CARDIO

Question 1

The damaging effects of cardiopulmonary bypass are, to a large degree, due to activation of the humoral amplification system. The humoral amplification system includes which of the following?

A. The coagulation cascade.
B. The fibrinolytic cascade.
C. Complement activation.
D. A and C.
E. A, B, and C.

Answer 1

A. The coagulation cascade.
B. The fibrinolytic cascade.
C. Complement activation.
D. A and C.
E. A, B, and C.

Question 2

2. Which of the following does not typically occur during the first few minutes of cardiopulmonary bypass?
   A. Interstitial fluid increases.
   B. Blood flow becomes nonpulsatile.
   C. Platelet count decreases.
   D. Complement is activated.
   E. Systemic vascular resistance falls.

Answer 2

A. Interstitial fluid increases.
B. Blood flow becomes nonpulsatile.
C. Platelet count decreases.
D. Complement is activated.
E. Systemic vascular resistance falls.

Question 3

Which of the following arteries is most likely to be involved with serious atherosclerosis?
A. The right coronary artery.
B. The left coronary artery.
C. The anterior descending coronary artery.
D. The circumflex coronary artery.

Answer 3

A. The right coronary artery.
B. The left coronary artery.
**C. The anterior descending coronary artery. **
D. The circumflex coronary artery.

Question 4

A 78-year-old patient who is a candidate for CABG is concerned about the risks/benefits of the procedure. The following is/are true:
a. Operative mortality in patients > 70 years is more than double that of younger patients
b. If the patient is a woman, the risk is higher than it would be for a man c. A previous CABG procedure increases the complexity and complication rate, but does not alter mortality rate
d. Results are better if there is ischemic cardiomyopathy than if there is hibernating myocardium

Answer 4

a. Operative mortality in patients > 70 years is more than double that of younger patients
b. If the patient is a woman, the risk is higher than it would be for a man
c. A previous CABG procedure increases the complexity and complication rate, but does not alter mortality rate
d. Results are better if there is ischemic cardiomyopathy than if there is hibernating myocardium

Question 5

5. Concerning operative revascularization (CABG) the following is/are true:
   a. CABG is more effective than medical treatment for relieving angina and improving physical work capacity
   b. In CABG for unstable angina, there is no difference in late outcome between stable and unstable cohorts
   c. For CABG, the most common arterial graft is the left internal mammary artery
   d. Long term patency is improved when arterial grafts are used but there is no difference in the early mortality rate

Answer 5

*a. CABG is more effective than medical treatment for relieving angina and improving physical work capacity
*b. In CABG for unstable angina, there is no difference in late outcome between stable and unstable cohorts
*c. For CABG, the most common arterial graft is the left internal mammary artery
d. Long term patency is improved when arterial grafts are used but there is no difference in the early mortality rate

Question 6

A 70-year-old woman with intractable angina pectoris undergoes cardiac catheterization for possible mechanical intervention. She prefers PTCA to open correction. The following is/are true:
a. A long symmetric lesion in the left main coronary artery would be appropriate for PTCA
b. Multiple obstructive lesions in the same artery would be a contraindication to PTCA
c. A focal lesion in the left anterior descending coronary artery where the vessel is 1 mm in diameter would allow PTCA
d. Successful PTCA for a simple lesion carries a recurrent stenosis risk of less than 10%

Answer 6

a. A long symmetric lesion in the left main coronary artery would be appropriate for PTCA
b. Multiple obstructive lesions in the same artery would be a contraindication to PTCA
c. A focal lesion in the left anterior descending coronary artery where the vessel is 1 mm in diameter would allow PTCA
d. Successful PTCA for a simple lesion carries a recurrent stenosis risk of less than 10%

Question 7

7. Coronary bypass procedures have been demonstrated to: A. Reduce the incidence of myocardial infarction.
   B. Significantly relieves angina symptoms.
   C. Statistically improve the life span.
   D. Improve the ejection fraction of the left ventricle in many patients in whom it is significantly depressed preoperatively.

Answer 7

ABCD
7. Coronary bypass procedures have been demonstrated to: A. Reduce the incidence of myocardial infarction.
B. Significantly relieves angina symptoms.
C. Statistically improve the life span.
D. Improve the ejection fraction of the left ventricle in many patients in whom it is significantly depressed preoperatively.

Question 8

he following patients are best treated with coronary artery bypass grafting (CABG):
A. A 60-year-old man with class II angina, 75% proximal right coronary artery lesion, and normal ventricular function.
B. A 60-year-old man with unstable angina, three-vessel disease, and an ejection fraction of 35%.
C. A 60-year-old nondiabetic man with class III angina symptoms and focal discrete lesions in the mid-right coronary artery and mid-left circumflex artery.
D. A 60-year-old man with diabetes, class IV angina, 75% proximal left anterior descending and 75% proximal right coronary artery obstruction, and left ventricular ejection fraction of 60%.

Answer 8

BD
A. A 60-year-old man with class II angina, 75% proximal right coronary artery lesion, and normal ventricular function.
B. A 60-year-old man with unstable angina, three-vessel disease, and an ejection fraction of 35%.
C. A 60-year-old nondiabetic man with class III angina symptoms and focal discrete lesions in the mid-right coronary artery and mid-left circumflex artery.
D. A 60-year-old man with diabetes, class IV angina, 75% proximal left anterior descending and 75% proximal right coronary artery obstruction, and left ventricular ejection fraction of 60%.

Question 9

Perioperative myocardial infarction occurs following coronary bypass procedures in approximately:
A. 15%.
B. 10%.
C. 7%.
D. Less than 5%.

Answer 9

A. 15%.
B. 10%.
C. 7%.
D. Less than 5%.

Question 10

Following acute myocardial infarction, ventricular septal defects occur in:
A. 20%.
B. 10%.
C. 15%
D. 2% or less.

Answer 10

A. 20%.
B. 10%.
C. 15%
D. 2% or less.

Question 11

Which of the following is/are indications for aortic valve replacement for aortic stenosis?
A. Syncope.
B. Congestive heart failure.
C. Angina.
D. Transvalvar gradient of 35 mm. Hg without symptoms.

Answer 11

A. Syncope
B. Congestive heart failure.
C. Angina.
D. Transvalvar gradient of 35 mm. Hg without symptoms.

Question 12

Which of the following may be indications for operation for mitral stenosis?
A. Systemic embolization.
B. Infective endocarditis.
C. Onset of atrial fibrillation.
D. Worsening pulmonary hypertension.

Answer 12

for mitral stenosis?
A. Systemic embolization.
B. Infective endocarditis.
C. Onset of atrial fibrillation.
D. Worsening pulmonary hypertension.

Question 13

Which of the following is/are not true?
A. Operation improves survival in patients with severe, symptomatic mitral valve disease.
B. Left ventricular dilatation with class I or class II heart failure is an indication for operation with mitral regurgitation.
C. Tricuspid regurgitation is most commonly caused by abnormalities of the leaflets themselves.
D. Mitral valve replacement requires resection of the mitral valve leaflets and chordae.

Answer 13

A. Operation improves survival in patients with severe, symptomatic mitral valve disease.
B. Left ventricular dilatation with class I or class II heart failure is an indication for operation with mitral regurgitation.
C. Tricuspid regurgitation is most commonly caused by abnormalities of the leaflets themselves.
D. Mitral valve replacement requires resection of the mitral valve leaflets and chordae.

Question 14

Which of the following are relative indications for mitral valve replacement, as opposed to mitral valve repair?
A. Extensive leaflet calcification.
B. Mitral regurgitation.
C. Chordal rupture of the anterior mitral leaflet. D. Significant annular dilatation.

Answer 14

Which of the following are relative indications for mitral valve replacement, as opposed to mitral valve repair?
A. Extensive leaflet calcification.
B. Mitral regurgitation.
C. Chordal rupture of the anterior mitral leaflet. D. Significant annular dilatation.

Question 15

Which of the following are relative indications for mechanical, as opposed to tissue, valve replacement?
A. Patient younger than 30 years.
B. Young female patient who desires children.
C. An elderly patient.
D. Tricuspid valve replacement.

Answer 15

A. Patient younger than 30 years.
B. Young female patient who desires children.
C. An elderly patient.
D. Tricuspid valve replacement.

Question 16

Which of the following statements are not true?
A. Bioprosthetic valves have a relatively high incidence of hemolysis.
B. Bioprosthetic valves have a lower incidence of postoperative prosthetic valve endocarditis.
C. Mechanical valves develop structural failure after an average of 7 to 10 years.
D. Mortality attributable to warfarin therapy approaches 5% per patient-year.

Answer 16

ALL
A. Bioprosthetic valves have a relatively high incidence of hemolysis.
B. Bioprosthetic valves have a lower incidence of postoperative prosthetic valve endocarditis.
C. Mechanical valves develop structural failure after an average of 7 to 10 years.
D. Mortality attributable to warfarin therapy approaches 5% per patient-year.

Question 17

Which of the following are not generally associated with mitral stenosis without regurgitation?
A. Pulmonary hypertension.
B. Pulmonary edema.
C. Left ventricular dilatation.
D. An opening snap after the second heart sound.

Answer 17

A. Pulmonary hypertension.
B. Pulmonary edema.
C. Left ventricular dilatation.
D. An opening snap after the second heart sound.

Question 18

A 52-year-old man with known aortic stenosis develops angina pectoris and has a single episode of syncope. The following is/are true:
a. Onset of angina indicates concomitant coronary artery disease independent of valvular lesion
b. Percutaneous aortic balloon valvuloplasty should be considered since it has generally favorable results
c. Patient is not an operative candidate since heart failure has not occurred
d. A measured transvalvular pressure gradiant > 50 mmHg would be an operative indication

Answer 18

a. Onset of angina indicates concomitant coronary artery disease independent of valvular lesion
b. Percutaneous aortic balloon valvuloplasty should be considered since it has generally favorable results
c. Patient is not an operative candidate since heart failure has not occurred
d. A measured transvalvular pressure gradiant > 50 mmHg would be an operative indication

Question 19

A 42-year-old woman has noted progressive exercise intolerance and fatigability. Examination discloses an opening snap in the mitral area suggestive of mitral stenosis. The following is/are true:
a. Critical mitral stenosis is defined as an orifice area reduced to 2 cm2
b. With a fixed mitral orifice, the change from sinus rhythm to atrial fibrillation has little effect on cardiac output
c. Mural thrombi and thromboembolism are directly related to the presence of atrial fibrillation
d. Depressed cardiac output is usually due to depressed myocardial contractility

Answer 19

a. Critical mitral stenosis is defined as an orifice area reduced to 2 cm2
b. With a fixed mitral orifice, the change from sinus rhythm to atrial fibrillation has little effect on cardiac output
c. Mural thrombi and thromboembolism are directly related to the presence of atrial fibrillation
d. Depressed cardiac output is usually due to depressed myocardial contractility

Question 20

Concerning valvular heart disease, the following is/are true: a. Mitral stenosis is the most common lesion
b. Of all cardiac valves, the aortic is the most anterior
c. Stenosis is the most common lesion of the aortic valve
d. Rheumatic heart disease is the most common cause of valve dysfunction

Answer 20

a. Mitral stenosis is the most common lesion
b. Of all cardiac valves, the aortic is the most anterior
c. Stenosis is the most common lesion of the aortic valve
d. Rheumatic heart disease is the most common cause of valve dysfunction

Question 21

A 2-month-old boy who appeared normal at birth has become cyanotic and is found to have a systolic ejection murmur over the pulmonic area and a boot-shaped heart on chest radiograph. The following is/are true: a. Echocardiography alone is sufficient to confirm the diagnosis of Tetralogy of Fallot
b. Cyanotic spells may be appropriately treated by propranolol
c. The Blalock-Taussig shunt connects the right ventricle to the pulmonary artery
d. Increasing cyanotic spells is the most common indication for operation e. Operative repair of right ventricular outflow obstruction is never extended across the pulmonic valve since intolerable pulmonary insufficiency would result

Answer 21

a. Echocardiography alone is sufficient to confirm the diagnosis of Tetralogy of Fallot
b. Cyanotic spells may be appropriately treated by propranolol
c. The Blalock-Taussig shunt connects the right ventricle to the pulmonary artery
d. Increasing cyanotic spells is the most common indication for operation
e. Operative repair of right ventricular outflow obstruction is never extended across the pulmonic valve since intolerable pulmonary insufficiency would result

Question 22

Within 2 hours of birth, a baby girl is obviously cyanotic and chest radiograph shows the heart to appear like “an egg on its side.” The following is/are true:
a. The most common cause of cyanosis this early is transposition of the great vessels (TGV)
b. If TGV is present, echocardiography will show that the posterior vessel leaving the left ventricle is a pulmonary artery
c. If TGV is confirmed by echocardiography, cardiac catheterization has little to add
d. The EKG is helpful in making the diagnosis of TGV since it shows reversed dominance of the ventricles
e. To improve mixing of pulmonary and systemic circulations, prostaglandin should be used to increase pulmonary vascular resistance

Answer 22

a. The most common cause of cyanosis this early is transposition of the great vessels (TGV)
b. If TGV is present, echocardiography will show that the posterior vessel leaving the left ventricle is a pulmonary artery
c. If TGV is confirmed by echocardiography, cardiac catheterization has little to add
d. The EKG is helpful in making the diagnosis of TGV since it shows reversed dominance of the ventricles
e. To improve mixing of pulmonary and systemic circulations, prostaglandin should be used to increase pulmonary vascular resistance

Question 23

A 5-year-old girl is found on routine examination to have a pulmonic flow murmur, fixed splitting of P2 and a right ventricular lift. The following is/are true:
a. Cardiac catheterization is indicated if the chest film shows cardiomegaly
b. Radiology report of “scimitar syndrome” findings on the chest film would indicate need for an arteriogram
c. If the catheterization report is “ostium secondum defect,” at least one pulmonary vein drains anomalously
d. Measured pulmonary vascular resistance of 14 Woods units/m2 with an ASD mandates early repair
e. An ASD with Qp/Qs of 1.8 can be observed until symptoms occur

Answer 23

a. Cardiac catheterization is indicated if the chest film shows cardiomegaly
b. Radiology report of “scimitar syndrome” findings on the chest film would indicate need for an arteriogram
c. If the catheterization report is “ostium secondum defect,” at least one pulmonary vein drains anomalously
d. Measured pulmonary vascular resistance of 14 Woods units/m2 with an ASD mandates early repair
e. An ASD with Qp/Qs of 1.8 can be observed until symptoms occur

Question 24

A 2-month-old boy is found to be in congestive heart failure manifested by tachypnea, tachycardia and diaphoresis with poor weight gain. The physical findings suggest a ventricular septal defect (VSD). Management should include:
a. Pulmonary artery banding
b. Urgent closure if a VSD is found on echocardiography
c. Medical treatment only with digitalis and diuretics
d. If a VSD is found, repair is unlikely to be possible because of elevated pulmonary vascular resistance
e. If a restrictive VSD is found, spontaneous closure is a possibility and operative repair should be delayed

Answer 24

a. Pulmonary artery banding
b. Urgent closure if a VSD is found on echocardiography
c. Medical treatment only with digitalis and diuretics
d. If a VSD is found, repair is unlikely to be possible because of elevated pulmonary vascular resistance
e. If a restrictive VSD is found, spontaneous closure is a possibility and operative repair should be delayed

Question 25

A premature infant in respiratory distress is found to have a continuous “machinery” murmur over the precordium. The following is/are true: a. The most likely diagnosis is coarctation of the aorta b. If large pulmonary arteries are noted, a patent ductus is likely c. To discriminate between a and b, prostaglandin administration can be used which will constrict the patent ductus arteriosus d. If a ductus if found, operative repair should be delayed until the respiratory symptoms improve to reduce mortality rates e. Normal ductus closure depends on increased oxygen saturation in the pulmonary artery

Answer 25

a. The most likely diagnosis is coarctation of the aorta **b. If large pulmonary arteries are noted, a patent ductus is likely** c. To discriminate between a and b, prostaglandin administration can be used which will constrict the patent ductus arteriosus d. If a ductus if found, operative repair should be delayed until the respiratory symptoms improve to reduce mortality rates **e. Normal ductus closure depends on increased oxygen saturation in the pulmonary artery**

Question 26

A 9-year-old boy with hypertension has no palpable femoral pulses. Coarctation of the aorta is suspected. The following is/are true: a. The most common associated abnormality is a bicuspid aortic valve b. Chest radiograph is likely to show rib notching c. The etiology is felt to be secondary to an inflammatory aortitis d. In infancy, coarctation may present with a pink upper body and cyanotic lower body e. “Paradoxical hypertension” seen after operative repair indicates residual stenosis from incomplete correction

Answer 26

**a. The most common associated abnormality is a bicuspid aortic valve** **b. Chest radiograph is likely to show rib notching** c. The etiology is felt to be secondary to an inflammatory aortitis **d. In infancy, coarctation may present with a pink upper body and cyanotic lower body** e. “Paradoxical hypertension” seen after operative repair indicates residual stenosis from incomplete correction

Question 27

Which of the following would be an acceptable method of repair for a neonate with symptomatic isolated coarctation of the aorta? A. Resection with end-to-end anastomosis. B. Prosthetic patch aortoplasty. C. Subclavian flap aortoplasty. D. Prosthetic tube graft repair.

Answer 27

**A. Resection with end-to-end anastomosis.** B. Prosthetic patch aortoplasty. **C. Subclavian flap aortoplasty.** D. Prosthetic tube graft repair.

Question 28

Which of the following may be physical examination findings in a young adult with coarctation of the aorta? A. Posterior systolic murmur between the scapulas. B. Diminished femoral pulses. C. Elevated blood pressure in left arm as compared with right arm. D. Peripheral cyanosis.

Answer 28

**A. Posterior systolic murmur between the scapulas.** **B. Diminished femoral pulses.** **C. Elevated blood pressure in left arm as compared with right arm.** D. Peripheral cyanosis.

Question 29

In an infant with suspected PDA, which of the following would be the optimal method of confirming the diagnosis? A. Chest film. B. Cardiac catheterization. C. Retrograde aortography via an umbilical artery catheter. D. Two-dimensional echocardiography with continuous-wave and color-flow Doppler echocardiography.

Answer 29

A. Chest film. B. Cardiac catheterization. C. Retrograde aortography via an umbilical artery catheter. **D. Two-dimensional echocardiography with continuous-wave and color-flow Doppler echocardiography.**

Question 30

Which of the following are potential complications of untreated coarctation of the aorta? A. Endocarditis. B. Pulmonary vascular disease. C. Cerebrovascular accident. D. Congestive heart failure.

Answer 30

**A. Endocarditis.** B. Pulmonary vascular disease. **C. Cerebrovascular accident.** **D. Congestive heart failure.**

Question 31

The direction of an intracardiac shunt at the atrial level is controlled by: A. The size of the defect B. The compliance of the right and left ventricles. C. The systemic oxygen saturation. D. Right atrial pressure. E. The presence or absence of an associated ventricular septal defect (VSD).

Answer 31

A. The size of the defect **B. The compliance of the right and left ventricles.** C. The systemic oxygen saturation. D. Right atrial pressure. E. The presence or absence of an associated ventricular septal defect (VSD).

Question 32

Which of the following statements about VSDs is/are correct? A. Perimembranous lesions are located in the region of the membranous portion of the interventricular septum near the anteroseptal commissure of the tricuspid valve. B. Muscular VSDs are holes in the interventricular septum that are bordered by muscle on three sides and by the pulmonary and the aortic valve annulus superiorly. C. VSD, in its isolated form, is the most commonly recognized congenital heart defect. D. The conduction bundle runs along the posteroinferior rim of a perimembranous VSD.

Answer 32

**A. Perimembranous lesions are located in the region of the membranous portion of the interventricular septum near the anteroseptal commissure of the tricuspid valve.** B. Muscular VSDs are holes in the interventricular septum that are bordered by muscle on three sides and by the pulmonary and the aortic valve annulus superiorly. **C. VSD, in its isolated form, is the most commonly recognized congenital heart defect.** **D. The conduction bundle runs along the posteroinferior rim of a perimembranous VSD.**

Question 33

Tetralogy of Fallot consists of all of the following features except: A. ASD. B. VSD. C. Dextroposition of the aorta. D. Pulmonary stenosis. E. Right ventricular hypertrophy.

Answer 33

**A. ASD** B. VSD. C. Dextroposition of the aorta. D. Pulmonary stenosis. E. Right ventricular hypertrophy.

Question 34

Which of the following has the greatest impact on the physiology of tetralogy of Fallot? A. The size of the ASD. B. The size of the VSD. C. The degree of pulmonary stenosis. D. The amount of aortic overriding.

Answer 34

A. The size of the ASD. B. The size of the VSD. **C. The degree of pulmonary stenosis** D. The amount of aortic overriding.

Question 35

Surgical treatment of a patient with tetralogy of Fallot can include any of the following except: A. Maintenance of ductal patency with prostaglandins (PGE 1) to provide pulmonary blood flow while the baby is transferred to an institution equipped to provide more definitive therapy. B. Banding of the pulmonary artery in an acyanotic patient with tetralogy of Fallot to control pulmonary blood flow and prevent the development of pulmonary hypertension. C. Placement of a subclavian-to-pulmonary artery shunt on the side opposite the aortic arch in a 3-day-old infant with severe cyanosis. D. Closure of the VSD and transannular patching of the right ventricle onto the main pulmonary artery in a 2-day-old infant.

Answer 35

A. Maintenance of ductal patency with prostaglandins (PGE 1) to provide pulmonary blood flow while the baby is transferred to an institution equipped to provide more definitive therapy. **B. Banding of the pulmonary artery in an acyanotic patient with tetralogy of Fallot to control pulmonary blood flow and prevent the development of pulmonary hypertension.** C. Placement of a subclavian-to-pulmonary artery shunt on the side opposite the aortic arch in a 3-day-old infant with severe cyanosis. D. Closure of the VSD and transannular patching of the right ventricle onto the main pulmonary artery in a 2-day-old infant.

Question 36

Optimal treatment for the neonate who presents with transposition of the great arteries {S,D,D}* and intact ventricular septum includes: A. PGE 1 infusion to maintain duct patency. B. Administration of intravenous fluid to increase intravascular volume. C. Hyperventilation to decrease pulmonary resistance. D. Oxygen administration to increase arterial oxygen tension. E. Atrial balloon septostomy to improve atrial mixing.

Answer 36

**A. PGE 1 infusion to maintain duct patency.** **B. Administration of intravenous fluid to increase intravascular volume.** C. Hyperventilation to decrease pulmonary resistance. D. Oxygen administration to increase arterial oxygen tension. **E. Atrial balloon septostomy to improve atrial mixing.**