior)
4.22 Deletion of chromosome 22q11 is the most frequent known interstitial deletion
found in man with an incidence of 1 in 4000 live births. The deletion has been reported
in association with >80 different birth defects and malformations occurring in many
combinations and with widely differing severity. The 22q11 deletion syndrome
(22q11DS)
A. is due to a macrodeletion of chromosome 22q11.2.
B. is strongly associated with hypothyroidism.
C. is inherited as an autosomal recessive disorder.
D. is characterized by defects in derivatives of the embryonic pharyngeal arches and
pouches.
E. is associated with B-cell mediated immune deficiency.
4.23 Hypercyanotic spell is a serious condition in patients with tetralogy of Fallot.
Hypercyanotic spell
A. is seen in all patients with teralogy of Fallot.
B. is characterised by absence of murmur.
Paediatric Cardiothoracic Surgery: Questions
77
C. is accompanied by decrease in pulmonary vascular resistance.
D. is accompanied by increase in systemic vascular resistance.
E. is best managed by promoting right to left flow across the ventricular septal defect.
4.24 Extracorporeal membrane oxygenation (ECMO) is a modified adaptation of
conventional cardiopulmonary bypass techniques for prolonged cardiopulmonary
support using intrathoracic or extrathoracic cannulation. ECMO support
A. associated cardiac stun is characterised by a marked decrease in PaO
2
.
B. is only useful in cases where the primary lung injury is accompanied by the presence
of oxygen toxicity.
C. is indicated for oxygenation index > 40 or > 35 for 4 hours.
D. results in increase in peak and mean blood flow velocities by 30-35%.
E. results in increase in diastolic blood pressure.
4.25 Kawasaki Disease (KD) is a multisystem inflammatory illness of young
childhood that can result in acute vasculitis, most strikingly of the coronary arteries. In
KD
A. approximately 25% of children develop coronary artery abnormalities.
B. ITPKC, a positive regulator of T cell activation, confers susceptibility to KD in
Japanese populations.
C. immune complex deposits are observed in inflamed arterial tissue.
D. primary autoimmune aetiology is most likely.
E. steroids are the primary therapy of choice.
4.26 Congenital defects of the interatrial septum are the most common congenital
heart disease presenting in adulthood. Which of the following statements regarding
interatrial septal defects is correct?
A. Ostium primum atrial septal defects are considered the severest form in the spectrum
of endocardial cushion defects.
B. Ostium secundum atrial septal defects result from the lack of septation between the
pulmonary veins and the superior vena cava or right atrium.
C. Sinus venosus atrial septal defect is the least common type of atrial septal defect.
D. Clinically silent atrial septal defects produce a left-to-right shunt.
E. A pulmonary-to-systemic blood flow ratio (Qp:Qs ratio) of 1:1.5 will cause a patient
to be symptomatic.
4.27 Transposition of the great arteries (TGA), also referred to as complete
transposition, is a congenital cardiac malformation characterised by atrioventricular
concordance and ventriculoarterial (VA) discordance. TGA
A. has a male predominance.
B. is associated with noncardiac malformations in 90% cases.
C. with left ventricular outflow tract obstruction is more commonly seen when the
ventricular septum is intact.
D. is characterised by systemic and pulmonary circulations in series.
E. -associated central cyanosis is worsened by intravenous prostaglandin E1.
Shahzad G. Raja
78
4.28 The cardiovascular system is the first organ system to form and function in the
vertebrate embryo. Which of the following statements regarding cardiogenesis is
correct?
A. The heart tube at the time of its formation is a three-layered structure.
B. Endothelial-derived cells in the cardiac cushions function to separate the common
outflow tract into the pulmonary artery and aorta
C. Endothelial and hematopoietic cells arise from a common ectodermal precursor, the
hemangioblast.
D. Endoderm-derived endothelial precursors called angioblasts aggregate to form the
dorsal and ventral aortae and the vitelline vessels.
E. The mesocardium plays an important role in signaling to cardiomyocytes.
4.29 The aortopulmonary (AP) window is a congenital malformation characterized
by a communication between the ascending aorta and the pulmonary artery in the
presence of separate semilunar valves. AP window
A. is rarely associated with other cardiac defects.
B. between the ascending aorta and the origin of the right pulmonary artery is termed
type I.
C. results in right to left shunt.
D. closes spontaneously in majority of cases.
E. type III consists in the anomalous origin of the right pulmonary artery of the aorta.
4.30 Congenital tracheal stenosis is a rare disorder characterized by the presence of
focal or diffuse complete tracheal cartilage rings, resulting in a fixed tracheal
narrowing. Congenital tracheal stenosis
A. is most commonly associated with interrupted aortic arch.
B. in approximately 50% cases is generalized.
C. of focal variety usually involves lower one-third.
D. of focal variety is charcterized by narrow distal end of the trachea and bronchi.
E. when discovered early in life has better prognosis.
4.31 Compression and displacement of the trachea and esophagus as a result of
anomalous development of the aorta and its branches are not uncommon in the
pediatric patient. A majority of patients are asymptomatic, but patients may present
with respiratory and gastrointestinal symptoms. Which of the following statements
regarding thoracic vascular anomalies is correct?
A. Patients with double aortic arch are usually asymptomatic.
B. In patients with double aortic arch chest x-ray is diagnostic.
C. The most common of the aortic arch anomalies is an aberrant left subclavian artery.
D. An aberrant right subclavian artery rarely causes symptoms.
E. An aberrant right subclavian artery originates from right aortic arch.
4.32 Congenital bronchial atresia is a rare anomaly that results from focal
obliteration of a proximal segmental or subsegmental bronchus that lacks
communication with the central airways. Congenital bronchial atresia
A. is characterised by abnormal development of structures distal to the atretic bronchi.