SESAT 2020 Flashcards
1
Q
what is the most likely cause of a pulmonary AVM
A
hereditary hemorrhagic telegictesia
2
Q
Plan for pulmonary arteriovenous malformation (PAVM)
A
All require treatment, embolization is the preferred approach.
3
Q
previous fundoplication with mesh that has now eroded, what is the plan
A
likely esophagectomy, not really able to repair the erosion
4
Q
treatment for a flail chest if care is not progressing
A
chest wall stabilization
5
Q
how to quantify pectus severity
A
Haller index (3.25-3.5 or above is indication for repair)
6
Q
how to deal with lung parenchymal bleeding following gun shot wound
A
tractotomy
7
Q
what is a tumor that is a spindle cell neoplasm
A
solitary fibrous tumor
8
Q
treatment plan for a found solitary fibrous tumor
A
resection
9
Q
long term therapy after resection of a solitary fibrous tumor
A
annual CT surveillance (large recurrence rate)
10
Q
What is the malignant potential of purely GGO nodules
A
virtually zero potential
11
Q
At what size would you want to operate on a GGO
A
8 - 10 mm
12
Q
For mixed solid and GGO nodules, when are you worried about mets
A
When the solid component is:
1) > 5mm
or
2) >50% of the total GGO size
13
Q
What cause of a pleural effusion are you concerned about with a high adenosine deaminase? (ADA)
A
TB
14
Q
How would you diagnose TB as the cause of an effusion?
A
Pleural biopsy
15
Q
At what percentage of artery involvement of a tumor is complete circumferential resection required
A
25%
16
Q
If you are going to operate on a pancost tumor, what is the first step
A
Induction chemoradiotherapy
17
Q
Patient with bad emphysema is intubated. Next her blood pressure falls, what is happenning and what is next step
A
Auto-peep is occurring
Disconnect from vent and allow prolonged expiration
18
Q
What are the criteria for transplantation in COPD patients
A
1) FEV1 < 20%
2) DLCO < 20%
3) BODE score > 7
4) Hospitalization with pC02 > 50
5) pHTN
19
Q
What to do if you suspect a bronchopleural fistula after pneumopectomy and patient isnt dying
A
Chest tube in pnumonectomy side and place that pneumonectomy side down
20
Q
Which has better survival in esophageal cancer with nodal disease, surgery or chemo-radiation?
A
Neither, same outcomes
21
Q
What is the percent of nodal involvement in T3 esophageal cancer
A
50%
22
Q
Treatment for T3 esophogeal cancer?
A
Neoadjuvant chemo-radiation followed by surgery
23
Q
If you have advanced NSCLC, what PDL1 expression do you need to be above to respond to therapy
A
> 50%
24
Q
Best therapy for effort based thoracic outlet syndrome
A
1st rib resection
25
Stage II or III EGFR + lung cancer, what do you do after resection
adjuvant platinum based chemotherapy
26
Trauma -> intubation
Found ptx -> chest tube -> large air leak and decreased ventilation ability, next step?
Bronch with repositioning of ET tube
27
What does N2 disease for lung cancer mean treatment wise
Mediastinal radiation is needed
28
What margins are generally needed for wedge resections in lung cancer
the larger of 2cm or tumor diameter
29
which is between in lung tumors 1-2 cm in size, wedge or segmentectomy
segmentectomy
30
What is the official number of lung segments
19
31
What is the best way to locate the GEJ
proximal extent of the rugal folds
32
How to best managed an infected malignant pleural effusion if it is already being drained
Antibiotics (90% success rate)
33
What type of nodule has popcorn calcification
harmatoma
34
What lung cancer can mimic (on path) a atypical carcinoid tumor
small cell lung cancer
35
What level of esophageal tumor can you do EMR/ablation
T1a only
36
How do you deal with septations in an empyema to avoid decortication
TPA and DNAse
37
What is the primary treatment for neurogenic tumor (most occur in the posterior mediastinum)
resection
38
What test should you get first on a posterior mediastinal neuroendocrine tumor before resection
MRI for tumor extension
39
Small asymptomatic esophageal lesion, what do you do?
Observation
40
Symptomatic, large submucosal esophageal lesion, treatment?
minimally invasive enucleation
41
Best way to biopsy if you think sarcoidosis?
endobronchial biopsy of mediastinal adenopathy
42
What esophageal tumor extent counts as T1A
Up to the muscularius mucosa but not past it
43
Barretts esophagus with high grade dysplasia:
1) Nodule
2) generalized area
Treatment?
1) Nodule -> EMR
2) Region -> RFA
44
What degree of compression of the tracha is needed to cause symptoms (tumor mass effect)
50-75%
45
What is the limit of size on tracheal resection
4cm
46
How to manage R1 resection for adenoid cystic carcinoma of the trachea?
adjuvant radiotherapy
47
Does hilar release help with cervical trachea length?
no
48
Most common cancer following transplant?
Post-transplant lymphoproliferative disease (B lymphoid cells)
49
Treatment of post transplant lymphoproliferative disease
reduce immunosuppression and give rituximab
50
What infection would preclude you from a lung transplant
Burkholderia cepacia
51
Type III hiatial hernia with GERD and GI motility issues
laparascopic hiatial hernia repair with partial fundoplication
52
What predicts recurrence after resection of a chest wall sarcoma?
Grade of the tumor (the biology)
53
Chest wall reconstruction needs after removal of mesh for infection if its a late infection
Just removal of the material, a fibrous rind will have already formed, stabilizing the chest wall
54
Treatment of eosinophilic esophagitis?
topical steroids and PPI
55
Esophageal cancer with peritracheal nodes, treatment?
Definitive chemoradiaiton +- surgery
56
Treatment for a recurrent met from a thymoma
Resection
(Sterotatic ablation if cannot tolerate surgery)
57
Barretts region with no high grade dysplaisa but nodule with high grade displasia, the nodule is removed with EMR, next step?
RFA remaining barretts
58
What to do before surgery for an aspergilloma
Rule out active TB
59
Management of tracheo-esophageal fistula following esophagectomy?
Primary repair with muscle flap, no role for stenting
60
Large interthoracic mass and low glucose, what is it
Solitary fibrous tumor (Doege-Potter Syndrome)
61
What is a requirement of diaphragmatic pacing
preservation of lower motor neurons
62
How should you first treat a stage II empyema
VATS washout +- decort
63
What is a timing on stage II empyema
1 to 4 weeks following an effusion
64
What incision in the diaphragm is safe and gives you the most exposure (thoracoabdominal)
circumferential incision
65
Initial treatment for GERD + obesity
medically supervised weight loss and Roux en Y gastric bypass
66
What to do if residual germ cell tumor after systemic chemotherapy
resect it
67
young patient with bad lungs, intubated, unable to wean, listed for transplant, next steps?
VV ecmo and extubation
68
What are the biggest two risk factors in developing esophageal adenocarcinoma
Age and male gender
69
Esophageal cancer treatment gold standard
neoadjuvant chemoradiation followed by surgery
70
What is the recommended follow up time for barretts esophagous
No dysplasia: 3-5 years
Low grade dysplasia: 6mth - 12 mth
High grade dysplasia w/o treatment: 3 mth
71
What is the staging of a thymoma
Stage 1: no invasion
Stage 2: pericardial invasion
Stage 3: surrounding structure invasion
72
Esophagous with white lesions, hyperkeratosis, indistinct layers on biopsy. Dx and Tx?
Verrucous carcinoma
Esophagectomy
73
SCJ joint infection, treatment?
Operative debridement, including the joint, open packing
74
Esophogeal Adenocarcinoma genes
ERBB2
KRAS
EGFR
VEGFA
75
Esophageal SCC genes
PTEN
RB1
FGFR1
NOTCH1
76
What is the most likely source of descending mediasteinitis
odontogenic infection
77
Pt w/ progressive dyspnea and fatigue, CT shows mass with areas of calcification with extrinsic compression of surrounding. What is it and what is is caused by
Fibrosing mediastinitis
Fungal infection (Usually Histoplasmosis)
78
Best treatment for benign SVC syndrome
Stenting
79
Stage IV lung cancer with targetable mutation, whats the treatment
targeted immunotherapy, not chemotherapy
80
What treatment it contraindicated in ILD
sterotatic radiation
81
Best and worst tube types of adenocarcinoma
Best - lepidic
Worst - micropapillary
82
Surgically resectable small cell lung cancer, what do you do first?
Mediastinal staging (lobar resection is the preferred surgery)
83
What is the cutoff for minimally invasive adenocarcinoma of the lung
<= 5mm, no need for lobectomy
84
Treatment of Stage II N0 lung cancer
Surgery with adjuvant chemotherapy
85
Treatment of Stage II N2 lung cancer
Surgery with adjuvant radiation
86
Treatment of esophageal - tracheal fistula following definitive radiation
Esohpageal stent w/ feeding access
87
Treated esophageal cancer with chemorads, new lesion at LES, what treatment
Esophageal resection
88
Standard of care for Stage IIIB lung cancer
definitive chemoradiation
89
First choice for palliation for an obstructing esophogeal mass
endoscopic dilation and stent placement
90
Is there a margin distance for carcinoid tumors
No distance, either positive or negative.
If negative, no need for anything further
91
Next step if concerned about traumatic diaphgramatic injury
Surgical exploration (ex lap)
92
Type III achalasia, what is preferred treatment and what should be avoided
Preferred: POEM
Avoided: Pneumatic dilation
93
Scleroderma and GERD like symptoms with complete emptying, what do you do?
24 hr pH probe monitoring to establish GERD
94
Esophageal diverticulum near diaphgram, what type and what are next setps?
Type: pulsion due to high LES
Next Step: high-resolution manometry
95
How soon to stop plavix
5 days
96
What type of dissection do you cause with a seldinger technique
Type B
97
What do you do if you have a type B from cannulation
Switch to short tip diserpsion cannula
98
What is the cardiac protection strategy with cold agglutination disease
warm cardioplegia and systemic normothermia
99
What is necessary screening for a found ascending aortic aneurysm
echocardiogram for 1st degree relatives
100
What is the most common reason for developing a type A
Hypertension
101
Treatment of sarcoma in the heart
Full thickness resection
102
Best way to deal with electrolyte issues on CPB
Z-BUF
103
What is Z-BUF
zero balance ultrafiltration
filters blood through a filter, gets anything smaller out (fluid, electrolytes, heparin)
104
Bicaval cannulation, CPB starts and LA distends, what happened
Venous cannulation is mal-positioned
105
Left SVC without an innominate vien, what do you do?
Cannulate the SVC
(Cannot clamp is no innominate)
106
What is the absolute indication for needing preemptive for subclavian-carotid transposition for q zone 2 tevar
patent LIMA-LAD
107
Marfan, pregnant lady, viable pregnancy, 4.2cm root, management?
Elective C section followed by aortic root replacement
108
450U/kg heparin given, ACT still low, next steps
1) Recheck ACT
2) 2 units FFP or ATIII
109
What do you need to do if you have a presumed low flow state
PA catheter directed therapy
110
Indication for AICD
1) EF < 35 % and Class II or III
2) EF < 30% for all comers
111
patient with new HF, low ef, first step?
Optimization of medical management
112
Type A, residual perfused false lumen with some viscera coming off false, next step?
No intervention, routine surveillance
113
When can you do FFR and not IVUS
Small women
114
Most common cause of bloody pericardial effusion
malignancy
115
How to treat recurrent pericarditis?
Escalation therapy:
1) colchicine
2) Steroids
3) intrapericardial steroids
116
Biggest predictor of mortality following post MI VSD
renal function
117
How to differentiate constrictive pericarditis and restrictive cardiomyopathy
Constrictive Pericarditis:
- respiratory variations in filling
- fast diastolic flow across MV
- equalization of end diastolic pressures in the LV and RV
Restrictive Cardiomyopathy:
- minimal respiratory variations in filling
- slow diastolic flow across MV
- LVEDP increased after fluid bolus
118
When is cardiac resynchronization indicated
Ef <35% w/ LBBB and QRS > 150 ms
119
What is the criteria for CTEPH
PA pressure > 25
wedge pressure < 15
Presence of clots after 3 months on anticoagulation
120
If you suspect CTEPH, what is the next step?
VQ scan
121
Who should be screened for lung cancer
>20 pack year smoking hx
122
What is the treatment for end stage achalasia
esophagectomy
123
How do you determine end stage achalasia
barium esophagram
124
Lung cancer, hypercalcemia, and confusion, next step?
Hydration
125
Lung cancer, pet avid nodes but equivocal for mets, next step
Aggressive mediastinal staging before any treatment decision
126
Multiple failed hiatal hernia repairs, best next treatment?
Roux-en-y
127
Difference between a Dor and Toupet fundoplication
The region covered
Dor - anterior
Toupet - posterior
128
New born with cyst in right lung, what is it and what next step?
Congential pulmonary airway malformation
CT scan is needed next
129
Pockets of air behind the sternum, what is it?
Hernia w/ bowel in chest
130
best test if you think a diaphragmatic hernia
CT scan
131
what is a metaiodobenzylguanidine scan for?
Also known as MIBG
This is for localizing pheochoromocytoma lesions in the body
132
What is a contraindication for magnetic sphincter augmentation
Normal peristalsis <70% of the time
133
How to bronch/intubate with a cancer with mass effect on the trachea?
Mild to moderate stricture - flexible fiber optic
Severe stricture - rigid bronch
134
Germ cell tumor , mets to lung, resection, found to not be a teratoma, next step?
More chemo!!!
135
During septal myectomy, what preoperative factor increases the chance of complete heart block
right bundle block
136
What medications to be discharged on following CABG
ASBD - aspirin, statin, beta blocker, diuretic
137
For ischemic MR, what is the biggest predictor of current MR following ring annuloplasty?
basal inferior dyskinesis
138
What gradient is too high after septal myectomy (provoked gradient)
25mmHg
139
Are septic pulmonary emboli an indication for TVR in endocarditis
no
140
Official recommendation for AC for a bioprosthetic valve in the mitral or tricuspid position
Warfarin for 3 months
141
What is the timing on CABG following STEMI and NSTEMI
3 days after STEMI
6 hrs after NSTEMI
142
Possible dissection during central cannulation, next step?
Axillary cannulation
143
SVG to LAD, new symptoms and 70% or higher stenosis in SVG, what is the revascularization strategy?
keep the SVG and place LIMA, no concern for competitive flow
144
What is the timing for CABG following interventions in the carotid artery?
CEA - 2 weeks
Stenting - 6 weeks
145
CABG and mitral repair, off CBP, > mild MR remains, next step?
Mitral valve replacement
146
What is needed to use a catheter to close a VSD?
10-14 days post infarct and a size <1.5cm
147
Indications for intervening on severe MR
Symptomatic
or
Asymptomatic and LVEF < 60% or LV end systolic diameters > 40mm
148
First initial therapy for severe functional MR
optimize medical therapy and consider CRT
149
What is the cross sectional area : height cut off for root or ascending operation in marfan patients
>10
150
Patient looks marfanoid but has ansuersysms throughout, dx?
Loeys-Dietz syndrome
151
What is the main advantage in off vs on pump CABG
lower blood transfusion
152
what is the size cut off for replacing the aorta while doing another procedure
4.5 cm
153
Where does the oxygen to the heart come from in blood cardioplegia
Dissolved oxygen, not Hgb bound
154
What does adding MV replacement to a CABG for ischemic MR do outcome wise?
Improved freedom from HF
155
What is the antiplatelet strategy right after CABG
ASA must be started within 6 hours
156
What pre-op antibiotics should be given if thinking prothestic valve
1st gen cephalasporin and a glycopeptide (Vanc)
157
Do you delay with a valve vegetation that should be operated on but the patient has a TIA from the vegetation
no
158
Is staph aureus an indication for right sided valvular surgery
NO, only left
159
Where must epicardial leads be placed to be effective for CRT
Lateral wall, not apex
160
PPM with lead in the LV, what do you do
Removal under direct supervision
161
When is warfarin safe in pregnancy
second and third trimester
162
What is the order of intervention for coarctation of the aorta from best to worst
Sent>surgery> balloon angioplasty
163
How to treat pacemaker infection
Complete removal and replacement on contralateral line
164
What to do with HOCM after septal myectomy
ICD
165
Does a genetic mutation in Fibrillin mean marfan
NO
166
When do you intervene on AR if concomitemnt procedure
Mod or greater
167
What to do with small coronary aneurysms
nothing
168
what is the best study for diagnosing pulmonary stenosis
Cardiac MRI
169
How to treat an isolated arch aneurysm
type 1 hybrid arch repair
170
Thrombus formation in valve 5 weeks after surgery, next step?
TPA continuous infusion
171
What is the initial treatment for valve thrombosis
IV heparin and life long warfarin (only replacement if acutely de-compensating; use a mechanical)
172
What is the preferred cerebral protection strategy for DHCA
Antegrade over retrograde
retrograde over nothing
173
What is the limit of rewarming after circ arrest
36.5C
174
What to give to stop bleeding after DHCA and everything is normal
recombinant activated factor VII
175
Best way to reduce post op a fib
beta blocker
176
Best way to reduce stroke in LVAD patients
keep map< 90
177
What surveillance is good in patients with TOF
cardiopulmonary exercise testing (subjective decline can be indolent)
178
When to intervene on severe PR
if there are symptoms
179
Post op Afib management
1) unstable -> cardioversion
2) no HF -> beta blocker
3) some HF -> amiodarione
180
generally when should you do AC following post op afib
72 hrs
181
Fever, chest pain, and neurologic symptoms 1 month after catheter based AF ablation
atrio-esophogeal fistula, need to operate
182
After surgery, Pa02 130s on 100% Fi02, next step?
increase PEEP
183
Corner stone of mucor treatment
aggressive surgical resection
184
Management for lye ingestion
thoracotomy and laparatomy with cervical fistula
185
What drug to wean iNO
Sildenafil
186
What is a metabolic predictor of poor outcomes on VA ECMO
diabetes
187
Pulmonary contusions, intubated, getting worse, PEEP doesnt help, what next?
prone positioning
188
Drug of choice for ICU delirium
dex
189
When does HIT usually develop
5-10 days after exposure
190
in ARDS, what are the only maneuvers to improve survival besides lung protective ventilation
prone positioning
neuromuscular blockade
191
What is the goal for supportive ventilation
maintain Pa02 > 55
192
What to check for first if you want to improve pulmonary vascular resistance
ensure not hypoxic
193
Dobutamine vs iNO
LOOK AT BLOOD PRESSURE
194
Routine preop antibiotics are what
nasal mupirocin
195
Best reversal agent for warfarin
PCC
196
Lung infection + sulfur granules
Actinomyces
Treat with penicillin G
197
CABG and fast post opertaive change suspect for graft failure
coronary arteriography
198
Drug to treat high PVR post OHT
inhaled prostacyclin
199
how do decrease CO2 in ARDS
decrease ventilatory rate
200
What gender and medical condition puts one at risk for a deep sternal wound infection
female gender
chronic lung disease
201
What IV med decreases opioid use
ketamine
