Cardiothoracic Surgery

Question 0

Fixed split second heart sound

Answer 0

Atrial septal defect

Treatment is with surgical repair. Echocardiogram

Question 1

Six month old baby with crowing respiration during which he assumes a hyperextend position. Also mild difficulty in swallowing.

Answer 1

Vascular ring. Combination of pressure on the esophagus and pressure on the trachea. Bronchoscopy confirms.

Question 2

A three month old boy is hospitalized for failure to thrive. He has a loud pansystolic heart murmur best heard at the left sternal border. Chest x-ray shows increased pulmonary vascular markings. What is it? Management.

Answer 2

Ventricular septal defect. Echocardiography and surgical correction

Question 3

What are the indications for a surgical valvular replacement of the aorta?

Answer 3

A gradient of more than 50 mmHg, or at the first indication of congestive heart failure, angina, or syncope

Question 4

Drug addicted man develops congestive heart failure. He has a loud, diastolic murmur have the right, second intercostal space. What is it? Management.

Answer 4

Acute aortic insufficiency caused by endocarditis. Emergency valve replacement, and abx for a long time

Question 5

35-year-old woman has dyspnea on exertion orthopnea paroxysmal nocturnal dyspnea cough and hemoptysis progressing for five years. Has atrial fibrillation and low pitched, rumbling diastolic apical heart murmur.

Answer 5

Mitral stenosis. Start with echocardiogram. Surgical mitral valve repair or balloon valvuloplasty

Question 6

A postoperative patient who underwent open-heart surgery is determined to have a cardiac index of 1.7 L per minute per square meter and a left ventricular end diastolic pressure of 3 mmHg

Answer 6

Normal cardiac index is 3 L per minute per meter squared. Normal left ventricular and diastolic pressure or pulmonary wedge pressure should be 10 – 12 mmHg

Clear indication for increased fluid intake

Question 7

Patient who had triple coronary bypass is determined on the second postoperative day to have a cardiac output of 2.3 L per minute. It’s pulmonary wedge pressure is 27 mmHg. What is likely happening?

Answer 7

Cardiac output is low, the ventricle is failing.

Question 8

pulmonary function required to resect a lung?

Answer 8

FEV1 of at least 800 mL

Question 9

Diagnostic studies for a central hilar region of the lung?

Answer 9

Bronchoscopy’s and biopsy

Question 10

Diagnostic studies for a peripheral lesion of the lung?

Answer 10

Transthoracic needle biopsy

Question 11

54-year-old right-handed labor notices coldness and tingling in his left hand as well as pain in the forearm when he does strenuous work. He also experienced transitory vertigo, blurred vision, difficulty articulating his speech. What is it? Management.

Answer 11

Subclavian steal syndrome.

Combination of claudication of the arm with posterior brain neurological symptoms. Duplex scanning will demonstrate retrograde flow through the vertebral artery when the patient exercises the arm.

Surgical bypass resolves the problem

Question 12

62-year-old man is found on physical examination to have a 6 cm pulsatile mass deep in the abdomen, between the xiphoid and the umbilicus. What is it? Management.

Answer 12

Abdominal aortic aneurysm
Sonogram
Greater than 6 cm in diameter require surgery, less than or equal to 4 cm manage conservatively.

Question 13

62 year old man has vague poorly described epigastric and upper back discomfort. Physical exam shows 6 cm pulsatile mass deep in the abdomen and xiphoid and umbilicus. The mass is tender to palpation. What is it? Management.

Answer 13

An abdominal aortic aneurysm that is beginning to leak. Consult vascular surgeons today

Question 14

68 year old man brought to the ED with excruciating back pain that began 45 minutes ago. He is diaphoretic and has a systolic blood pressure of 90.0 there is an 8 cm pulsatile mass palpable deep in the abdomen above the umbilicus.

Answer 14

The aneurysm is rupturing right now. He needs immediate, emergency surgery.

Question 15

A wealthy, retired man has claudication when walking more than 15 blocks.

Answer 15

Vascular surgery and angioplastic stenting are palliative procedures.

They do not care arteriosclerotic disease. Claudication has unpredictable course. No indication for early operation or intervention. Quit smoking, exercise, may prescribe cilostazol

Question 16

What is the management for a patient with severe claudication of the right calf that is a non-smoker?

Answer 16

Must be claudication that interferes with lifestyle

Doppler studies. Ankle – brachial index. If he has a significant gradient, CT angio or MRI angio comes next, followed by bypass surgery or stenting.

Question 17

How does Cilastozol is all work?

Answer 17

Cilostazol is a phosphodiesterase inhibitor with therapeutic focus on cAMP. It inhibits platelet aggregation and is a direct arterial vasodilator. Its main effects are dilation of the arteries supplying blood to the legs and decreasing platelet coagulation.

Question 18

For work up of claudication that interferes with lifestyle, Doppler studies looking for pressure gradients show that a pressure gradient is found. What is the next step?

Answer 18

Do arteriogram next.

Surgical bypass, or angioplasty and stents

Question 19

45-year-old man shows up in the ER with a pale, cold, pulseless, parasthetic, painful, and paralytic lower extremity. The process began two hours ago. Physical exam shows no pulses anywhere in that lower extremity. Post at the rest is 95 bpm, grossly irregular. What is it? Management.

Answer 19

Embolization by the broken off tail of a clot from the left atrium.

– Doppler studies – if complete occlusion, do embolectomy with Fogarty catheter
– If ischemic for several hours, add a fasciotomy to prevent a compartment syndrome.

Question 20

A 74-year-old man has sudden onset of extremely severe, tearing chest pain that radiates to the back and migrates down shortly after its onset. His blood pressure is 220/110, on equal pulses in the upper extremities and a wide mediastinum on chest x-ray. ECG and cardiac enzymes are negative for MI. What is it? What is the best next step in management?

Answer 20

Dissecting aneurysm of the thoracic aorta
– Spiral CT scan is the best study to confirm the diagnosis.
–If ascending aorta, emergency surgery should be performed
– If descending aorta, intensive therapy in the ICU for the hypertension is preferable.

Question 21

Treatment for embolic occlusion of right common iliac at the aortic bifurcation.

Answer 21

Emergency embolectomy using a Fogarty balloon tipped catheter

Question 22

Disadvantage of the Ventilation-perfusion (V/Q) scan in diagnosing a patient with symptoms of PE?

Answer 22

In presence of areas of atelectasis and pneumnonic infiltrates or lung disease, it cannot be diagnostic.