Surgery- Cardiac Flashcards
SUR - 6.1
Methods intended for direct myocardial oxygenation, except for:
A) Aorto-coronary bypass grafting (ACBG)
B) Coronary thromboendarterectomy
C) PTCA (percutaneous transluminal coronary angioplasty)
D) IABP (intra-aortic balloon pump)
E) Pacemaker implantation
ANSWER
E) Pacemaker implantation
EXPLANATION
Surgical bypass grafting bypasses the coronary narrowing or blockage, thrombendarterectomy removes the narrowed segment (except for the adventitia layer), PTCA dilates it, IABP improves coronary filling and circulation. Pacemakers are used to treat bradyarrythmias, and so that answer is the exception.
SUR - 6.2
Surgical access methods for cardiac procedures, except for:
A) median sternotomy
B) left sided standard, antero-lateral thoracotomy
C) parasternal mediastinotomy
D) subcostal mediastinotomy
E) right sided postero-lateral subscapulary thoracotomy
ANSWER
E) right sided postero-lateral subscapulary thoracotomy
EXPLANATION
Access methods listed as A, B, C and D are used to expose the heart for surgical procedures (A is the commonmost, D is the least frequent). Procedures carried out in extracorporeal circulation are usually performed through a standard median sterntomy. Left sided antero-lateral thoracotomy is suitable for establishing atrio-femoral bypass, treating diseases of the pericardium or for closed mitral commissurotomy. Parasternal mediastinotomy is used in minimally invasive cardiac surgery, and subcostal incisions provide good access to treat pericardial effusion or tamponade. Right sided postero-lateral thoracotomy is not suitable for cardiac surgery, it is used in thoracic surgery (e.g.: pulmonary procedures).
SUR - 6.5
Your patient has fever following mechanical heart valve surgrey. Suggested methods of investigation are necessary, except for:
A) echocardiography
B) blood cultures
C) antibiotic therapy
D) diagnostic pericardial fluid sampling
E) redo valve surgery in presence of vegetations
ANSWER
D) diagnostic pericardial fluid sampling
EXPLANATION
Multiple methods of examination are necessary in investigation of fever following heart valve implantation. CT, repeated blood tests etc. can be useful as well, but diagnostic pericadiocentesis is not reasonable in this scenario.
SUR - 6.6
Cardio-vascular mortality in Hungary:
A) is not significant
B) significant, but is comparable to current european trends
C) statistic data is not available
D) is second following mortality of malignancies
E) is on top of the mortality list
ANSWER
E) is on top of the mortality list
EXPLANATION
50-55% of overall mortality in Hungary is due to cardiovasular diseases. That puts Hungary in the 3rd worst position in Europe.
SUR - 6.8
Haemoptysis can be a sign of the following cardio-pulmonary disorders, except for:
A) mitral regurgitation
B) mitral stenosis
C) aortic stenosis
D) pulmonary embolism
ANSWER
C) aortic stenosis
EXPLANATION
Haemopysis is the classical symptom of pulmonary embolism. Pulmonary congestion seen both in mitral stenosis and regurgitation may present haemoptysis, but not in isolated aortic stenosis.
SUR - 6.9
What is the exact location of the coarctation of the aorta?
A) between the right subclavian and the right carotid arteries
B) between the right and the left carotid arteries
C) between the left carotid and the left subclavian arteries
D) between the left subclavian artery and the duct of Botallo
ANSWER
D) between the left subclavian artery and the duct of Botallo
EXPLANATION
The morphological stenosis in coarctation of the aorta is on the border of the aortic arch and the descending aorta, between the left subclavian artery and the duct of Botallo.
SUR - 6.10
Symptoms of pericardial tamponade, except for:
A) elevated central venous pressure
B) decreased cardiac output
C) low blood pressure
D) elevated left ventricular filling pressure
ANSWER
D) elevated left ventricular filling pressure
EXPLANATION
Pericardial tamponade is caused by fluid collection in the pericardial cavity. Compression of heart chambers in the localised pericardial space results in reduction of diastolic filling capacity.
SUR - 6.11
Which of the following devices is capable of supporting circulation and providing oxygenisation at the same time following cardiac surgery?
A) intra-aortic balloon pump (IABP)
B) single or biventricular circulatory assist device (VAD)
C) extracorporeal membrane oxygenisator (ECMO)
ANSWER
C) extracorporeal membrane oxygenisator (ECMO)
EXPLANATION
Intra aortic ballon pump improves coronary perfusion in diastole. Ventricular assist devices provide patients with the necessary cardiac output themselves. Oxygenisation is only provided by ECMO.
SUR - 6.12
The following congenital cardiac defects depend on ductal circulation, except for:
A) pulmonary atresia
B) hypoplastic left heart syndrome
C) interruption of the aortic arch
D) ventricular septal defect
ANSWER
D) ventricular septal defect
EXPLANATION
A patent ductus areriosus is mandatory in pulmonary atresia and hypoplastic left heart syndrome because it is the only connection between left and right sided circulation, as pulmonary and systemic circulations are provided by the same single ventricle. In patients with interrupted aortic arch lower body is perfused throught the patent ductus arteriosus by the right ventricle, so ductus closure results lower body ischaemia. In cases of ventricular septal defect ductus Botalli closure is preferable to aviod pulmonary congestion.
SUR - 6.13
Which procedure is palliative heart surgery?
A) aortic valve replacement
B) closure of ventricular septal defect
C) Blalock-Taussig shunt
D) coarctectomy
ANSWER
C) Blalock-Taussig shunt
EXPLANATION
Aortic valve replacement, closure of ventricular septal defects and coarctectomy provide anatomical restoration of the effected regions. Blalock-Taussig shunts improve pulmonary circulation (e.g. in tertalogy of Fallott) but do not eliminate the primary pathological disorder
SUR - 6.15
Surgical correction procedure of the transposition of the great arteries:
A) arterial switch
B) closure of atrial septal defects
C) coarctectomy
ANSWER
A) arterial switch
EXPLANATION
Arterial switch procedure provides anatomical restoration in transposition of the great arteries. The other two surgeries correct different abnormalities.
SUR - 6.16
Lifelong anticoagulation is necessary following the implantation of:
A) a stentless biological (tissue) heart valve
B) a mechanical heart valve
C) a homograft
D) a stented biological (tissue) heart valve
ANSWER
B) a mechanical heart valve
EXPLANATION
Patients following mechanical heart valve implantation surgery need to be put on lifelong anticoagulant therapy despite good left ventricular function and stabile sinus rythm. Patients who received bioprosthetic heart valves (tissue valves) need to take anticoagulants for three months only, if their left ventricular function is good and they maintain stabile sinus rythm. Anticogulants are not necessary following homograft implantation (in patients who would not require anticoagulation for other reasons).
SUR - 6.17
In which case is the implantation of a mechanical heart valve contraindicated?
A) poor left ventricular function
B) there is a contraindication for chronic anticoagulant therapy
C) chronic atrial fibrillation
ANSWER
B) there is a contraindication for chronic anticoagulant therapy
EXPLANATION
In cases where chronic anticoagulation is contraindicated implantation of a mechanical heart valve is not recommended (e.g.: hemophylia, gastric ulcer, colorectal polyposis, female patients who wish to get pregnant in the future).
SUR - 6.19
Emergency surgery is NOT indicated in acute myocardial infarction with the following mechanical complications:
A) left ventricular aneurysm
B) acut mitral regurgitation caused by papillary muscle rupture
C) rupture of the ventricular free wall
D) postinfarct ventricular septal defect
ANSWER
A) left ventricular aneurysm
EXPLANATION
Postinfarct papillary muscle rupture, verticular septal rupture, left ventricular free wall rupture all require emergency surgery. Left ventricular aneurysms are deformities which may be subjects for surgical correction, but not in an emergency setting.
SUR - 6.20
Coronary angiography is necessary prior to surgery, except for:
1) patients older than 60 years of age with degenerative aortic valve stenosis
2) patients with angina pectoris
3) patients with persisting ischaemic symptoms following myocardial infarction
4) patients with mitral stenosis younger than 40 years of age
A) the 1st, 2nd and 3rd answers are correct
B) the 1st and 3rd answers are correct
C) the 2nd and 4th answers are correct
D) only the 4th answer is correct
E) all of the answers are correct
ANSWER
D) only the 4th answer is correct
EXPLANATION
Coronary angiography is indicated before any cardiac surgical intervention in patients above 40 years of age. If the medical history of a patient contains data suggesting myocardial ischaemia under 40 years of age angiography is obviously necessary as well.
