1. Which is not true of cardiopulmonary resuscitation (CPR)?

A. Closed chest massage is as effective as open chest

massage.
B. The success rate for out-of-hospital resuscitation may
be as high as 30% to 60%.
C. The most common cause of sudden death is ischemic
heart disease.
D. Standard chest massage generally provides less than
15% of normal coronary and cerebral blood flow.
Answer: A

DISCUSSION: Closed chest massage is not as effective as

open-chest massage in normalizing blood pressure or
perfusion of vital organs, and closed chest massage does
generally deliver 5% to 15% of normal coronary and
cerebral blood flow. The success rate for out-of-hospital
resuscitation has been as high as 30% to 60% when
communities are prepared to institute CPR early after a
cardiac arrest. Ischemic heart disease is the most
common cause of sudden death.

2. Which maneuver generally is not performed early before

chest compression in basic life support outside the
hospital?
A. Call for help.
B. Obtain airway.
C. Electrical cardioversion.
D. Ventilation.
Answer: C

DISCUSSION: Basic life support does involve calling for

help, obtaining an airway, and beginning ventilation
before starting chest compression. Electrical
cardioversion requires special equipment and trained
personnel and thus is part of advanced cardiac life
support.

3. Which treatment would be least effective for asystole?

A. External pacemaker.
B. Intravenous epinephrine, 10 ml. of 1:10,000.
C. Intravenous calcium gluconate, 10 ml. of 10% solution.
D. Intravenous atropine, 0.5 mg.
Answer: C

DISCUSSION: Recommended treatment for asystole is

administration of atropine. If atropine is unsuccessful
epinephrine is given. Ultimately cardiac pacing is
necessary if atropine and epinephrine do not establish an
adequate heart rate. Calcium has no clear role in treating
asystole.
2. 4. The most important factor that influences the outcome
of penetrating cardiac injuries is:
A. Comminuted tear of a single chamber.
B. Multiple-chamber injuries.
C. Coronary artery injury.
D. Tangential injuries.
Answer: C

DISCUSSION: Multiple studies in the literature confirm

that injuries to the coronary arteries are the most
important factor in determining outcome after a
penetrating cardiac injury. Tangential injuries are the
least serious. Injury to a single chamber—even if
comminuted—or to multiple chambers is less likely to be
fatal than are injuries that involve a major coronary
artery.

5. The most useful incision in the operating room for

patients with penetrating cardiac injury is:
A. Left anterior thoracotomy.
B. Right anterior thoracotomy.
C. Bilateral anterior thoracotomy.
D. Median sternotomy.
E. Subxyphoid.
Answer: D

DISCUSSION: The subxyphoid incision is useful for

determining if there is blood in the pericardium and if
there is an intracardiac injury; however, exposure is
extremely limited, and definitive repair can rarely be
performed through the incision. Left (or right) anterior
thoracotomy is easily performed, especially in the
emergency room, and gives adequate exposure to certain
areas of the heart. However, each has significant
limitations in exposure. Either may be extended across
the thoracotomy into the other side of the chest, thus
producing a bilateral anterior thoracotomy. Exposure is
excellent through this incision, and most injuries can be
satisfactorily repaired through this approach. Most
cardiac operations today are performed through median
sternotomy incisions. If the patient is in the operating
room, this incision is easily performed and always
provides excellent exposure for all areas of the heart.

6. In patients who present with a penetrating chest injury,

injury to the heart is most likely when the following
physical sign(s) is/are present:
A. Hypotension.
B. Distended neck veins.
C. Decreased heart sound.
D. All of the above.
Answer: D

DISCUSSION: Hypotension, increased venous pressure

(distended neck veins), and decreased heart sounds make
up the classic Beck's triad associated with cardiac
tamponade. If these three findings are present in a person
who has a penetrating chest wound, intracardiac injury is
almost certain and operative intervention is mandatory.

7. 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: AC

DISCUSSION: The most commonly used methods for

coarctation repair are resection with anastomosis and
subclavian flap aortoplasty. Both have been shown to
provide adequate relief of the obstruction with acceptable
rates of restenosis. The choice of repair depends on the
patient's anatomy and the surgeon's experience. Patch
aortoplasty was used frequently in the past; however,
because of concern over restenosis and aneurysm
formation it is no longer commonly performed. Prosthetic
tube graft repair is avoided except in some complex
cases and some cases of recoarctation.
8. Which of the following constitutes a true vascular ring?
A. Pulmonary artery sling.
B. Double aortic arch.
C. Anomalous origin of right subclavian artery from the
descending aorta.
D. Cervical aortic arch.
Answer: B

DISCUSSION: Only the double aortic arch secondary to

persistence of the right and left fourth aortic arches forms
a true vascular ring. Pulmonary artery sling may cause
symptoms that are due to compression of the trachea,
and an anomalous right subclavian may cause dysphagia,
but these anomalies do not constitute complete rings.
Cervical aortic arch, which is thought to be secondary to
persistence of the third aortic arch, is not a complete ring
and usually is asymptomatic.

9. Which of the following may not 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: ABC

DISCUSSION: A systolic murmur that radiates posteriorly

is characteristic of coarctation of the aorta. Coarctation
produces obstruction to aortic flow, and thus the femoral
pulse has a diminished volume with delayed upstroke.
Hypertension in coarctation is multifactorial, but the most
important factors are diminished renal flow (single clip,
single kidney-Goldblatt model) and mechanical factors. If
the right subclavian artery is anomalous and arises distal
to the coarctation, blood pressure may be greater in the
left arm than in the right. Isolated coarctation does not
produce cyanosis.

10. In a premature infant with hyaline membrane disease

and inability to be weaned from mechanical ventilation,
which of the following would suggest hemodynamically
significant patent ductus arteriosus (PDA)?
A. Continuous murmur.
B. Hyperactive precordium with bounding peripheral
pulses.
C. Jaundice.
D. Diminished femoral pulses.
Answer: AB

DISCUSSION: PDA causes a left-to-right shunt that

produces left ventricular volume overload. Physical
findings include evidence of hyperdynamic circulation
with a prominent apical impulse and bounding peripheral
pulses. The classic murmur of PDA is a continuous or
mechanical murmur heard over the precordium and
radiating to the medial third of the clavicle. Diminished
femoral pulses are not seen with isolated PDA and would
suggest other anomalies. PDA may result in hepatomegaly
but does not cause jaundice.

11. 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: D

DISCUSSION: Echocardiography is the best method for

confirming the diagnosis of a PDA. Two-dimensional
echocardiography can demonstrate PDA and exclude
associated anomalies. Doppler echocardiography can
demonstrate the shunt, determine direction of shunting,
and provide an estimate of shunt magnitude. The chest
film is not particularly helpful and may be normal or show
cardiomegaly with pulmonary congestion. In general,
cardiac catheterization should be reserved for older
patients and those with suspected associated anomalies
or pulmonary hypertension.

12. Which of the following are potential complications of

untreated coarctation of the aorta except ?
A. Endocarditis.
B. Pulmonary vascular disease.
C. Cerebrovascular accident.
D. Congestive heart failure.
Answer: ACD

DISCUSSION: Coarctation of the aorta produces an

obstruction to blood flow and hypertension, turbulent
flow, and increased left ventricular afterload. There is an
increased incidence of coronary artery disease. Prior to
the introduction of effective techniques for relief of
coarctation, the most common causes of death were
endocarditis, aortic rupture, congestive heart failure, and
cerebrovascular accident. Pulmonary vascular disease
does not occur with isolated coarctation.

13. The atrial septal defect (ASD) most commonly

associated with partial anomalous pulmonary venous
return (PAPVR) is:
A. Secundum defect.
B. Sinus venosus defect.
C. Ostium primum defect.
D. Complete atrioventricular (AV) canal defect.
E. Coronary sinus defect.
Answer: B

DISCUSSION: Although partial anomalous return of the

pulmonary veins can occur with any of the ASDs listed, it
is particularly common with sinus venosus defects and is
considered by many to be part of this lesion. The most
common anomaly is drainage of the right superior
pulmonary vein to the lateral aspect of the superior vena
cava.

14. 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: B

DISCUSSION: The direction of an intracardiac shunt is

governed by the compliance of the downstream
chambers. For an atrial level shunt, the compliance of the
right and left ventricles and their ability to distend with
increased volume during diastolic filling dictates the
direction of the shunt flow. Since the right ventricle is
usually a more compliant—and therefore more
distensible—chamber than the left ventricle, flow across
an ASD occurs from left to right across the open tricuspid
valve during diastole. The size of an ASD does not
correspond to the degree of shunt as long as the defect is
large enough to be unrestrictive to flow. A large shunt can
occur through a relatively small defect if the ventricular
compliance is favorable.

15. The ASD most commonly associated with mitral

insufficiency is:
A. Secundum defect
B. Sinus venosus defect
C. Ostium primum defect.
D. Coronary sinus defect.
Answer: C

DISCUSSION: Ostium primum defects, or “partial” AV

canal defects, are commonly associated with a “cleft” of
the anterior leaflet of the mitral valve. Depending on the
deformity of the mitral valve, these defects can be
accompanied by variable degrees of mitral insufficiency.
This cleft of the mitral valve needs to be repaired at the
same time that the defect is closed. Although other types
of ASDs can be associated with mitral insufficiency, this
is not as common. When mitral stenosis exists with a
secundum ASD the condition is often referred to as
Lutembacher's syndrome.

16. An electrocardiogram (ECG) in a patient with a

systolic ejection murmur that shows an incomplete
bundle branch block in the precordial lead is most
consistent with:
A. A secundum ASD.
B. A sinus venosus ASD with PAPVR.
C. An ostium primum ASD.
D. A complete AV canal defect.
Answer: A

DISCUSSION: Many patients with secundum ASDs have an

incomplete bundle branch block on their ECG. This is in
contradistinction to patients with ostium primum defects,
who often have a left axis deviation. Although the ECG is
not pathognomonic of the defect, the findings are
sometimes helpful along with other clinical and diagnostic
information toward elucidating the nature of the defect.

17. ASDs can all be closed with a pericardial or prosthetic

patch. Which of the following ASDs can also be safely
closed primarily without the use of a patch?
A. Secundum ASD.
B. Sinus venosus ASD with PAPVR.
C. An ostium primum ASD.
D. A complete AV canal defect.
Answer: A

DISCUSSION: Secundum ASDs can frequently be closed

primarily, although the use of a prosthetic or pericardial
patch is indicated for large defects. The other types of
ASDs are more safely closed with a patch.

18. Obstruction to pulmonary venous return is associated

with which of the following anomalies except?
A. Partial anomalous pulmonary venous connection
(PAPVC) to the superior vena cava.
B. Infracardiac (Type III) total anomalous pulmonary
venous connection (TAPVC).
C. Pulmonary vein stenosis.
D. Cor triatriatum.
E. Supracardiac (Type I) TAPVC.
Answer: BCDE

DISCUSSION: Obstruction to pulmonary venous return is

the most important factor affecting circulatory function
when pulmonary venous anomalies exist. This obstruction
is most prevalent and severe in patients with infracardiac
TAPVC, but it also occurs in as many as 50% of patients
with supracardiac TAPVC and 20% of patients with
intracardiac TAPVC to the coronary sinus. Obstruction to
pulmonary venous return is also the primary
pathophysiologic effect of both pulmonary vein stenosis
and cor triatriatum. Obstruction, however, is rare with
partial anomalous pulmonary venous connection,
especially with the common form of PAPVC to the
superior vena cava.

19. Postoperative complications associated with repair of

TAPVC include:
A. Complete heart block.
B. Acute pulmonary hypertensive crisis.
C. Pleural effusions.
D. Pulmonary venous obstruction.
Answer: BD

DISCUSSION: In the early postoperative period after repair

of obstructed forms of TAPVC, acute episodes of
pulmonary hypertension may develop as a response to
stress. To minimize this potentially fatal complication,
infants are kept anesthetized with fentanyl and
pancuronium for at least 48 hours. Residual or recurrent
pulmonary venous obstruction occurs in only 5% to 10% of
patients after TAPVC repair, but if identified it requires
early reoperation. Reoperation is usually successful if the
obstruction is at the level of the anastomosis.
Unfortunately, in some cases, the obstruction is in the
pulmonary veins and surgical relief is less successful.
Although complete heart block and pleural effusions can
occur after any cardiac operation, they rarely occur after
TAPVC repair.

20. Which of the following statements about VSDs is/are

correct except?
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: ACD

DISCUSSION: Perimembranous VSDs occupy the area of

the membranous portion of the interventricular septum
adjacent to the anteroseptal commissure of the tricuspid
valve. Often a remnant of the membranous portion of the
interventricular septum (the membranous flap) is left
hanging on the posteroinferior rim of the defect. The
annulus of the tricuspid and aortic valves often form a
part of the rim of the defect, but in some patients they are
separated from the VSD by a thin rim of muscle tissue
that protects the conduction bundle. Muscular VSDs have
exclusively muscular rims on all four sides. VSDs in the
outlet septum that extend to the annuluses of the aortic
and pulmonary valves are called doubly committed or
juxta-arterial defects. Isolated VSDs occur at an
approximate rate of 2 per 1000 live births and represent
30% to 40% of all congenital heart malformations at birth.
The conduction bundle in patients with perimembranous
VSDs does run along the posteroinferior rim of the defect
on the left ventricular side. Sutures used for repair of a
perimembranous VSD should be placed well away from
this area to avoid the creation of surgically induced
complete heart block.

21. Which of the following statements about VSDs is/are

true except?
A. When coarctation of the aorta is associated with VSD,
it most commonly occurs in infants with large lesions who
have to undergo repair before age 3 months.
B. In some patients with VSD, aortic valve incompetence
develops over time and progresses.
C. In the United States doubly committed or juxta-arterial
VSDs are most commonly associated with aortic
insufficiency.
D. PDA is present in approximately one fourth of infants
with a VSD and concomitant congestive heart failure.
Answer: ABD

DISCUSSION: VSD in combination with severe coarctation

of the aorta occurs in approximately 17% of patients. This
combination is more common among infants with large
VSDs undergoing operation before age 3 months. Aortic
valve incompetence does develop over time in some
patients with VSD, presumably as a result of progressive
prolapse of the right aortic cusp through the defect. In the
United States two thirds of patients with VSD and aortic
insufficiency have perimembranous lesions and one third
have a doubly committed or juxta-arterial lesion. In Japan,
however, the reverse is true: two thirds have doubly
committed or juxta-arterial lesions and one third have
perimembranous lesions. A moderate- or large-sized PDA
is associated with VSD in approximately 6% of patients of
all ages; however, in infants with VSD and concomitant
congestive heart failure, PDA is present in approximately
25%.

22. Which of the following statements about VSD is/are

correct except?
A. A large VSD is approximately the size of the pulmonary
valve orifice or larger.
B. Large VSDs associated with high pulmonary blood flow
result in an enlarged left atrium on chest x-ray.
C. Patients with small (restrictive) VSDs tend to have
normal right ventricular and pulmonary arterial pressures
with normal pulmonary vascular resistance and no
evidence of pulmonary vascular disease.
D. A pulmonary vascular resistance greater than 10 to 12
units per sq. m. is considered a contraindication to
operation.
Answer: BCD

DISCUSSION: A large VSD is approximately the size of the

aortic valve orifice or larger and causes systemic right
ventricular systolic pressures. In the absence of right
ventricular outflow tract obstruction, the pulmonary
artery systolic pressure will also be systemic in the
presence of a large VSD. Large VSDs associated with a
high pulmonary blood flow do result in an enlarged left
atrium because of increased pulmonary venous return.
When marked enlargement of the left atrium is present in
a patient suspected of having a VSD, the presence of
coexisting mitral valve regurgitation should also be
considered. Patients with small VSDs do have normal
right ventricular and pulmonary arterial pressures. There
is only a slight elevation of pulmonary blood flow relative
to the systemic flow, and the pulmonary vascular
resistance is normal without evidence of pulmonary
vascular disease. At any age, the presence of pulmonary
vascular disease so severe that the pulmonary vascular
resistance is fixed and greater than 10 to 12 units per sq.
m. is considered a contraindication to operation.

23. Which of the following statements about VSDs is/are

correct except?
A. Spontaneous closure of VSDs occurs in 25% to 50% of
patients during childhood.
B. Tachypnea and failure to thrive are symptoms
frequently associated with large VSDs.
C. Patients with normal pulmonary vascular resistance
and left-to-right shunting across the VSD have
Eisenmenger's complex.
D. Patients with a large VSD and low pulmonary vascular
resistance can present with a middiastolic murmur at the
apex.
Answer: ABD

DISCUSSION: Spontaneous and complete closure of VSDs,

even large ones, has been estimated to occur in 25% to
50% of patients during childhood. The probability of
eventual spontaneous closure is inversely related to the
age at which the patient is observed. Tachypnea, poor
feeding, growth failure, recurrent respiratory infections,
exercise intolerance, and severe cardiac failure may
develop in patients with large VSDs. Patients with
Eisenmenger's complex are cyanotic, polycythemic, and
severely limited in their exercise tolerance, owing to
markedly elevated pulmonary vascular resistance
associated with a predominantly right-to-left shunt across
the VSD. A middiastolic murmur can be present at the
apex in patients with a large VSD associated with low
pulmonary vascular resistance. This indicates high
pulmonary blood flow with a large flow across the mitral
valve into the left ventricle.

24. Which of the following is/are true of the surgical

treatment of VSDs?
A. A right ventricular approach is employed for the repair
of most perimembranous VSDs.
B. Intracardiac repair is advisable for patients with
intractable symptoms and for asymptomatic infants with
evidence of increasing pulmonary vascular resistance.
C. Complete heart block is a common complication.
D. Hospital mortality after repair of VSD in infants
approaches 20%.
Answer: B

DISCUSSION: The right atrial approach is preferred for the

repair of most perimembranous VSDs. Prompt intracardiac
repair is indicated for infants with large defects, large
shunts, and pulmonary hypertension who present with
intractable left ventricular failure, recurrent pulmonary
infections, severe growth failure, or evidence of
increasing pulmonary vascular resistance. In the modern
era, complete heart block requiring a permanent
pacemaker is a very uncommon complication of surgical
closure of a ventricular septal defect. Hospital mortality
after closure of a VSD currently approaches zero. While in
earlier years younger age was an incremental risk factor
for hospital death in some surgical experiences, this risk
has been neutralized during the past decade.

25. 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: A

DISCUSSION: Although ASD is a frequent component of

tetralogy of Fallot, it was not included by Fallot as part of
his classic tetralogy. Occasionally, the inclusion of an
ASD prompts use of the term pentalogy of Fallot. The
other four anomalies listed were all mentioned by Fallot in
his original description of this defect.

26. 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: C

DISCUSSION: The VSD in tetralogy of Fallot is

nonrestrictive, and therefore its size does not affect the
degree of shunting that can occur. Likewise, an ASD,
which may or may not be a component of tetralogy of
Fallot, can provide right-to-left shunting at the atrial level
but is not the main contributor to the cyanosis of this
disease. The degree of right-to-left shunt across the VSD
is dictated by the variable compliance of the downstream
chambers, and the increased resistance imposed by
severe pulmonary stenosis creates greater amounts of
right-to-left shunting and, therefore, more intense
cyanosis. The position of the aorta in relation to the VSD
is not important as long as no subaortic obstruction
exists.

27. Which of the following anomalies is not associated

with tetralogy of Fallot?
A. Absence of the left pulmonary artery.
B. A right aortic arch.
C. A retroesophageal subclavian artery.
D. Anomalous origin of the left anterior descending
coronary artery from the right coronary artery.
E. Primary pulmonary hypertension.
Answer: E

DISCUSSION: The first four defects listed occasionally are

associated with tetralogy of Fallot. A right aortic arch is
seen in 25% of patients with that lesion. Anomalous
coronary arteries or a retroesophageal subclavian artery
are found in as many as 5% to 10% of patients. Absence
of a pulmonary artery is unusual but can present in as
many as 3% of patients. Pulmonary hypertension is
distinctly unusual with tetralogy of Fallot unless the
patient has had excessive pulmonary blood flow from
collaterals or systemic-to-pulmonary artery shunts for a
long time. It is because these patients usually do not have
pulmonary hypertension that infant correction with
transannular patches can be performed with such great
success.

28. 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: B

DISCUSSION: Patients with tetralogy of Fallot who do not

appear cyanotic still have mild arterial hypoxemia by
arterial blood gas determination. Patients with tetralogy
of Fallot rarely have excessive pulmonary blood flow, and
the development of pulmonary hypertension is not a
concern in this population. Banding of the pulmonary
artery is never a consideration in patients with tetralogy
of Fallot, since the predominant physiologic effect of the
defect results from too little pulmonary blood flow to
begin with. Acyanotic patients with tetralogy of Fallot
(“pink tets”) can usually be followed for several months
and their defects repaired electively as a first-stage
procedure (usually by age 6 months). All of the other
therapies are appropriate treatment for babies with
tetralogy of Fallot. Prostaglandins maintain patency of the
ductus arteriosus, providing an anatomic systemic-to-
pulmonary artery shunt that sustains pulmonary blood
flow until a more permanent surgical solution can be
provided. The advent of prostaglandin therapy has
enabled numerous critically ill infants to become
stabilized enough to reach a tertiary care institution and
receive proper surgical therapy who might not otherwise
have survived had it not been for the ability of pulmonary
blood flow to be maintained through the reversal of duct
closing. The choice of palliative shunting or total
anatomic correction rests largely with the experience and
skill of the surgical team and is dictated in part by the
anatomy of the pulmonary arteries. Either of these options
is acceptable.

29. The predominant determinant of outcome for patients

with pulmonary atresia and an intact ventricular septum
revolves around:
A. The size of the ASD.
B. The baby's age at presentation.
C. The size of the right ventricular cavity and tricuspid
valve.
D. The presence of a tricuspid—as opposed to a bicuspid—
pulmonary valve.
E. The level of hypoxemia at presentation.
Answer: C

DISCUSSION: The long-term outcome for babies with

pulmonary atresia and intact ventricular septum depends
on the ability to convert the cardiac circulation into a two-
ventricle versus one-ventricle physiology. Patients with a
good-sized right ventricle and tricuspid valve can often be
treated with pulmonary valvotomy or right ventricular
outflow patching alone and can have a fairly acceptable
outcome. Patients with a small right ventricle that cannot
provide adequate pumping to the pulmonary bed and is
often associated with a small tricuspid valve annulus may
need to be staged toward a Fontan procedure—and,
consequently, a less acceptable outcome. The size of an
ASD is not relevant except that in patients with this
syndrome, the right side of the heart will decompress
across the ASD until antegrade flow can be established.
Therefore, an ASD in some part is an essential feature of
this lesion. The degree of arterial hypoxemia, the nature
of the pulmonary valve, and the patient's age at
presentation may all be factors that relate to clinical
management, but they do not imply specific
consequences with respect to long-term outcome.

30. Which of the following statements about double-outlet

right ventricle are true?
A. A VSD is usually present.
B. In the Taussig-Bing type of double-outlet right ventricle,
the VSD is usually noncommitted.
C. Patients with double-outlet right ventricle and a
subaortic VSD usually have pulmonary stenosis.
D. Patients with double-outlet right ventricle with a
subpulmonary VSD (Taussig-Bing malformation) tend to
mimic patients with transposition of the great arteries
and VSD in their presentation and natural history.
Answer: ACD

DISCUSSION: A VSD is usually present in patients with

double-outlet right ventricle and is the only outlet from
the left ventricle. Both great arteries may arise totally
from the right ventricle, or one or both may overlie the
ventricular septum immediately above the VSD. To
categorize the heart as having a double-outlet right
ventricle, more than 50% of each great artery must arise
from the right ventricle. In the Taussig-Bing type of
double-outlet right ventricle, the VSD is related to the
pulmonary valve annulus and is termed a subpulmonary
defect. Additional morphologic characteristics peculiar to
this entity have been described. Most patients with
double-outlet right ventricle and a subaortic VSD have
concomitant pulmonary stenosis that protects the lungs
from pulmonary vascular disease and also results in a
clinical course similar to that of patients with tetralogy of
Fallot. In the absence of pulmonary stenosis the
presentation, clinical course, and natural history of the
Taussig-Bing malformation are similar to those of
transposition of the great arteries with VSD. Cyanosis is
present, usually from birth, since streaming directs the
desaturated systemic venous return toward the aorta and
the oxygenated left ventricular blood toward the
pulmonary artery. These patients tend to develop early
congestive heart failure and can develop severe
pulmonary vascular disease early in life. They usually
experience symptoms within the first few months of life.

31. Which of the following statements about the surgical

repair of double-outlet right ventricle are true?
A. In double-outlet right ventricle with a subaortic or
doubly committed VSD, a tunnel-type repair connecting a
committed VSD with its respective great artery is usually
employed.
B. Repair of the Taussig-Bing malformation can be
accomplished using an intraventricular tunnel technique
or by performing a straight patch closure of the VSD
combined with an arterial switch procedure.
C. The hospital mortality rate is highest when a subaortic
VSD is present.
D. Some hearts with double-outlet right ventricle and a
noncommitted VSD must be repaired using a modification
of the Fontan procedure.
Answer: ABD

DISCUSSION: When the VSD is subaortic or doubly

committed, the tunnel-type repair connects the left
ventricle via the VSD and tunnel to the aorta. The Taussig-
Bing malformation can be repaired using an
intraventricular tunnel technique described by
Kawashima. This repair can best be accomplished when
the great arteries are in a more or less side-by-side
relationship with the aorta to the right of the pulmonary
artery. The infundibular septum is generously resected
and the VSD is connected to the aorta by an
intraventricular tunnel that runs posterior to the
pulmonary artery. The most common approach for the
repair of the Taussig-Bing malformation involves patch
closure of the VSD to the pulmonary artery. This creates
transposition of the great arteries with an intact
interventricular septum. An arterial switch procedure then
establishes ventriculoarterial concordance. Of all the
types of double-outlet right ventricle the hospital
mortality is lowest when a subaortic or doubly committed
VSD is present. Double-outlet right ventricle is associated
with a noncommitted VSD in approximately 10% of
patients in surgical series. The repair of this subset of
patients is associated with a relatively high mortality, as
compared with the results obtained after repair of other
forms of double-outlet right ventricle. At times, because of
the remote location of the VSD and because of other
compelling anatomic features, complete repair cannot be
performed. In this case, a modification of the Fontan
procedure must be employed.

32. Management of a patient with tricuspid atresia within

the first month of life may include:
A. Creation of a systemic artery–to–pulmonary artery
shunt.
B. Observation.
C. Creation of a bidirectional superior cavopulmonary
anastomosis.
D. Pulmonary artery banding.
E. Fontan procedure.
Answer: ABD

DISCUSSION: Initial management of newborn infants with

tricuspid atresia is determined by the anatomic and
physiologic factors that affect the balance of pulmonary
and systemic blood flow. Infants with severely limited
pulmonary blood flow and arterial oxygen saturations of
less than 70% should be stabilized with PGE 1 to maintain
patency of the ductus arteriosus until a systemic-to-
pulmonary artery shunt can be performed. Patients with
unobstructed pulmonary blood flow may exhibit only mild
cyanosis but suffer from significant congestive heart
failure. Many of these patients are best managed by
pulmonary artery banding to decrease the volume
overload on the left ventricle and to prevent the early
development of irreversible pulmonary vascular disease.
Some patients with moderate restriction of pulmonary
blood flow may have balanced delivery of blood to the
systemic and the pulmonary circulation. These patients
can be carefully followed until such time as an imbalance
develops or they become candidates for a bidirectional
superior cavopulmonary (Glenn) anastomosis or a Fontan
procedure. The normally high pulmonary vascular
resistance present in the first month of life precludes the
performance of either the Glenn or the Fontan procedure
in the newborn.

33. Which of the following should contraindicate

performance of the Fontan procedure?
A. Patient age of 25 years.
B. Severe mitral insufficiency.
C. Left ventricular end-diastolic pressure of 18 mm. Hg.
D. Right pulmonary artery stenosis.
E. Pulmonary vascular resistance of 6 Woods units.
Answer: CE

DISCUSSION: Good ventricular function and low

pulmonary vascular resistance are essential requirements
for a successful Fontan procedure. The Fontan operation
should not be performed when ventricular ejection
fraction is less than 30% or ventricular end-diastolic
pressure is greater than 15 mm. Hg. Pulmonary vascular
resistance in excess of 4 Woods units should also be
considered an absolute contraindication for Fontan
correction. Age at the time of Fontan procedure does not
appear to be a major risk factor, except before age 2
years. Although patients who have survived into the third
or fourth decade are likely to have ventricular
dysfunction, a Fontan procedure can be performed
successfully in these older patients if ventricular function
and pulmonary vascular resistance meet the above
criteria. In patients with tricuspid atresia a competent
mitral valve is important for satisfactory cardiac output
after the Fontan procedure. The presence of severe mitral
insufficiency, however, should not necessarily
contraindicate the procedure. In these cases it is
recommended that the mitral valve be repaired or
replaced in combination with the creation of a
bidirectional superior cavopulmonary anastomosis. A
completion Fontan operation is performed later. Distorted
or stenosed pulmonary arteries are common sequelae of
systemic-to-pulmonary artery shunts and may result in
unsatisfactorily high pulmonary vascular resistance. In
most cases, these stenoses can be repaired at the time of
Fontan correction or with a bidirectional superior
cavopulmonary anastomosis.

34. Initial management of a newborn infant with

hypoplastic left heart syndrome should include:
A. Intravenous administration of PGE 1.
B. Supplemental oxygen.
C. Routine intubation and mechanical ventilation to
achieve a PCO 2 between 30 and 35 mm. Hg.
D. Cardiac catheterization and balloon atrial septostomy.
Answer: A
DISCUSSION: Postnatal stabilization of infants with
hypoplastic left heart syndrome requires patency of the
ductus arteriosus and balance of the systemic and the
pulmonary circulation. Because the ductus is the only
pathway from the right ventricle to the systemic
circulation, duct patency must be maintained with
intravenous PGE 1. To minimize the workload on the
single ventricle and ensure adequate delivery of oxygen to
the tissues, an equal delivery of blood to both the lungs
and the body is sought. The normal postnatal decrease in
pulmonary vascular resistance often results in
overperfusion of the pulmonary circulation and
underperfusion of the systemic circulation. Maneuvers
that further decrease pulmonary vascular resistance,
such as the addition of supplemental oxygen, lowering the
PCO 2 to less than 35 mm. Hg, or eliminating any
resistance at the atrial septum by balloon septostomy
only worsens the imbalance.

35. The performance of a bidirectional superior

cavopulmonary (Glenn) anastomosis as the second stage
in the reconstructive approach to hypoplastic left heart
syndrome:
A. Provides early relief of volume load on the single right
ventricle.
B. Increases peripheral oxygen saturations to greater
than 90%.
C. Permits concomitant repair of pulmonary artery or
aortic arch stenoses.
D. Improves mortality and morbidity of subsequent Fontan
procedure.
Answer: ACD

DISCUSSION: After the first-stage reconstructive

(Norwood) procedure, the circulation is inherently
inefficient because of the obligatory recirculation of a
portion of both saturated and desaturated blood. Closure
of the arterial shunt and creation of a bidirectional Glenn
anastomosis eliminates this inefficient recirculation and
significantly diminishes the volume load on the single
right ventricle. Distorted and stenosed central pulmonary
arteries or aortic arch obstructions should be repaired at
the same time the bidirectional Glenn procedure is
performed. In almost all series the mortality of the Fontan
procedure has decreased since the adoption of the three-
stage approach for hypoplastic left heart syndrome.
Because systemic and pulmonary venous blood continue
to mix in the right atrium after a bidirectional Glenn
procedure, cyanosis persists with peripheral oxygen
saturations between 75% and 85%.

36. Which of the following statements about truncus

arteriosus are true?
A. Most infants survive without operations until late
childhood.
B. Most infants present with cyanosis.
C. Most infants present with congestive heart failure.
D. Repair requires a conduit from right ventricle to
pulmonary arteries.
Answer: BCD

DISCUSSION: While an occasional child survives to age 3

or 4 years, without either palliative or totally corrective
surgical treatment few live past early infancy. The lesion
is one of excessive pulmonary blood flow because of the
origin of the pulmonary arteries from the truncus
arteriosus; physiologically, the pulmonary arteries arise
directly from the aorta. Although the aortic saturation can
never be 100% because of some element of bidirectional
shunting at the VSD, the physiologic manifestations are
congestive heart failure and excessive pulmonary blood
flow rather than cyanosis. The congestive heart failure
becomes severe as pulmonary vascular resistance drops.
If congestive heart failure later improves spontaneously,
it is because of the development of pulmonary vascular
disease. Complete repair always requires closure of the
VSD, detachment of the pulmonary arteries from the
common trunk, and re-establishment of an outflow tract
from the right ventricle to the pulmonary artery. This
conduit usually contains a valve and can be either a
homograft or a synthetic conduit containing a porcine
valve.
37. Truncus arteriosus is a diagnosis with anatomic
components including:
A. VSD.
B. Abnormal origin of pulmonary arteries.
C. Subaortic stenosis.
D. Single ventricular outflow valve.
Answer: ABD

DISCUSSION: By definition, a VSD is always present

immediately beneath the truncal valve. The pulmonary
arteries arise abnormally from the single trunk, which is
due to failed partitioning of the embryonic conus during
the first few weeks of fetal development. In the
classification of Collett and Edwards, Type I truncus
arteriosus has a single arterial trunk giving rise to an
aorta and a main pulmonary artery; in Type II the right
pulmonary arteries arise immediately adjacent to one
another from the dorsal wall of the truncus; in Type III the
right and left pulmonary arteries originate from either side
of the truncus; and in Type IV the proximal pulmonary
arteries are absent and pulmonary blood flow is by way of
major aortopulmonary atresia and is no longer considered
truncus arteriosus. Subaortic stenosis cannot occur in
this anomaly. The single ventricular outflow valve is the
truncal valve. It may contain from two to six cusps, but
most often there are three and, next most often, four.
38. 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: ABE

DISCUSSION: Because with transposition of the great

vessels the systemic and the pulmonary circulations exist
in parallel rather than in series, survival depends on
mixing between pulmonary and systemic circulations.
Initially infants with transposition and intact atrial septum
survive because of aortopulmonary flow through PDA,
which may be maintained with prostaglandin infusions.
Although increased pulmonary flow may cause
enlargement of the left atrium and stretching of the
foramen ovale resulting in atrial-level mixing of
oxygenated and nonoxygenated blood, inadequate mixing
at the atrial level will result in marginal tissue
oxygenation, which does not improve with oxygen
administration. Atrial balloon septotomy results in
improved admixture and oxygen delivery in these patients
and should be performed promptly if peripheral acidemia
and severe cyanosis are present. Relative dehydration
may decrease the degree of interatrial shunting and
volume infusion often improves hemodynamics in infants.
Decreased pulmonary vascular resistance may increase
pulmonary blood flow at the expense of systemic blood
flow and alter the loading conditions of the left ventricle,
which may complicate early arterial repair.

39. Factors that preclude the use of a single-stage arterial

switch reconstruction of dextrotransposition of the great
vessels include:
A. Age older than 6 weeks with a left ventricular pressure
of less than 50% of systemic pressure.
B. Dynamic left ventricular outflow tract obstruction.
C. Intramural coronary artery anatomy.
D. Valvar pulmonic stenosis.
E. Subpulmonary VSD.
Answer: AD

DISCUSSION: Single-stage arterial switch procedure for

reconstruction of transposition of the great vessels, with
or without associated VSD has become the standard of
treatment in the majority of cardiac centers.
Contraindications to arterial switch repair include fixed
types of left ventricular outflow tract obstruction,
including valvar pulmonic stenosis, which would render
the systemic semilunar valve stenotic or incompetent.
Anatomic abnormalities without stenosis, such as a
bicuspid valve, however, are suitable for surgical
correction. The location of VSD does not affect surgical
outcome, and most VSDs can be approached adequately
through the right atrium or the anterior great vessel. Most
dynamic forms of left ventricular outflow tract obstruction
are often relieved partially or completely by realignment
of the ventricular septum with the hemodynamic changes
following successful arterial switch repair. When,
however, the left ventricle has not been prepared to
sustain the pressure load of the systemic circulation by
the decrease in pulmonary vascular resistance that
occurs in the first few weeks of life and when the
ventricular pressure is less than 50% of the systemic
ventricular pressure, one-stage repair is contraindicated,
and staged repair with pulmonary banding and shunt
followed by arterial switch must be contemplated.

40. Complications commonly associated with the atrial

(Senning and Mustard) repairs of transposition of the
great arteries include:
A. Atrial arrhythmias.
B. Systemic or pulmonary venous obstruction.
C. Right ventricular outflow tract obstruction.
D. Systemic ventricular failure.
E. Progressive elevation of pulmonary vascular
resistance.
Answer: ABD

DISCUSSION: The atrial repair of transposition of the

great arteries—rerouting systemic and pulmonary venous
blood at the atrial level—results in the right ventricle's
becoming the systemic ventricle. This results in an
anatomic right ventricle with abnormal geometry
sustaining the afterload of a more ideally suited left
ventricle. Long-term complications of ventricular
dilatation, AV valve regurgitation, and right ventricular
failure have been reported in as many as 10% of patients
many years following the atrial operation. The multiple
suture lines in the atrium have been associated with a
high incidence of late atrial arrhythmias and a low
incidence of sinus rhythm following the Mustard and
Senning operations. These complications do not appear to
be as frequent with the arterial switch repair. In addition,
the complicated interatrial baffles have been associated
with pulmonary or systemic venous baffle obstruction.
Because the right ventricular outflow tract is not
addressed during an atrial switch operation, right
ventricular outflow tract obstruction is not a recognized
complication following the repair. Right ventricular
outflow tract and supravalvar pulmonic stenosis,
however, have been reported in patients after the arterial
switch repair, owing to the reconstruction of the right
ventricular outflow tract in that operation. Although
progression of pulmonary arterial obstruction has rarely
been reported following early repair with the atrial or the
arterial switch procedure, it is an unusual complication if
operation is undertaken in infancy. Delayed repair beyond
age 6 months to 1 year, however, has been associated
with a higher incidence of progressive development of
pulmonary vascular obstructive disease. The rapidity of
the development of pulmonary vascular disease is
increased by the coexistence of a VSD.

41. Critical aortic stenosis in the neonate is characterized

by which of the following?
A. It is most often due to commissural fusion of a trileaflet
valve.
B. It may be associated with coarctation of the aorta,
PDA, and mitral stenosis.
C. It can be managed medically until the child is large
enough to undergo aortic valve replacement.
D. Success of valvotomy is determined by the adequacy of
the left ventricle.
Answer: BD

DISCUSSION: Critical aortic stenosis in the neonate most

often presents in the first week of life with severe and
progressive congestive heart failure and may be
associated with coarctation of the aorta, PDA, and mitral
stenosis. The prognosis is poor unless valvotomy can be
performed expeditiously. Medical management cannot
stabilize these infants for valve replacement at a later
age. Infants whose left ventricle is too small to sustain
the systemic circulation are unlikely to survive aortic
valvotomy and, thus, should be managed as patients with
hypoplastic left heart syndrome. The aortic valve in
neonatal aortic stenosis is most commonly unicuspid or
bicuspid.

42. Surgical management of aortic valve disease in an

older child may include:
A. Enlargement of the aortic annulus.
B. Incision of fused commissures.
C. Insertion of a porcine valve prosthesis.
D. Transfer of the pulmonary valve to the aortic position.
Answer: ABD

DISCUSSION: The majority of older children with aortic

stenosis and significant transvalvular gradients can be
treated successfully by aortic valvotomy. This can be
done percutaneously with balloon dilatation or surgically
with direct visualization of the aortic valve and incision of
the fused commissures. Aortic valve replacement is rarely
necessary as a primary procedure but may be required in
children who develop progressive aortic insufficiency
after a previous intervention. When valve replacement is
performed it is desirable to insert the largest prosthesis
possible, to allow for growth. Enlargement of the aortic
annulus is commonly performed for this purpose. If a true
valve prosthesis is employed, a mechanical valve is
preferred. Durability of xenograft valves in children is
limited owing to early calcification and leaflet
degeneration. The pulmonary autograft technique may be
the best method of aortic valve replacement in children.
With this operation the patient's own pulmonary valve is
transferred to the aortic position and a pulmonary
allograft is inserted to replace the pulmonary valve.
Although the pulmonary autograft may not achieve the
long-term durability of a mechanical valve, the patient
does not face the long-term complications of
thromboembolism and bleeding imposed by a mechanical
valve and lifelong anticoagulation.

43. Which of the following statements about subvalvular

aortic stenosis are true?
A. Most patients present in early infancy with severe
congestive heart failure.
B. An ejection click is a specific physical sign of subaortic
stenosis.
C. The subaortic membrane is approached surgically via
the aorta and aortic valve.
D. A concomitant septal myectomy decreases the
incidence of recurrent subaortic stenosis.
Answer: CD

DISCUSSION: Subaortic stenosis is rarely encountered in

neonates. Most often it is discovered in an asymptomatic
child during a routine physical examination. A loud
crescendo–decrescendo systolic murmur without an
ejection click is usually noted. The presence of an
ejection click is more consistent with isolated valvular
aortic stenosis. Discrete subaortic stenosis is approached
surgically with cardiopulmonary bypass, aortic cross-
clamping, and cardioplegic arrest. The aorta is opened
and the aortic valve leaflets are retracted, exposing the
fibrous membrane. The fibrous ring is carefully excised,
taking care to avoid injury to the anterior leaflet of the
mitral valve and the penetrating conduction bundle. Once
the subaortic membrane is excised a septal myectomy
further opens the left ventricular outflow tract and
diminishes the likelihood of recurrent subaortic stenosis.

44. Management of hypertrophic obstructive

cardiomyopathy may include except:
A. Propranolol and verapamil.
B. Aortic valve replacement.
C. Dual-chamber sequential pacing.
D. Combined septal myectomy and mitral valve plication.
Answer: b
DISCUSSION: The majority of patients with hypertrophic
obstructive cardiomyopathy are treated medically with
beta-blockers such as propranolol and calcium channel
blockers such as verapamil. Patients whose symptoms do
not respond to medical therapy are treated surgically with
a transaortic septal myectomy. Recent reports indicate
that simple plication of the anterior leaflet of the mitral
valve performed in addition to the septal myectomy
further opens the left ventricular outflow tract by
eliminating systolic anterior motion of the mitral valve.
Aortic valve replacement is not an appropriate treatment
for hypertrophic obstructive cardiomyopathy. Some
patients who are poor surgical candidates may
experience relief of symptoms and left ventricular outflow
gradients with dual-chamber permanent pacing.
Appropriate pre-excitation of the ventricular septum can
prompt the septum to move away from the left ventricular
wall during systole and open the outflow tract.

45. Which of the following statements about supravalvular

aortic stenosis are true?
A. Surgical repair is indicated only when the systolic
gradient exceeds 75 mm. Hg.
B. Simple excision of the supravalvular membrane results
in satisfactory relief of the stenosis in most patients.
C. The diffuse form of supravalvular aortic stenosis may
cause obstruction to branches of the aortic arch.
D. Reoperation after repair of discrete supravalvular
aortic stenosis is rare unless abnormalities of the valve
itself also exist.
Answer: CD

DISCUSSION: Supravalvular aortic stenosis is a

progressive disease and should be repaired surgically if
symptoms are present or the systolic gradient exceeds 50
mm. Hg. In addition to excision of the supravalvular
membrane, a patch of dacron or pericardium must be
placed across the area of narrowing and down into at
least one of the sinuses of Valsalva. Reoperation is rare
after this procedure unless associated aortic valve
disease is also present. In the diffuse form of the disease
the thickening of the aortic wall commonly results in
significant luminal narrowing of the ascending aorta and
its major branches.

46. Each year the approximate number of Americans who

die from complications of coronary artery disease is:
A. 100,000.
B. 250,000.
C. 500,000.
D. 1,000,000.
E. Over 2,000,000.
Answer: C
DISCUSSION: It is estimated that approximately 7,000,000
Americans currently have symptomatic coronary artery
disease. Of these some 1,500,000 experience myocardial
infarction annually and approximately 500,000 die each
year from complications.

47. 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: C

DISCUSSION: In order of frequency, the anterior

descending coronary artery is the most commonly
involved with atherosclerosis, followed by the right
coronary, the circumflex, and the left main coronary
artery.

48. Which of the following statements about collaterals in

the normal coronary circulation is true?
A. There is a rich and quite effective collateral circulation
in the coronary arterial bed.
B. The coronary arterial bed has minimal effective
collaterals.
C. The coronary arterial bed is an absolute example of
anatomic end-arteries.
Answer: B

DISCUSSION: The collateral circulation to the heart is

relatively poor. In the human heart there are few natural
collaterals of sufficient diameter for delivery of a
significant quantity of blood. Most of the collaterals are
approximately 200 mm. or smaller, and channels of this
size cannot conduct significant quantities of blood for
cardiac requirements. There is no absolute example of
anatomic end-arteries in humans. While the magnitude of
arterial collateral circulation varies considerably, all
organs have some collaterals.

49. If blood entering the normal arterial circulation of the

heart is 100% saturated with oxygen, oxygen saturation of
blood in the coronary sinus can be expected to be
approximately:
A. 75%.
B. 60%.
C. 50%.
D. 35%.
E. Less than 20%.
Answer: D

DISCUSSION: The heart has an unusually high rate of

oxygen utilization and consumes approximately two thirds
of the oxygen in the arterial blood. The oxygen saturation
of the blood in the coronary sinus is usually about 30% to
35% and varies with the magnitude of cardiac disease.
The body as a whole extracts approximately 25% of the
oxygen it receives, thus emphasizing the great need of
the heart for oxygen at rest as well as at exercise.

50. 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: ABCD

DISCUSSION: In a variety of studies, coronary bypass

procedures have been demonstrated to reduce the
incidence of subsequent myocardial infarction as well as
to relieve significantly anginal symptoms. They also
improve the life span of most patients as well as the
ejection fraction of the left ventricle in those in whom it
was depressed preoperatively.
51. The 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: BD

DISCUSSION: CABG has been shown to prolong patient

survival compared with medical therapy in those patients
with left main occlusive disease and those with three-
vessel or two-vessel disease with proximal left anterior
descending involvement in association with class III or
greater anginal symptoms, impaired ejection fraction, or
easily inducible ischemia with exercise. Although
percutaneous transluminal coronary angioplasty (PTCA)
appears to be comparable to CABG in nondiabetic
patients, patients with diabetes appear to have a
significant survival advantage when CABG is used.
Similarly, patients with more extensive coronary artery
disease are better treated with CABG than with PTCA.

52. Sternal wound infections that spread to the

mediastinum are associated with a mortality rate of:
A. 60%.
B. 30%.
C. 25%.
D. Less than 15%.
Answer: D

DISCUSSION: Although the mortality rate following sternal

infections with mediastinitis formerly was high, it is now
greatly reduced. In most series, mediastinitis is cured in
more than 90% of patients who are treated aggressively
with débridement and placement of muscle flaps or
omentum into the mediastinum to speed wound healing.

53. Perioperative myocardial infarction occurs following

coronary bypass procedures in approximately:
A. 15%.
B. 10%.
C. 7%.
D. Less than 5%.
Answer: D

DISCUSSION: Following improvements in myocardial

protection and coronary grafting techniques,
perioperative myocardial infarction now occurs in less
that 2% to 4% of patients in most series.

54. Following acute myocardial infarction, ventricular

septal defects occur in:
A. 20%.
B. 10%.
C. 15%
D. 2% or less.
Answer: D

DISCUSSION: Postmortem studies indicate that 8% to

10% of fatal cases of myocardial infarction are due to
rupture of the heart. In addition, infarction of the
interventricular septum with subsequent formation of a
ventricular septal defect occurs in 1% to 2% of patients
with acute myocardial infarction. The usual interval
between the acute infarction and septal rupture—4 to 12
days—correlates with the histologic finding of maximal
cardiac muscle degeneration.

55. Which of the following clinical characteristics is/are

associated with a higher mortality after emergency CABG
for failed PTCA except?
A. Multivessel disease.
B. Rescue atherectomy.
C. Cardiogenic shock prior to CABG.
D. Previous bypass surgery..
Answer: ACD

56. Which statement(s) about operative mortality and

perioperative incidence of myocardial infarction for
elective CABG (X) versus emergency CABG following
failed PTCA (Y) is/are accurate?
A. The operative mortality is higher for Y but the
incidence of perioperative myocardial infarction is
unchanged between X and Y.
B. The operative mortality is unchanged between X and Y
but the perioperative incidence of myocardial infarction is
higher in Y.
C. The operative mortality and perioperative incidence is
higher in X than in Y.
D. The operative mortality and perioperative incidence of
myocardial infarction are no different for X and for Y.
Answer: C

57. Which of the following statements about patients

treated by placement of an internal mammary artery (IMA)
bypass graft at primary CABG is/are correct?
A. The risk for morbidity and mortality from reoperative
coronary bypass grafting is increased.
B. Left ventricular function is better preserved at the time
of reoperation.
C. The risk of sternal wound complications is greatly
increased if the contralateral IMA is harvested at the time
of reoperation.
D. A light clamp should be applied to the IMA pedicle to
limit cardiac warming during cardioplegic arrest at the
time of reoperation.
E. A functional study demonstrating a large portion of
myocardium at risk should be obtained before
reoperation.
Answer: BDE

DISCUSSION: Patients who have an intact IMA graft

should have severe anginal symptoms and a significant
portion of myocardium at risk before reoperative coronary
bypass grafting is considered. A functional study may
better define the proportion of myocardium at risk for
ischemia and infarction. Patients with an intact IMA graft
are less likely to require reoperation, but if stenosis distal
to the IMA and disease in other vein grafts have
progressed or if a large portion of myocardium is at risk,
reoperation is recommended. The presence of an intact
IMA is not a contraindication to reoperation; in fact, this
population of patients have better-preserved ventricular
function and are, perhaps, better candidates for
reoperation. Placement of an IMA graft at the time of the
first operation was critically important, neutralizing the
adverse effects of elevated serum cholesterol,
hypertension, and smoking on reoperation-free survival.
The risk of damaging an intact IMA graft is 3% to 5%. A
lateral projection of the IMA at cardiac catheterization
will define its course, particularly in relation to the
sternum, to allow more careful sternal re-entry. The IMA
should be minimally dissected and a light clamp applied
during cardioplegic arrest to limit cardiac warming and
improve myocardial protection. The IMA may be detached
and recycled if needed. The use during reoperation of the
contralateral IMA does not increase the risk of sternal
wound complications.

58. Considering the results of coronary reoperation in

comparison to primary CABG, choose the incorrect
statement:
A. Operative morbidity and mortality are increased over
those for primary CABG.
B. Mortality most often stems from cardiac causes after
reoperation.
C. Survival of patients after hospital discharge following
coronary reoperation is nearly equivalent to survival after
primary CABG.
D. Compared to primary CABG, return of anginal
symptoms is delayed after reoperative CABG.
E. Myocardial protection and the risk of myocardial
infarction in reoperation are complicated by increased
noncoronary collaterals, patent atherosclerotic
saphenous vein grafts, and more diffuse coronary
atherosclerosis.
Answer: D

DISCUSSION: The mortality and morbidity after

reoperative CABG are approximately two to three times
that of primary CABG. In contrast to primary CABG, where
the majority of deaths are a result of failure of other organ
systems, 75% to 85% of deaths after reoperative CABG
are due to cardiac causes. The increased risk of
reoperation results from more advanced native vessel
disease, a longer cross-clamp time, a longer cross-clamp
time per graft, a longer time to initiate cardiopulmonary
bypass, and increased blood loss. The increased
frequency of pulmonary complications, myocardial
infarction, neurologic injury, and death, stems from the
technical factors of reoperation and the characteristics of
the patient population. Technical factors include difficulty
in finding targets secondary to pericardial reaction and
more diffusely diseased vessels, the risks of injuring the
heart or great vessels on sternal re-entry, increased blood
loss and risk of requiring transfusion, less available
conduit for bypass, and greater difficulty in providing
optimal myocardial protection. Characteristics of this
patient population that increase risks include advanced
age and diminished ventricular function. While survival
after reoperation is nearly equivalent to that after primary
CABG, angina symptoms return at twice the frequency in
the first year after operation (47% versus 20%) then return
at a similar annual rate (2% to 3%).

59. Which statements are correct comparisons of gated

equilibrium and initial-transit radionuclide measurements
of left ventricular function?
A. Gated equilibrium techniques provide more accurate
measurements of ejection fraction than initial-transit
methods.
B. Left ventricular imaging time for a gated equilibrium
study is at least 10 times that of an initial-transit study.
C. Both techniques require the same
radiopharmaceuticals.
D. Both techniques require a bolus injection.
Answer: B

DISCUSSION: Both techniques are equally accurate for

measuring left ventricular ejection fraction. The left
ventricular imaging time for gated equilibrium studies is
at least 10 times that of initial-transit radionuclide
angiocardiography. Initial-transit techniques use data
from fewer than 10 heartbeats, whereas equilibrium
studies require more than 100 heartbeats to acquire data
with similar information density. The initial-transit study
can be performed with any radioactive substance, but the
gated equilibrium technique requires a
radiopharmaceutical that remains within the blood pool
for imaging. The initial-transit radionuclide study requires
a bolus injection, but an equilibrium study can be acquired
up to several hours after injection and must be acquired
while the tracer is at equilibrium.

60. The radionuclide variable that contains the greatest

amount of prognostic information in patients with
coronary artery disease is:
A. Exercise ejection fraction.
B. Change in regional wall motion from rest to exercise.
C. Maximal cardiac output during exercise.
D. Change in heart rate during exercise.
Answer: A

DISCUSSION: The exercise ejection fraction is the single

most important radionuclide variable relating to
subsequent cardiac death or myocardial infarction, and
this single variable contains 80% of the prognostic
information in the test.

61. Which of the following statements about left

ventricular aneurysm is/are correct?
A. Ventricular aneurysms are commonly associated with
systemic arterial embolization.
B. Absent collateral circulation in an area of myocardium
supplied by an acutely occluded artery favors aneurysm
formation.
C. Posterobasal aneurysms are more common than those
located in the anteroapical region.
D. Aneurysm repair can improve associated cardiac valve
dysfunction.
E. Persistent ST segment elevation after acute myocardial
infarction suggests aneurysm formation.
Answer: BDE

DISCUSSION: The mural thrombus frequently present on

the endocardial surface of an aneurysm is usually
adherent and rarely embolizes. Collateral circulation,
when present, often prevents transmural necrosis
following arterial occlusion. Since the left anterior
descending coronary artery is the vessel most commonly
occluded in patients with ventricular aneurysms, most of
the aneurysms are anteroapical. Improvements in
ventricular contour and reduction in ventricular volume
accompany aneurysm repair. Although persistent
elevation of ST segments following myocardial infarction
is very suggestive of aneurysm formation, the diagnosis
should be confirmed by more definitive tests.

62. Which of the following factors does/do not increase

early mortality associated with repair of left ventricular
aneurysm?
A. Class IV cardiac status.
B. Size of aneurysm.
C. Presence of left main coronary disease.
D. Emergent operation.
E. Location of aneurysm.
Answer: BE

DISCUSSION: Class IV cardiac status and emergent

operation both imply extensive myocardial damage and in
most reported series are associated with increased
operative mortality. Similarly, the presence of significant
stenosis of the left main coronary artery increases the
operative mortality of virtually all cardiac procedures. On
the other hand, neither the size of the aneurysm nor its
location affect early operative mortality, despite the fact
that posterior aneurysms are technically more difficult to
repair and are much less common.

63. The most effective medical therapy in ameliorating

the symptoms of Kawasaki's disease and preventing the
development of giant coronary artery aneurysms is
administration of:
A. Antibiotics.
B. Antiviral agents.
C. Aspirin.
D. Gamma globulin.
E. Glucocorticoids.
Answer: D
DISCUSSION: Kawasaki's disease is a multisystemic
disorder of unknown cause and is the leading cause of
acquired heart disease in children in both Japan and the
United States. Although many clinical aspects of
Kawasaki's disease suggest an infectious agent, the
search for a single agent has been unsuccessful; neither
antibacterials nor antivirals have a role in the therapy of
Kawasaki's disease. The goal of initial therapy of
Kawasaki's disease is the reduction of inflammation,
including coronary and myocardial inflammation. After the
diagnosis of Kawasaki's disease is secured, patients are
treated with intravenous gamma globulin and large doses
of aspirin. Gamma globulin, 2 gm. per kg., is administered
as a single infusion over 12 hours. Treatment with
intravenous immune globulin has been shown to decrease
the duration of fever, to decrease the prevalence of
cardiovascular complications, and to prevent the
progression to giant coronary aneurysms. High-dose
aspirin therapy contributes to the resolution of the acute
manifestations of Kawasaki's disease. When Kawasaki's
disease is diagnosed, children are given a regimen of
aspirin, 100 mg. per kg. per day, which is continued until
defervescence. Thereafter, they are maintained on small
doses of aspirin, 3 to 5 mg. per kg. per day, for 8 weeks.
The goal of aspirin therapy is amelioration of symptoms
and prevention of the thrombotic and embolic
complications of Kawasaki's disease. Aspirin does not
decrease the risk of the development of coronary
aneurysms. There is no role for glucocorticoids in the
treatment of Kawasaki's disease.

64. Indications for surgical intervention in Kawasaki's

disease include which of the following?
A. The presence of multiple coronary artery aneurysms.
B. Myocardial infarction and severe left ventricular
dysfunction.
C. The presence of a 5 mm. aneurysm in the right
coronary artery.
D. Progressive stenosis in the left anterior descending
coronary artery.
E. None of the above.
Answer: D

DISCUSSION: The indications for surgical treatment of

Kawasaki's disease include: (1) progressively stenotic
coronary lesions demonstrated on coronary arteriography,
with no distal coronary aneurysms with stenosis; (2)
localized aneurysm with significant stenosis in the left
main coronary artery; (3) significant stenosis in two
coronary arteries; (4) presence of collateral vessels
arising from a coronary artery with a proximal aneurysm;
(5) progressive stenosis in the left anterior descending
coronary artery; and (6) presence of a left ventricular
aneurysm. Advanced thrombosis of coronary aneurysms
causing critical stenoses in multiple coronary arteries is
the most common indication for surgical intervention.

65. Which of the following statements about the

pathophysiology of Ebstein's anomaly is/are true?
A. The tricuspid valve is usually insufficient.
B. Typically there is a left-to-right shunt across the ASD.
C. The redundant anterior leaflet of the tricuspid valve
may cause obstruction of the right ventricular outflow
tract.
D. Pulmonary hypertension is a common late
complication.
E. High pulmonary vascular resistance in neonates
exacerbates tricuspid regurgitation and cyanosis.
Answer: ACE

DISCUSSION: Ebstein's anomaly is characterized by

downward displacement of the tricuspid valve into the
right ventricular cavity. The anterior leaflet is large and
“sail-like,” while the other two leaflets are rudimentary.
Although the tricuspid valve occasionally may be stenotic,
it is usually regurgitant. The tricuspid regurgitation and
functional right ventricular outflow tract obstruction
caused by the large anterior leaflet lead to right-to-left
shunting across the ASD. Systemic venous hypertension
is often present, but pulmonary hypertension almost never
occurs with this malformation. Finally, neonates that
present with Ebstein's anomaly are markedly cyanotic,
owing to their high pulmonary vascular resistance. This
causes a functional pulmonary atresia, which increases
right-to-left shunting across the ASD.

66. In the surgical treatment of Ebstein's anomaly, which

of the following is/are true?
A. In neonates, the tricuspid valve orifice may be
oversewn and a systemic-pulmonary shunt created to
provide pulmonary blood flow.
B. Techniques in repair of the tricuspid valve do not utilize
plication of the atrialized right ventricle.
C. Closure of the ASD alone is adequate repair of the
malformation.
D. If tricuspid valve replacement is performed, the valve
should be sutured above the coronary sinus to avoid injury
to the conduction system.
E. Currently, mechanical prostheses are recommended for
tricuspid valve replacement because the durability of
bioprosthetic valves in the tricuspid position is so poor.
Answer: AD

DISCUSSION: In a recent report on the surgical treatment

of Ebstein's anomaly in neonates, Starnes described a
technique consisting of oversewing the tricuspid valve,
atrial septectomy, and placement of a systemic-
pulmonary shunt. These patients are then later staged to
a modified Fontan procedure when they outgrow their
shunts. Repair of the ASD alone was performed early in
the treatment of Ebstein's anomaly and was associated
with high mortality rates. It is not considered an adequate
repair. Most techniques in tricuspid valve repair for
Ebstein's malformation utilize plication of the atrialized
right ventricle in addition to excision of redundant atrial
tissue. If tricuspid valve replacement is necessary,
current approaches utilize bioprosthetic valves because
of their excellent durability in the tricuspid position.
Placement of the valve ring above the coronary sinus has
been associated with a lower rate of postoperative heart
block.

67. Which of the following congenital lesions of the

coronary circulation causes a cardiac murmur that is
similar to the murmur produced by a PDA?
A. Origin of the left coronary artery from the pulmonary
artery.
B. Origin of the right coronary artery from the pulmonary
artery.
C. Coronary artery fistula.
D. Membranous obstruction of the ostium of the left main
coronary artery.
Answer: C

DISCUSSION: The major clinical finding with a coronary

artery fistula is a continuous murmur over the site of the
abnormal communication. This murmur may closely
resemble that of PDA.

68. The congenital coronary lesion most likely to cause

death in infancy is:
A. Coronary artery fistula.
B. Origin of the left coronary artery from the pulmonary
artery.
C. Origin of the right coronary artery from the pulmonary
artery.
D. Congenital coronary aneurysm.
Answer: B

DISCUSSION: The prognosis for most patients with origin

of the left coronary artery from the pulmonary artery is
poor. It has been estimated that 95% of patients with this
anomaly die within the first year of life unless surgical
therapy is undertaken. Patients whose right coronary
artery originates from the pulmonary artery are usually
asymptomatic. Patients with coronary fistulas
occasionally suffer congestive heart failure early.
Congenital aneurysms of the coronary arteries are most
often asymptomatic until complications occur, usually
later in life.

69. The congenital coronary lesion associated with

minimal or absent clinical manifestations and nearly
normal life expectancy is:
A. Congenital origin of both coronary arteries from the
pulmonary artery.
B. Congenital coronary artery fistula.
C. Membranous obstruction of the ostium of the left main
coronary artery.
D. Congenital origin of the right coronary artery from the
pulmonary artery.
Answer: D

DISCUSSION: Clinical manifestations of congenital origin

of the right coronary artery from the pulmonary artery are
usually minimal or absent. This malformation is thought to
have been associated with death. The oldest reported
patient with this malformation died at age 90 years from
unrelated problems.

70. 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: ABC

DISCUSSION: With progressive narrowing of the aortic

valve area from the normal 3 to 4 sq. cm. to 1 sq. cm.,
patients become symptomatic. The classic symptoms
produced by aortic stenosis are syncope, congestive
heart failure, and angina. Once symptoms occur, life
expectancy is limited to 2 to 5 years. Therefore,
symptomatic aortic stenosis is an indication for aortic
valve replacement. The risk of death with asymptomatic
aortic stenosis is quite low, and aortic valve replacement
is not indicated for asymptomatic patients with a
transvalvar gradient less than 50 mm. Hg.

71. Under which of the following circumstances is

medical management logical?
A. Moderate aortic insufficiency seen on
echocardiography with normal left ventricular end-systolic
dimensions.
B. Moderate to severe aortic insufficiency seen on
echocardiography with cardiomegaly on chest
roentgenography.
C. Moderate aortic insufficiency seen on
echocardiography with symptoms of congestive heart
failure.
D. Moderate aortic insufficiency with an end-systolic left
ventricular dimension of 70 mm. as seen on
echocardiography.
Answer: A
DISCUSSION: The left ventricle is usually able to
compensate for a long time for the increased volume load
imposed by aortic insufficiency. The natural history of
asymptomatic aortic stenosis is excellent; 10-year
survival for moderate aortic insufficiency managed
medically is as high as 85% to 95%. Medical management
typically consists of diuretics and afterload reduction;
however, once the compensatory mechanisms begin to
fail, survival is limited. Half of patients with signs or
symptoms of congestive heart failure die within 2 years.
Therefore, evidence of left ventricular dilation by
echocardiography (left ventricular end-systolic dimension
greater than 55 mm., cardiomegaly on chest
roentgenography) or symptoms of congestive heart failure
are indications for aortic valve replacement.

72. 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: ABCD

DISCUSSION: Although each is only a relative indication

for operation for mitral stenosis, systemic embolization,
infective endocarditis, onset of atrial fibrillation, and
worsening pulmonary hypertension may each be an
indication for operation for mitral stenosis. Systemic
embolization, infective endocarditis, and onset of atrial
fibrillation are each complications of mitral stenosis that
portend a risk of further complication with continued
medical therapy. Patients older than 40 years with mild
class II congestive heart failure stand to gain
symptomatically from operation for significant mitral
stenosis and do not run excessive risk of multiple
reoperative procedures.

73. 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: CD

DISCUSSION: Relative to medical therapy alone, surgical

therapy has been shown to improve survival in patients
with severe, symptomatic mitral valve disease. In mitral
regurgitation, left ventricular dilatation is an indication for
surgical intervention regardless of failure symptoms. The
most common cause of tricuspid regurgitation is tricuspid
annular dilatation without abnormalities of the leaflets
themselves. Mitral valve replacement with preservation of
both leaflets or at least the posterior leaflet is well
described and is probably advisable for most patients to
preserve left ventricular function and reduce the
probability of ventricular-annular separation.

74. Which of the following generally are not symptoms of

tricuspid valve disease?
A. Pulmonary edema.
B. Hepatic failure.
C. Anasarca.
D. Hoarseness.
Answer: AD

DISCUSSION: Hepatic failure and anasarca are indeed

common symptoms of severe, long-standing tricuspid
valve disease with increased venous pressure. Pulmonary
edema is a consequence of left-sided heart disease and
does not result from a tricuspid lesion. Similarly,
hoarseness is most common after mitral valve disease
with left atrial enlargement and is rarely due to tricuspid
valve disease alone.
75. 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: A

DISCUSSION: Extensive mitral valve calcification is a

relative indication for mitral valve replacement. Mitral
regurgitation or significant annular dilatation may,
however, be amenable to mitral valve repair. Chordal
rupture of the anterior leaflet is generally reparable using
chordal transposition or polytetrafluoroethylene (PTFE)
chordae.

76. Which of the following are not true?

A. Tricuspid regurgitation due to annular dilatation alone
generally does not require valve replacement.
B. Mitral valve replacement with either a bioprosthesis or
a mechanical valve requires warfarin anticoagulation.
C. Tricuspid valve replacement is generally an indication
for using a tissue valve.
D. Chronic renal failure is a relative indication for tissue
valves.
Answer: B
DISCUSSION: Tricuspid regurgitation due to annular
dilatation alone generally can be treated with tricuspid
annuloplasty or with correction of associated mitral valve
disease. Mitral valve replacement with a mechanical
valve does require warfarin anticoagulation; however,
mitral valve replacement with a bioprosthesis may be
managed with aspirin alone. Tricuspid valve replacement
is an indication for using a tissue valve because of the
significant incidence of valve thrombosis when a
mechanical valve is in the tricuspid position. Chronic
renal failure is a relative indication for tissue valves
because valve calcification is rare and because
anticoagulation of patients on dialysis carries high risks
of morbidity and mortality.

77. 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: A

DISCUSSION: Age younger than 30 years is a relative

indication for mechanical valves because of an increased
incidence of calcification of tissue valves in younger
persons. A young female who desires children would be a
relative contraindication to mechanical replacement
because of the risk of teratogenesis and hemorrhage
during pregnancy secondary to warfarin therapy.
Advanced age is a relative indication for biologic valves to
avoid complications of anticoagulation and because the
probability of reoperation is low. Tricuspid valve
replacement is a relative contraindication to mechanical
valve replacement, owing to the increased incidence of
tricuspid valve thrombosis with a mechanical prosthesis.

78. 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: ABCD

DISCUSSION: Bioprosthetic valves have a relatively low

incidence of hemolysis. Bioprosthetic and mechanical
valves do not differ significantly in the associated
incidences of postoperative prosthetic valve endocarditis.
Bioprosthetic valves develop structural failure after an
average of 7 to 10 years, whereas mechanical valves have
a life span of well beyond 10 years. The mortality
attributable to warfarin therapy approaches 1% per
patient-year.

79. 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: c

DISCUSSION: Pure mitral stenosis without regurgitation

may be associated with pulmonary hypertension,
pulmonary edema, and an opening snap after the second
heart sound. Left ventricular dilatation would be rare in
pure mitral stenosis and generally occurs with volume or
pressure overload of the left ventricle, as with mitral
regurgitation.

80. The most common location of accessory pathways in

patients with the Wolff-Parkinson-White syndrome is the:
A. Left free wall.
B. Right free wall.
C. Posterior septum.
D. Anterior septum.
Answer: A

DISCUSSION: All major published series of the Wolff-

Parkinson-White syndrome indicate that the majority of all
accessory pathways appear in the left free wall space. In
one series, approximately 60% of all accessory pathways
occur in the left free wall space. In Ebstein's anomaly,
pathways are usually located in the posterior septum
and/or right free wall spaces. If these patients are
excluded, approximately 70% of pathways occur in the
left free wall space.

81. The anatomic electrophysiologic basis of AV node re-

entry tachycardia is dual AV node conduction pathways.
AV node re-entry tachycardia is most likely to occur with
which of the following electrophysiologic aberrations?
A. Proximal antegrade block in the slow conduction
pathway.
B. Proximal retrograde block in the slow conduction
pathway.
C. Proximal antegrade block in the fast conduction
pathway.
D. Proximal retrograde block in the fast conduction
pathway.
Answer: C
DISCUSSION: A retrograde conduction block in either the
slow or fast pathway would be likely to prevent a re-
entrant circuit from developing. A proximal antegrade
block in the slow conduction pathway is extremely
unusual because of the short refractory period of the slow
conduction pathway. The most common conduction block
that occurs in patients with dual AV node physiology is a
proximal antegrade conduction block in the fast pathway
because of its longer refractory period. This antegrade
block in the fast conduction pathway allows AV
conduction to occur via the slow pathway and to return in
retrograde fashion up the fast pathway to establish the re-
entrant circuit responsible for AV node re-entry
tachycardia.

82. Match the four surgical procedures that have been

developed for the treatment of atrial fibrillation with the
major detrimental sequela(e) of atrial fibrillation that each
corrects.
A. His bundle ablation.
B. Left atrial isolation procedure.
C. Corridor procedure.
D. Maze procedure.
1. Patient's sensation of irregular heart rhythm.
2. Hemodynamic compromise because of loss of AV
synchrony.
3. Increased vulnerability to thromboembolism.
Answer: A-1. B-1,2. C-1. D1,2,3

DISCUSSION: The surgical procedure most commonly

employed for the treatment of atrial fibrillation is catheter
ablation of the His bundle. The International Catheter
Ablation Registry reveals that more than 60% of patients
who undergo elective catheter ablation of the bundle of
His do so for the treatment of atrial fibrillation. His bundle
ablation is an isolation procedure, in that it confines the
atrial fibrillation to the atria and protects the ventricles
from the unpleasant sensation of an irregular heartbeat.
Because the atria continue to fibrillate there is no
restoration of AV synchrony, and therefore there is no
improvement in cardiac hemodynamics. Moreover, the
continuing fibrillation of the left atrium means that
postoperatively the patient is still at the same risk for
thromboembolism. Thus, His bundle ablation corrects only
one of the three detrimental sequelae of atrial fibrillation,
namely the arrhythmia problem.
The left atrial isolation procedure confines atrial
fibrillation to the left atrium, allowing the sinus node to
drive the remainder of the heart in a normal sinus rhythm.
Thus, it alleviates the unpleasant sensation of an irregular
heartbeat. In addition, because AV synchrony is re-
established between the right atrium and right ventricle,
right-sided cardiac output is restored to normal. This
means that normal cardiac output is delivered through the
lungs to the left side of the heart. In the presence of a
normal left ventricle the left-sided cardiac output is also
normal, despite the fact that left-sided AV synchrony is
not present; however, because the left atrium is allowed
to fibrillate, the vulnerability to thromboembolism remains
unchanged postoperatively.
The corridor procedure allows the sinus node to drive the
heart in normal sinus rhythm, but because of the total
isolation of the sinoatrial and AV nodes from the
remainder of the atria, the atria may continue to fibrillate.
Even if they do not, in effect they are isolated from their
respective ventricles so that AV synchrony is lost on both
sides of the heart. As a result, the corridor procedure
alleviates the sensation of arrhythmia but does not
restore normal hemodynamics, nor does it decrease
vulnerability to thromboembolism. The maze procedure
ablates the re-entrant circuits responsible for atrial
fibrillation and restores the normal sinus rhythm. Thus, it
alleviates the sensation of arrhythmia, restores normal
hemodynamics, and alleviates the vulnerability to
thromboembolism.

83. All of the following statements about nonischemic

ventricular tachyarrhythmias are true except:
A. They usually occur in the right ventricle.
B. They are usually associated with a left bundle branch
block pattern during the tachycardia.
C. They are usually more refractory to medical therapy
than ischemic ventricular tachyarrhythmias.
D. They usually occur as a result of automaticity rather
than re-entry.
Answer: D

DISCUSSION: Nonischemic ventricular tachyarrhythmias

usually occur in the right ventricle, and as a result the
ECG shows a left bundle branch block–type pattern during
ventricular tachycardia. These arrhythmias are
notoriously refractory to medical therapy and they occur
almost exclusively on a re-entrant basis.

84. Which of the following statements about left atrial

myxoma are true?
A. This lesion, by site and histology, is the most common
primary cardiac tumor.
B. It is best diagnosed by cardiac catheterization and
angiography.
C. The symptom complex can mimic collagen vascular
disease.
D. It has an intracavitary growth pattern.
E. It has a multicentric origin in the chamber wall.
Answer: ACD

DISCUSSION: Eighty per cent of primary cardiac tumors

are benign, and half of these benign tumors are myxomas.
Seventy-five per cent of myxomas arise in the left atrium
in the region of the fossa ovalis. Echocardiography is the
technique of choice in the evaluation of intracardiac
tumors, and findings suggestive of myxoma occur in 95%
of patients examined. Invasive procedures, with the
attendant risk of tumor embolization, are not warranted.
Owing to an autoimmune phenomenon, left atrial
myxomas can present with systemic constitutional
symptoms of fever, malaise, weight loss, polymyositis,
and blood dyscrasias that mimic collagen vascular
disease. Of surgical significance is the fact that most
myxomas rarely extend deeper than the endocardium but
grow as polypoid, intracavitary masses. Attachment by a
vascular stalk thus allows tumor mobility, predisposing to
embolization and interference with mitral valve
competence and causing characteristic
echocardiographic findings.

85. Which of the following statements about malignant

cardiac tumors are true?
A. Sarcomas are the most frequent primary malignancy.
B. Metastatic tumors are usually asymptomatic.
C. Adjuvant chemotherapy and irradiation are efficacious
in prolonging survival.
D. Intra-atrial extension of renal neoplasms is a
contraindication for surgical resection.
E. Constrictive physiology is an indication for operation.
Answer: AB
DISCUSSION: Twenty per cent of primary cardiac tumors
are some variant of sarcoma. Precise histologic
classification is not imperative, as all have a similar
clinical picture with rapid systemic dissemination and
aggressive local invasion. In contrast, metastatic tumors
cause symptoms in only 10% of patients. Unfortunately,
most primary and secondary cardiac malignancies
infrequently respond to systemic chemotherapy or
mediastinal irradiation. Surgical treatment is most
successful with renal tumors extending into the right
atrium. Significant 5-year survival can be achieved with
concomitant nephrectomy and intra-atrial resection of the
tumor thrombus. Relief of tamponade is worthwhile;
however, extensive decortication provides little help.

86. Disadvantages of temporary pacing through skin

electrodes applied to the anterior chest wall include all of
the following except:
A. Skin burns.
B. Painful chest wall muscle contractions.
C. Ventricular fibrillation.
D. Inability to pace.
Answer: C

DISCUSSION: In 1952 Zoll first described successful

pacing through external metal electrodes applied to the
anterior chest wall. Clinical experience with this
technique has shown that it is both feasible and lifesaving
for temporary pacing; however, disadvantages of the
external pacing technique include skin burns when too
little electrode jelly is applied, painful chest wall muscle
contractions, and inability to pace in thick-chested or
emphysematous patients. Ventricular fibrillation induced
by external temporary cardiac pacing is exceedingly rare.

87. In adults the most common cause of acquired

complete heart block is:
A. Ischemic heart disease.
B. Sclerodegenerative disease.
C. Traumatic injury.
D. Cardiomegaly.
Answer: B

DISCUSSION: Before permanent pacemakers were

available, 50% of patients with complete heart block died
within 1 year. The most common cause of acquired
complete heart block in adults is sclerodegenerative
disease of the cardiac skeleton and AV conduction
system. Other less common causes of complete heart
block include ischemic heart disease, cardiomyopathic
processes, Chagas' disease, and traumatic injury.
88. The most common indication for permanent pacing is:
A. Complete heart block.
B. Second-degree AV block.
C. Chronic bifascicular block.
D. Sick sinus syndrome.
Answer: D

DISCUSSION: Patients with sinus node dysfunction may

develop a number of arrhythmias, such as inappropriate
sinus bradycardia, chronotropic incompetence, sinoatrial
exit block, and sinus arrest. This group of rhythm
disorders typically occurs in older patients with or
without underlying heart disease and is collectively
known as the “sick sinus syndrome.” In addition, many
patients with sick sinus syndrome have associated atrial
tachyarrhythmias, particularly atrial fibrillation. This
association of atrial tachyarrhythmias in patients with the
sick sinus syndrome is called the tachycardia-bradycardia
(or tachy-brady) syndrome. The most common indication
for permanent pacing occurs in patients with the sick
sinus syndrome.

89. Decreasing pacemaker electrode tip size results in:

A. Lower pacing thresholds.
B. Improved electrogram sensing.
C. Decreased battery life.
D. Less patient discomfort.
Answer: A

DISCUSSION: Decreasing pacemaker electrode tip size

results in lower pacing thresholds, both at the time of
implant and subsequently, because of higher current
density. However, better sensing function is directly
related to electrode area and is adversely affected by
small electrode size. Therefore, a compromise between
pacing and sensing efficiency is required. Typical
electrode surface areas for pacing are between 8 and 10
sq. mm.

90. At the time of ventricular pacemaker implantation,

lead resistance is determined at a voltage near that of the
pacemaker's output. The calculated resistance at 5 volts
should range from:
A. 10 to 100 ohms.
B. 125 to 250 ohms.
C. 300 to 800 ohms.
D. 1000 to 1500 ohms.
Answer: C

DISCUSSION: At the time of pacemaker implantation, in

addition to measuring pulse amplitude (voltage and
current) and pulse width, resistance is also determined.
As described by Ohm's law, resistance is calculated by
dividing voltage by current. Resistance calculations are
made at a voltage near that of the pacemaker's output.
The calculated resistance at 5 volts should range from
300 to 800 ohms. An unsatisfactorily low resistance is
unsatisfactory because current is wasted and battery life
is shortened. Conversely, excessively high resistance
(more than 800 ohms) increases battery life but decreases
the current delivered to the heart for pacing.

91. A ventricular inhibited-demand pacemaker using the

Intersociety Commission for Heart Disease Resources
(ICHD) code is designated as:
A. DVI.
B. VVI.
C. VOO.
D. VDD.
Answer: B

DISCUSSION: A ventricular inhibited-demand pacemaker

using the ICHD code is designated as VVI. As the ICHD
code states, the pacemaker senses intrinsic ventricular
activity and is inhibited when this activity exceeds the
standby or escape rate of the pacemaker. When the
intrinsic ventricular rate falls below the escape rate of the
pulse generator, the pacemaker begins to function at its
programmed rate.
92. In rate-modulated pacing, the pacing rate is
determined by a physiologic parameter other than atrial
rate and is measured by a special sensor in the
pacemaker or pacing lead. The most commonly used
physiologic parameter in rate-modulated pacemakers is:
A. QT interval.
B. Venous blood temperature.
C. Mixed venous oxygen saturation.
D. Body motion.
Answer: D

DISCUSSION: During exertion, the required increase in

cardiac output is obtained mostly by the increase in
paced heart rate, although increased venous filling and
maintenance of AV synchrony are also important
contributors. The most commonly used physiologic
parameters in rate-modulated pacemakers at the present
time are body motion and minute ventilation. Other
parameters that are less commonly used or under
evaluation include QT interval, venous blood temperature,
mixed venous oxygen saturation, contractility, stroke
volume, venous pH, and the paced depolarization
gradient.

93. The most common pacing mode used in patients with

symptomatic bradycardia and an underlying sinus rhythm
is:
A. AAI.
B. DVI.
C. DDD.
D. VVI.
Answer: C

DISCUSSION: “Universal,” or DDD, pacing has been shown

to have many benefits over other pacing modalities,
including the ability to track the intrinsic sinus rate, pace
the atrium and ventricle, maintain atrioventricular
synchrony, and avoid the pacemaker syndrome.
Recognition of these benefits has steadily increased the
use of DDD pacemakers in the last decade, and at the
present time DDD is the most common pacing mode.

94. A transvenous pacemaker generator pocket should be

placed on the patient's nondominant side over the:
A. Anteromedial chest wall.
B. Anterolateral chest wall.
C. Inferomedial chest wall.
D. Inferolateral chest wall.
Answer: A

DISCUSSION: Bipolar impulse generators can be placed

either in the subcutaneous tissue or beneath the muscle.
Migration of the impulse generator most commonly occurs
in infraclavicular pacemakers pockets. Migration tends to
follow the curvature of the chest wall, and the impulse
generator tends to migrate laterally. This can be
prevented by creating an anteromedial pocket large
enough to contain the impulse generator and lead. In
susceptible persons the impulse generator can be further
secured to the chest wall to prevent migration.

95. Pacemaker-mediated tachycardia is caused by:

A. Pacemaker induction of atrial fibrillation.
B. Sensing of retrograde atrial activation.
C. Inappropriate ventricular sensing.
D. Lead fracture.
Answer: B

DISCUSSION: Pacemaker-mediated tachycardia occurs in

the setting of intact ventriculoatrial conduction. Typically,
premature ventricular contractions may be conducted
retrogradely through the AV conduction system and cause
retrograde activation of the atrium. If this retrograde
atrial activation occurs after completion of the
programmed pacemaker ventriculoatrial refractory period,
the atrial event is sensed by the DDD pacemaker and
evokes a paced ventricular event that may cause further
VA conduction. If each ventricularly paced event results
in atrial activation sensed by the pacemaker, pacemaker-
mediated tachycardia will be generated.
96. Which cardiovascular pharmacologic agents are safe
to use during routine abdominal surgery in a 75-year-old
woman with documented hypertension and mild coronary
artery disease?
A. Nifedipine.
B. Atenolol.
C. Hydralazine.
D. Captopril.
E. Reserpine.
Answer: ABD

DISCUSSION: Nifedipine is tolerated fairly well by elderly

patients and is safe to use in the perioperative period with
close hemodynamic monitoring. Atenolol is a safe beta-
blocker to use during the perioperative period and
provides protection from cardiac rhythm disturbances and
rebound hypertension. Hydralazine, if given without a
beta-blocker, often elicits reflex tachycardia, which limits
its usefulness. Captopril is a safe agent that does not
appear to interfere with the normal cardiovascular
response to anesthesia, and abrupt withdrawal of this
agent may result in severe hypertension and should be
avoided. Reserpine is an adrenergic inhibitor that may
depress cardiac output and result in hypotension, so its
use in the perioperative setting is limited.
97. Which inotropic drugs are safe for use in elderly
patients with mild congestive heart failure in the
postoperative period?
A. Digitalis compounds.
B. Dopamine.
C. Amrinone.
D. Melrinone.
E. Dobutamine.
Answer: BCDE

DISCUSSION: Dopamine and dobutamine stimulate

cardiac beta-receptors and are very useful in providing
inotropic support for patients in the postoperative period.
Melrinone and amrinone are phosphodiesterase inhibitors
that have strong inotropic effects while causing arterial
and venous dilation. Melrinone and amrinone are useful in
patients with low cardiac output, especially in the setting
of congestive heart failure. Digitalis compounds can be
troublesome in the postoperative period owing to the
toxic effects of these agents. Furthermore, perioperative
hypoxia and hypokalemia increase myocardial
susceptibility to digitalis-induced ventricular arrhythmias.

98. Which anticoagulation treatment plan(s) is/are

appropriate for a 72-year-old man with a mechanical heart
valve in place who takes Coumadin (warfarin) and now
requires elective left colon resection?
A. Discontinuation of Coumadin therapy on the day of the
operation.
B. Discontinuation of Coumadin therapy on the day of the
operation with replacement of clotting factors with fresh
frozen plasma (FFP) before the start of the surgical
procedure.
C. Discontinuation of Coumadin therapy 5 days before
operation with no further anticoagulation therapy before
surgery.
D. Discontinuation of Coumadin therapy 5 days before
operation with the institution of intravenous heparin as
the prothrombin time normalizes.
E. Discontinuation of Coumadin therapy 2 days before
operation followed by large doses of aspirin.
Answer: D

DISCUSSION: Many patients who require anticoagulation

with Coumadin for underlying cardiac disease need to
undergo routine general surgical procedures. The current
recommendations for patients who have been on long-
term Coumadin therapy is to discontinue Coumadin 5 days
before an operative procedure. As the patient's
prothrombin time normalizes intravenous heparin should
be started. The patient should be maintained on a
therapeutic dose of heparin with an activated partial
thromboplastin time (aPTT) of at least 60 seconds.
Heparin should then be withheld approximately 4 to 6
hours before the surgical procedure. The operation is then
performed in a “heparin window,” where the level of
anticoagulation can easily be titrated or totally reversed
with protamine if necessary.

99. Which of the following treatment plans is appropriate

for a 68-year-old patient with moderate to severe
congestive heart failure following a major abdominal
surgical procedure?
A. Aggressive use of inotropic support with epinephrine.
B. Aggressive diuresis with furosemide and inotropic
support with dopamine.
C. Afterload reduction with nitroprusside and inotropic
support with dopamine.
D. Close perioperative monitoring and inotropic support
with melrinone.
E. Intravenous digitalis with diuresis using furosemide as
needed.
Answer: CD

DISCUSSION: Treatment of congestive heart failure using

epinephrine alone is contraindicated owing to the
profound vasoconstrictive properties of epinephrine,
which only exacerbate the heart failure. Diuresis with
furosemide and inotropic support with dopamine is
acceptable for patients with mild congestive heart failure;
however, in the postoperative period pharmacologic
diuresis can lead to profound hypovolemia requiring
continuous invasive hemodynamic monitoring. The ideal
choice for the postoperative management of patients with
severe congestive heart failure is afterload reduction
using nitroprusside and inotropic support with dopamine.
This helps to stimulate the failing heart while decreasing
the afterload pressure against which the heart must
pump. Melrinone is a useful phosphodiesterase inhibitor,
which has been shown to be useful in the treatment of
mild to moderate congestive heart failure. Digitalis along
with a diuretic in the postoperative period can be
troublesome owing to the potential toxicity of digitalis
while the patient has ongoing fluid and electrolyte shifts.

100. Which of the following steps is/are appropriate for a

65-year-old woman who develops atrial fibrillation with
associated mild hypotension and rapid ventricular
response following partial gastric resection?
A. Correction of electrolytes and blood chemistries.
B. Evaluation for possible myocardial infarction.
C. Treatment with intravenous lidocaine.
D. Attempt to limit the ventricular response with digitalis.
E. Immediate cardioversion.
Answer: ABD

DISCUSSION: When a patient develops postoperative

atrial fibrillation following an extracardiac procedure,
correction of the patient's blood chemistries and
electrolytes is essential. The patient must also undergo
evaluation for a possible myocardial infarction as the
cause of the atrial dysrhythmia. The first rule in treatment
is to slow the ventricular response and attempt to limit
hemodynamic instability. Digitalis is effective in slowing
down the ventricular response and thus improving the
hemodynamic status of the patient. Lidocaine has little
use in controlling atrial dysrhythmias but is very effective
in decreasing ventricular ectopy. Immediate cardioversion
is rarely indicated for new-onset atrial fibrillation. Only
after correction of all underlying metabolic and
electrolyte defects as well as an attempt at medical
conversion and ventricular rate control is cardioversion
recommended.

101. 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: E

DISCUSSION: Cardiopulmonary bypass stimulates a

whole-body inflammatory response, and the
concentrations of several inflammatory mediators (e.g.,
complement fraction C5a) have been associated with
subsystem dysfunction following cardiopulmonary bypass.
This inflammatory response is complex and has several
arms, including the coagulation, fibrinolytic, and
complement systems. Simply blocking one pathway is
unlikely to completely prevent bypass-induced injury.

102. Adequate flow during cardiopulmonary bypass is best

indicated by:
A. Systemic blood pressure of 90/50 mm. Hg.
B. Arterial PO 2 of 230 mm. Hg.
C. Mixed venous hemoglobin saturation of 78%.
D. Central venous pressure of 1 mm. Hg.
E. Plasma lactate value of 6 mg. per dl.
Answer: C

DISCUSSION: The purpose of cardiopulmonary bypass is

to provide adequate circulation of blood to sustain
aerobic metabolism. Oxygen consumption during bypass
depends on bypass flow until a critical flow is attained.
With higher flows there is no further increase in oxygen
consumption (i.e., oxygen consumption becomes flow
independent), and the mixed venous hemoglobin
saturation increases. A mixed venous hemoglobin
saturation of 78% indicates that bypass flow is above the
critical level and that flow is adequate. The other
variables do not ensure adequate bypass flow.

103. 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: A

DISCUSSION: Several events occur during the first few

minutes of bypass. The tubing and oxygenator surfaces
are coated by serum proteins that in turn activate
platelets. This reduces the platelet count. The roller pump
produces nonpulsatile flow, which is different from the
usual pulsatile cardiac flow. Serum complement is
activated by exposure of blood to the nonphysiologic
surfaces of the pump-oxygenator, and systemic vascular
resistance falls. Interstitial fluid accumulates during
bypass; however, this occurs later during bypass.

104. Which of the following are physiologic benefits of

intra-aortic balloon counterpulsation to the ischemic
ventricle except?
A. Preload reduction.
B. Afterload reduction.
C. Coronary blood flow enhancement.
D. Decreased ventricular end-diastolic pressure.
Answer: BCD

DISCUSSION: In general, preload relates to the volume of

blood or fluid presented to the left ventricle. Although wall
tension does increase with increased volume, Starling
properties are called forth for added efficiency. Preload is
controlled by volume status as well as capacity of the
venous system. The effects of balloon counterpulsation on
cardiac preload are minimal and secondary to other
changes. As the balloon collapses in the aorta, the
absence of the balloon volume, or “abyss,” creates a
decrease in ventricular afterload. In effect this decreases
ventricular wall tension, reducing myocardial oxygen
consumption significantly. During counterpulsation, the
intra-aortic balloon inflates in diastole, elevating coronary
perfusion pressure significantly. Maximal coronary artery
perfusion occurs in this part of the cardiac cycle. Thus,
ischemic ventricles benefit especially from balloon
pumping. The balloon pump does not directly decrease
the left ventricular end-diastolic pressure. However, in
ventricles failing from ischemia the combination of
afterload reduction and improved coronary blood flow
usually augments cardiac function, producing decreased
cardiac filling pressure or left ventricular end-diastolic
pressure.

105. Which of the following are the major indications for

instituting intra-aortic balloon pumping?
A. Medically refractory angina.
B. Acute papillary muscle rupture.
C. Left main coronary artery lesion.
D. Ventricular failure after cardiac surgery.
E. PTCA failure.
Answer: ABDE

DISCUSSION: Medically refractory angina is one of the

major indications for implementing the intra-aortic balloon
pump. When intravenous nitroglycerin becomes
ineffective at relieving chest pain or results in early
hypotension, the balloon pump should be used in
preparation for surgical revascularization or percutaneous
angioplasty. By reducing left ventricular afterload, the
pump reduces regurgitation into the left atrium. Thus,
balloon counterpulsation is very helpful for treating
patients with acute mitral insufficiency secondary to
papillary muscle rupture. Patients should undergo valve
surgical procedures emergently, as balloon pump support
is only temporizing. The mere presence of a left main
coronary lesion is not an indication for use of the balloon
pump. In former years such pumps were inserted
prophylactically before induction of anesthesia for
coronary bypass surgery. Newer anesthetic techniques
have largely obviated this; however, in the presence of a
left main lesion and medically refractory angina the
balloon pump should be used. The balloon pump is quite
effective in helping to wean patients who have
postcardiotomy left ventricular failure from
cardiopulmonary bypass. This is one of the major uses of
this device. The Emory University group was the first to
expound on the efficacy of the balloon pump in stabilizing
patients following percutaneous angioplasty failure. With
the pump inserted, most patients can be transported to
the operating room safely, many being stable enough to
harvest an internal mammary graft instead of having to
defer to the more accessible but less preferable
saphenous vein.

106. Which of the following are the most frequent

complications of intra-aortic balloon counterpulsation?
A. Stroke.
B. Limb ischemia.
C. Arrhythmias.
D. Aortic thrombosis.
Answer: B

DISCUSSION: Stroke rarely occurs secondary to intra-

aortic balloon pump use. The balloon must be positioned
well below the aortic arch vessels and never proximal to
the left subclavian artery origin. Strokes have been
reported from emboli being thrown retrograde from the
balloon; however, this is very rare. Limb ischemia is one
of the most frequent complications of balloon pumping.
The combination of iliofemoral atherosclerosis and
catheter luminal obstruction may impede distal flow. This
may require catheter removal to re-establish flow. In 2%
to 10% of patients, arterial reconstruction is necessary to
repair balloon-related complications. Smaller catheters
have helped prevent limb ischemia. Arrhythmias in
general are not complications of balloon pumping. In fact,
arrhythmias related to ischemia may be controlled by the
balloon pump. Aortic thrombosis can occur very rarely
with pump use. A more frequent occurrence is distal
embolization with limb ischemia. Patients should be
heparinized while the balloon catheter is in place.
Following cardiac surgery heparinization is usually
delayed for 12 to 24 hours.

107. Permanent artificial hearts are being developed that

are electrically powered. Wireless techniques are used to
transmit the electrical energy across the body wall using
the principle of:
A. Infrared sensor.
B. Inductive coupling.
C. Thermionic coupling.
D. High-pressure liquid chromatography (HPLC).
E. Infrared spectroscopy.
Answer: B

DISCUSSION: Electrical energy can be transmitted across

the body wall by tunnelling an electric wire; however,
experience has shown that infection, starting at the skin
line and burrowing deeper into the body, will occur over
time. This infection can be delayed, but not stopped, by
the use of a velour covering on the wire. Wireless
electrical energy transmission was first used in clinical
surgery by W.W.L. Glenn in the 1950s for powering
pacemakers. The remarkable advances in electronics
have facilitated this technique; however, the placement of
the two coils parallel to one another (with the skin
between), as opposed to interlocking as in an industrial
transformer, reduces the efficiency of transmission from
approximately 99% to 70%.

108. The following statements about the pneumatic

artificial heart is/are correct:
A. It can support the circulation for over 1 year.
B. It may be complicated by infection or
thromboembolism.
C. When further developed, it will be an ideal permanent
heart substitute.
D. It is an ideal “bridge” for transplantation.
E. It can be implanted using techniques similar to those
used for heart transplantation.
Answer: ABE

DISCUSSION: The pneumatic artificial heart was

developed as a permanent cardiac substitute, but the
need for two tubes to pass through the chest wall and the
bulky power unit have relegated the pneumatic heart to
short-term use as a bridge to transplantation. The heart is
implanted using similar techniques as a heart
transplantation. The presence of foreign surfaces and
crevices make the device prone to thromboembolism and
infection. Most surgeons feel that left ventricular support
or biventricular assist pumps represent a better option for
those patients with end-stage congestive heart failure
who require use of a bridge device.

109. A cyanotic infant has echocardiographic evidence of

a univentricular heart (UVH). The following is/are true:

a. The most common form of the disorder is a double-inlet

right ventricle
b. To be classified as a ventricle, the chamber must
receive at least half of an inlet valve
c. This infant is a good candidate for a Blalock-Taussig
shunt
d. Optimal correction of UVH diverts all vena caval blood
flow into the pulmonary arteries (Fontan procedure)
e. In the absence of pulmonic stenosis, UVH usually
presents as congestive heart failure
Answer: b, c, d, e

Univentricular heart is defined by the connection of the

atria to only one ventricular chamber, usually the left as a
double inlet left ventricle. A chamber must receive at
least half of an inlet valve to be considered a ventricle.
The presentation of UVH depends on the pulmonary blood
flow; if pulmonary stenosis is present there is increased
cyanosis and the infant is a candidate for a Blalock-
Taussig shunt. In the absence of pulmonic stenosis,
pulmonary flow is excessive and the presentation is
congestive heart failure. Optimal correction of UVH
diverts all vena caval flow into the pulmonary arteries as
the Fontan procedure.

110. 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: a, b, d

Coarctation of the aorta occurs just distal to the origin of

the left subclavian artery and results from contraction of
ectopic tissue from the ductus arteriosus. The most
common associated abnormality is a bicuspid aortic
valve. Extensive collateral development involves the
mammary and intercostal arteries producing rib notching
on the chest radiograph. In infancy, flow to the lower body
is from the ductus arteriosus before it closes, producing
differential cyanosis. The “paradoxical hypertension” seen
postoperatively is thought to relate to sympathetic nerve
stimulation and does not reflect an incomplete repair.

111. A 48-year-old woman with episodic syncope has

echocardiographic evidence of a mass in the left atrium.
The following is/are true statement(s):

a. Transseptal puncture should be used for definitive

diagnosis
b. If this is a primary cardiac tumor it is most likely to be
malignant
c. If this is a myxoma attached to the atrial septum, the
adjacent septum should be removed with it
d. In infancy, the most common cardiac tumor is a
rhabdomyosarcoma
e. The most common primary malignant tumor of the heart
is angiosarcoma
Answer: c, e

Primary cardiac tumors commonly arise in the left atrium

and can present with dyspnea, syncope, congestive
failure and systemic embolism. Transseptal puncture
should not be used for diagnosis because of the risk of
embolism. Most primary cardiac tumors are benign by a
3:1 ratio. The most common malignant tumor is the
angiosarcoma. Myxoma is the most common benign
tumor, but it can recur and the adjacent atrial septum
should be resected with it. In infancy, the most common
cardiac tumor is a rhabdomyoma.

112. 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: a, b, d

In this typical scenario for Tetralogy of Fallot,

echocardiography can confirm the diagnosis with no need
for cardiac catheterization. Cyanotic spells are treated by
supplemental oxygen, sedation with morphine and a beta
blocker such as propranolol. For palliative increase in
pulmonary blood flow, the Blalock-Taussig shunt is
utilized connecting the subclavian artery to the pulmonary
artery. Increasing cyanosis and cyanotic spells are the
most common indication for operative repair. To correct
the right ventricular outflow obstruction in Tetralogy, a
transannular patch may be required extending into the
pulmonary artery. Fortunately the pulmonary valvar
insufficiency that results is well tolerated in the absence
of tricuspid insufficiency or ventricular dysfunction.

113. A 12-year-old boy is found to have an ejection

systolic murmur over the aortic region with a precordial
thrill and normal cardiac size on chest radiograph. The
following is/are true:

a. A systolic ejection click would signify that the stenosis

is supravalvar
b. In the absence of cardiomegaly, cardiac catheterization
to measure the pressure gradient is necessary
c. Development of syncope would suggest an intracranial
lesion
d. In valvar aortic stenosis a pressure gradient of 80
mmHg is an indication for operative repair regardless of
symptoms
e. In membranous subvalvar aortic stenosis a pressure
gradient of 40 mmHg is an indication for operative repair
Answer: d, e

In the patient with findings of aortic stenosis, a systolic

ejection click is evidence that the obstruction is valvular.
Cardiac size does not provide an indication of the severity
of the stenosis and is frequently normal. The development
of angina or syncope reflects inadequate cardiac output
and signifies late-stage disease. A pressure gradient over
75 mmHg is an indication for operation in valvar aortic
stenosis even if the patient is asymptomatic while a
lesser gradient of 30 mmHg or more is considered
sufficient for operative correction of membranous
subvalvar stenosis.
114. 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: a, b

TGV is the most common cause of cyanosis in the first

week of life, and this diagnosis can be confirmed by
echocardiographic demonstration of a posterior
pulmonary artery attached to the left ventricle. Cardiac
catheterization is useful to confirm the anatomy, detect
other lesions, define the coronary anatomy and improve
cardiac mixing by balloon atrial septostomy. The EKG is
not helpful in the diagnosis of TGV since it shows only
normal right ventricular dominance. Prostaglandin
improves the mixing of the circulation by opening the
ductus arteriosus and reducing pulmonary vascular
resistance.

115. A one-year-old boy thought to have Tetralogy of

Fallot is found on cardiac catheterization to have double-
outlet right ventricle (DORV). The follow is/are true:

a. Spontaneous closure of the VSD is rare

b. Location of the VSD has little effect on the degree of
cyanosis
c. Double outlet left ventricles do not occur
d. Coincidental aortic stenosis with DORV is not
compatible with life
e. Doubly committed VSD refers to its relationship to the
great vessels
Answer: a, e

In DORV, the location of the VSD affects the direction of

flow of oxygenated blood and thus determines the degree
of cyanosis. Fortunately, the VSD rarely closes since that
would result in severe decompensation or death. Double
outlet left ventricles occur but are less common than
DORV. A number of other anomalies are associated with
DORV including both valvar and subvalvar pulmonary and
aortic stenosis. The VSD may be directed to either or both
great vessels (doubly committed) or remote from them
(noncommitted).
116. 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: b

The findings suggest an atrial septal defect (ASD) that

can be confirmed by 2D echocardiography eliminating the
need for cardiac catheterization. The ostium secondum
type defect is most commonly found, but it is the sinus
venosus type that is associated with anomalous
pulmonary venous drainage. In the scimitar syndrome, the
anomalous pulmonary vein can be seen on a chest
radiograph and, since these are associated with a
hypoplastic lung that is supplied by an anomalous
systemic artery from the aorta, an arteriogram is
appropriate. An ASD with a significant left-to-right shunt
as demonstrated by a Qp/Qs ratio in excess of 1.5 should
be repaired. When the pulmonary vascular resistance is
elevated above 10–12 Woods units/m2 the patient is not a
candidate for repair due to fixed pulmonary hypertension.

117. A 2-month-old infant has EKG evidence of myocardial

ischemia and echocardiography suggests anomalous
origin of the left coronary artery from the pulmonary
artery. The following is/are true:

a. Ischemia is due to perfusion of the myocardium with

inadequately oxygenated blood
b. Selective coronary angiography should not be
attempted because of the risk of myocardial infarction
c. Conservative treatment is preferred to allow the
coronary artery to grow to a size that will allow bypass
construction
d. If the infant deteriorates, ligation of the coronary at its
origin is a viable option
e. The severity of the abnormality insures that it will
always be detected in the first year of life
Answer: d

Anomalous origin of the left coronary artery from the

pulmonary artery results in reverse flow in the coronary
into the low-pressure system as a steal from the coronary
circulation. If collaterals from the right coronary develop
to allow adequate myocardial perfusion, the disorder is
frequently not diagnosed until later in life when a murmur
is heard. Selective coronary arteriography is appropriate
to define the anatomy and operative repair is undertaken
promptly. Ligation of the anomalous coronary can be
lifesaving but leaves the child dependent on a single
vessel and coronary bypass is preferred.

118. 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: c, e

Large VSDs present at 6–8 weeks of age when the

normally elevated pulmonary vascular resistance falls,
allowing an increase in the left-to-right shunt. Since
roughly half of all VSDs undergo spontaneous closure,
particularly with restrictive defects, the initial
management is medical. The diagnosis is confirmed by
echocardiography and cardiac catheterization. Advanced
pulmonary vascular changes do not occur usually until 2
years of age and banding is only rarely indicated for
palliation for multiple complex muscular VSDs.

119. A 1-year-old girl with dyspnea and poor feeding is

found to be in congestive heart failure. Echocardiography
shows an atrio-ventricular septal defect (AVSD). The
following is/are true:

a. The second heart sound will show fixed splitting

b. Despite diagnostic echocardiography, cardiac
catheterization is indicated to assess pulmonary artery
resistance
c. Pulmonary artery banding is indicated to limit
pulmonary flow and allow the child to grow
d. AVSD is classified according to the morphology of the
anterior leaflet of the common A-V valve
e. Operative repair is best performed after 2 years of age
Answer: a, b, d

AVSD is a defect of endocardial cushion development

which produces morphologic abnormalities of both AV
valves and both atrial and ventricular septa. It is usually
classified according to the morphology of the anterior
leaflet of the AV valve. The pulmonary vascular resistance
remains elevated in infancy delaying diagnosis and
producing fixed splitting of the second heart sound.
Cardiac catheterization is indicated to assess pulmonary
vascular resistance, but pulmonary artery banding is no
longer performed to protect the pulmonary bed. Instead,
operative repair is made, preferably before the age of 6
months.

120. The child in the previous question undergoes cardiac

catheterization confirming a VSD with Qp/Qs ratio of 2.0
and right ventricular systolic pressure half of systemic
pressure. The following is/are true:

a. If aortic insufficiency is detected, the defect is likely to

be subpulmonic in location
b. Finding aortic stenosis in addition to the VSD would be
highly unlikely
c. The cath data indicate a restrictive type of VSD
d. If pulmonary vascular resistance falls with tolazoline
administration, it is safe to close the VSD
e. Operative closure of VSDs is possible without
ventriculotomy
Answer: a, c, d, e

The finding of aortic insufficiency in a patient with VSD

suggests prolapse of the aortic valve due to a
subpulmonic or supracristal defect. Associated aortic
stenosis, mitral stenosis and coarctation are common
with VSDs. The finding of a moderate left-to-right shunt
and a right ventricular pressure well below systemic
levels indicates a restrictive VSD. If elevated pulmonary
vascular resistance is found, the ability to respond to a
vasodilator like tolazoline indicates that the resistance is
not fixed and operative repair is possible. Operative repair
of VSDs is frequently possible via atriotomy or through the
pulmonary artery.

121. 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: b, e

A continuous “machinery” murmur is characteristic of

patent ductus arteriosus typically seen in the premature
infant. Normal closure of the ductus is prompted by a fall
in pulmonary vascular resistance that increases the left-
to right shunt and oxygen levels from the aorta.
Indomethacin can cause ductus closure by
cyclooxygenase inhibition which decreases endogenous
prostaglandins. Prostaglandin infusion would keep the
ductus open. Operative closure can be done safely in even
the smallest neonates and usually promptly relieves the
respiratory distress.

122. A neonate in congestive heart failure has

echocardiographic evidence of a single truncal vessel
from which the pulmonary arteries arise, a VSD and
truncal valvar stenosis. The following is/are true:

a. Natural history of this anomaly allows only 20% one-

year survival
b. The most likely configuration of the truncal valve is
bicuspid
c. Location of the pulmonary arteries minimizes the risk of
pulmonary vascular obstructive disease (Eisenmengers)
d. Repair of the lesion requires an extracardiac conduit
e. Optimal timing of operative repair is at 6–12 months
Answer: a, d

The defect described is truncus arteriosus which carries

an 80% one year mortality rate uncorrected. The truncal
valve is most commonly tricuspid (65%) or quadricuspid
(25%); least likely bicuspid (9%). The large left-to-right
shunt makes these patients particularly likely to develop
pulmonary vascular obstruction (Eisenmenger’s
syndrome). Operative repair requires detachment of the
pulmonary arteries which are reconnected to the right
ventricle by an extracardiac conduit, and the optimal
timing for repair is within the first 6 months of life.

123. A neonate in respiratory distress has

echocardiographic evidence of hypoplastic left heart
syndrome (HLHS). The following is/are true:

a. Initial management should include prostaglandin

infusion
b. Ventilatory adjustment should maintain PaCO2 at
approximately 40 mmHg
c. Survival depends on sustained patency of the ductus
arteriosus
d. Cardiac transplantation for HLHS requires inclusion of
the donor aortic arch
e. Reconstruction for HLHS converts the pulmonary artery
into the main outlet for a functional single ventricle
(Norwood)
Answer: a, b, c, d, e

The neonate with HLHS has a severely underdeveloped

left ventricular and aortic arch and is dependent on
patency of the ductus which is facilitated by
prostaglandin infusion. Ventilator adjustment to reduce
supplemental oxygen and maintain PCO2 of 40 mmHg
avoids excessive pulmonary flow. The options for
treatment include cardiac transplantation which requires
a donor aortic arch and reconstruction by the Norwood
procedure which converts the pulmonary artery into the
main outlet for a functional single ventricle.

124. 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: d
The ventricular hypertrophy which accompanies aortic
stenosis increases oxygen demand while mechanical
forces increase resistance to perfusion, resulting in
ischemia. Only one half of these patients with angina have
coronary artery disease. Percutaneous balloon
valvuloplasty of the aortic valve has high complication
and recurrence rates. Any such patient with symptoms
has an indication for operations as would the patient with
a transvalvular gradiant > 50 mmHg.

125. The patient in the previous question with AI

progresses to profound heart failure requiring medical
management. The following is/are true:

a. Perperal vasdilators are contraindicated

b. The inta-aortic balloon pump can be used to improve
cardiac output
c. Furosemide and nitroglycerin would be appropriate
d. Valve replacement is necessary
Answer: c, d

Peripheral vasodilators are key to the treatment of AI

favoring peripheral blood flow. The intraaortic pump is
contraindicated because diastolic augmentation worsens
aortic regurgitation. Both furosemide and nitroglycerin
would be of value to treat the failure, but the most
effective treatment requires replacement of the valve.
126. 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: c

Normal adults have a 4–6 cm2 mitral orifice and reduction

to 2 cm2 is mild stenosis while reduction to 1 cm2 is
considered critical mitral stenosis. Even with a fixed
orifice, the onset of atrial fibrillation reduces cardiac
output by 20%. Mural thrombi and thromboembolism are
directly related to the presence of atrial fibrillation. Mitral
stenosis spares ventricular function, and the loss of
cardiac output is from decreased preload.
127. 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: c, d

Aortic valvular stenosis is the most common type of

valvular lesion followed by mitral stenosis. Anatomically,
the pulmonic valve is the most anterior of the cardiac
valves. Rheumatic heart disease is the most common
cause of valve dysfunction and the most common cause
of multivalvular disease.

128. A 47-year-old male with fatigue and cardiac failure

has a high-pitched, decrescendo diastolic murmur along
the left sternal border and an apical diastolci rumble. His
blood pressure is 148/45 mmHg. The following is/are true:

a. Chest radiograph will show cor bovinum

b. The apical murmur is due to the Gallavardin
phenomenon
c. A carotid shudder would be expected
d. Abdominal exam will show a pulsatile liver
Answer: a

This patient with aortic insufficiency has a volume loading

strain on the heart which produces cor bovinum as
dramatic enlargement. The apical murmur produced by
turbulence with mitral forward flow mimics mitral
stenosis and is called an Austin-Glint murmur. A carotid
shudder occurs with aortic stenosis and a pulsatile liver is
typical of tricuspid insufficiency.

129. Concerning the adaptation to cardiac valvular

dysfunction, the following is/are true:

a. Severe heart failure is more likely from acute than

chronic valvular dysfunction
b. Valvular dysfunction produces both volume and
pressure afterload stress on the heart
c. Early cardiac dilation from valve dysfunction shifts the
Frank-Starling curve to depress cardiac output
d. The LaPlace law predicts that wall stress decreases
with increasing ventricular radius
Answer: a, b

Valvular dysfunction produces both volume and pressure

overload representing afterload stress on the heart.
Although cardiac reserves allow for gradual adaptation to
chronic valvular dysfunction, acute dysfunction is less
well tolerated and more likely to result in severe heart
failure. The increase in diastolic filling which initially
dilates the heart, shifts the Frank-Starling curve to
improve ejection and cardiac output. The LaPlace law
predicts that wall stress increases with increasing
ventricular radius but is inversely related to wall
thickness.

130. A 31-year-old male drug abuser presents with fever,

chills and multiple bilateral lung abscesses. Right heart
endocarditis is suspected. The following is/are true:

a. The organisms most likely responsible are gram-

negative and fungal
b. The pulmonic valve is most likely to be affected
c. A negative echocardiogram is useful to exclude the
diagnosis
d. Valve replacement is necessary if the native valve is
excised to treat infection
Answer: a

The typical endocarditis in a drug-abuser involves fungal

and gram-negative organisms which infect the tricuspid
rather than the pulmonic valve. An echocardiogram is
useful to confirm the presence of vegetations but it may
overlook smaller ones so it cannot be used to exclude the
diagnosis. Although valve replacement is usually
preferable, the infected tricuspid valve can be excised
without prosthetic replacement.

131. In the initial management of the patient in the

previous question with suspected acute MI, the following
is/are true:

a. Oxygen and lidocaine should be administered

prophylactically
b. If chest pain persists, IV nitroglycerin should be used to
limit infarct size
c. Ca-channel blockers are also of value to limit infarct
size
d. Morphine IV can be used but has no therapeutic effect
Answer: b

Initial treatment during an early evolving MI should

include oxygen, but lidocaine should be used only if
arrhythmias occur. Nitroglycerin IV is of value to limit
infarct size but not Ca-channel blockers which have no
such benefit. By decreasing pain and anxiety, morphine IV
has a significant therapeutic effect in decreasing
myocardial oxygen demand.

132. Concerning the physiology of the coronary

circulation, the following is/are true:
a. Under circumstances of increased oxygen demand by
the myocardium, O2 extraction from arterial blood can
increase
b. Coronary flow is maximal during systole
c. Adenosine is the most important metabolic regulator of
coronary blood flow
d. Sympathetic nerve stimulation constricts coronary
arteries despite the need for increased cardiac output
Answer: c, d

Since myocardium maximally extracts O2 from blood at

rest, increased demand requires increased delivery.
Systolic pressures compress intramyocardial vessels, so
maximal coronary flow is during diastole. Adenosine, a
breakdown product of ATP, is a vasodilator and the most
important metabolic regulator of coronary blood flow.
Although sympathetic nerves produce coronary
vasoconstriction, the autoregulatory vasodilatory
responses to increased myocardial demand overwhelm
that effect.

133. True statement(s) concerning cardiac vascular

anatomy include the following:

a. In 80%–85% of cases the posterior descending coronary

artery (PDA) arises from the circumflex coronary artery
b. The PDA gives off the AV nodal artery
c. The great cardiac vein ascends along the right coronary
artery to empty into the coronary sinus
d. Thebesian veins drain from only left and right ventricles
Answer: b

In 80%–85% of cases the circumflex coronary artery ends

with branches to the left ventricle while the PDA
originates from the right coronary in 80%–85% of cases.
The PDA gives off the AV nodal artery and its occlusion
can result in heart block. The great cardiac vein ascends
along the left anterior descending coronary artery and the
Thebesian veins drain all 4 chambers.

134. In the medical management of coronary artery

disease, the following is/are true:

a. Nitroglycerin primarily dilates coronary arterioles

b. b-blocking agents act to reduce myocardial O2 demand
c. Ca-channel blocking agents reduce ventricular
contractility
d. Ca-channel agents should not be used if there is an
element of coronary vasospastic disease
Answer: b, c

Nitroglycerin primarily dilates venous capacitance

vessels, but at higher doses can produce coronary and
systemic arterial dilation. b-adrenergic blocking agents
reduce myocardial O2 demand by decreasing heart rate
and contractility. Ca-channel blocking agents reduce
ventricular contractility, produce vasodilation and may
protect myocytes. They are particularly effective for
coronary vasospastic disease.

135. A 67-year-old man with documented acute MI

progresses in 24 hours to cardiogenic shock. The
following is/are true:

a. The mortality rate for cardiogenic shock after acute MI

is increased more than 10 fold in comparison to no shock
b. Age, ejection fraction, MI size and previous MI serve as
predictors of cardiogenic shock
c. Acute loss of more than 20% of myocardium frequently
results in cardiogenic shock and death
d. Emergency revascularization is contraindicated for the
MI patient in cardiogenic shock
Answer: a, b

Cardiogenic shock is unusual after acute MI but increases

the mortality rate from 4% to 65%. All of the risk factors
described plus a history of diabetes mellitus can predict
cardiogenic shock. The volume of myocardium lost
acutely that is associated with shock is 40%. Recent
studies suggest that emergency coronary bypass can be
used within 18 hours of shock to reduce the mortality rate
to 7%.

136. A 52-year-old man with chest pain and tachycardia

has ECG evidence of an acute MI. The following is/are
true:

a. Thrombolytic therapy should be considered

immediately since the benefit is greater the earlier it is
given
b. Of the drugs available, recombinant tPA produces
better results than SK or APSAC although it is more
expensive
c. Thrombolytic therapy requires catheterization for
intracoronary administration
d. Addition of heparin and antiplatelet drugs produces no
incremental benefit
Answer: a

Thrombolytic therapy for acute MI is of significant value in

reducing mortality with benefit related to early
administration. Although rtPA can produce higher
coronary patency rates, the results of treatment are no
better than with SK or APSAC. Thrombolytic drugs were
initially given intracoronary but can be used effectively
when given systemically IV. There is an added benefit
from heparin and antiplatelet drugs to prevent
rethrombosis.
137. Following repair of an abdominal aortic aneurysm, a
66-year-old man develops severe chest pain, diaphoresis,
bradycardia and hypotension. The following is/are true:

a. The electrocardiogram is most likely to show a

prominent Q in lead 3 if this is an MI
b. If Q wave is present, the infarct is subendocardial
rather than transmural
c. Creatine kinase measurement alone is diagnostic of MI
d. Since bradycardia rarely occurs with MI, another
diagnosis should be considered
Answer: a

Pain is the most common complaint in patients with

myocardial infarction although 20%–25% are
asymptomatic. Inferior MIs involving the right coronary
frequently have parasympathetic activity with
bradycardia, hypotension and a prominent Q wave in lead
3. The presence of a Q wave indicates a transmural MI
which can be confirmed by measurement of the specific
isoenzyme for cardiac tissue (CK-MB) since creatine
kinase can be elevated non-specifically after stroke or
operation.

138. 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: b

The ideal lesion for PTCA is focal symmetric stenosis in

an epicardial vessel. However, it is relatively
contraindicated for significant disease in the left main
coronary, for multiple obstructive lesions in the same
artery, and for vessels less than 2 mm in diameter.
Restenosis rates of 20% to 40% occur within the first 4–6
months after successful dilation for simple lesions.

139. 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: a, b

Operative mortality for patients > 70 years was 8% in the

CASS study as compared to 3% in younger patients. For
reasons not entirely clear, the risk of CABG is higher in
women than in men. Reoperative procedures carry a
higher operative mortality due to technical difficulties,
more advanced disease, and less complete
revascularization. Congestive heart failure is a major
determinant of poor surgical outcome, but the results are
better when there is viable myocardium (hibernating) than
when there is irreversible ischemic cardiomyopathy.

140. Four days after a transmural MI, a 74-year-old man

develops hypotension and congestive heart failure. The
following is/are true:

a. An intra-aortic balloon pump should be used and

cardiac catheterization performed
b. If the infarct was posterior, this is most likely due to a
ventricular septal defect
c. Pulmonary wedge pressure tracing of prominent V
waves without an O2 step-up suggests papillary muscle
rupture
d. Operative repair of a post MI VSD should be delayed to
allow strengthening of the myocardium to hold sutures
Answer: a, c

Both ventricular septal defect (VSD) and ruptured

papillary muscle occur from 3–5 days post-MI and should
be managed by intra-aortic balloon pump, decreasing
afterload and cardiac catheterization for diagnosis. A VSD
is most likely in an elderly hypertensive female who has
sustained an anterior transmural MI; posterior MIs
typically lead to papillary muscle rupture which is
diagnosed by prominent V waves on pulmonary wedge
pressure tracing. Survival rate for both of these
complications is improved by early rather than late repair.

141. A 52-year-old woman with chest pain is considered

for coronary arteriography on the basis of her risk factors.
The following is/are true statement(s):

a. All patients with typical anginal symptoms should have

coronary arteriography
b. Atypical patients with borderline positive stress tests
should have arteriography
c. Patients who require valve procedures do not require
arteriography
d. Patients in refractory heart failure awaiting cardiac
transplantation should have coronary arteriography
Answer: b

Patients with typical angina and ECG changes should

have angiography only if they are refractory to medical
management and/or a candidate for revascularization.
Patients with atypical signs and symptoms should have
angiography to confirm or exclude the diagnosis. Patients
with valve disease and risk of coronary artery disease
should have angiography but patients awaiting cardiac
transplantation are not candidates for revascularization
and do not require coronary angiography.

142. The patient in the previous question is found to have

disease unsuitable for PTCA. 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: a, b, c

Randomized studies show that CABG is more effective

than medical therapy for relieving angina, improving
physical work capacity and improving overall quality of
life. When CABG is used for unstable angina, the initial
complication and mortality rates are higher than for
stable angina, but the late outcomes are similar. Use of
arterial grafts for CABG has increased with the left
internal mammary artery used most commonly; when at
least one mammary artery is used, the early mortality rate
is improved.

143. In the workup of a 45-year-old man with suspected

coronary artery disease, the following is/are true:

a. Thyroid tests are included to rule out hyperthyroidism

b. Typically positive stress ECG would show elevated ST
segments
c. Dipyridamole is a useful adjunct to thallium scanning as
it increases coronary perfusion pressure
d. Persisting defects on thallium scan indicate reversible
myocardial ischemia
Answer: a
Diagnostic studies for coronary artery disease should
detect risk factors such as diabetes mellitus,
hyperlipidemia and hyperthyroidism. The stress ECG
typically shows downward sloping ST segment
depression. Dipyridamole is a coronary artery vasodilator
that reduces systemic and coronary perfusion pressures.
The persisting thallium scan defect reflects irreversibly
scarred myocardium.

144. Following successful thrombolytic treatment of the

patient in the previous question, he develops recurrent
chest pain in 24 hours. The following is/are true:

a. Rethrombosis is most likely and thrombolytic therapy

alone should be repeated
b. The problem could have been prevented by early
elective catheterization and PTCA
c. Patient has an indication for catheterization and PTCA
if single vessel disease is found
d. Findings of multivessel disease at catheterization
would indicate need for operative bypasses
e. If operative bypass is deemed necessary, there should
be a 30-day delay to allow myocardial healing
Answer: c, d

After thrombolytic therapy for acute MI, angina recurs in

30%–35% and is an indication for cardiac catheterization
and mechanical intervention to prevent infarct extension.
Prophylactic catheterization, however, has not been found
to provide benefit. If the findings at catheterization show
limited disease treatable by PTCA, then it should be
performed. But if multivessel disease or unfavorable
anatomy is found, operative bypass should be carried out
early since results are best within 30 days of the MI.

145. A 59-year-old male has undergone successful CABG

with 4 grafts constructed but remains in low cardiac
output (< 2L/min/m2) postoperatively. The following is/are
true:

a. An inotropic drug should be used initially to increase

cardiac output
b. If low cardiac output persists despite optimal
physiological and pharmacological support, a balloon
pump (IABP) should be inserted
c. Decreased cardiac filling pressures suggest the
possibility of cardiac tamponade
d. When IABP is used, the balloon is inflated during
diastole
Answer: b, d

Initial efforts to improve cardiac output should include

correction of poor oxygenation or acidosis and
optimization of rhythm, preload and afterload before an
inotropic agent is used. If low cardiac output persists
despite physiological and pharmacological support, an
IABP should be inserted. It improves coronary artery
perfusion by counterpulsation during diastole. Cardiac
tamponade is heralded by increased cardiac filling
pressures, narrowed pulse pressure and pulsus
paradoxus.

146. A 42-year-old asymptomatic attorney undergoes a

routine exercise test which is reported positive for
myocardial ischemia. The following is/are true:

a. This is a rare event since less than 5% of patients with

coronary artery disease (CAD) are asymptomatic with
exercise
b. Such a patient could progress to heart failure from
ischemic cardiomyopathy
c. Typical angina pectoris is promptly relieved by rest or
relaxation
d. Dyspnea on exertion can represent an angina
equivalent
Answer: b, c, d

As many as 25% of CAD patients found by exercise testing

are asymptomatic. Progressive coronary obstruction in
these patients can produce heart failure from ischemic
cardiomyopathy. Typical angina is relieved promptly by
rest or relaxation. Ischemic reductions in ventricular
contractility and compliance can produce dyspnea on
exertion as an angina equivalent.

147. A 52-year-old man develops postoperative

supraventricular tachycardia to a rate of 180/min. and
hypotension. The following is/are true:

a. Since a heart rate of 180/min should be tolerated at his

age, the hypotension must have another cause
b. A vagal maneuver that breaks the tachycardia suggests
atrial flutter as the etiology
c. Atrial overdrive pacing should be tried for paroxysmal
atrial tachycardia (PAT)
d. Verapamil IV should be used for rate control
e. Cardioversion is preferred for patients on digoxin
Answer: c, d

A tachyarrhythmia over 150 beats/min can produce

hypotension and myocardial ischemia and demands
urgent therapy. Vagal maneuvers may break PAT but are
not usually effective for atrial flutter or fibrillation. Atrial
overdrive pacing should be attempted for PAT or atrial
flutter. Verapamil is the most effective approach to rate
control for supraventricular arrhythmias, but
cardioversion of patients on digoxin should be undertaken
cautiously since they are prone to ventricular
tachycardia.

148. A 77-year-old man with a healed transmural

myocardial infarction has a medically refractory
ventricular arrhythmia. The following is/are true:

a. Direct current catheter endocardial ablation has a high

likelihood of success.
b. If the arrhythmia is inducible at EP study, there is an
indication for operative intervention.
c. A recent MI would be a contraindication to operation
d. Ventricular failure would be a contraindication to
operation
e. Monomorphic ventricular tachycardia is least amenable
to surgical resection.
Answer: b, c, d

After catheter ablation, only 25% of patients remain free

of ventricular arrhythmia off of drug therapy. If the
arrhythmia is inducible at EP study and the patient is an
acceptable risk, with a myocardial scar he has an
indication for operation. Both recent MI and ventricular
failure are contraindications to operation. Monomorphic
ventricular tachycardia is the arrhythmia most amenable
to surgical resection.
149. A 68-year-old man suffers sudden cardiac death
(SCD) but is resuscitated and brought to the hospital for
evaluation and treatment. The following is/are true:

a. The most likely cause of SCD is ventricular arrhythmia

b. There is 30–40% chance of recurrent SCD in one year
c. Empiric antiarrhythmic drug therapy improves survival
d. An inducible ventricular tachyarrhythmia at EP study
carries a favorable prognosis
e. If a ventricular aneurysm is found with arrhythmia,
aneurysm resection is adequate treatment
Answer: a, b

Ventricular arrhythmias cause 75% of SCD, while 25% are

due to acute MI. There is a 30–40% chance of recurrent
SCD in one year. An inducible ventricular tachyarrhythmia
carries a poor prognosis with < 50% five year survival
from SCD unless it can be abolished. Empiric
antiarrhythmic drug therapy does not improve survival.
Aneurysmectomy alone is not adequate therapy for
arrhythmias associated with aneurysms since the
arrhythmia usually originates in adjacent mechanically
stressed myocardium.

150. The following is/are true concerning the anatomy of

the conduction system:
a. There is no special conduction path from the sinoatrial
(SA) to the atrioventricular (AV) node
b. The blood supply to the AV node is from the anterior
descending coronary artery
c. The only normal muscular connection between atria
and ventricles is the bundle of His
d. The aortomitral continuity is the only area where
supraventricular accessory pathways cannot occur
e. The sinus node artery arises from the right or
circumflex coronary artery
Answer: a, c, d, e

The SA node is located at the junction of the superior

vena cava and the right atrial appendage and receives its
blood supply from the right or circumflex coronary artery.
There is no special conduction path between SA and AV
nodes. The bundle of His is the only normal
atrioventricular muscle connection but abnormal
pathways can occur anywhere except the area known as
the aortomitral continuity. The blood supply to the AV
node is from the posterior descending coronary artery.

151. The following is/are true concerning the physiology of

arrhythmias:

a. A physical or electrical stimulus causes sodium fast

channels and calcium slow channels to open
b. During the effective refractory period, only the slow
calcium channels are closed
c. Rapid repolarization follows potassium egress from the
cell
d. Extracellular hypokalemia increases sodium channel
size increasing automaticity
e. Catecholamines increase outward potassium flow from
myocytes
Answer: a, c, d

Physical or electrical stimuli cause sodium fast channels

and calcium slow channels to open. During the effective
refractory period, both slow calcium channels and fast
sodium channels are closed and the myocardium cannot
be excited. Then potassium channels reopen, allowing
potassium out, and rapid repolarization occurs.
Extracellular hypokalemia increases transmembrane
potassium gradient and sodium channel size increasing
automaticity. Catecholamines decrease outward
potassium flow from myocytes enhancing automaticity.

152. A 72-year-old man has had several episodes of

ventricular tachycardia and is a candidate for
electrophysiological (EP) study. The following is/are true:

a. The goal of the EP study is either sustained or non-

sustained ventricular tachycardia
b. Patients with less than 5 repetitive complexes in
response to stimulation are considered noninducible
c. An induced reentry from ventricular stimulation is not
necessarily pathological
d. Microreentry arrhythmias are typical after myocardial
infarction
e. Macroreentry arrhythmias are typical of myocardial
ischemia
Answer: a, b

For arrhythmias of ventricular origin, the EP study goal is

either sustained or nonsustained ventricular tachycardia.
Patients with less than five repetitive complexes in
response to stimulation are considered noninducible.
Ventricular reentry does not occur in normal myocardium,
so all reentrant arrhythmias are pathological.
Macroreentry arrhythmias are typical after myocardial
infarction, while microreentry arrhythmias are typical of
myocardial ischemia.

153. A 29-year-old male with supraventricular

tachyarrhythmias is suspected to have Wolff-Parkinson-
White (WPW) syndrome. The following is/are true:

a. Electrophysiologic studies (EPS) will require catheters

in or at the right atrium, His bundle, right ventricle and
coronary sinus
b. Pacing for EPS uses stimuli twice the diastolic
threshold
c. The anomalous conducting bundle (Kent) is found in the
right free wall if the coronary sinus catheter records the
earliest atrial activity during reciprocating tachycardia
d. If the atrial catheter records the earliest activity during
tachycardia, the bundle of Kent is located in the left free
wall
e. If neither left or right bundle-branch block prolong the
VA interval, the anomalous bundle is in the septum
Answer: b, e

For supraventricular arrhythmias, EPS requires catheters

placed in the right atrium and ventricle, coronary sinus
and His bundle. A programmable stimulator is used for
stimuli that are twice the diastolic threshold and 2 msec
in duration. When the coronary sinus catheter records the
earliest activity during reciprocating tachycardia, the
bundle of Kent is in the left free wall while it is in the right
free wall if the earliest activity is in the atrial catheter.
When neither left or right bundle-branch block prolong the
VA interval, the bundle is in the septum.

154. A 62-year-old woman whose arrhythmia is

noninducible at EP study has depressed LV function
without aneurysm. The following is/are true:
a. If her arrhythmia is ventricular tachycardia, she is not a
candidate for an Automatic Implantable Cardiac
Defibrillator (AICD) since it only recognizes fibrillation
b. If an AICD is appropriate, it offers a 50% improvement
in mortality compared to drug therapy
c. Poor ventricular function is a contraindication to AICD
implantation
d. AICD should not be used for patients awaiting cardiac
transplantation
e. AICD can provide antitachycardia pacing as well as
defibrillation
Answer: b, e

The AICD is capable of recognizing ventricular

tachycardia as well as fibrillation and can provide
antitachycardia pacing, low or high-energy defibrillation
or some combination. It offers a 50% improvement in
mortality with 95% freedom from SCD at 5 years after
implantation. Neither poor ventricular function nor
pending transplantation are contraindications to AICD
implantation.

155. A 27-year-old surgery resident has had multiple

episodes of supraventricular tachycardia (SVT) and on EP
study is felt to have WPW syndrome. The following is/are
true:
a. The pathophysiology of WPW is a single bundle of Kent
b. Dangerous ventricular responses in WPW are due to the
shorter refractory period of the accessory pathway
c. Identification of the accessory pathway of WPW is an
indication for its interruption
d. Approximately half of the patients who have successful
division of accessory pathways demonstrate VA block
postop
e. Both radiofrequency catheter and surgical ablation
offer excellent results with low morbidity
Answer: b, d, e

The pathophysiology of WPW is the Kent bundle of which

10–20% are multiple rather than single. The shorter
refractory periods permit rapid and dangerous ventricular
responses to atrial flutter or fibrillation. In 0.25% of the
population, accessory pathways of WPW can be identified,
but in the absence of a history of SVT, they have a normal
life expectancy. Approximately half the patients who have
successful division of accessory pathways demonstrate
VA block postop. Both radiofrequency catheter and
surgical ablation offer excellent results with low
morbidity and the catheter technique is less costly.

156. In the pharmacological management of cardiac

arrhythmias, the following is/are true:
a. Membrane-stabilizing local anesthetics (Class 1) act via
sodium channel blockage
b. Class 1 drugs also shorten the refractory period
c. b-blocking drugs (Class 2) block the sympathetic
nervous system but not circulating catecholamines and
Class
d. Bretylium and other Class 3 drugs inhibit potassium
influx into cells
e. Calcium channel blockers (Class 4) directly affect the
SA and AV nodes
Answer: a, d, e

Class 1 drugs are local anesthetics that act via sodium

channel blockade, and lengthen the refractory period.
Class 2 b-blocking drugs inhibit both the sympathetic
nervous system and circulating catecholamines. Class 3
drugs inhibit potassium influx into cells 4 drugs affect
slow channel-dependent pacemaker tissue (SA and AV
nodes).
1. The bronchial circulation:
A. Is the blood supply to the conducting airways.
B. Drains into a peribronchial venous network that may
expand considerably with conditions such as bronchiectasis
and chronic obstructive pulmonary disease.
C. Is an especially important consideration in pulmonary
transplantation.
D. All of the above.
Answer: D

DISCUSSION: The bronchial circulation is the primary blood

supply for the conducting airways, pulmonary vessels,
lymphoid tissue, and squamous cell carcinomas. In
conditions such as mitral stenosis, bronchiectasis, or
chronic obstructive pulmonary disease, the rich
peribronchial venous network that drains the bronchial
circulation may expand considerably, creating significant
left-to-right shunts. Whenever the pulmonary artery
circulation is obstructed, there is a tendency for bronchial
circulation to increase; thus, the bronchial circulation is an
important consideration during lung transplantation as well
as in the surgical treatment of cyanotic congenital heart
disease and chronic pulmonary embolism.

2. Clearance of mucus produced in the tracheobronchial tree

in chronic bronchitis secondary to smoking may:
A. Be hampered by the fact that the amount of mucus is
increased by the number of mucus-producing cells at the
expense of ciliated cells.
B. Be slowed if patients have decreased lung volume and are
therefore unable to generate a vigorous cough that would
cause an inflammatory process.
C. Cause a decrease in diffusion capacity and associated
hypoxemia.
D. All of the above.
Answer: A

DISCUSSION: Chronic bronchitis may have an acute

component, and in these patients therapy with antibiotics
and bronchodilators may improve the flow rate as measured
by pulmonary function tests within 3 or 4 days of the
cessation of smoking and treatment of the acute condition.
However, the chronic bronchitic will continue to produce
large amounts of mucus, most evident in the morning, even
after the acute process has been resolved. Clearance of
these secretions is hampered by the inability to cough,
perhaps secondary to the pain of thoracotomy or abdominal
surgery or by a decrease in the number of ciliary cells that
help move mucus up the tracheobronchial tree. This causes
plugging of small airways and atelectasis, which may
progress to pneumonia. For this reason, cessation of
smoking for 3 to 5 days before surgery is very beneficial in
preventing pulmonary complications during the
postoperative period.
3. The pulmonary circulation:
A. Is the only vascular system in which the veins do not
have the same course as the arteries.
B. Has a direct connection of vein to adjacent lung tissue by
connective tissue fibers, making the diameter of the tissue
fibers dependent upon lung volume.
C. Supplies the metabolic needs of the alveoli.
D. All of the above.
Answer: C

DISCUSSION: Pulmonary artery circulation transports

oxygenated blood to the alveoli level where gas exchange
occurs, and it is here that the matching of ventilation and
perfusion is so important during the postoperative period.
The loss of lung volume that generally occurs after all
surgical procedures does not return to baseline for 5 to 7
days and may play an important role in the ventilation-
perfusion ratio. Improving or returning lung volume to normal
is performed by manipulating functional residual capacity
(FRC) and preventing atelectasis, which in turn maintains
circulation to the alveolus and optimizes the ventilation-
perfusion ratio.

4. Which of the following screening tests are important for

preoperative evaluation of pulmonary function?
A. History and physical examination.
B. Room air arterial blood gases.
C. Chest film.
D. Vital capacity and forced expiratory volume in 1 second
(FEV 1).
E. Cardiopulmonary exercise testing.
Answer: ABCDE

DISCUSSION: The most important clues to impairment of

respiratory function are found in the history and physical
examination. A negative history and physical examination in
combination with a relatively normal room air arterial blood
gas and normal chest film are sufficient to screen patients
to support the clinical impression that there is minimal
pulmonary disease. Patients with symptoms, positive
physical findings, and/or abnormalities in the arterial blood
gases or chest film can be screened most effectively with an
additional evaluation of the vital capacity and FEV 1. More
elaborate tests such as cardiopulmonary exercise testing
are reserved for patients with obvious and marked
impairment of pulmonary function who are being evaluated
for the feasibility of surgical intervention.

5. Carbon monoxide diffusion capacity (DLCO) has been

shown to correlate with:
A. The thickness of the alveolar lining membrane.
B. The permeability of the erythrocyte to carbon dioxide.
C. Pulmonary emboli.
D. Total alveolar-capillary capacity.
Answer: ABCD

DISCUSSION: The single-breath DLCO is a screening test

that has been shown to be decreased in all of the above
examples. It is an estimate of the total capacity of the
functional alveolar microarchitecture and has been
demonstrated to be an independent measure of physiologic
capability apart from the FEV 1 and forced ventilatory
capacity.

6. The closing volume is:

A. The volume remaining in the lung at the end of expiration
below which alveolar collapse begins to occur, resulting in
physiologic shunting.
B. Higher in young persons.
C. Not changed during surgery.
D. Relative to the oxygen content of mixed venous blood.
Answer: AC

DISCUSSION: The closing volume is conceptually the

remaining lung volume at the end of expiration below which
alveolar collapse begins to occur, causing intrapulmonary
right-to-left shunting and thus desaturation of blood in the
left atrium. In a normal young person this closing volume is
well below the functional residual capacity (FRC); thus, such
physiologic shunting does not occur until there is a
decrease in the elastic properties of the lung. Although FRC
gradually increases with age, so does the effective closing
volume. Eventually some alveoli are being underventilated
(at end-expiration), allowing physiologic right-to-left
shunting to occur. Closing volume is unchanged, but FRC
decreases during surgery (i.e., shunting occurs). Closing
volume has no direct relationship to the oxygen content of
the mixed venous blood.

7. The effect of high positive end-expiratory pressures

(PEEP) on cardiac output is:
A. None.
B. Increased cardiac output.
C. Decreased cardiac output because of increased afterload
to the left ventricle.
D. Decreased cardiac output because of decreased effective
preload to the left ventricle.
Answer: D

DISCUSSION: Higher levels of PEEP can be associated with

decreases in cardiac output as a consequence of an
effective decrease in the preload to the left ventricle owing
to impaired left ventricular filling.

8. Weaning patients from maximum ventilator support

usually involves:
A. Weaning PEEP first, tidal volume second, and the fraction
of inspired oxygen (FIO 2) third.
B. Weaning FIO 2 first, ventilator rate second, and PEEP
third.
C. Weaning FIO2 first, PEEP second, and tidal volume third.
D. Weaning FIO 2 first, PEEP second, and ventilator rate
third.
Answer: D

DISCUSSION: When the inspired oxygen concentration is

greater than 60% for more than 24 to 28 hours, the risk of
oxygen toxicity increases. PEEP is usually weaned to
physiologic levels (i.e., 5 to 7 cm. H 2O) before weaning
either rate or tidal volumes. Generally, the optimal tidal
volume to achieve alveolar recruitment is selected and
usually is not decreased unless peak airway pressures
increase. If decreases in ventilatory rate are not tolerated,
airway pressure support can be added.

9. Which of the following statements about bronchoscopy is

false?
A. The morbidity and mortality are approximately 0.2% and
0.08%, respectively.
B. The most common complications of bronchoscopy are
related to premedication of patients.
C. Adjunctive cancer therapy such as laser treatment and
brachytherapy may be administered via this route.
D. A chronic cough and unilateral wheezing are accepted
indications for bronchoscopy.
E. Early postoperative bronchoscopy for atelectasis is
contraindicated following pulmonary resection.
Answer: E

DISCUSSION: The stated complication rates are true and

reported from a comprehensive review of over 24,000
patients. Although the most common complications are
related to the premedication, significant hemorrhage,
pneumothorax, bronchospasm, and dysrhythmias have been
reported. In addition to laser and brachytherapy,
phototherapy and immunotherapy have been given by
bronchoscopy. Unilateral wheezing may represent a
bronchial foreign body, and a chronic cough could signify
myriad pulmonary disorders. Accordingly, both are amenable
to diagnostic bronchoscopy. Most thoracic surgeons favor
early bronchoscopy for lobar atelectasis following
pulmonary surgery.

10. Flexible bronchoscopy is preferred over rigid

bronchoscopy for all of the following except:
A. Patients with cervical spine injuries requiring intubation.
B. The evaluation of a smoke inhalation injury.
C. Transcarinal needle aspiration of an enlarged subcarinal
lymph node.
D. The removal of a bronchus intermedius foreign body from
an infant.
E. A cost-effective evaluation of mild hemoptysis.
Answer: D

DISCUSSION: Neither patients with significant cervical spine

disease or injuries nor those with large aortic arch
aneurysms should undergo rigid bronchoscopy, given the
greater risk of complications. Even if severe, smoke
inhalation injury can be assessed adequately by flexible
bronchoscopy. Transbronchial needle aspiration of lesions
that on computed tomography (CT) look suspicious is safe
and quite easily performed with fluoroscopic guidance.
Hemoptysis as a presenting symptom should be evaluated
by flexible bronchoscopy. In contrast, for massive
hemoptysis an airway should be secured for ventilation with
a rigid bronchoscope. Similarly, an airway needs to be
maintained while removing endobronchial foreign bodies
from infants or children. Since adequate port sites for
instrumentation are also needed, the rigid bronchoscope is
preferred in this setting.

11. Which of the following approaches is/are currently

acceptable for the management of spontaneous
pneumothorax?
A. Chest tube replacement alone for the patient with a first
episode.
B. Operation on presentation for any patient with a first
episode.
C. Video-assisted thoracic surgery (VATS) bleb excision and
pleurodesis for recurrent pneumothorax on the same side.
D. Thoracotomy with bleb excision and pleurodesis for
unilateral recurrent pneumothorax.
E. Operation after a first episode in an airline pilot.
Answer: ACDE

DISCUSSION: Primary spontaneous pneumothorax typically

occurs in young patients with congenital blebs at the apices
of the lungs. Rupture of these blebs causes pneumothorax,
which recurs in about 30% of patients. Standard care on
initial presentation is chest tube placement alone. Operation
traditionally has been performed during the initial episode
only if there is prolonged air leakage (longer than 7 days); in
patients with bilateral pneumothorax; those who live in an
area where prompt medical care, if needed, is not available;
and those frequently exposed to extremes of pressure (e.g.,
airline pilots). Both VATS and thoracotomy approaches to
excision of blebs and pleurodesis have been shown to be
effective. The availability of the apparently safer VATS
approach has led some to favor earlier operation.

12. For which patient(s) with a pulmonary infiltrate of

uncertain cause would you favor VATS over open wedge
excision?
A. An AIDS patient with a diffuse infiltrate who is ambulatory
but requires supplemental oxygen. Bronchoalveolar lavage
is negative.
B. A 64-year-old previously healthy man with increasing
shortness of breath, a diffuse infiltrate, and restrictive lung
disease as shown by pulmonary function studies.
C. A 74-year-old diabetic woman with a rapidly progressing
process throughout the right lung who is ventilator- and
pressor-dependent.
D. A 44-year-old man with fever, left-sided infiltrate, and
shortness of breath.
E. A 79-year-old man on a ventilator for right lower and
middle lobe pneumonia which has been culture negative.
Answer: ABD

DISCUSSION: Lung biopsy by VATS or minithoracotomy is

often indicated in the work-up of a pulmonary infiltrate that
has not been successfully diagnosed by less invasive
studies. This procedure probably is not indicated for cancer
patients with acute pneumonitis, as broad-spectrum
antibiotics frequently are successful treatments. For those
who do require the procedure, the choice between VATS and
thoracotomy is determined by the severity of illness. In
those who are critically ill and ventilator dependent,
changing the tube to an endobronchial tube for
thoracoscopy may be risky, and in these cases an anterior
thoracotomy with single-lumen ventilation is indicated.
These patients, who are frequently heavily sedated and are
likely to remain so for some time postoperatively, are
unlikely to benefit from the greatest advantage of VATS, the
reduction of postoperative pain. It is, then, the ambulatory
patient with a chronic interstitial process who benefits the
most from the VATS approach.

13. Which of the following statements about the cause and

prevention of postintubation tracheal stenosis are correct?
A. Postintubation airway stenosis can largely be avoided by
providing assisted ventilation via endotracheal tube rather
than tracheostomy tube.
B. Postintubation tracheal stenosis at the cuff level results,
more or less equally, from low blood pressure, advanced
age, steroids, high intracuff pressure, sensitivity to tube
materials, gas sterilization elution products, and systemic
disease.
C. In women and smaller men large endotracheal tubes can
produce lesions of the glottis and subglottis that can
progress to stenosis.
D. Stomal stenosis is due principally to cicatricial closure of
large stomas resulting from removal of a disk or segment of
tracheal wall during tracheostomy.
E. A large-volume tracheostomy tube cuff such as that now
used on most available tubes can become a high-pressure
cuff if filled beyond its resting maximal volume.
Answer: CE

DISCUSSION: Use of an endotracheal tube, of course, avoids

a stoma and related complications. Cuff lesions, however,
are incurred from cuffs on endotracheal tubes,
cricothyroidostomy tubes, and tracheostomy tubes. A cuff is
the common factor. Endotracheal tubes, on the other hand,
cause erosion at the level of the glottis and subglottis, in
particular. Although many factors may play some role in the
origin of airway stenosis, the principal factor is pressure
necrosis of the mucosa, submucosa, and ultimately of the
cartilage, with subsequent cicatrization. Large endotracheal
tubes do, indeed, cause necrosis and airway injury at narrow
areas in the upper airway, at glottic and cricoid levels. Such
injuries lead to posterior commissure stenosis, arytenoid
fixation, vocal cord erosion and granulomas, anterior
commissure stricture, and subglottic circumferential
stenosis. While excision of a large amount of tracheal wall
can lead inevitably to healing by contraction with narrowing
of the tracheal circumference, the most usual cause of
stomal stenosis is erosion of the stoma by pressure from the
tracheostomy tube. This in turn may relate to leverage by
equipment. Additional factors appear to be subsidiary. A
large volume, low pressure tracheostomy tube cuff, such as
those currently available, if properly constructed, will seal
the trachea before it is necessary to stretch the cuff by
adding an increasing volume of air. If the cuff is stretched
beyond that resting volume, which usually occludes the
normal trachea, high pressures will develop because the
plastic material from which all of these cuffs are now made
is not very extensible. Therefore, the pressure-volume curve
rises sharply once the limit of unstretched volume is passed.
A low-pressure cuff then becomes a high-pressure cuff.

14. Which of the following statements about the treatment

of postintubation airway stenosis are correct?
A. Emergency management of airway obstruction due to
stenosis at the level of a prior tracheal stoma is best
accomplished by establishing a new tracheostomy in normal
tracheal tissue just below the scar of the old stoma.
B. Radial lasering and dilatation usually leads to permanent
resolution of postintubation tracheal stenosis.
C. Splinting of a cervical trachea with a silicone T-tube for 6
to 8 months generally leads to permanent resolution of
stricture.
D. Postintubation tracheal stenosis that extends into the
subglottic larynx is treated by resection of a cylindrical
sleeve of stenotic airway and end-to-end reconstruction.
E. Acquired tracheoesophageal fistula due to intubation
injury is corrected by surgical closure of the fistula
concurrent with resection and reconstruction of the
damaged trachea.
Answer: E

DISCUSSION: Emergency management of postintubation

tracheal stenosis is accomplished by dilatation under
general anesthesia using rigid bronchoscopes and dilators.
Tracheostomy is employed only when the patient requires a
prolonged or a permanent airway before or instead of
resection and reconstruction. If a new tracheostomy is
needed it is preferable to place it through the area of
existing stenosis—in this case the site of prior
tracheostomy—rather than to injure normal trachea that will
be needed for resection and reconstruction. If the stenosis
is below the sternal notch, a long tracheostomy tube is
inserted at the usual position (second and third rings) but
extends past the now dilated stenotic lesion.
Lasering almost never results in a permanently satisfactory
airway; the exception is the very limited lesion described as
a thin, weblike stenosis. Such lesions are rare.
Unfortunately, laser is widely used and often compounds
existing damage by concurrent placement of a tracheostomy
tube below the lesion in the normal trachea. T-tubes are
very useful for temporizing when repair is not possible or
must be delayed. It almost never leads to resolution of a
stricture unless it is an extremely limited one. Soon after
removal of the T-tube the stricture reasserts itself.
If the lesion involves the subglottic larynx, complex repair is
required to preserve the recurrent laryngeal nerve's anatomy
and function. The posterior cricoid plate is salvaged and
resurfaced with a flap of membranous tracheal wall; the
anterior subglottic larynx is reconstructed with a “prow” of
distal tracheal cartilage and mucosa.
A tracheoesophageal fistula is managed (after weaning from
a respirator) by layered closure of the esophagus,
interposition of a flap of well-vascularized tissue (such as a
pedicled strap muscle), and resection and reconstruction of
the damaged trachea. Since the fistula results from the
pressure of a cuff, often against an esophageal feeding tube,
there is circumferential damage to the trachea at the level
of the fistula. Resection and reconstruction are therefore
necessary, in addition to closure of the fistula, for
successful treatment of this complex lesion.

15. Which of the following statements are true?

A. Pyogenic lung abscess occurs most frequently in the
lower lobe of the left lung.
B. Anaerobic bacteria are commonly present in pyogenic
lung abscess.
C. Operation is usually required to eradicate a pyogenic lung
abscess.
D. Penicillin is the treatment of choice for lung abscess.
Answer: BD

DISCUSSION: Pyogenic lung abscess is the result of

aspiration of debris from the oropharynx. Since most
patients are unconscious and supine when this occurs, the
aspirated material usually finds its way into the most
dependent bronchi. These are the superior division of the
right lower lobe and the posterior segment of the right upper
lobe. The organisms most commonly responsible for
pyogenic lung abscess are the same anaerobic bacteria
found in the mouths of patients with poor oral hygiene. In
addition to anaerobic organisms alpha- and beta-hemolytic
streptococci, staphylococci, nonhemolytic streptococci, and
Escherichia coli may be present. Gram-negative rods and
staphylococci are particularly common in hospital-acquired
infections. These organisms are almost always penicillin
sensitive. Surgical therapy is rarely necessary to eradicate a
pyogenic lung abscess. Penicillin, alone or in combination
with metronidazole, is the drug of choice. Metronidazole
alone probably lacks sufficient activity against anaerobic
and microaerophilic streptococci. Clindamycin is also
effective against most anaerobic bacteria present in
pyogenic lung abscesses.

16. Amphotericin B is effective for the following lung

infections:
A. Histoplasmosis.
B. North American blastomycosis.
C. Aspergillosis.
D. Mucormycosis.
E. Sporotrichosis.
Answer: ABD

DISCUSSION: Amphotericin B is effective against most

fungal infections, including histoplasmosis and North
American blastomycosis. Aspergillosis is caused by the
fungus Aspergillus fumigatus, an organism that is resistant
to treatment with iodides, nystatin, hydroxystilbamidine, and
amphotericin B. The treatment for this fungal infection is a
surgical procedure, if the patient's condition permits.
Surgical excision and amphotericin B usually are necessary
to treat mucormycosis. Itraconazole is the drug of choice for
sporotrichosis. Itraconazole, ketoconazole, and fluconazole
should be considered as primary or secondary drugs when
treating systemic fungal infections.

17. The following statements are true.

A. A distinguishing roentgenographic appearance of lung
abscess, the air-fluid level can be seen only on
roentgenograms obtained in the upright or lateral decubitus
position.
B. The fungus ball characteristic of aspergillosis can be
seen roentgenographically in either the upright or
recumbent position.
C. Actinomycosis and nocardiosis are both fungal diseases
of the lung that respond to treatment with the newer azole
antifungal agents.
D. The commonest fungal lung infection in the United States
is due to Histoplasma capsulatum.
Answer: ABD

DISCUSSION: An air-fluid level distinguishes a lung abscess.

While this can be seen easily in an upright or lateral
decubitus roentgenogram, it cannot be seen when the
patient is recumbent. The fungus ball characteristic of
aspergillosis is identified by its crescent-shaped shadow on
a roentgenogram. When the patient changes from an upright
to recumbent position, the fungus ball may also change
position in the cavity in the lung. Both actinomycosis and
nocardiosis are bacterial infections and do not respond to
antimycotic treatment. Actinomyces israelli is treated with
penicillin and Nocardia asteroides is sensitive to
trimethoprim-sulfamethoxazole. The most common fungal
infection in North America is histoplasmosis. More than 30
million people have been infected, most of whom are
asymptomatic.

18. Pneumocystis pneumonia is an opportunistic infection

caused by Pneumocystis carinii. Which of the following
statements are true?
A. P. carinii is a fungus.
B. Pneumocystis pneumonia is the most common
opportunistic infection in patients with AIDS.
C. The diagnosis of Pneumocystis pneumonia depends on
the demonstration of P. carinii organisms in lung tissue.
D. There is no effective treatment for Pneumocystis
pneumonia.
Answer: BC

DISCUSSION: P. carinii is a protozoan that stains with silver

methenamine and resembles a fungus. It responds to
antiprotozoal drugs. Pneumocystis pneumonia occurs in 80%
of AIDS patients. The diagnosis is made by demonstrating
the organisms in lung tissue by transbronchoscopic lung or
brush biopsy, percutaneous needle biopsy, or open lung
biopsy. Both trimethoprin-sulfamethoxazole and pentamidine
isethionate are effective against P. carinii.

19. Which of the following statements are true?

A. The pleural space does not extend into the neck.
B. Positive intrapleural pressures as high as 40 cm. H 2O
and negative pressures as low as -40 cm. H 2O are possible.
C. The pleural cavities cannot absorb more than 500 ml. of
fluid per day.
D. All pleural effusions are of clinical significance and
should be investigated.
Answer: BD

DISCUSSION: The pleural spaces extend into the neck as

well as retrosternally and into the costophrenic sinuses.
This should be kept in mind when performing procedures
such as subclavian and jugular puncture, to avoid
pneumothorax. Markedly elevated intrapleural pressures are
obtained with the Valsalva maneuver, and extreme negative
pressures can be produced with forced inspiratory effort
against a closed glottis. Because of the many microvilli
present on the mesothelial cells that line the pleural cavity,
a liter or more of fluid is easily secreted or absorbed within
a 24-hour period. Most pleural effusions are caused by
infection, tumor, or congestive heart failure and should be
investigated to determine the proper course of management.

20. Which of the following statements are true?

A. Chylothorax, or chyle in the pleural cavity, usually is not a
serious condition.
B. Chyle is easily identified by its milky appearance, which
looks like no other kind of pleural effusion.
C. The commonest causes of chylothorax are trauma and
tumor.
D. The thoracic duct can be ligated with impunity.
Answer: CD

DISCUSSION: Chylothorax is most often the result of trauma;

however, spontaneous chylothorax is also a manifestation of
tumor and should be investigated to identify occult
malignancies. Chyle in the thorax is characteristically milky
white but can be mistaken for the pseudochylothorax of
rheumatoid disease or tuberculosis. If necessary, a
diagnosis can be confirmed by lymphangiography. This also
facilitates ligation of the thoracic duct, should this become
necessary to control the loss of chyle.

21. Which of these statements about pleural tumors is/are

true?
A. The commonest type of pleural tumor is primary pleural
mesothelioma.
B. Exposure to asbestos dust is causally related to the
development of malignant mesothelioma.
C. Localized benign mesotheliomas are asymptomatic.
D. Complete pleurectomy for malignant mesothelioma
usually results in cure.
Answer: B

DISCUSSION: Pleural involvement by metastatic disease is

much more common than primary pleural tumors. Patients
with localized benign pleural mesotheliomas may have
symptoms of arthralgia, clubbing of the fingers, or fever,
which usually disappear after excisional surgery. The
evidence relating industrial exposure to asbestosis and
malignant pleural mesothelioma is quite strong. Excisional
surgery for malignant mesothelioma is usually only
palliative. Most patients succumb within 1 to 2 years of the
diagnosis, regardless of the kind of treatment they receive.

22. Which of the following correctly describe a patient with

spontaneous pneumothorax?
A. The patient is almost always elderly and debilitated.
B. An unsuspected primary or metastatic lung tumor may be
present.
C. The administration of supplemental oxygen is of little
benefit to the patient.
D. The patient should always be treated with an intercostal
tube and closed pleural drainage.
E. Video-assisted thoracic surgery (VATS) should be
considered for persistent air leak in patients with secondary
spontaneous pneumothorax.
Answer: BE

DISCUSSION: A patient with spontaneous pneumothorax

may be old and debilitated, but the typical patient is an
otherwise healthy young adult, usually one who smokes. An
incidental, unsuspected lung cancer is discovered on rare
occasions when operation is performed to control a
persistent air leak. Perhaps smoking is a common factor.
Absorption of air from the pleural space can be facilitated by
the administration of supplemental oxygen. Increasing the
oxygen tension lowers the partial pressure of nitrogen (P N2)
of the capillary blood and increases the partial pressure
difference between the pleural space and the pulmonary
capillary. If the pneumothorax results in less than 20%
collapse of the lung an asymptomatic patient can be safely
observed; however, a larger or persistent pneumothorax is
best treated with an intercostal tube thoracostomy. Patients
with bullous emphysema may require stapling of bullae and
pleurectomy, which can be done by open thoracotomy or
thoracoscopically (VATS).

23. Which of the following statements about spontaneous

pneumothorax (PSP) is/are correct?
A. The risk of recurrence after resolution of the first episode
of PSP or secondary spontaneous pneumothorax (SSP) is
35% to 45%.
B. Patients with PSP are typically tall, thin, young adult
males with a history of smoking.
C. Secondary spontaneous pneumothorax is associated with
family history in 10% of cases.
D. For bleb resection and pleurodesis thoracoscopic
thoracotomy and open thoracotomy provide similar cure
rates for patients with primary spontaneous pneumothorax.
E. Causes of secondary pneumothorax include trauma and
iatrogenic needle puncture.
Answer: ABD

DISCUSSION: Patients with PSP are usually 20- to 40-year-

old males with a common long-chested body habitus. The
majority of PSP patients have a history of tobacco use and
10% have a family history of PSP. The majority of cases of
SSP are due to advanced emphysema in a population of
patients aged 50 to 70 years. Additional causes of SSP
include tuberculosis, cystic fibrosis, P. carinii infection, lung
cancer, and lung abscess. For patients with PSP bleb
resection and pleurodesis performed thoracoscopically
provides cure rates similar to those of open thoracotomy.
Because of the nature of underlying pulmonary diseases,
open thoracotomy appears to provide better results for
patients with SSP.
24. Which of the following are relative contraindications for
surgical management of emphysema?
A. Rapidly progressive dyspnea.
B. Bullae occupying less than one third of a hemithorax on
plain chest radiography.
C. Elevated room air PCO 2.
D. “Pink puffer” patients.
E. FEV 1 less than 35% of predicted value.
Answer: BCE

DISCUSSION: Relative contraindications to operation for

bullous emphysema include patients with carbon dioxide
retention, FEV 1 less than 35% of predicted value, small
bullae that occupy less than one third of a hemithorax, and
“blue bloaters,” who are prone to the sequelae of chronic
bronchitis. Patients who have primarily emphysema (“pink
puffers”) and rapidly progressive dyspnea are usually good
candidates for operation.

25. Which of the following treatments would be appropriate

therapy for symptoms that persist on medical therapy and
bronchiectasis involving, in order of decreasing severity, the
left lower lobe, the right middle lobe, and the left upper
lobe?
A. Left pneumonectomy.
B. Wedge resection of the left lower lobe.
C. Left lower lobectomy.
D. Simultaneous left lower lobectomy and right middle
lobectomy.
Answer: C

DISCUSSION: Pneumonectomy is seldom indicated today for

bronchiectasis. Anatomic resection of involved segments
with either segmentectomy or lobectomy is preferred to
nonanatomic wedge resection. Bilateral pulmonary
resections should generally be done as staged procedures,
the most symptomatic side being resected first. Then, the
contralateral side is resected only if symptoms persist
during a prolonged course of medical therapy.

26. Which of the following would not be acceptable

sequences of preoperative studies in a patient being
prepared for lingulectomy for bronchiectasis?
A. CT alone.
B. CT, bronchoscopy, bronchography.
C. Bronchoscopy alone.
D. Bronchoscopy, bronchography.
Answer: C

DISCUSSION: Bronchoscopy alone is generally not

diagnostic for bronchiectasis. Thin-section, high-resolution
CT can diagnose bronchiectasis and define the airway
anatomy sufficiently for resection. Bronchography is
performed less frequently today but can be very useful in
diagnosing bronchiectasis and defining airway anatomy for
pulmonary resection.

27. Which of the following statements about pulmonary

mycobacterial infection is/are correct?
A. Worldwide, tuberculosis no longer represents a significant
public health problem.
B. Mycobacterium tuberculosis is responsible for the
majority of cases of pulmonary mycobacterial disease.
C. Mycobacterium kansasii pulmonary infection almost
always requires surgical treatment.
D. Atypical mycobacteria are never primary pulmonary
pathogens in humans.
E. Mycobacterium avium-intracellulare is generally resistant
to most antimycobacterial drugs in vitro.
Answer: BE

DISCUSSION: Tuberculosis remains the leading infectious

killer in the world today. M. tuberculosis is responsible for
the vast majority of pulmonary mycobacterial disease. M.
kansasii infection responds to multiple drug chemotherapy
and relatively infrequently requires surgical treatment.
Atypical mycobacteria can be primary pulmonary pathogens
in humans. M. avium-intracellulare is usually resistant in
vitro to most antituberculosis drugs.
28. Which of the following chemotherapeutic regimens are
currently recommended for the treatment of pulmonary
infection caused by M. tuberculosis?
A. Isoniazid, rifampin, pyrazinamide, and streptomycin for 24
months.
B. Isoniazid for 9 months with ethambutol for the first 3
months.
C. Isoniazid and rifampin for 6 months with pyrazinamide
added for the first two months.
D. Isoniazid alternating with rifampin at 3-month intervals for
12 months.
E. Isoniazid and rifampin for 9 months.
Answer: CE

DISCUSSION: Treatment of tuberculosis with a single drug

leads to rapid emergence of drug-resistant organisms. Any
treatment regimen that employs only one drug for a period of
time encourages the development of drug-resistant
tuberculosis. Currently, the American Thoracic Society
recommends either (1) a 6-month regimen consisting of
isoniazid, rifampin, and pyrazinamide for 2 months followed
by isoniazid and rifampin for 4 months or, alternatively, (2) a
9-month course of isoniazid and rifampin. Prolonged courses
of treatment beyond 9 to 12 months no longer are
considered necessary.
29. Which of the following are appropriate indications for
pulmonary resection for mycobacterial disease?
A. Localized pulmonary disease caused by M. avium-
intracellulare.
B. Advanced lobar tuberculous pneumonia with massive
hilar lymphadenopathy and bronchial obstruction in a young
child.
C. Localized pulmonary disease due to multiple drug–
resistant M. tuberculosis.
D. An asymptomatic tuberculous cavity greater than 12 cm.
in diameter.
E. Massive hemoptysis from a right upper lobe cavity
occurring during an appropriate course of chemotherapy for
pulmonary tuberculosis in a sputum-negative patient.
Answer: ACE

DISCUSSION: Modern antimycobacterial chemotherapy is

very effective. Surgical treatment of pulmonary
mycobacterial disease is rarely necessary; however,
pulmonary disease caused by M. avium-intracellulare or
multiple drug–resistant M. tuberculosis is not likely to
respond to chemotherapy and should be resected if the
disease is localized. Chemotherapy for tuberculosis is
almost invariably curative in children, regardless of the
extent of disease. The size of a tuberculous cavity is not an
indication for resection. Massive hemoptysis from a cavitary
lesion is life threatening and is an indication for pulmonary
resection.
30. Which statements about squamous papillomatosis of the
trachea is/are correct?
A. It is the most common type of benign tracheal tumor in
adults.
B. It is the most common type of benign tracheal tumor in
children.
C. Most are treated with segmental tracheal resection.
D. There is no risk of malignant degeneration.
E. It is associated with a herpesvirus.
Answer: A

DISCUSSION: Squamous papillomatosis is the most common

benign tracheal and bronchial tumor in adults. Up to 50% of
untreated lesions may degenerate into squamous cell
carcinoma. The lesion is associated with human
papillomavirus types 6 and 11, and therefore, interferon
therapy is under investigation. Most patients can be treated
successfully by repeated bronchoscopic fulguration, laser
ablation, or cryotherapy.

31. Which of the following statements about pulmonary

hamartomas is/are true?
A. Hamartomas are benign chondromas.
B. Most are located in the conducting airways.
C. Wedge resection is curative.
D. A lobectomy is necessary to obtain draining hilar lymph
nodes.
E. Hemoptysis is common.
Answer: C

DISCUSSION: Pulmonary hamartomas are benign masses

consisting of cartilage, lymph tissue, fat, and epithelial
elements. Eighty per cent are located in the lung periphery
and are treated by a small wedge resection, usually with a
thoracoscope. Most are asymptomatic, and there is no risk
of malignant degeneration.

32. Which of the following statements about typical

carcinoid tumors are true?
A. They make up the majority of bronchial adenomas.
B. They frequently have lymph node metastases.
C. The carcinoid syndrome is observed in 33%.
D. Overall survival at 5 years is 90%.
E. Overall survival at 5 years is 50%.
Answer: AD

DISCUSSION: Eighty-five per cent of bronchial adenomas are

carcinoid tumors. Typical carcinoid tumors have few mitotic
figures and infrequent lymph node metastases (fewer than
10%). Only 10% to 15% of patients present with the
carcinoid syndrome (flushing, wheezing, diarrhea). Survival
after resection is more than 90% at 5 years but decreases to
approximately 50% for atypical histology.

33. Which is/are true of adenoid cystic carcinoma?

A. It is a common type of salivary gland tumor.
B. Another name is cylindroma.
C. Most patients are completely resected for cure.
D. Different histological types have different prognoses.
E. Tissue invasion is rare.
Answer: ABCD

DISCUSSION: Adenoid cystic carcinomas (cylindromas) are

commonly observed salivary gland tumors that can occur in
the conducting airways. The undifferentiated solid type is
associated with distant metastases, of which the cribriform
and tubular types are associated with perineural and
submucosal invasion. Most patients (60%) can be resected
for cure.

34. A solitary pulmonary nodule is discovered in an

asymptomatic 55-year-old smoker with no evidence of
extrathoracic dissemination. The most appropriate
management would be to:
A. Obtain serial chest films every 3 months to determine the
growth potential of the nodule.
B. Perform transthoracic needle aspiration (TTNA) before
considering pulmonary resection to confirm malignancy.
C. Conduct an extensive systematic evaluation to exclude
the possibility that the nodule represents a metastatic
lesion.
D. Proceed with pulmonary resection after ascertaining that
the patient would tolerate removal of the requisite amount
of lung.
E. Obtain baseline serum levels of carcinoembryonic antigen
and p53.
Answer: D

DISCUSSION: A patient with a solitary pulmonary nodule—a

single spherical lesion within the lung— represents an
important and challenging diagnostic problem in thoracic
oncology. A solitary pulmonary nodule is assumed to be
primary lung cancer until proved otherwise; the differential
diagnosis includes metastatic carcinoma, granuloma, and
benign pulmonary tumors. In most cases, solitary pulmonary
nodules should be resected after thorough investigation to
establish that systemic dissemination has not already
occurred. CT of the chest, liver, and adrenals is performed to
confirm the location of the tumor, to evaluate the
mediastinum, and to assess the abdomen for systemic
disease. If there is no evidence of metastases on CT, the
patient should undergo bronchoscopy, which may establish
the histologic diagnosis and determine resectability if an
endobronchial lesion exists.
Pulmonary function studies are obtained preoperatively to
assess the potential for pulmonary resection. A thorough
review of systems is undertaken to rule out medical
contraindications to thoracotomy. TTNA is not performed
routinely and should be reserved for patients with marginal
pulmonary function, for whom thoracotomy would be
performed only after verification of a malignant histologic
diagnosis.

35. After thoracotomy, pulmonary resection, and mediastinal

lymph node dissection, a patient is determined to have a
squamous cell carcinoma 2 cm. in diameter, located 1 cm.
from the carina along the right mainstem bronchus. Three
peribronchial lymph nodes are positive for cancer, and all
other lymph node stations are negative. The correct stage,
according to the TNM system, is:
A. T1N0M0 Stage I.
B. T1N1M0 Stage II.
C. T2N1M0 Stage II.
D. T3N1M0 Stage IIIa.
E. T2N3M0 Stage IIIb.
Answer: C

DISCUSSION: The TNM staging system for carcinoma of the

lung provides a consistent, reproducible description of the
anatomic extent of disease at the time of diagnosis. In the
TNM system, T represents the primary tumor and numerical
suffixes describe increasing size or involvement; N
represents regional lymph nodes with suffixes to describe
levels of involvement; and M designates the presence or
absence of distant metastases.
TUMOR (T)
TX Occult carcinoma (malignant cells in sputum or bronchial
washings but tumor not visualized by imaging studies or
bronchoscopy)
T1 Tumor 3 cm. or less in greatest diameter, surrounded by
lung or visceral pleura, but not proximal to a lobar bronchus
T2 Tumor larger than 3 cm. in diameter, or with involvement
of main bronchus at least 2 cm. distal to carina, or with
visceral pleural invasion, or with associated atelectasis or
obstructive pneumonitis extending to the hilar region but not
involving the entire lung
T3 Tumor invading chest wall, diaphragm, mediastinal
pleura, or parietal pericardium; or tumor in main bronchus
within 2 cm. of, but not invading, carina; or atelectasis of
obstructive pneumonitis of the entire lung
T4 Tumor invading mediastinum, heart, great vessels,
trachea, esophagus, vertebral body, or carina; or ipsilateral
malignant pleural effusion
NODES (N)
N0 No regional lymph node metastases
N1 Metastases to ipsilateral peribronchial or hilar nodes
N2 Metastases to ipsilateral mediastinal or subcarinal nodes
N3 Metastases to contralateral mediastinal or hilar, or to
any scalene or supraclavicular nodes
DISTANT METASTASES (M)
M0 No distant metastases
M1 Distant metastases
The TNM subsets are subsequently grouped in a series of
stages of disease to identify groups of patients with similar
prognosis and therapy.

STAGE T N M
Occult TX N0 M0
Stage I T1-2 N0 M0
Stage II T1-2 N1 M0
Stage IIIa T3 N0-1 M0
T1-3 N2 M0
Stage IIIb T4 N0-2 M0
T1-4 N3 M0
Stage IV Any T Any N M1

36. After complete resection of Stage I non-small cell lung

cancer (NSCLC), the role of adjuvant therapy is best
summarized thus as:
A. Postoperative radiation therapy improves disease-free
survival.
B. Postoperative radiation therapy improves overall survival.
C. Postoperative chemotherapy improves disease-free
survival.
D. Postoperative chemotherapy improves overall survival.
E. Adjuvant therapy is not indicated after complete
resection of Stage I NSCLC.
Answer: E
DISCUSSION: Prospective randomized trials conducted by
the Lung Cancer Study Group demonstrate that
postoperative chemotherapy may be responsible for
significantly longer disease-free survival in patients with
Stage III (and perhaps Stage II) NSCLC. The efficacy of
postoperative chemotherapy and radiotherapy in patients
with extensive lymph node involvement or positive surgical
margins in reducing systemic recurrences and prolonging
disease-free survival has also been demonstrated. Adjuvant
therapy is not associated with improved overall survival and
has not been shown to be beneficial in patients with Stage I
NSCLC.
Radiation therapy is an effective adjuvant treatment in many
patients with carcinoma of the lung. Adjuvant radiotherapy,
applied to patients with completely resected Stage II or
Stage III (but not Stage I) NSCLC, has been shown to
decrease local recurrence but has no significant effect on
survival. However, postoperative irradiation may provide a
survival advantage in patients who have resection and are
found to have metastases to hilar or mediastinal lymph
nodes. Thus, the purpose of adjuvant radiotherapy is
prevention of local tumor recurrence, especially when lymph
node sampling of the mediastinum at thoracotomy is
incomplete.

37. Compared to segmentectomy or wedge resection,

lobectomy for NSCLC is associated with:
A. Similar operative morbidity but higher operative mortality.
B. Similar operative mortality but higher operative morbidity.
C. More severe postoperative pulmonary dysfunction.
D. Lower incidence of locoregional recurrence.
E. Equivalent locoregional recurrence.
Answer: D

DISCUSSION: The risk of recurrence after surgical resection

according to the magnitude of the resection has been
analyzed by the Lung Cancer Study Group. In a prospective,
randomized trial involving more than 400 patients with T1N0
lung cancer, lobectomy was compared to segmentectomy
and wedge resection. There was no significant difference in
morbidity and mortality among the procedures. Furthermore,
no difference was observed in postoperative pulmonary
function between patients who underwent lobectomy and
those who underwent lesser procedures. The rate of
locoregional recurrence was significantly lower in patients
who underwent lobectomy (5%) as compared with those who
underwent either segmentectomy or wedge resection (15%).
In another study, segmentectomy was compared to
lobectomy in patients with Stage I lung cancer. In this study,
the rate of locoregional recurrence was lower in patients
who underwent lobectomy (5%), as compared with those
who underwent segmentectomy (23%). Furthermore, there
was a survival advantage in the patients undergoing
lobectomy for T2 disease.
38. In contrast to NSCLC, small cell lung cancer (SCLC) is
characterized by:
A. Greater response rate to chemotherapy.
B. Inability to achieve surgical cure.
C. Less frequent association with paraneoplastic syndromes
at the time of diagnosis.
D. Lower likelihood of metastases present at the time of
diagnosis.
E. Slower growth.
Answer: A

DISCUSSION: For the purposes of staging, estimating

prognosis, and selecting therapy, lung cancer is divided into
two categories: NSCLC and SCLC. SCLC is characterized by
more rapid growth, higher prevalence of metastases at the
time of diagnosis, and greater responsiveness to
chemotherapy and radiation therapy. After ascertaining the
histological diagnosis of SCLC, staging is performed,
including thorough neurological examination and CT
evaluation of the chest, abdomen, and brain. For most
patients with limited-stage disease, treatment is initiated
with six cycles of combination chemotherapy. Radiotherapy
to the chest is usually employed after three initial cycles of
chemotherapy and is continued for 4 weeks. Among patients
with limited-stage disease, thoracotomy for pulmonary
resection is recommended for the subset of patients with
stage I SCLC.

39. Which of the following statements about the diagnosis

and staging of mesothelioma is/are correct?
A. Fluid obtained by thoracentesis is usually adequate for
accurate diagnosis.
B. Open biopsy or thoracoscopy should be performed to
obtain tissue for diagnosis.
C. Immunohistochemistry should be performed in all cases
of suspected mesothelioma.
D. Chest CT and/or magnetic resonance imaging (MRI) are
useful in the staging of mesothelioma.
E. Head CT and bone scans are useful in the staging of
mesothelioma.
Answer: BCD

DISCUSSION: Approximately 90% of patients with

mesothelioma develop pleural effusion, but cytologic
specimens from pleural fluid are inaccurate for the diagnosis
of mesothelioma, and open or thoracoscopic biopsy is
required. Accurate diagnosis of mesothelioma is difficult:
the epithelial variant must be differentiated from
adenocarcinoma, whereas the sarcomatous form often
resembles benign sarcomas. Immunohistochemistry using a
panel of antibodies, and sometimes electron microscopy, is
required for all cases. Relentless local spread is typical, and
chest CT or MRI is essential to evaluate potential local
extension into the chest wall, pericardium, mediastinum, or
diaphragm. Metastatic disease is less common and occurs
late (if at all) in the disease course, so head CT and bone
scans are indicated only if clinical findings are suspicious
for metastasis.

40. Which of the following statements about therapy for

malignant pleural mesothelioma is/are correct?
A. The role of surgery is confined to biopsy for diagnosis and
pleurodesis for palliation of effusion.
B. Extrapleural pneumonectomy involves resection en bloc
of the lung, visceral and parietal pleura, pericardium, and
diaphragm.
C. If a lesion is unresectable by extrapleural
pneumonectomy, pleurectomy/decortication is
contraindicated.
D. Neither surgery, chemotherapy, nor radiation therapy as a
single therapy improves survival.
E. Multimodality therapy, combining surgery, chemotherapy,
and radiation therapy may improve survival in select
patients.
Answer: BDE

DISCUSSION: In debilitated patients, palliation by

pleurodesis is indicated; however, cytoreductive techniques,
including pleurectomy/decortication, and extrapleural
pneumonectomy, are indicated for patients who can tolerate
surgery. For Stage I disease, extrapleural pneumonectomy is
offered. If the patient cannot tolerate pulmonary resection
or if the lesion is unresectable by extrapleural
pneumonectomy, pleurectomy/decortication is appropriate.
Both cytoreductive procedures, when used in a
multimodality setting, may improve survival in selected
patients. They also improve quality of life by relieving or
delaying two severe symptoms of mesothelioma: dyspnea
secondary to lung restriction by the tumor and pain from
tumor invasion. No single modality (surgery, chemotherapy,
or radiation therapy) improves survival.

41. All of the following may be acceptable operative

approaches to management of the thoracic outlet syndrome
except:
A. Scalenectomy.
B. Excision of a cervical rib.
C. Thoracoplasty.
D. First rib resection.
E. Division of anomalous fibromuscular bands.
Answer: C

DISCUSSION: Supraclavicular decompression of the thoracic

outlet is the preferred operative approach for the thoracic
outlet syndrome. This procedure consists of extensive
anterior scalenectomy, middle scalenectomy, removal of a
cervical rib (if present), and, on occasion, first rib resection.
Transaxillary first rib resection has been widely used as well
but is associated with a greater risk for complications.
Numerous fibromuscular anomalies have been described in
association with the thoracic outlet syndrome.
Thoracoplasty has no role in the management of this
disorder.

42. Initial conservative (nonsurgical) management of the

thoracic outlet syndrome may include all of the following
except:
A. Weight reduction.
B. Improvement of posture.
C. Exercises to strengthen the muscles of the shoulder
girdle.
D. Pentoxifylline.
E. Avoiding hyperabduction.
Answer: D

DISCUSSION: The initial management of the thoracic outlet

syndrome is nonoperative. A trial of weight reduction,
shoulder girdle strengthening exercises, improvement of
posture, and avoidance of hyperabduction should be
recommended for 4 months or longer. These measures are
successful in 50% to 70% of patients, particularly in young
to middle-aged females with poor posture. Pentoxifylline is a
hemorrheologic agent used in selected patients with
peripheral arterial insufficiency and has no known benefit in
the thoracic outlet syndrome.

43. Which of the following statements about pectus

excavatum are correct?
A. It is the most common congenital malformation of the
chest wall.
B. The most frequent presenting complaint is the cosmetic
deformity.
C. The manubrium and first and second costal cartilages
typically are involved in the deformity.
D. It may be associated with cardiac defects and other
skeletal defects such as scoliosis.
E. Restrictive alterations in chest wall mechanics and
abnormalities in pulmonary function tests have been
documented.
Answer: ABDE

DISCUSSION: Congenital deformities of the chest wall

represent a spectrum of deformities ranging from minor
cosmetic defects to gross deformities incompatible with life.
Pectus excavatum, or funnel chest, is the most common of
the congenital deformities of the chest wall, accounting for
90% of such defects. It is characterized by a concave,
posteriorly displaced sternum due to overgrowth of the
costal cartilages. Most commonly the defect begins at the
junction of the manubrium and the body of the sternum and
becomes progressively deeper toward the xiphoid. The
manubrium and the first and second costal cartilages
typically are normal. The defects have both physiologic and
psychologic consequences and are often associated with
other abnormalities, including congenital heart disease,
Marfan's syndrome, and other skeletal defects, including
scoliosis. Patients most often present because of the
cosmetic defect but frequently are found to have other
symptoms, including impaired cardiopulmonary function and
scoliosis. Pulmonary complaints include dyspnea and
respiratory tract infections. Restrictive alterations in chest
wall mechanics and abnormalities in pulmonary function
tests, including decreased vital capacity, decreased total
lung capacity, decreased maximal ventilatory volume, and
decreased maximal breathing capacity, have been
documented.

44. Surgical correction of pectus excavatum is

characterized by which of the following?
A. Significant cosmetic improvement initially but a high
incidence of recurrence of the defect on late follow-up.
B. An increase in exercise tolerance and respiratory reserve
postoperatively.
C. Improvement in FEV 1, vital capacity, and total lung
capacity.
D. Improvement in maximal ventilatory volume, total
progressive exercise time, and maximal exercise capacity.
E. Prevention of the development of “thoracogenic
scoliosis.”
Answer: BDE

DISCUSSION: Because of the significant cosmetic and

psychological improvement, subjective increase in exercise
tolerance, documented improvement in cardiac and
respiratory status, and prevention of the development of
scoliosis following surgical intervention in these patients,
surgical correction should be considered for all patients
with moderate to severe deformity. Cosmetic results of
surgical correction are excellent, and recurrence is
uncommon. Objective improvement in cardiac function has
been documented postoperatively, owing to relief of the
sternal compression. Postoperatively, worsening of the FEV
1, vital capacity, and total lung capacity have been noted,
whereas a significant improvement in maximal ventilatory
volume, total progressive exercise time, and maximal
oxygen consumption has also been documented. Following
surgical correction there is a consistent increase in maximal
exercise capacity at every level of workload, a lower heart
rate at every workload, and an increase in exercise
duration.

45. Which of the following statements about the diagnosis of

chest wall tumors is/are correct?
A. Pain is a common presenting symptom.
B. Firmness and fixation to underlying bone and muscle are
important to note in the physical examination as aids to
diagnosis.
C. In general, chest wall tumors are slow growing and
produce symptoms late in their course.
D. CT is the most useful imaging study for making the
diagnosis and for planning surgical resection of chest wall
tumors.
E. Angiography should be performed routinely.
Answer: BCD

DISCUSSION: Seventy-five per cent of patients present with

a slow-growing, painless chest wall mass. A firm mass that
is fixed to an underlying rib is more likely to be of bony or
cartilaginous origin. Conversely, soft, mobile tumors are
more likely to be of soft tissue origin. CT defines depth of
invasion and extent of tumor and is the most useful imaging
modality. Angiography should be employed selectively,
primarily for very large and vascular tumors.

46. Which of the following statements about chest wall

resection and reconstruction is/are correct?
A. Most tumors of soft tissue and bone require 4-cm. margins
to be adequately resected.
B. At least one normal rib above and below the primary
tumor should be included in the resection.
C. Techniques of chest wall reconstruction are directed at
the prevention of paradoxical chest wall movement with
respiration.
D. Soft tissue defects are most conveniently addressed by
stretching the existing skin over the defect under tension.
E. Chest wall defects that are covered by the scapula
require no special reconstructive procedures, even if the
defects are quite large.
Answer: ABCE

DISCUSSION: Margins of resection of chest wall tumors

should be at least 3 cm. of skin, 4 cm. of muscle, and 6 cm.
of bone. Old biopsy sites should be included in the
specimen. A normal rib above and below the specimen
should also be included. Prevention of paradoxical chest
wall movement is the primary goal of chest wall
reconstruction. Large soft tissue defects are best managed
by myocutaneous pedicle flaps. In general, defects larger
than 5 cm. require reconstruction. Defects covered by the
scapula require no reconstruction.

47. Prolonged extracorporeal membrane oxygenation

(ECMO):
A. Is highly successful in the treatment of severe respiratory
failure in newborn infants.
B. Is contraindicated in adult respiratory distress syndrome
(ARDS).
C. Causes hemolysis and renal failure.
D. Requires total systemic heparinization (activated clotting
time longer than 500 seconds).
E. Is identical to heart/lung bypass for cardiac surgery.
Answer: A

DISCUSSION: The survival rate of newborn infants who are

moribund from respiratory failure with ECMO is 80% to 90%.
ECMO is also indicated in ARDS with a survival rate from
40% to 50%. Hemolysis and renal failure are rare
complications. ECMO requires low-dose partial
heparinization, with clotting times in the range of 200
seconds. Several modifications in the conventional
heart/lung machine permit the extension of ECMO from
hours to days.

48. Indications for ECMO include:

A. Newborn infants with pulmonary hypoplasia secondary to
congenital diaphragmatic hernia.
B. Meconium aspiration syndrome in full-term babies (at
least 35 weeks).
C. Children with pulmonary infection after bone marrow
transplantation.
D. Adults with acute viral pneumonia.
E. Adults requiring mechanical ventilation and 100% oxygen
for 2 weeks or longer.
Answer: BD

DISCUSSION: At present ECMO is not used for infants

smaller than 1500 gm. because of a high risk of intracranial
bleeding. ECMO is very successful in the treatment of
respiratory failure in full-term newborn infants.
Immunosuppression is a relative contraindication to ECMO.
ECMO is indicated in adults with acute, potentially
reversible respiratory failure, but mechanical ventilation and
high oxygen concentration for more than 10 days are
contraindications.

49. Venovenous ECMO:

A. Avoids major arterial access.
B. Provides cardiac and pulmonary support.
C. Can be accomplished via cannulation at separate venous
sites or at a single venous site using a double-lumen
catheter.
D. Provides greater venous drainage than venoarterial
ECMO.
E. Maintains the normal pulsatile blood flow to the systemic
circulation.
Answer: ACE

DISCUSSION: Venovenous ECMO has become the access

technique of choice for patients with respiratory failure
without significant requirement for cardiac (hemodynamic)
support. In neonates, a double-lumen cannula allows ECMO
to be performed through a single incision over the right
internal jugular vein. It can also be performed by separate
cannulation of the femoral and jugular veins. In either
configuration, venovenous ECMO avoids cannulation of any
major arteries and maintains the normal pulsatile circulation
through the heart and lungs. Venous drainage is no different
with venovenous ECMO.

50. As compared with venovenous ECMO, venoarterial

ECMO:
A. Requires cannulation of a major artery and vein.
B. Provides both cardiac and respiratory support.
C. Can be performed with less anticoagulation.
D. Usually maintains a normal pulse pressure.
Answer: AB

DISCUSSION: Venoarterial ECMO can provide total

cardiorespiratory support via cannulation of a major vein
and artery (usually the right internal jugular vein and
common carotid artery in neonates). With most roller and
vortex pumps, the arterial inflow from the ECMO circuit is
nonpulsatile, and therefore pulse pressure is often reduced
or absent. Venoarterial ECMO requires the same degree of
anticoagulation as venovenous techniques.

51. A 24-year-old male has new onset of chest pain. Chest

films demonstrate a large anterosuperior mass. Appropriate
evaluation should include:
A. CT of the chest.
B. Measurement of serum alpha-fetoprotein and beta–human
chorionic gonadotropin.
C. A barium swallow.
D. A myelogram.
Answer: AB

DISCUSSION: Elevated levels of serum alpha-fetoprotein and

beta–human chorionic gonadotropin are indicative of a
malignant nonseminomatous germ cell tumor. Optimal
therapy for such a tumor is based on a cis-platinum-
containing chemotherapeutic regimen. After normalization
of serum markers, resection of residual disease is
performed. Extensive surgical procedures prior to
chemotherapy are not warranted. Confirmation of the
diagnosis can usually be obtained using needle biopsy
techniques. In some institutions patients are treated based
on elevated serum markers alone. CT imaging is useful to
evaluate tumor invasiveness, airway compression, vascular
involvement, and the likelihood of resectability. Barium
swallow may be helpful in the evaluation of enteric cysts.
Myelography may be useful in patients with posterior
mediastinal masses to evaluate for spinal column
involvement.

52. Systemic syndromes frequently associated with

mediastinal tumors include:
A. Myasthenia gravis.
B. Hypercalcemia.
C. Malignant hypertension.
D. Carcinoid syndrome.
Answer: ABC

DISCUSSION: Myasthenia gravis occurs in 10% to 50% of

patients with thymoma. The incidence with which
myasthenia gravis occurs in patients with a thymoma
increases with the age of the patient. In males over 50 and
females over 60 years of age, the incidence appears to be
greater than 80%. Hyperparathyroidism due to a mediastinal
parathyroid adenoma is a cause of hypercalcemia. Although
parathyroid glands may occur in the mediastinum in 10% of
the patients, they are usually accessible through a cervical
incision. A sternotomy is required infrequently, even in those
patients with a mediastinal parathyroid gland. Most often
the adenomas are found embedded in or near the superior
pole of the thymus. Mediastinal paraganglioma may produce
significant catecholamines, predominantly norepinephrine.
Catecholamine production causes a classic group of
symptoms associated with pheochromocytomas, including
periodic sustained hypertension often accompanied by
orthostatic hypotension, and hypermetabolism manifested
by weight loss, hyperhydrosis, palpitation, and headaches.
Mediastinal carcinoid tumors have been more frequently
associated with Cushing's syndrome because of the
production of adrenocorticotrophic hormones. These tumors
uncommonly cause the carcinoid syndrome.

53. A 36-year-old female developed dyspnea on exertion that

has progressed over 3 months. Chest film reveals a left
anterior mediastinal mass with evidence of elevated left
hemidiaphragm. CT indicates probable invasion of the
pericardium. Paratracheal or subcarinal adenopathy is not
identified. Appropriate intervention in this patient would
include:
A. A median sternotomy with radical resection of the tumor,
sacrificing the left phrenic nerve and excising the involved
pericardium.
B. A mediastinoscopy with biopsy.
C. A left anterolateral thoracotomy or median sternotomy
with generous biopsy of the tumor.
D. Observation with repeat chest radiography in 3 months.
Answer: C

DISCUSSION: The differential diagnosis of an invasive

anterosuperior mediastinal mass includes thymoma,
lymphoma, germ cell tumor, undifferentiated carcinoma, and
carcinoid tumors. These tumors often have a very similar
histologic appearance, which may cause an inaccurate
diagnosis based on light microscopy alone. Use of electron
microscopy and immunohistochemistry may be necessary to
correctly determine the specific histologic diagnosis. Frozen
section should be used to determine adequacy of tissue
biopsy. Histologic diagnosis based on frozen section
examination in many of these tumors may be erroneous.
Although radical resection of tumor is indicated for
thymoma, chemotherapy and radiotherapy are the
modalities used for the treatment of patients with
lymphomas and germ cell tumors. Exact determination of
tumor histology by permanent section should precede
radical resectional therapy. Generous tissue biopsy is
necessary for the precise subtyping of lymphomas.
Mediastinoscopy is useful in patients with paratracheal and
pericarinal masses or adenopathy, particularly when right-
sided. Observation of a patient with invasive mediastinal
mass is not warranted.

54. An 18-year-old male presents with a history of increasing

shortness of breath that worsens in the recumbent position.
On physical examination, the neck veins are noted to be
distended, with facial plethora that is accentuated by lying
the patient down. A 2.5-cm. left supraclavicular lymph node
is palpable. Chest film reveals an extensive right
anterosuperior mediastinal mass. Appropriate intervention
may include:
A. An urgent biopsy of the mediastinal mass under general
anesthesia with subsequent initiation of therapy.
B. CT.
C. Pulmonary function testing in the sitting and supine
positions.
D. A biopsy of the right supraclavicular lymph node under
general anesthesia.
E. A biopsy of the supraclavicular lymph node under local
anesthesia.
Answer: BCE

DISCUSSION: Although most patients with a mediastinal

mass may undergo surgical procedures under general
anesthesia with a minimal risk, patients with a large
anterior, superior, or middle mediastinal mass, particularly
those with posture-related dyspnea and superior vena caval
syndrome, have an increased risk of developing severe
respiratory complications during general anesthesia. Useful
techniques for identifying less symptomatic patients who
have significant airway compression include CT imaging and
pulmonary function tests. A reduction of the tracheal
diameter by more than 35% on a CT scan and reduction of
peak expiratory flow during pulmonary function testing are
sensitive indicators of functional airway compression. In
patients with airway compression and superior vena caval
obstruction, the risk of general anesthesia is significant.
Attempts to obtain a histologic diagnosis should be limited
to needle biopsies or open procedures performed under local
anesthesia. In situations in which histologic diagnosis
cannot be obtained using these methods, therapy may be
initiated with radiation, corticosteroids, and chemotherapy.
However, a histologic diagnosis may not be obtainable in as
many as 40% of these patients after initiation of treatment.
Some proceed with biopsy of the mediastinal mass under
general anesthesia. However, alterations in anesthetic
management include: (1) induction of anesthesia in a semi-
Fowler's or upright position, (2) availability of rigid
bronchoscopy to allow reestablishment of an adequate
airway, (3) use of a long endotracheal tube to allow
advancement of the tube beyond the site of obstruction, (4)
avoidance of muscle relaxants and the use of spontaneous
ventilation when possible, (5) lower extremity intravenous
cannulation, and (6) standby cardiopulmonary bypass.

55. A 42-year-old male who is scheduled to undergo elective

knee surgery has a preoperative chest film that
demonstrates a 5-cm. posterior mediastinal mass. The
patient denies any neurologic symptoms and physical
examination fails to elucidate any neurologic deficit. CT
confirms the presence of a 5-cm. mediastinal mass in the
left costovertebral gutter with minimal enlargement of the
seventh thoracic foramen. Appropriate intervention includes:
A. Resection of the posterior mediastinal mass using a
standard posterolateral incision.
B. A CT with myelography or magnetic resonance (MR)
imaging.
C. Two-stage removal of the tumor, performing the resection
of the thoracic component first with subsequent removal of
the spinal column component at a later date.
D. One-stage removal of the dumb-bell tumor, excising the
intraspinal component prior to resection of the thoracic
component.
Answer: BD

DISCUSSION: Approximately 10% of neurogenic tumors

extend into the spinal column and are termed dumb-bell
tumors because of the characteristic shape. Although 60%
of patients with such tumors have neurologic symptoms
related to spinal cord compression, the significant
proportion of patients without symptoms underscores the
importance of evaluating all patients with a posterior
mediastinal mass for possible intraspinal extension. CT, MR
imaging, and vertebral tomography may demonstrate an
enlargement of the foramen, erosion of bone, or
intervertebral widening, which are indicative of a dumb-bell
tumor. If these findings are present, CT with myelography or
MR imaging is indicated to evaluate the presence and extent
of the intraspinal component. A one-stage removal of the
tumor is recommended, with excision of the intraspinal
component prior to resection of the thoracic component to
minimize the risk of spinal column hematoma.

56. True statements regarding patients with a mediastinal

mass include:
A. Asymptomatic patients have a benign mass in over 75%
of cases.
B. Symptomatic patients are more likely to have a malignant
lesion than a benign lesion.
C. In a patient with a chest film demonstrating a mediastinal
mass, a Tru-cut needle biopsy is a safe procedure.
D. Seminomas usually produce alpha-fetoprotein.
Answer: AB

DISCUSSION: Seventy-six per cent of the asymptomatic

patients with a mediastinal mass seen in one series over a
recent 20-year period had a benign leison. In contrast, 62%
of the symptomatic patients had a malignant neoplasm
during this period. A number of intrathoracic and
extrathoracic lesions may have an appearance similar to a
primary mediastinal mass on routine chest films, as do a
large number of cardiovascular lesions. Although
angiography was used in the past for this differentiation, CT
with contrast and MRI now distinguish a primary mediastinal
mass from a cardiovascular lesion. Tru-cut needle biopsy of
a cardiovascular lesion may be associated with significant
hemorrhagic complications. Seminomas rarely produce
beta–human chorionic gonadotropin and never produce
alpha-fetoprotein. In contrast, over 90% of the
nonseminomas secrete one or both of these hormones.

57. Which of the following would be the least appropriate in

the management of acute suppurative mediastinitis?
A. Wide débridement.
B. Irrigation under pressure.
C. Topical antibacterials.
D. Long-term systemic antibacterials.
E. Closure with muscle flaps.
Answer: D

DISCUSSION: Acute suppurative mediastinitis is a classic

wound problem and forms a paradigm for principles of
management. Wide débridement is perhaps the most
important step in correcting this type of invasive wound
sepsis. Drainage requires removal of tissue with vascular
compromise. Tissue that is infected and can serve as an
ongoing nidus for infection, particularly cartilage, must be
removed. Irrigation is effective only when the irrigation fluid
reaches into and flushes out débris and bacteria. The
irrigation is insufficient if only dilutional and not also
mechanically effective. Since infected tissue tends to
become isolated from the systemic circulation the direct
application of antibacterials reaches avascular areas. Some,
such as silver sulfadiazine, penetrate avascular tissue
better than, for instance, ointments or povidone iodine, and
such an agent should be chosen. Wide débridement and the
washing of debris with pressure irrigation make the wound
then available to topical applications, which are often best
packed into these deep, irregular cavities. Long-term
systemic antibacterials serve no purpose and lead to
potential resistant bacterial overgrowth. Although systemic
antibacterials provide a measure of protection up to the
margin where vascularized and nonvascularized tissues
meet, topical agents are better in the actual infected site.
Once closed, these wounds rapidly become sterilized. Even
the infection at the bone level is far different from traditional
osteomyelitis, and long-term systemic therapy is
unnecessary. Muscle flaps are a great advance in closure
technique, since they provide bulky protection, obliterate
dead space, and help vascularize the wound.

58. Each of the following is appropriate for managing acute

suppurative mediastinitis except:
A. Alloplastic material and skin flaps.
B. Rectus abdominis muscle flaps.
C. Omentum.
D. Pectoralis major muscle flaps.
E. Rigid internal fixation.
Answer: A

DISCUSSION: Alloplastic materials may be nonreactive in

the laboratory and biologically acceptable in other areas
(artificial hips, breast prostheses). Their introduction into a
contaminated wound, however, would more likely promote
rather than reduce infection. Various meshes and other
types of “protection” devices are not necessary. Skin flaps
alone do not obliterate dead space and have not been shown
either to reduce or resist infection. The rectus abdominis
muscle is a superb source of readily available tissue that
can be rotated into very large cavities. The nature of the
muscle allows it to be “dressed into” irregular cavities. It
has an excellent, easily movable skin territory overlying it,
which can also be transferred if locally available skin is
wanting. The omentum has the great ability to fit into the
many irregularities of some defects. For appropriately
selected cases it is excellent. The pectoralis major muscle
flaps are the usual initial choice since they are in the
operative field. When the musculotendinous insertion is
released their mobility is often sufficient. Additionally, it
avoids the need for abdominal incisions. The latissimus
dorsi muscle as a flap is dependable and includes sternal
defects in the scope of its arc of rotation. It requires
rotating the patient on the operating table and thus is less
readily available than the other flaps.

59. Clinical features suggestive of myasthenia gravis include

all of the following except:
A. Proximal muscle weakness.
B. Diplopia.
C. Sensory deficits of the extremities.
D. Dysphagia.
Answer: C

DISCUSSION: Weakness of proximal weight-bearing muscle

groups is the hallmark of the clinical diagnosis of
myasthenia gravis. The weakness or fatigue occurs with
repetitive activity and improves with rest. The majority of
patients (90%) experience ocular muscle involvement,
manifested as diplopia or ptosis most easily demonstrated
with sustained upward gaze. Cranial nerve involvement is
uncommon but can be present, with symptoms of dysphagia,
nasal regurgitation, and aspiration. Since myasthenia gravis
is a disorder of neuromuscular transmission at the motor
end plate, deep tendon reflexes and sensory examination
are normal.

60. The diagnosis of myasthenia gravis can be confirmed

most reliably using:
A. Anti–acetylcholine receptor antibody titers.
B. The Tensilon test.
C. Electromyography (EMG).
D. Single-fiber EMG.
E. Physical examination.
Answer: D

DISCUSSION: Although findings from a careful history and

physical examination are suggestive of the diagnosis of
myasthenia gravis, specific diagnostic testing is required to
confirm the diagnosis. Elevated anti–acetylcholine receptor
antibodies are present in 85% to 90% of patients with
generalized myasthenia but are often negative in patients
with early or ocular myasthenia gravis. The Tensilon test is
also positive in approximately 90% of patients with
generalized myasthenia gravis, but both false-negative and
false-positive results occur, especially in patients with mild
or early disease. Standard EMG studies are helpful if
positive, but their overall sensitivity may be as low as 35%.
The specialized technique of single-fiber EMG is the most
reliable diagnostic test, being abnormal in 90% of patients
with mild disease and in virtually 100% in patients with
severe generalized myasthenia gravis.

61. All of the following statements are true about the

pathogenesis of myasthenia gravis except:
A. The number of functional acetylcholine receptors at the
motor end plate is reduced.
B. An autoimmune mechanism involving antibodies to the
acetylcholine receptor has been proposed.
C. Complement system involvement has been demonstrated.
D. A nonspecific “thymitis” may initiate the autoimmune
response.
E. Clinical improvement following thymectomy is correlated
with decreased acetylcholine receptor antibody titers.
Answer: E

DISCUSSION: Myasthenia gravis is generally regarded as an

autoimmune disorder due to antibodies directed toward the
acetylcholine receptor. A variety of autoimmune
mechanisms have been proposed; the ultimate result is a
reduction in the number of functional acetylcholine
receptors at the motor end plate. Proposed immune
mechanisms include complementmediated receptor
destruction, antibody-induced accelerated receptor
turnover, and simple receptor blockade. In spite of these
proposed immune mechanisms, the severity of myasthenia
symptoms and improvement following therapy do not
correlate with antibody titers. Although the source of these
autoantibodies is not proven, it is generally felt that a
nonspecific thymitis may trigger the autoantibody response,
the thymic myoid cells serving as the source of the antigen.

62. Which of the following statements about the relationship

of the thymus and myasthenia gravis is/are true?
A. Thymic abnormalities are present in up to 80% of patients
with myasthenia gravis.
B. Thymoma is present in up to 20% of patients with
myasthenia gravis.
C. Myasthenia gravis will occur in up to 60% of patients with
thymomas.
D. Myasthenia patients with thymoma respond more
favorably to thymectomy.
E. Thymoma is the most common abnormality of the thymus
in patients with myasthenia gravis.
Answer: ABC

DISCUSSION: The central role of the thymus gland in the

pathogenesis of myasthenia gravis is based on the
observation that more than 80% of patients have histologic
abnormalities of the thymus and on the beneficial effect of
thymectomy on patients' symptoms. Of the patients with
documented abnormalities of the thymus the majority have
B-cell lymphoid hyperplasia; only 20% have a thymoma.
Conversely, up to 60% of patients with known thymoma will
have or ultimately develop myasthenia gravis. In these
patients, with thymoma and myasthenia gravis, the response
to thymectomy is less favorable than in those without
thymoma.

63. Which of the following statements about the results of

thymectomy for myasthenia gravis are true?
A. Patients with ocular symptoms experience clinical
improvement in 90% of cases.
B. Clinical remission can be expected in 90% of cases.
C. The response rate to thymectomy for patients with
generalized symptoms is 90%.
D. Patients with thymoma experience improvement in 75%.
E. Continued medical therapy is required in 75%.
Answer: C

DISCUSSION: Overall, improvement can be expected in 90%

of patients who undergo thymectomy for generalized
myasthenia gravis. In general, the results are more favorable
in patients with mild generalized myasthenia. In patients
with only ocular symptoms, the benefit following
thymectomy is less clear; improvement is documented in
80%. The response rate is even less (30%) in patients with
thymoma. Complete remission occurs in 40% to 50% of
patients following thymectomy, and the remainder require
some continued medical therapy.

64. All of the following are true of the treatment of

myasthenia gravis except:
A. The transcervical approach to surgical thymectomy is
less likely to benefit the patient with myasthenia gravis.
B. Corticosteroids result in improvement in 80% of patients.
C. Plasma exchange is associated with improvement in up to
90% of patients.
D. Medical therapy with Mestinon (pyridostigmine) is
associated with remission in approximately 10% of patients.
E. Surgical thymectomy, regardless of the approach, is
associated with improved remission and response rates as
compared with medical therapy.
Answer: A

DISCUSSION: Although Mestinon therapy results in clinical

improvement in most patients, complete remission can be
expected in only 10%. In addition, intolerable side effects
may limit their usefulness. In patients who fail to respond to
Mestinon therapy, and in those who experience significant
side effects, corticosteroids can be utilized, with
improvement expected in 80% of patients. Plasma exchange
results in improvement in 90% of patients, but the cost of
therapy and its transient duration of benefit limit the use of
pheresis therapy to special circumstances such as
preoperative preparation or in myasthenic crisis. Overall,
response rates to surgical thymectomy range from 80% to
95%, and complete remission occurs in 30% to 50%. This
benefit following thymectomy has not been shown to depend
on the particular technique utilized. Remission and response
rates are similar for transcervical, standard transsternal,
and the “maximal thymectomy” techniques.

65. Which of the following is/are acceptable alternatives in

the management of malignant pericardial effusion?
A. Pericardiocentesis.
B. Subxiphoid pericardiotomy (“pericardial window”).
C. Thoracotomy with pericardiectomy.
D. Instillation of tetracycline or bleomycin into the
pericardial space.
E. Treatment of the underlying malignancy.
Answer: ABCDE

DISCUSSION: In patients with symptomatic malignant

pericardial effusions, management options may be designed
to establish a diagnosis, relieve symptoms, or prevent
recurrence. Pericardiocentesis is very successful in
removing fluid for diagnosis and alleviating symptoms;
however recurrence rates are greater than 50%. This rate
can be reduced to around 20% with instillation of sclerosing
agents such as tetracycline or bleomycin. Surgical
techniques, including subxiphoid pericardiotomy and
thoracotomy with pericardiectomy, offer the highest
success rates (approximately 90%) but are more invasive
and usually require general anesthesia. Systemic antitumor
therapy with chemotherapy or radiation therapy can be
effective in controlling malignant effusions in cases of
sensitive tumors such as lymphomas, leukemias, and breast
cancer.

66. Which of the following statements about cardiac

tamponade is/are correct?
A. At least 500 ml. of fluid must be present in the
pericardium of an adult to cause symptoms of tamponade.
B. A drop in systemic blood pressure of greater than 20 mm.
Hg during inspiration (pulsus paradoxus) is a finding specific
to cardiac tamponade.
C. The vast majority of patients with cardiac tamponade
demonstrate a low QRS voltage, nonspecific ST T-wave
abnormalities, and electrical alternans (alternation of QRS
amplitude) on the electrocardiogram.
D. In trauma victims with cardiac tamponade, the three
components of “Beck's triad” (hypotension, elevated jugular
venous pressure (JVP), and muffled heart sounds) are almost
always present.
E. When the diagnosis is made, treatment must be instituted
rapidly and may include pericardiocentesis, creation of a
pericardial window, and identification and treatment of the
underlying cause.
Answer: E

DISCUSSION: Development of tamponade symptoms

depends on the rate of accumulation of fluid. As little as 100
to 200 ml. accumulating rapidly may cause symptoms,
whereas a slowly developing pericardial effusion of over 1
liter may remain asymptomatic. Pulsus paradoxus is not
specific for tamponade; it may occur in patients with severe
congestive heart failure, chronic obstructive pulmonary
disease, hypovolemia, acute pulmonary embolism, or shock.
Electrocardiographic findings of low QRS voltage and
nonspecific ST T-wave changes are common in this
condition, but electrical alternans, often considered
pathognomonic of cardiac tamponade, is present in only a
small number of patients. Trauma victims with tamponade
frequently lack one or more of the elements of Beck's triad;
for example, associated hypovolemia may lead to low or
normal jugular venous distention. Since cardiac tamponade
is life threatening, therapy designed to drain the pericardial
fluid must be provided quickly and the underlying cause
must be established and controlled.

67. Which of the following statements about constrictive

pericarditis is/are correct?
A. Most patients who develop constrictive pericarditis after
cardiac operation present with symptoms within 6 months of
the procedure.
B. Results of pericardiectomy for constrictive pericarditis
are worse in patients who develop constriction after
mediastinal irradiation.
C. Drainage of asymptomatic pericardial effusions arising
from acute pericarditis is advised to prevent development of
constrictive pericarditis.
D. If surgical treatment is planned for constrictive
pericarditis it should involve total or complete
pericardiectomy.
E. Echocardiography can usually make the diagnosis by
imaging a thickened pericardium.
Answer: BD

DISCUSSION: The time course in the development of

constrictive pericarditis after cardiac surgery ranges from 1
month to nearly 9 years, but the mean interval from surgery
to presentation is about 23 months. Most series have
reported poorer outcomes from pericardiectomy for
postirradiation constrictive pericarditis, possibly owing to
underlying myocardial fibrosis. In this subset, 5-year survival
averages 50%, as compared with 75% for constrictive
pericarditis of all causes. Constrictive pericarditis is a rare
complication of acute pericarditis. As a result, drainage of
asymptomatic (nonpurulent) pericardial effusions from acute
pericarditis is not required. Patients with significant
symptoms from constrictive pericarditis should undergo
total pericardiectomy, even though this procedure carries an
operative mortality rate of approximately 10%. Limited
pericardiectomy has proven to be ineffective for this
condition. It can be difficult to distinguish constrictive
pericarditis from restrictive cardiomyopathy.
Echocardiography may help by demonstrating chamber
dimensions and wall motion abnormalities, but CT and MRI
more accurately assess pericardial thickness.

68. The relationship between small-cell and non-small cell

lung cancers can be described by the following:

a. They differ by histology, clinical behavior and cell of origin

b. Of all lung cancers, approximately 80% are non-small cell
and 20% are small cell
c. Both cell types are predictably responsive to
chemotherapy
d. The International Staging System can be applied to both
tumor types
e. The majority of non-small cell cancer patients vs. the
minority of small cell cancer patients are candidates for
pulmonary resection
Answer: b

Although small cell and non-small cell lung cancers do differ

by histology and clinical behavior, they probably have a
common origin since c-myc or n-myc amplified small cell
lung cancer lines will undergo transition to non-small cell
phenotypes after insertion of an activated ras/gene. The
overall incidence of lung cancers is 80% non-small cell and
20% small cell. Only the small cell carcinoma is predictably
responsive to chemotherapy.
The staging system for small cell lung cancer is based on
limited vs. extensive disease outside of a tolerable
radiotherapy portal while the International Staging System
uses TNM descriptors for 4 clinical stages. Unfortunately,
only about 30% of patients with non-small cell lung cancer
have potentially resectable tumors.

69. A 62-year-old male smoker presents with right anterior

chest pain. There is a 3 cm mass attached to the chest wall
with radiographic evidence of rib erosion and positive
cytology for non-small cell carcinoma. Which of the follow
is/are true:

a. The patient is inoperable due to tumor size and chest wall

involvement
b. Radiation therapy is the preferred initial treatment
c. Operative resection should be performed with en bloc
removal of the tumor and adjacent chest wall as well as a
mediastinal lymph node resection
d. Positive mediastinal nodes will have little effect on
survival
e. The patient would be classified Stage IIIa
Answer: c, e

Survival after resection for non-small cell lung cancer is

related to the stage of the disease with a strong adverse
effect from nodal involvement. This is true even for large
peripheral tumors that extend into the chest wall as in this
case where a 40–50% survival would be expected in the
absence of nodes (T3N0:Stage IIIa) but only a 15% survival
with nodal involvement. Radiation therapy would be a
postoperative consideration to reduce the incidence of local
recurrence. En bloc operative resection of the involved lobe
and mediastinal nodes for staging would offer the greatest
likelihood of cure.

70. For the patient in the pervious question to become an

operative candidate which of the following must be met?

a. Extrathoracic metastases must be able to be controlled

by another modality, e.g. radiotherapy
b. Tumor doubling time must exceed 40 days
c. If there is recurrence at the primary site, it must be
treated before the metastatic disease
d. Even if effective systemic therapy is available, resection
of metastases is preferred
e. If pulmonary reserve is marginal, resection of the maximal
number of metastatic foci should be performed
Answer: c

There are a number of controversial areas in the area of

operative approaches to metastatic disease in the lung, but
there is general agreement that any extrathoracic
metastases preclude eligibility for pulmonary resection.
Although tumor doubling time is a measure of its
aggressiveness, it is too variable to have prognostic
significance and is generally disregarded as a criterion for
resection. Primary site recurrence must be treated before
the metastatic focus to prevent further seeding. If effective
systemic therapy is available as would be expected in
breast and testicular cancer or osteogenic sarcoma, it is
preferred over surgical resection. Similarly, pulmonary
resection should not be undertaken unless the pulmonary
reserve will allow all metastatic foci to be resected.

71. Biopsy of the lesion in the previous question is reported

as “bronchial carcinoid with no signs of atypia.” Which of the
follow is/are true?

a. Sleeve resection of the bronchus would be appropriate

b. Lymph node biopsy at time of resection is unnecessary
c. Associated carcinoid syndrome is very unlikely
d. If carcinoid syndrome were found in a tumor this size,
hepatic metastases would be likely
e. When bronchial carcinoid syndrome occurs, right-sided
cardiac valves are affected
Answer: a, c, d

In the absence of atypia, carcinoids are only locally

malignant and can be managed by limited lung and/or
bronchial resection. Therefore, a sleeve resection of the
bronchus preserving distal lung would be appropriate.
Lymph node sampling at the time of resection, however, is
advisable to ensure that a complete resection has been
performed. The carcinoid syndrome is rarely found except in
the presence of a large primary tumor or hepatic
metastases. When the carcinoid syndrome does occur, it is
left-sided cardiac valves that are affected rather than right,
which one would expect with gastrointestinalcarcinoids.

72. In the evaluation and preparation of a 55-year-old smoker

for resection of a 3 cm pulmonary adenocarcinoma, the
following is/are true:

a. Preoperative cessation of smoking does not reduce

postoperative pulmonary complications
b. Resting PaCO2 is of more value than PaO2
c. FEV1 is of more value than measured vital capacity
d. Diffusion capacity should be measured routinely
e. V/Q lung scan is useful when pulmonary reserve is
marginal
Answer: b, c, e
Preoperative cessation of smoking for a period of 2 weeks
can reduce pulmonary complications and should be required.
In the preoperative assessment for pulmonary resection, the
PaCO2 is of more value than the PaO2 since an elevated
PaCO2 > 50 mmHg identifies the very high risk patient with
chronic lung disease. Hypoxemia may be secondary to the
mechanical effects of the tumor producing
ventilation/perfusion mismatch. The latter can be confirmed
by V/Q lung scan which also serves to identify areas of
functioning lung in patients with marginal pulmonary
function. The best screening test for adequacy of pulmonary
reserve is the FEV1. It identifies obstructive pulmonary
disease which is more important than the restrictive lung
disease identified by vital capacity measurement. Diffusion
capacity measurement provides little additional information
of value.

73. Following resection of a T1N1 squamous cell cancer in a

47-year-old male, the following is/are true:

a. There is a higher risk of local recurrence than with any

other histologic type of non-small cell cancer
b. The greatest risk to the patient is a distant metastasis
c. Of all metastatic sites, liver is most likely
d. If the patient survives five years, there is a greater risk of
a new lung cancer than recurrence
e. To improve survival, the patient should be considered for
adjuvant chemotherapy
Answer: a, b, d

The risk of local recurrence for non-small cell carcinomas of

the lung is much more common for those of squamous cell
histology than the others and averages 20%–30% overall.
The greatest risk, however is of distant metastases which
occur in 70%–80% of patients, regardless of stage. Almost
all recurrences are seen within five years, and of the distant
metastatic sites, the brain is most commonly affected. In
this patient with Stage II disease, radiation therapy would
be a consideration to reduce the incidence of local
recurrence, but not chemotherapy. After five years, the
highest risk would be from a new lung cancer rather than a
recurrence.

74. A 42-year-old woman with hemoptysis is seen to have a 2

cm mulberry appearing polypoid lesion in the left mainstem
bronchus suspicious for bronchial adenoma. The differential
diagnosis includes which of the following:

a. Mucoepidermoid carcinoma
b. Plasma cell granuloma
c. Carcinoid tumor
d. Adenoid cystic carcinoma
e. Mucous gland adenoma
Answer: all of the above

The term bronchial adenoma includes a spectrum of tumors

arising from epithelial stem cells which vary from the benign
mucous gland adenoma to the malignant adenoid cystic and
mucoepidermoid carcinomas as well as the carcinoid tumors
of similar varied behavior. Among these variants, the
carcinoid are most common representing 80%–90% of all
bronchial adenomas.

75. A 42-year-old man has a solitary “coin lesion” 2 cm in

diameter in the area of the right upper lobe on a routine
chest radiograph. Which of the following is/are true?

a. A previous radiograph from five years prior showing the

lesion to be 1.2 cm in diameter indicates malignancy
b. If a CT scan shows mediastinal adenopathy,
mediastinoscopy is preferable to thoracotomy
c. In the absence of previous radiographs, the lesion should
be followed by serial films at 6 month intervals
d. Calcification in a concentric or “popcorn” configuration
denotes a benign lesion
e. Needle aspiration showing “chronic inflammatory cells”
denotes a benign lesion
Answer: b, d

In the evaluation of a solitary lung lesion, previous

radiographs are important, particularly if the lesion is new. A
coin lesion that is growing slowly does not necessarily
indicate malignancy, since the most common benign tumor,
hamartoma, has a variable pattern of slow growth and
typically will show “popcorn” calcification. Concentric
calcification is also most suggestive of a benign granuloma.
In the absence of previous radiographs, the lesion must be
assumed to be malignant until proved otherwise and should
not be dismissed to follow-up. If a CT scan shows
mediastinal adenopathy, then mediastinoscopy with biopsy
is appropriate to make a diagnosis. Needle aspiration results
of “chronic inflammatory cells” is non-diagnostic.

76. A 2 cm peripheral squamous cell carcinoma in the lung

of a 60-year-old male with a pleural effusion positive for
malignant cells would be classified as:

a. T1N0M1
b. T3N0M0
c. T3N0M1
d. T4N0M0
e. T4N0M1
Answer: d, e

The presence of a pleural effusion in association with a

primary lung cancer is usually an ominous sign precluding
surgical resection. However, if more than one sample of the
effusion is negative for malignant cells and it is non-bloody,
it can be considered unrelated to the tumor and excluded as
a staging element. When the effusion cytology is positive,
the tumor is considered T4 regardless of size or nodal
status.

77. A 53-year-old woman who had a malignant tumor

removed 2 years ago presents with a solitary lung nodule 1.5
cm in diameter. The following is/are true:

a. If the primary tumor originated in the breast, the lesion is

most likely to represent a new primary lung cancer.
b. If the primary tumor was melanoma, the lesion is most
likely to be metastatic
c. If the remainder of the lung fields are clear, a CT scan is
unnecessary
d. If the primary tumor was in the GI tract, there is very little
chance that the lesion is a new primary lung cancer
e. Fine needle aspiration should always be performed prior
to resection of the lung lesion
Answer: a, b

A new pulmonary lesion in a patient with a history of a

previously treated malignancy poses a diagnostic and
therapeutic challenge. A CT scan should always be obtained
since plain radiographs can detect lesions only 9 mm in
diameter or greater. The lesion is most likely to be
metastatic if the prior malignancy was sarcoma or
melanoma and most likely to be a new primary lung cancer if
the prior malignancy originated in the head, neck or breast.
When the original lesion was in the GI or GU tract, there is
an equal chance that it is metastatic or a new primary. Fine
needle aspiration does not usually alter the plan for excision
and is done only when the patient is not an operative
candidate or desires to know the diagnosis.

78. A 61-year-old male presents with a painful mass 3.5 cm

in diameter below the clavicle and attached to the chest
wall. The following is/are true:

a. A CT scan is the best study to determine rib destruction

b. The lesion should be removed enbloc without biopsy to
minimize the chances for local recurrence
c. The chances are approximately 40% that the lesion is
metastatic
d. If it is metastatic, the most likely primary tumor is in the
lung or pancreas
e. Fortunately, less than 50% of chest wall tumors are
malignant
Answer: c

Chest wall tumors are uncommon, accounting for only 1–2%

of all body tumors. About 57% of chest wall tumors are
primary, whereas 43% are metastatic. Solitary metastases
most frequently arise from the thyroid gland, the GU tract
and the colon. Overall, about 60% of chest wall tumors are
malignant, most arising form bone or cartilage. The CT scan
is of value in demonstrating the relationship between the
mass and contiguous structures, but of little value in
determining bone destruction because of the oblique course
of the ribs. Specific rib films are most helpful. Now that
multimodality therapy is available, core needle biopsies are
recommended and have not increased the incidence of local
recurrence.

79. Concerning the sternum, the following is/are true:

a. The xiphoid process is the anterior border of the thoracic

outlet
b. Gladiolus is the body of the sternum
c. The angle of Louis is at the level of the 2nd costal
cartilage
d. The 11th rib is attached via costal cartilage to the xiphoid
e. The sterno-manubrial junction is at the level of T4
posteriorly
Answer: a, b, c, e

The sternum consists of 3 segments, the upper manubrium,

the body or gladiolus, and the xiphoid process which ends in
the rectus sheath and has no costal attachments. The
xiphoid marks the anterior border of the thoracic outlet. The
junction of the manibrium and body is the sternal angle or
angle of Louis which corresponds to the level of T4
posteriorly and attaches to the 2nd costal cartilage
anteriorly.

80. A 22-year-old woman recovering from a traumatic head

injury is noted to have bright red bleeding when her
tracheostomy is suctioned. The following is/are true
statement(s):

a. Antibiotics should be administered to treat the bronchitis

b. Deflation of the tracheal tube cuff is a useful diagnostic
maneuver
c. If massive bleeding occurs, a finger should be used to
compress the innominate artery against the sternum
d. Operative treatment of a tracheoinnominate fistula
includes resection and prosthetic replacement of the
innominate artery
e. Tracheal resection is usually required for a
tracheoinnominate fistula to prevent recurrence
Answer: b, c

The complication of tracheoinnominate artery fistula

characteristically occurs in young women and is often
heralded by bleeding during the tracheostomy suctioning.
Deflation of the tracheal tube cuff confirms the diagnosis if
massive bleeding occurs. At that point the tracheal tube cuff
should be overinflated and a finger inserted into the
tracheostomy incision to tamponade the bleeding.
Throughout this, the airway must be protected. Operative
repair through an upper sternal split requires resection of
the innominate and coverage of the oversewn vessels with
viable tissue since the wound is contaminated. No
prosthetic material should be inserted and tracheal
resection is not necessary.

81. A 52-year-old alcoholic with fever and a cough

productive of purulent sputum is found to have the opacity
on chest film as shown (Fig. 62-15). The following is/are true
statement(s):

a. The findings suggest a parapneumonic empyema

b. If pus is found on aspiration of the pleural space, a chest
tube should be placed
c. If pus is found on aspiration, bronchoscopy is a necessary
part of the patient’s evaluation
d. In this situation, rib resection for drainage is preferred to
a large-bore chest tube
e. Decortication of the lung should be considered if the lung
fails to expand within 4 weeks
Answer: a, b, c

The posterior location of the infiltrate and fluid collection is

typical of a parapneumonic empyema. The most important
test is pleural aspiration which will usually yield frank pus,
at which time a chest tube should be placed. Formerly, oily
Dionosil was used to perform an empyemagram; this
substance is now no longer commercially available. In the
case of parapneumonic empyemas, tube drainage alone may
be sufficient to allow full expansion of the lung. If this is not
the case, a formal rib resection or early decortication should
be performed. Decortication or marsupialization is indicated
if the lungs fail to expand after 6–8 weeks. Every patient
with spontaneous empyema should undergo bronchoscopy
to rule out endobronchial obstruction by foreign body or
tumor.

82. The lesion shown (Fig. 62-6) was found on a 32-year-old

male on a routine chest film required for his employment.
Which of the following is/are true?

a. The stippled calcification and intact cortex of the rib are

characteristic of osteochondroma
b. The stippled calcification is characteristic of osteogenic
sarcoma
c. If the lesion is osteogenic sarcoma, the optimal treatment
is resection and radiation therapy
d. If the lesion is an osteochondroma, it need not be
resected in this age group
e. The radiographic picture is typical for Ewing sarcoma
Answer: a

Osteochondroma is the most common benign rib tumor and

has a 3:1 male incidence. The stippled calcification and
intact rib cortex are characteristic for this lesion in contrast
to the bone destruction of Ewing sarcoma and combined
bone destruction and “sunburst” calcification of osteogenic
sarcoma. For both Ewing and osteogenic sarcoma,
multimodality therapy using preoperative chemotherapy
followed by resection yields better results than with
radiation therapy. Osteochondromas in prepubertal children
can be observed unless they become painful or enlarged, but
are routinely resected in adults.

83. To resect a chondrosarcoma of the chest wall in a 42-

year-old man, ribs 2–4 were removed, leaving a defect 8 x 8
cm. For reconstruction, the following is/are true:

a. If this were to be posterior, beneath the scapula,

reconstruction would not be required
b. If this defect is anterior, the primary benefit of
reconstruction is an improved cosmetic result
c. Whenever chest wall reconstruction is considered, it
should be delayed 6–12 months to allow detection of
recurrent tumor
d. If Marlex is used for reconstruction, no wound drainage
tube is necessary
e. If PTFE is used for reconstruction, both pleural and wound
tubes should be used
Answer: a, d, e

Skeletal chest wall defects that are full-thickness and occur

posteriorly where they can be covered by the scapula do not
require reconstruction. Anterior chest wall defects do
require reconstruction, primarily to stabilize the chest wall
and prevent paradoxical motion. The reconstruction should
be immediate for optimal physiological benefit. Since Marlex
mesh is porous, only a wound catheter is needed as pleural
fluid will drain through it. PTFE, however, is a solid sheet
necessitating both pleural and wound drainage.

84. An upright chest film of a cachectic, homeless 47-year-

old woman shows blunting of the right costophrenic angle.
The following is/are true:

a. A lateral decubitus film should be obtained to confirm the

presence of fluid rather than a CT scan
b. Tuberculous effusion can readily be identified by stain and
culture of aspirated fluid
c. A pleural fluid glucose level lower than in the serum is
diagnostic of empyema
d. Bloody pleural effusion in this patient is diagnostic of an
underlying malignancy
e. Pleural fluid cytology report of lumphoma should be
viewed with skepticism
Answer: a, e

Although the CT scan is a very sensitive indicator of pleural

effusion, a lateral decubitus is the simplest way to
differentiate fluid from pleural thickening or fibrosis.
Tuberculous pleuritis is difficult to diagnose by stain or
culture which have a 30% yield, but the diagnosis is
facilitated by needle biopsy of the pleura. Pleural fluid
glucose lower than in serum is characteristic of rheumatoid
arthritis, neoplasms, and tuberculosis as well as empyema.
A red-tinged fluid can occur from needle trauma, but even
frankly bloody fluid in this patient may reflect trauma as well
as underlying malignancy. Pleural inflammation induces
reactive changes in mesothelial cells that makes them
resemble lymphocytes, so a lymphoma diagnosis is suspect.

Following shotgun wound of the chest wall, a 39-year-old

woman desires reconstruction without a foreign-body
prosthesis. Old incisions prohibit use of her rectus
abdominus muscles. Considering chest wall muscles for
reconstruction, the following is/are true statement(s):

85. The pectoralis major muscle is available and innervated

by the medial and lateral pectoral nerves so named because
it describes their relationship to the pectoralis minor
a. The serratus anterior muscle is available since its
absence has no functional significance
b. There is no serratus posterior muscle
c. The latissimus dorsi muscle is available and supplied by
the thoracodorsal artery
d. The latissimus dorsi is innervated by the thoracodorsal
nerve with fibers from C6, C7 and C8
Answer: d, e

The pectoralis major muscle can be used for reconstruction

but the medial and lateral pectoral nerves are named from
their respective cords of the brachial plexus. The serratus
anterior muscle holds the scapula to the chest wall and its
absence produces the functional and cosmetically disabling
winged scapula. The serratus posterior muscle is attached
to the 7th cervical and first three thoracic vertebrae
posteriorly and functions as an accessory muscle of
respiration. The constancy of the vascular pedicle to the
latissimus dorsi and its size allow this muscle to be used to
reconstruct defects of the head, neck, chest wall and
pleural cavity. It is innervated by the thoracodorsal nerve
with fibers from C6, C7 and C8.

86. A 38-year-old man presents with facial and upper

extremity edema, venous distention in the neck and arms
and a cyanotic appearance. The following is/are true
statement(s):
a. The most likely cause of the problem is mediastinal
granulomatous disease
b. A venogram should be obtained to confirm the diagnosis
c. Mediastinoscopy for diagnosis is contraindicated
d. If a malignancy is identified, resection is indicated for
palliation
e. If the etiology is benign disease, gradual improvement
without operation is to be expected
Answer: e

Although mediastinal granulomatous disease is one cause of

the superior vena cava syndrome described, the most
common cause (75%) is malignant disease. A venogram
adds little information to the typical findings and increases
risk from extravasation of contrast medium subcutaneously
from the venous hypertension. Mediastinoscopy can be used
for diagnosis with recognition of increased risk of bleeding
and airway problems from the edema associated with the
endotracheal intubation required for the procedure. If a
malignancy is found, operative resection is usually
precluded by the extent of mediastinal invasion. Fortunately,
in the case of benign disease, the symptoms tend to improve
with time as chest wall and mediastinal collaterals enlarge.

87. A 39-year-old woman with hypertension and radicular

chest wall pain was found to have the lesion seen on chest
radiograph (Fig. 63-23). The following is/are true
statement(s):

a. The location of the lesion suggests a teratoma

b. High urinary vanillylmandelic acid levels would indicate
that the lesion is a paraganglioma
c. If the lesion was seen on a film 5 years earlier, resection
would not be indicated
d. A neurosurgical consultation should be obtained
e. Vasoactive intestinal polypeptide level elevation suggests
a ganglioneuroma
Answer: d, e

The posterior mediastinal location of the tumor is most

indicative of a neurogenic tumor while teratomas are
characteristically found in the anterior mediastinum.
Neurogenic tumors can undergo malignant degeneration and
should be resected, particularly in this symptomatic patient
even if known to be present for years. The radicular pain
suggests the possibility of intraspinous extension of the
tumor, and therefore a neurosurgical consultation is
appropriate. Both urinary vanillylmandelic acid elevation and
vasoactive intestinal polypeptide can be produced by
ganglioneuroma but would not be characteristic of a
paraganglioma.