1

Objective Questions
On
Cardio-Pulmonary Bypass
And
Perfusion
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Preface
It is, indeed, my pleasure to present this collection of objective questions to you.

Thanks to my teachers and, perhaps, due to the era when I was an M.Ch. student, I developed
passion for cardio pulmonary perfusion. This passion got further nurtured, when the IACTS
appointed me as the national coordinator for PGDPT course. During the long tenure as the
national coordinator, it was always my endeavour to provide ‘new’ MCQs, during the
examinations.

The ‘PerfuTech’ programme , conducted by India Medtronic, with me as the programme

director, gave me a golden opportunity to closely interact with perfusionists from all over India
and Bangladesh. ‘Perfu-Quiz’ always remained a high point of these PerfuTech programmes and
provided a platform for healthy competition amongst perfusionists.

At the end of my career as a teacher for perfusionists, I thought of bring out a collection of
objective questions and quizzes to help students understand vital points of perfusion and face
exams in a better way.

While preparing this collection simple factual MCQs (like, ‘Normal WBC count is …’ type) are
avoided, unless they are of special importance to understanding of perfusion. MCQs are set
intentionally at random to ‘strengthen’ thought process.

Rather than just providing answers as Q1=b or Q24=c, I have also tried to provide , whenever
possible, an explanation or the theory behind the answer.

During the course of my tenure as a teacher and coordinator for PGDPT course, I was generously
helped by Ms. Kinnari Chudasama, Parmita Desai and Shibani Trivedi ( not in the order of help
received !!!!), to prepare various objective questions. I am really thankful to them. All the three
ladies should carry forward the solemn duty of teaching cardio-pulmonary perfusion to students.

I am specially thankful to Mr. Raju Kokane for frequent ‘telephonic consultations’ while
preparing this compilation!

This compilation should not only make students better prepared for examinations, but, should
also make them a better perfusionist.

Anil Tendolkar
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Index
1. Anatomy , Physiology & Biochemistry ……………………………………………. 4

2. Pathology, Bacteriology and Investigations ………………………………………… 16

3. Pharmacology ……………………………………………………………………….. 24

4. Perfusion Physiology/ Technology/ Clinical Perfusion …………………………….. 30

5. Cardiac Anesthesia & Surgery………………………………………………………. 77

6. Answers to all questions with explanation………………………………………….. 84

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Anatomy, Physiology & Biochemistry

MCQs
1) The Thebesian veins open into
a) SVC
b) Coronary sinus
c) RA
d) IVC
2) Thebesian vein openings are least seen in
a) RA
b) RV
c) LA
d) LV
3) Pulmonary capillary wedge mean pressure reflects
a) CVP
b) RV end diastolic pressure
c) aortic diastolic pressure
d) LV end-diastolic pressure
4) Which of the following pressures reflects LVEDP
a) CVP
b) PA systolic pressure
c) PA diastolic pressure
d) aortic diastolic pressure
5) One milliequivalent weight of a substance is equal to
a) molecular weight in milligrams / ( atomic weight of substance x valence)
b) Atomic Wt. in mg of the substance.
c) Wt in mg of the substance / atomic Wt
d) (Wt. in grams x valence) / molecular weight
6) Fill in the blanks with an appropriate combination:
Hypoxia or Hypercarbia causes pulmonary ______ and cerebral ______
a) Vasoconstriction and vasodilation
b) Vasodilation and vasoconstriction
c) Vasodilation and Vasodilation
d) Vasoconstriction and Vasoconstriction
7) LV preload does not depend on
a) venous return
b) coronary artery blocks
c) duration of cardiac cycle
d) intrapericardial pressure
 5

8) Which of the following is a tributary of Superior Vena cava

a) azygos vein
b) hemiazygos vein
c) accessory hemiazygos vein
d) superior azygos vein
9) In which of the following conditions, Azygos vein is severely dilated?
a) bilateral SVC
b) unroofed coronary sinus
c) IVC interruption
d) dextrocardia with situs solitus
10) Cannulation of IVC is easier through right femoral vein than through left femoral vein
because,
a) right femoral vein is larger in caliber than left femoral vein
b) right femoral vein is in line with the IVC
c) surgeon stands on the right side of the patient during surgery
d) usually, surgeons are right handed hence it is easy
11) Advantages of iliac artery cannulation over femoral artery cannulation are all of the
following, except,
a) cannulation can be done with a large caliber cannula
b) better asepsis
c) no chance of lymph collection
d) faster speed & ease of dissection and cannulation
12) Sinutubular junction is a part of
a) RA
b) LA
c) LV
d) aorta
13) pK of a buffer indicates
a) concentration of the buffer in blood
b) concentration of the buffer in the tissue
c) ratio of acid to base
b) ratio of base to acid
e) pH at which the buffer is most efficient.
14) pK of bicarbonate buffer system is
a) 3.1
b) 4.1
c) 5.1
d) 6.1
e) 7.1
15) Due to low oncotic pressure of the priming fluid, the RBCs first become
a) biconvex
b) biconcave
c) sickle shaped
d) tear drop shaped
 6

16) The problem with a biconvex RBC is

a) it is more fragile
b) it carries less hemoglobin
c) it has less affinity for oxygen
d) it starts combining with CO2
17) The minimal size of a colloid particle is
a) 10,000-20,000 Daltons
b) 20,000- 30,000 Daltons
c) 30,000- 40,000 Daltons
d) 40,000- 50,000 Daltons
18) Other name for hormone Vasopressin is
a) antidiuretic hormone
b) aldosterone hormone
c) bradykinin peptide
d) kallikrein peptide
19) Catacholamines are released from
a) supra aortic nucleus of hypothalamus
b) paraventricular nucleus of hypothalamus
c) adrenal medulla
d) adrenal cortex
20) Which of the following hormones does not affect the blood flow through kidneys?
a) T3
b) angiotensin
c) epinephrine
d) prostaglandins
21) Which of the following substances normally is never filtered during glomerular filtration
a) glucose
b) sodium
c) erythrocyte
d) potassium
22) Which of the following affects intracellular potassium uptake?
a) adrenaline
b) noradrenaline
c) insulin
d) thyroxin
23) Circulation time for blood in a normal patient is
a) 10 seconds
b) 20 seconds
c) 40 seconds
d) 80 seconds
24) Which of the following is NEVER a branch of Left Coronary Artery?
a) ramus intermedius artery
b) posterior left ventricular artery
c) acute marginal artery
d) posterior descending artery
e) obtuse marginal artery
 7

25) On coming in contact with damaged endothelial surface, platelets secrete

a) adrenaline
b) ADP
c) ATP
d) alanine
26) Heparin is produced by
a) eosinophils
b) neutrophils
c) basophils
d) lymphocytes
e) erythrocytes
27) Heparin is naturally stored in
a) brain
b) lung
c) blood
d) spleen
28) At normothermia, the viscosity of blood at 40% hematocrit, as compared water, is
a) 2 times
b) 4 times
c) 6 times
d) 8 times
e) 10 times
29) Diffusion of a gas is inversely proportional to
a) partial pressure
b) area
c) solubility
d) distance
30) Mean arterial pressure =
a) (syst. BP+ diast. BP)/2
b) (syst. BP+ diast. BP)/3
c) diast BP + (systolic BP/2 )
d) diast BP + (pulse pressure/3)
e) 2 x Pulse Pressure.
31) Which of the following is the characteristic property of a platelet ?
a) phagocytosis
b) antibody production
c) chemotaxis
d) erythropoiesis
e) aggregation
32) Metabolic acidosis is diagnosed if at 370 C temperature, ABG report shows
(in appropriate units)
a) pH - 7.4 pCO2 - 35 HCO3 - 25
b) pH - 7.2 pCO2 - 30 HCO3 - 10
c) pH - 7.2 pCO2 - 55 HCO3 - 28
d) pH - 7.5 pCO2- 20 HCO3 - 25
e) pH -7.5 pCO2 - 40 HCO3 - 35
 8

33) Soda-bi-carb is considered as not an ideal buffer because

a) it is costly as compared to other buffers
b) it precipitates at pH of 7.5
c) pK is not appropriate
d) after neutralisation, it is difficult to excrete
34) CO2 is carried in blood in all the following forms, except,
a) carboxyHb
b) dissolved CO2
c) carbonic acid
d) carbaminoHb
35) Oxygen saturation is calculated by
a) pO2 / 750
b) pO2/ max O2 capacity
c) actual O2 content / 100
d) actual O2 content /max O2 carrying capacity
e) actual O2 content /Hb x 1.34
36) Shape of a normal RBC is
a) spherical
b) biconcave
c) concavo- convex
d) oval
e) plano-convex
37) Sinus of Valsalva is a part of
a) RA
b) RV
c) LA
d) LV
e) Aorta
38) The Left Subclavian Artery is a branch of
a) aorta
b) innominate artery
c) left carotid artery
d) common carotid artery
39) Left SVC most commonly opens into
a) R SVC
b) coronary sinus
c) left atrium
d) IVC
e) L subclavian v.
40) Coronary Sinus opens most commonly into
a) RA
b) RV
c) LA
d) Thebesian veins
e) IVC
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41) Obtuse marginal (OM) artery is a branch of

a) Left Anterior Descending artery
b) Left Circumflex artery
c) Right Coronary artery
d) Posterior Descending artery
e) Left main coronary artery
42) Infundibulum is a part of
a) RA
b) RV
c) LA
d) LV
43) During ‘On Pump CABG’ decreased venous return takes place usually during anastomosis of
a) LAD
b) Diagonal
c) RCA
d) Ramus
e) OM2
44)Diagonal coronary artery is a branch of
a) RCA
b) LAD
c) LCx
d) PD
e) OM
45) All of following are a part of the conduction system of heart, EXCEPT
A) node of Arantius
B) S A node
C) Purkinje fibres
D) A V node
46) The basilar myocardial oxygen consumption rate is affected by all of the following ,
EXCEPT,
a) levels of thyroxine hormone
b) heart rate
c) temperatute
d) levels of Growth hormone
e) pressure generated
47) ‘p50’ of hemoglobin is
a) arterial pO2 required to achieve arterial oxygen saturation of 50%
b) FiO2 of sweep gas to achieve arterial oxygen saturation of 50%
c) FiO2 of sweep gas to achieve arterial pO2 of 50 mm of Hg
d) Sweep gas flow required to achieve venous pO2 & pCO2 of 50 mm of Hg
48) Normal colloidal osmotic pressure is (in mm of Hg)
a) 45
b) 35
c) 25
d) 15
 10

49) Normal serum osmolarity is (in milliosmols)

a) 185-195
b) 235-245
c) 285-295
d) 335-345
50) The ratio of flow from SVC:IVC in adult is
a) 1 : 1
b) 1.5 : 2
c) 1 : 2
d) 2 : 1.5
e) 2 : 1
51) One of the following is a branch of Innominate artery
a) right internal carotid artery
b) right subclavian artery
c) left external carotid artery
d) left subclavian artery
52) Left circumflex coronary artery cannot be not grafted directly during CABG operation as
a) it is deep in the left AV groove
b) it is behind MPA
c) it is in IVS
d) it is covered by fat and middle cardiac vein
53) Cerebral Perfusion Pressure =
a) (Arterial Systolic Pressure + Arterial Diastolic Pressure)/2
b) Mean Arterial Pressure – Intra Cranial Pressure
c) Arterial Systolic Pressure + Jugular Venous Pressure
d) (Mean Arterial Pressure + Mean Venous Pressure)/2
54) Cerebral Vascular Resistance is affected by all, EXCEPT,
a) pO2
b) pCO2
c) pH
d) Blood sugar levels
55) The fall in the cerebral metabolic rate for oxygen, per degree Centigrade, is
a) 7%
b) 7 ml/ 100 ml blood flow
c) 7 ml/ min/ 100 gm of tissue
d) 1/7
56) Which of the following statement is true?
Excessive cerebral blood flow during CPB

a) increases risk of hyperoxic brain damage

b) increases risk of cerebral micro embolism
c) causes reduction in tissue pCO2 levels
d) causes interstitial cerebral edema
 11

57) Which of the following statements about blood glucose is FALSE?

a) liver is one of the principle organ involved in glucose homeostasis
b) glucose is an obligatory fuel for brain
c) glucose transport from blood to brain is insulin dependent
d) ideal blood sugar level on CPB in an adult is 150-200mg/dl
58) Which of the following arteries DOES NOT supply brain?
a) Right subclavian artery
b) Right external carotid artery
c) Right internal carotid artery
d) Left common carotid artery
59) Which of the following arteries cannot be used for cannulation during MICS by
right sub mammary incision?
a) Right axillary artery
b) Left subclavian artery
c) Left femoral artery
d) Right femoral artery
60)Which of the following is NOT a platelet function?
a) adhere to an injured endothelium
b) aggregate to form a plug
c) secrete noradrenaline to cause vasospasm
d) stimulation of clotting cascade
61) The most abundant cation in the intracellular compartment is
a) sodium
b) potassium
c) chloride
d) bicarbonate
62) All of the following are causes of extracellular or interstitial edema, EXCEPT,
a) increased capillary pressure
b) high venous pressure and venous constriction
c) increased plasma proteins
d) increased capillary permeability
63) Which of the following sentences about ‘anterior cardiac veins’ is true?
a) anterior cardiac veins drain RV and open into RA
b) anterior cardiac veins drain RV and open into RV
c) anterior cardiac veins drain RA and open into RA
d) anterior cardiac veins drain RA and open into RV
64) Which of the following part of the heart is not perfused during retrograde coronary sinus
cardioplegia?
a) anterior RV wall
b) IVS
c) anterior LV wall
d) inferior LV wall
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65) The point on the heart where the a-v groove , IAS & IVS meet is called
a) crux
b) trigone
c) node
d) commissure
66) P wave on ECG corresponds to
a) atrial depolarization
b) conduction across AV node
c) conduction across bundle of His
d) ventricular depolarisation
e) ventricular repolarisation
67) In a normal ECG, ST segment is
a) elevated
b) up-sloping
c) isoelectric
d) depressed
e) down sloping
68) Left main coronary artery is not grafted during CABG operation as
a) it is behind MPA
b) it is too posterior
c) it is deep in the AV groove
d) it is covered by fat and middle cardiac vein
69) Which of the following vitamins is required for production of mature RBCs ?
a) vit A1
b) vit B12
c) vit C3
d) vit D2
70) The anemia that results when bone marrow does not produce enough RBCs is called
a) pernicious anemia
b) aplastic anemia
c) megaloblastic anemia
d) microcytic hypochromic anemia
71) The average of life of RBC, in an adult, is
a) 30days
b) 60days
c) 90 days
d) 120days
72) If bilateral SVC is present then the following vein is , usually, absent
a) left internal jugular vein
b) left subclavian vein
c) left brachiocephalic vein
d) left external jugular vein
e) left basilica vein
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73) During conventional atrial cannulation, an IVC cannula usually malpositions into
a) coronary sinus
b) hepatic vein
c) RV inflow
d) portal vein
74) In a direct SVC cannulation with a Paccificco cannula , side holes in the cannula tip help in
draining all of the following EXCEPT
a) right innominate vein
b) left subclavian vein
c) azygos vein
d) left innominate vein
75) Which of the following is a tributary of right superior vena cava ?
a) azygos vein
b) hemi-azygos vein
c) accessory hemi-azygos vein
d) superior azygos vein
76) Cross clamping of which of the following vessels would NEVER result in paraplegia?
a) upper descending thoracic aorta
b) lower descending thoracic aorta
c) supra renal abdominal aorta
d) infrarenal abdominal aorta
77) ‘Calyx’ & ‘Pelvis’ are parts of which of the following organs?
a) liver
b) kidney
c) cerebellum
d) stomach
d) azygos vein
78) CVP reading yields information regarding
a) plasma volume
b) intravascular volume
c) interstitial volume
d) total body volume
79) The passage of WBCs through the vessel wall without damaging vessel wall is called
a) chemotaxis
b) diapedesis
c) leucocytosis
d) transmigration
80) Which of the following is NOT a phase of hemostasis?
a) phase of vasoconstriction
b) phase of platelet plug formation
c) phase of clot formation
d) phase of lysis
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81) Thromboxane A2 is released by

a) basophil
b) monocyte
c) B cell
d) platelet
82) Pharmacologically Thromboxane A2 is
a) vasodilator
b) vasoconstrictor
c) natural, selective renal vasodilator
d) natural selective splanchnic vasoconstrictor
83) During ‘systemic inflammatory response’ , oxygen free radicals are released by
a) Neurophils
b) Basophils
c) Lymphocytes
d) Platelets
84) Normal value of mixed venous pO2 (in mm of Hg) is
a) 20
b) 40
c) 60
d) 80
85) The basilar oxygen consumption of a 50Kg weight adult is
a) 2.0ml/min/kg
b) 3.0ml/min/Kg
c) 4.0ml/min/kg
d) 5.0 ml/min/Kg
86) The formula for oxygen dissolved in 100 ml of blood is
a) Hb x 1.34 x pO2
b) pO2 x 0.003
c) Hb x Saturation x pO2
d) pO2 x Saturation
87) Fibrinolytic system is stimulated by
a) factor XIIa
b) complement C5a
c) calcium ions
d) bradykinin

Write Two
( the first two answers will be considered)

88) Valves of heart which close during ventricular diastole

89) Factors shifting oxygen hemoglobin dissociation curve to right
90) Factors affecting transcapillary fluid movement
91) Causes of decreased platelet count on CPB
 15

Match the following

92) Gr A pertains to a unique feature of a coronary artery. Gr B pertains to the coronary artery .
Group A Group B
( anatomical feature) ( coronary artery)
a) in right A-V groove a) OM ( )
b) in left A-V groove b) LAD ( )
c) on inferior surface of heart c) RCA ( )
d) behind MPA d) LM ( )
e) between RV & LV e) LCx ( )
f) between LAD and LCx f) PLV ( )
g) on posterior surface of heart g) Ramus ( )

Fill in the blanks

93) The enzyme responsible for converting CO2 & H2O to carbonic acid is --- ------
94) Infradiaphragmatically , IVC is joined by --------
95) With hypothermia ,solubility of gases --------
96) During hypothermia the neutral pH of water changes by---------
97) Left and Right Innominate veins join to form --------
98) Left External Iliac Artery is a branch of ---------
99) Solubility of CO2 is more than that of O2 by --------
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Pathology/ Bacteriology/Investigations

MCQs
100) Which of the following viruses in NOT transmitted through blood transfusions ?
a) hepatitis A
b) hepatitis B
c) hepatitis C
d) HIV
101) A case of TOF with 23g% hemoglobin is most likely to have a
a) damaged lung functions
b) low platelet count
c) impaired LV function
d) impaired cerebral status
102) Shunt through ASD is obligatory in a case with
a) tricuspid atresia
b) truncus arteriosus
c) single ventricle
d) TOF
103) The most common virulent bacterium in surgical infections is
a) Gr. A β hemolytic Streptococci
b) Staphylococcus aureus
c) Diplococcus pneumoniae
d) Acinatobactum virulence
104) In Supra cardiac TAPVC, the common chamber is connected to
a) RA
b) right innominate vein
c) coronary sinus
d) left innominate vein
105) C3a is
a) a complement which activates granulocytes
b) an activated form of Clotting factor III
c) a type of cyclic AMP
d) a corticosteroid which causes sodium retention
e) a collagen which layers membrane
106) If a patient has ‘cardiac cirrhosis’ then the organ damaged is
a) kidneys
b) lungs
c) heart
d) liver
 17

107) Atherosclerosis is least likely to affect

a) carotid arteries
b) pulmonary arteries
c) renal arteries
d) ilio-femoral arteries
108) Raised SGPT levels indicate
a) severe hemolysis
b) liver cell damage
c) blockage of intrahepatic bile duct
d) myocardial cell damage
109) Which of the following is not a part of Marfan’s syndrome?
a) aortic stenosis
b) ascending aortic aneurysm
c) arch aneurysm
d) aortic dissection
110) Heparinised whole blood can be kept in the bank for
a) 24 hrs
b) 48 hrs
c) 72 hrs
d) 96hrs
111) The changes that take place in whole blood on storing are all of the following, EXCEPT,
a) loss of platelets
b) rise in potassium
c) fall in glucose levels
d) loss of factor VIII
e) fall in the levels of ammonia
112) Which of the following congenital heart diseases WILL NOT have polycythemia?
a) pulmonary atresia with intact IVS
b) single ventricle with PS
c) tricuspid atresia with PS
d) severe PS with intact IVS and IAS
113) A Patent Ductus Arteriosus with L to R shunt results in all except
a) LAVO
b) RAVO
c) LVVO
d) dilatation of ascending aorta
114) Which of the following IS NOT a feature of d-TGA?
a) RV connected to Aorta
b) low arterial pO2
c) atrial septal defect present
d) RA connected to LV
e) parallel circulation
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115) Which of the following is NEVER a feature of TOF ?

a) high PCV
b) low arterial pO2
c) RVOT obstruction
d) clotting disorder
e) aortic Stenosis
116) Bilateral SVC is commonly associated with
a) tight MS with severe PH
b) gross AR due to Marfan’s syndrome
c) degenerative severe calcific AS
d) atherosclerotic coronary artery disease
e) primum ASD, gr II MR, Mod PH
117) Bacterium responsible for rheumatic heart disease is
a) Gr. A β hemolytic Streptococcus
b) Gr. A β hemolytic Staph. aureus
c) Gr. B β hemolytic Streptococcus
d) Gr. α β hemolytic Staph. aureus
118) Which of the following enzymes is the most sensitive for myocardial damage?
a) SGOT
b) SGPT
c) LDH
d) Total CPK
e) Troponin
119) An Atrial septal defect with L to R shunt results in
a) dilatation of aorta
b) LVVO
c) enlarged LA
d) RVVO
120) In Supra cardiac TAPVC, through vertical vein, the pulmonary veins open into
a) RA
b) right internal jugular vein
c) coronary sinus
d) left innominate vein
121) VSD with L to R shunt without PH results in
a) right atrial volume overload
b) overloading of pulmonary circulation
c) overloading of systemic circulation
d) dilatation of aorta
122) Mitral stenosis results in all of the following, EXCEPT,
a) dilatation of aorta
b) pulmonary venous congestion
c) RV hypertension
d) functional tricuspid regurgitation.
 19

123) Mitral incompetence results in all of the following, EXCEPT,

a) dilatation of aorta
b) LV volume overload
c) pulmonary venous congestion
d) RV hypertension
e) functional tricuspid hypertension
124) The problem in methemoglobinemia (mHb) is of
a) production of cytotoxic methemoglobin
b) inability of mHb to bind or release oxygen
c) mHb interfering with release of ATP in co-carboxylase cycle
d) nascent oxygen released from mHb destroying cell wall
125) PA diastolic pressure is monitored during CABG surgery for monitoring
a) LVEDP
b) lung compliance
c) interstitial volume
d) total body volume
126) Which of the following is NOT a part of Hypoplastic Left Heart Syndrome?
a) Pulmonary valve atresia
b) Mitral valve atresia
c) ASD
d) PDA
127) Which of the following statement about ‘Heparin Induced Thrombocytopenia( HIT)’ is
FALSE?
a) HIT results due to antiheparin-PF4 antibodies
b) HIT occurs usually 5-12 days after initiation of heparin therapy
c) HIT carries a higher risk for venous and arterial thrombosis
d) Treatment of HIT is to transfuse platelets
128) Which of the following events is most likely to cause a focal brain damage?
a) atherosclerotic plaque at aortic cannulation site
b) BP of <15 mm of Hg for a long period during CPB
c) arterial saturation of 90% with circulating PCV of 15% during CPB
d) too much negative pressure during assisted venous drainage
129) Which of the following statements regarding basophils is FALSE?
a) basophils appear mainly in Staphylococcal infections
b) basophils contain anticoagulant heparin
c) basophils contain histamine
d) basophils, on reaching tissues , become macrophages
130) The type of WBC necessary for removal of bacteria, cell debris and solid particles is
a) basophil
b) B cell
c) monocyte
d) neutrophil
 20

131) In blood, the proportion of ionic calcium to total calcium is

a) 5%
b) 25%
c) 50%
d) 75%
132) The earliest change after bank storage of whole blood is
a) fall in platelet count
b) steep fall in blood sugar
c) blood pH falling below 7.25
d) a sharp rise in blood ammonia levels
133) Etiology of valvar aortic stenosis can never be
a) rheumatic
b) degenerative
c) syphilitic
d) congenital
134) INR is calculated by the formula
a) [patient PT/ control PT]ISI
b) [patient PT]ISI
c) [control PT /patient PT]ISI
d) [patient PTT/control PTT] ISI
135) Which of the following pathologies would be found in a case with ischemic MR?
a) cuspal perforation or tear resulting in abnormal mitral valve openings
b) shortened & reduced number of chorde preventing normal excursion
c) massive annular dilatation resulting in poor coaptation of AML & PML
d) papillary muscle displacement causing restricted PML motion
136) Which of the following is not a component of aortic root aneurysm?
a) aneurysm of sinus of Valsalva
b) dilatation of aortic annulus
c) aortic cusp fusion
d) aneurysm of ascending aorta
137) ‘Over-riding aorta ’ is a feature of
a) TOF
b) TAPVC
c) truncus arteriosus
d) tricuspid atresia
138) An aneurysm of sinus of Valsalva can rupture into all of the following chambers, except,
a) RA
b) LA
c) RV inflow
d) RV infundibulum
139) Which of the following statements about circulation in Tricuspid Atresia is false?
a) shunt across ASD is always right to left
b) shunt across VSD is always right to left
c) VSD & or PDA is essential for survival
d) ASD is essential for survival
 21

140) The Complements activated by CPB circuit is

a) C1a
b) C2a
c) C3a
d) C4a
141) A feature of RBC damage is raised levels of
a) SGOT & LDH
b) SGPT & SGOT
c) SGPT & LDH
d) SGOT, SGPT & LDH
142) The common stimulus for the activation of the Complement, Fibrinolytic and
Clotting systems is production of
a) fibrinopeptide A
b) fibrinopeptide B
c) factor X a
d) factor XI a
e) factor XII a
143) If serum creatinine level is raised to 2mg%, it indicate that the kidneys are damaged
a) about 10%
b) about 30%
c) about 50%
d) about 70%
144) Which of the following conditions is associated with an undilated ascending aorta?
a) rheumatic mitral incompetence
b) coronary artery disease with hypertension as a risk factor
c) severe aortic stenosis
d) gross aortic regurgitation
145) Povidon Iodine is used in the operating room
a) for spraying O.R.
b) for sterilising instruments
c) as scrubbing solutions
d) as deodorants
e) as preoperative antibiotics
146) The bacterium commonly isolated in nosocomial infection is
a) Strept. epidermdis
b) Staph. aureus
c) E.coli
d) Pseudomonas species
147) Wearing of surgical gloves prevents a perfusionist from acquiring all of the following
virus infections from a patient, EXCEPT
a) Hepatitis A virus
b) Hepatitis B virus
c) Hepatitis C virus
d) Human Immunodeficiency Virus
 22

148) The tendency towards sickling of RBCs increases with which of the following conditions?
a) alkalosis
b) hyperthermia
c) hypoperfusion
d) hyperoxemia

Write Two
( the first two answers will be considered)
149) Enzymes tested to diagnose myocardial damage
150) Diseases transmitted through blood transfusion

151) Match the following

Group A Group B
(CHD) ( typical pathological feature)

a) complete AV canal a) MAPCA ( )

b) supra cardiac TAPVC b) parallel circulation ( )
c) d TGA c) common valve annulus ( )
d) tricuspid atresia d) vertical vein ( )
e) Pulmonary atresia e) obligatory ASD ( )

152)
Group C Group D
(Disease) (Peculiar problems)

a) TOF a) severe PH ( )
b) MS with AF b) cleft mitral valve ( )
c) AR due to Marfan’s syndrome c) ascending aortic aneurysm ( )
d) Non restrictive VSD d) polycythemia ( )
e) Primum ASD e) LA clots ( )
g) calcific aorta ( )
h) calcific mitral valve ( )
 23

153)
Group E Group F
(Pathology) (important aspect related to CPB)

1. MSMR+ TSTR+ AR, CCF 1.Right heart bypass ( )

2. Critical MS with AF 2. Bicaval Cannulation ( )
3. Arch aneurysm 3.IABP ( )
4. Multiple A-P collaterals 4. LA clot ( )
5. Operation on an infant 5.Coronary cannulation for cardioplegia ( )
6. Rupture of ASOV 6. pH-stat strategy while cooling ( )
7. Acute VSD 7. Closure of vert. vein before cardiotomy ( )
8. Extra cardiac TCPC 8. Antegrade cerebral perfusion ( )
9. Supra cardiac TAPVC 9. Cavoatrial venous cannula ( )
10.Gross AR with small VSD 10.Large venous return ( )
11. LV aneurysm repair 11.Trickle flow ( )
12. CABG with MVR 12. Extracardiac shunt closed prior to CPB ( )
13. ASD+ VSD + PDA 13. Distal anastomoses first ( )
 24

Pharmacology

MCQs
154) Heparin induces anticoagulation primarily by
a) preventing activation of platelets
b) preventing activation of prothrombin
c) chelating calcium
d) potentiating activity of Antithrombin III
e) destroying fibrin polymer
155) The average half life of unfractionated heparin is
a) 0.5 -1hr
b) 1-2 hrs
c) 6-8 hrs
d) 10-12 hrs
156) Heparin is metabolised in vivo by
a) lung
b) heart
c) RE cells and kidney
d) Protamine
157) One milligram of heparin is equal to
a) 30 units
b) 100 units
c) 300 units
d) 1000 units
e) 1300 units
158) The Potassium content in a 7.5gm % solution of KCl is
a) 0.1 meq/ml
b) 0.5 meq/ml
c) 1.0 meq /ml
d) 1.5 meq/ml
e) 2.0 meq/ml
159) One of the main side effect of Propofol is
a) convulsion
b) hypotension
c) multiple ventricular ectopics
d) severe vasoconstriction
160) Vecuronium is preferred over other muscle relaxants in cardiac surgery because
a) of its early onset of action
b) it is short acting
c) it is low in cost
d) it maintains a stable heart rate
 25

161) Etomidate is
a) a potent loop diuretic
b) a short acting intravenous anesthetic agent
c) the drug of choice for malignant ventricular arrhythmia
d) a myocardial protector due to its action on ATP
162) Which of the following statement regarding Fentanyl is FALSE?
a) it is an opioid
b) it has a slow onset of action
c) it has a short duration of action
d) it is 50 to 100 times more potent than morphine
163) Which of the following statements, regarding Midazolam, is true?
a) it is an ultra short acting muscle relaxant
b) it is an inhalational anesthetic
c) it is an intravenous anesthetic
d) it is an atropine analogue
164) Which of the following statements about contents of Ringer’s lactate solution is FALSE?
a) the sodium concentration is 130 mEq/L
b) the potassium concentration is 4mEq/L
c) it contains no calcium
d) although its pH is 6.5, it is an alkalizing solution
165) What is the fate of lactate ion of Ringer lactate in the body?
a) converted to bicarbonate
b) converted to citric acid
c) remains as lactate
d) excreted completely by kidneys
166) Which is the odd drug in the group
a) mephentine
b) phenylephrine
c) nitroprusside
d) nor- adrenaline
167) 3 g/kg /min dose of Dopamine results in stimulation of
a)  receptor
b)  receptor
c)  receptors
d) DOPAminergic receptors
e) H2 receptors
168) Chemically Mannitol is a type of
a) sugar
b) amino acid
c) triglyceride
d) globulin
 26

169) Adenosine is given prior to cardioplegia, immediately after aortic cross clamping for all of
the following, EXCEPT,
a) ability to convert SVT to sinus rhythm
b) coronary vasodilator
c) ischemic preconditioning of myocardium
d) reduce inflammatory injury to myocardium
170) Argatroban is
a) a potassium channel opener
b) a calcium channel blocker
c) an antifibrinolytic agent
d) a heparin substitute
171) K+ concentration in 6% hydroxyethyl starch in Saline is
a) 0.0 meq/L
b) 2.7 meq/L
c) 3.2 meq/L
d) 4.5 meq/L
172) Losartan is
a) an ACE inhibitor
b) a selective  blocker
c) a selective  blocker
d) an angiotensin receptor blocker
e) a hypnotic administered along with Propofol
173) Telmisartan is
a) an ACE inhibitor
b) a selective  blocker
c) a selective  blocker
d) an angiotensin receptor blocker
e) a hypnotic administered along with Propofol
174) N- Acetyl cystein is administered preoperatively to a patient planned for CABG, for
a) renal protection
b) bronchodilatation
c) better platelet aggregation
d) improve hemoglobin
e) lower cholesterol
175) Which is the ideal mode of delivering Adenosine for myocardial protection during OHS?
a) add to cold blood cardioplegia in BCP chamber
b) through crystalloid cardioplegia
c) root injection, after cross clamp prior to delivering cardioplegia
d) add to the blood prime in the reservoir
e) through retrograde blood cardioplegia
176) Patients for CABG are on allopurinol 1-2 days prior to surgery, for
a) free radical scavenging
b) inducing diuresis
c) improving coagulation profile
d) coronary vasodilatation
e) LIMA dilatation
 27

177) Which of the following statements about ‘heparin resistance’ is FALSE?

Heparin Resistance
a) is defined as ACT is < 480sec after 3mg/kg dose of heparin during OHS
b) is seen only if patient is on heparin for a minimum of 7days
c) can be seen in patients on IABP
d) can be due to insufficient antithrombin III
e) is treated by adding FFP
178) Which of the following statements about Heparin is FALSE?
a) heparin is a mixture of mucopolysaccharides with molecular weight > 10000 Daltons
b) heparin carries a strong positive charge and is the strongest base in the body
c) heparin is found in mast cells , lung and mucosa
d) heparin activates plasma antithrombin III
179) Most common adverse effect with Hydroxyethyl starch is
a) cerebral edema
b) renal dysfunction
c) thyroid dysfunction
d) pulmonary dysfunction
180) Which of the following statements about of ‘Gelatins’ is FALSE?
a) gelatin is a large molecular weight protein formed from hydrolysis of collagen
b) sodium content is same as in 0.45% NaCl
c) colloidal osmotic pressure is equal to plasma colloidal osmotic pressure
d) eliminated rapidly via kidney
181) Which of the following statements about Protamine is FALSE?
a) it has a very short half life
b) it is found in sperm of fish
c) it is electronegative
d) protamine-heparin complex causes hypotension by various mechanisms
182) Protamine neutralises action of heparin because
a) it is acidic
b) it converts heparin to proheparin
c) it is positive charged
d) it splits heparin to hemiparin & proparin
183) Abciximab is an antiplatelet agent and acts by
a) potentiating the action of aspirin
b) inhibition of platelet glycoprotein receptor
c) decreasing platelet sensitivity to ADP
d) blocking release of 5HT
184) Which of the following agents provide maximal neuroprotection during anesthesia?
a) fentanyl
b) propofol
c) flurothane
d) midazolam
 28

185) Sodium concentration of normal saline is

a) 77 mEq/L
b) 117 mEq/L
c) 134 mEq/L
d) 154 mEq/L
e) 176 mEq/L
186) During which of the following operations, Diltiazem could be administered by
anesthesiologists?
a) CABG
b) ASD closure
c) IC repair of TOF
d) AVR with biological valve
187) Which of the following actions would take place if NTG is administered during CPB?
a) decrease in venous reservoir level
b) increase in myocardial oxygen consumption
c) decrease in cerebral oxygen consumption
d) decreased dissociation of oxygen from hemoglobin
188) What is the content of albumin in 5 ml of 20% human albumin solution?
a) 2 gm
b) 2 mg
c) 1 gm
d) 5 mg
189) Which of the following is NOT a heparin substitute ?
a) Bivalirudin
b) Ivabrad
c) Danaproid
d) Argatroban
190) Pharmacologically Mannitol is
a) a K+ sparing diuretic
b) a loop diuretic
c) an osmotic diuretic
d) renal vasodilator
e) terminal tubule diuretic

191) Write one pharmacological action

( do not write use)

Noradrenaline
Aprotinin
Atenelol
Captopril
Aspirin
Isosorbide 5- mononitrate
Vecuronium
Nifedipin
 29

Write two
192) Drugs to reduce SVR during CPB
193) Drugs to increase only SVR during CPB

Match the following

194) A) Drug B) Commonest Use

1. Clopidogrel 1. to reduce HR during OPCAB ( )

2. Cefotaxime 2. preop stabilise post MI VSD ( )
3.Chlorhexidine 3. to dilate conduits during CABG ( )
4.Diltiazem 4. to preserve clotting mechanism during CPB ( )
5.Propofol 5. as a lipid lowering agent ( )
6.Esmolol 6. prevent angina pectoris ( )
7.Nicorandil 7. to prevent plaque/stent thrombosis ( )
8.Simvastatin 8. as a short acting IV anesthetic agent ( )
9. Monotrate 9. artery dilatation & an anti arrhythmic agent ( )
10.Isofurane 10. to prevent prosthetic valve thrombosis ( )
11.Nitroprusside 11. an inhalational anesthetic ( )
12.Losartan 12. treatment of acute AF ( )
13.Amiodorone 13. oral antihypertensive ( )
14.Coumarin 14. an antiseptic hand wash ( )
15.Tranexamic acid 15. an antibiotic ( )
 30

Perfusion Physiology/ Technology/ Clinical Perfusion

MCQ
195) Myocardial protection is poor with a single venous cannula due to
a) inability to deliver retrograde cardioplegia
b) faster rewarming of heart
c) persistent LV distention
d) low perfusion pressures
e) poor venous drainage
196) Which of the following does not produce hemolysis?
a) excessive hemodilution
b) narrow tip arterial cannula
c) use of old banked blood in the prime
d) hypothermia
197) Hemolysis results in all of the following , EXCEPT,
a) hyperkalemia
b) vasoconstriction
c) hypernatremia
d) renal damage
198) Hemodilution does not results in
a) tissue edema
b) low perfusion pressure
c) spherocytosis of RBCs
d) microcytosis of RBCs
199) Direct left innominate vein cannulation is indicated in which of the following conditions?
a) supra cardiac TAPVC into vertical vein
b) TCPC operation
c) intra cardiac TAPVC
d) A-V canal repair
200) Pump flow for an infant < 3kg in weight ( in ml/kg/min at normothermia ) should be
a) 60- 80
b) 90-110
c) 120-140
d) 150- 200
201) In aortic cannulation, only a short length of the cannula is introduced into aorta so that
a) aortic dissection is avoided
b) arterial line resistance is less
c) cannula does not enter innominate artery
d) adequate pump flows can be delivered
 31

202) The beveled tip of a straight aortic cannula should be directed towards
a) aortic valve
b) innominate artery
c) roof of the of transverse arch
d) descending aorta
e) lateral aortic wall
203) The direction of the tip of a short curved tip aortic cannula should be
a) towards aortic valve
b) towards ascending aorta
c) towards innominate artery
d) towards arch of the aorta
204) If after cannulation blood does not flow freely through an aortic cannula, then all of the
following are possible, except,
a) tip is touching the wall of the aorta
b) tip has entered the innominate artery
c) tip is in the wall of aorta
d) tip is facing aortic root
205) Excess of ‘back bleeding’ from arterial cannula to arterial line suggests
a) adequate size of the cannula
b) good arterial pressure
c) inadequate pump occlusion
d) cannula tip is placed intraluminally into aorta
206) When a centrifugal pump is used , arterial outflow line must have
a) arterial filter
b) flow meter
c) bubble trap
d) pulse oximeter
e) bypass line
207) In a membrane oxygenator size of the pores should be less than 1 micron to
a) inhibit gas leak
b) inhibit serum leak
c) inhibit gas and serum leak
d) improve oxygenation
d) improve CO2 removal
208) Which of the following characteristics is a peculiar to a venous cannula?
a) wire reinforced body
b) oval body
c) light house tip
d) right angled tip
209) Termination of CPB at 350 C rectal temperature, ensures all of the following EXCEPT,
a) contractility of heart is good
b) clotting is adequate after heparin reversal
c) VPCs are avoided
d) arterial blood pO2 is excellent
 32

210) Which of the following was NOT a problem in the historical oxygenators?
a) large priming volume
b) inadequate oxygenation
c) inadequate CO2 removal
d) hemolysis
211) During CPB all of the following will result in hypokalemia, EXCEPT,
a) glucose insulin infusion
b) priming of bank blood
c) intravenous sodabicarb to correct acidosis
d) intravenous calcium gluconate to improve contractility
212) Following CPB, a patient develops impaired vision only in right eye. The most probable
cause is
a) particulate embolism during CPB
b) low perfusion pressure on CPB
c) hypocarbia during CPB
d) low oncotic pressure on CPB
213) A continuous decrease in the venous reservoir level ,within seconds of starting CPB, is due
to
a) dissection by the arterial cannula tip
b) massive diuresis
c) development of cellular edema
d) loss of blood in soaked surgical sponges
e) loss of prime volume into the pleural space due to a rent in the pleura.
214) During an ASD closure operation, the venous reservoir level suddenly falls on opening the
RA. The cause is,
a) aortic dissection by the cannula tip
b) venous line kink
c) inadequate snaring of caval cannule
d) missed left SVC
e) missed PDA.
215) Which of the following shunts does not require closure prior to final correction of the
cardiac pathology ?
a) Blalock Taussig shunt
b) Glenn Shunt
c) Potts Shunt
d) Waterston – Cooley shunt
216) The current CPB circuit mimics circulation in which of the following animals?
a) fish
b) frog
c) bird
d) crocodile
 33

217) Which of the following events is least likely during CPB in a patient with atherosclerotic
cardio vascular disease?
a) decreased urine out put
b) high perfusion pressure
c) large left heart return
d) impaired cerebral perfusion
218) During VSD closure, the left heart can be vented through all of the following, except,
a) aortic root
b) inter atrial septum
c) right superior pulmonary vein
d) through VSD
219) The ideal placement of venous cannula passed through femoral vein for a MICS MVR is
a) till Supra renal IVC
b) at IVC RA junction
c) in RA through IVC
d) in SVC through RA, IVC
220) Which of the following conditions does not require a circulatory support in any form?
a) ascending aortic aneurysm
b) thoracic aortic aneurysm
c) thoracoabdominal aortic aneurysm
d) infrarenal aortic aneurysm
221) Left SVC is managed by temporary ligation during CPB if
a) right SVC is large
b) the pressure of right SVC is normal after ligation of L SVC
c) the bridging innominate vein is large
d) the venous return is unaffected after ligation of L SVC
222) Femoral vein cannulation is indicated in which of the following conditions?
a) RA myxoma
b) LA myxoma
c) TS with TR
d) tumour of RV
223) On CPB, ECG tracing on monitor becomes a ‘straight line’
a) on full bypass
b) on core cooling to 320 C
c) on core cooling to 280 C
d) after delivery of cold blood cardioplegia
224) Partial pressure of CO2 in atmospheric air, at sea level is
a) 30 – 40 mm of Hg
b) 20 – 30 mm of Hg
c) 10 – 20 mm of Hg
d) 1- 10 mm of Hg
e) < 1 mm of Hg
 34

225) Which of the following factors does not increase ultrafiltration?

a) increasing pressure on the inlet of the ultrafilter
b) occluding the outlet of ultrafilter
c) reducing vacuum pressure
d) increasing blood flow through filter
226) If pump output of a 70Kg 68yr old male with BSA 1.8m2, is 4.5 litres per minute, then the
‘Pump Index’ is
a) 0.4
b) 2.50
c) 8.1
d) 40%
227) During ‘trickle flow’, the pump flow is
a) 5ml/min
b) 50 ml/min
c) 50ml/min/m2
d) 0.5 L/min
e) 0.5 L/min/m2
228) Which of the following properties of a roller pump is most important while operating a
pediatric case?
a) the entire console should be battery operated
b) the console should be light in weight and portable
c) the arterial pump head should operate for long hours
d) all the pump heads should have a noiseless function
e) the arterial pump head should accept 1/4 inch tubings
229) A bubble oxygenator could not be used after 3-4 hours of pump run due to ,
a) decreased oxygenation
b) poor CO2 removal
c) inadequate defoaming
d) hemolysis
e) poor heat exchange
230) Which of the following is a rare complication of descending thoracic aorta clamping ?
a) liver dysfunction
b) paraplegia
c) sphincter disturbance
d) lower limb gangrene
231) To label hypothermia ‘profound’, the core temperature should be below
a) 250C
b) 220C
c) 200C
d) 180C
232) Which of the following is an absolute contraindication for using intra aortic balloon pump?
a) adjunct to PTCA
b) bridge to transplant
c) aneurysm of thoracic aorta
d) post infarct VSD
 35

233) The pore size of a cardioplegia filter for cell free solutions, is
a) 1.0 micron
b) 0.7 micron
c) 0.5 micron
d) 0.2 micron
234) Which of the following is NOT a cause of turbulence ?
a) straight, long arterial cannula
b) sharp turn to blood flow in oxygenator
c) blood passing over rough surface
d) high blood velocity
235) Apart from filtering WBCs, the aim of a cardioplegia filter is to filter out
a) clumps of RBCs
b) platelet aggregates
c) particulates of drug precipitate
d) bacteria and fungal spores
236) The pore size of a gas filter is
a) 1.0 micron
b) 0.7 micron
c) 0.5 micron
d) 0.2 micron
237) Maximum pressure drop permissible across an arterial cannula is
a) 80 mm of Hg
b) 100 mm of Hg
c) 120 mm of Hg
d) 140 mm of Hg
238) Which of the following complications is most likely to develop due to hyperoxia during
CPB ?
a) retinal damage
b) membrane lung syndrome
c) depression of immune system
d) blood cellular damage
239) The A-V bridge in pump circuit in pediatric perfusion,
a) helps in making the blood alkalotic during circulatory arrest
b) helps to overcome high resistance in arterial circuit
c) acts as a safety valve for choked arterial line filter
d) facilitates removal of air, collected during the arrest, from the circuit
240) Major advantage of venous reservoir bag over hardshell venous reservoir is
a) compact to transport
b) safety w.r.t. air embolism
c) lowest possible prime volume
d) ease of assembly and priming
241) ‘Driving Pressure’ for transfer of a gas across a membrane is
a) inlet gas pressure – atmospheric pressure
b) inlet gas pressure – outlet gas pressure
c) partial pressure on gas side -- partial pressure on blood side
d) sum of partial pressures on gas side -- sum of partial pressures on blood side
 36

242) The heat exchanger coils are made up of all of the following materials, EXCEPT,
a) stainless steel
b) aluminum
c) copper
d) polypropylene
243) Filtration capacity of a screen filter depends upon
a) material used
b) pore size
c) thickness
d) number of filters in the series
244) Which of the following is the most important consideration while choosing an arterial
filter for an adult CPB circuit?
a) bubble trap directing air to exit port
b) ease of assembly and deairing
c) maximum rated flow
d) priming volume < 100ml
e) pressure drop < 50 mm of Hg
245) The inflation of balloon in an intra aortic balloon pump should be at
a) 40 msec after QRS complex
b) at the dicrotic notch
c) 25 msec after the arterial pulse down slope has started
d) at the isoelectric point of ST segment
246) All of the following will occur with premature inflation of balloon of intra aortic balloon
pump, EXCEPT,
a) delayed closure of aortic valve
b) greatly increased after-load
c) reduced LV emptying
d) increased myocardial oxygen consumption
247) Deflation of the balloon of intra aortic balloon pump should occur during,
a) last rapid filling
b) isovulumic contraction
c) at the beginning of delayed ejection
d) first 10 msec of rapid ejection
248) Which of the following is least detrimental to a patient on intra aortic balloon pump?
a) late inflation of the balloon
b) early inflation of the balloon
c) late deflation of the balloon
d) early deflation of the balloon
249) Which of the following statements related to pediatric perfusion is false?
a) pediatric vascular system is more elastic
b) brain of the infant receives 5% to 10% of cardiac output
c) pediatric patient has a higher metabolic rate than an adult
d) some drugs exhibit different actions when used in pediatric patients
 37

250) Which of the following is NOT an action of Thyroxin

a) increases heart rate , contractility and cardiac output
b) increases sensitivity of  adrenergic receptor blockers
c) increases BMR
d) increases temperature
251) The serum level of which of the following hormones is decreased after CPB?
a) epinephrine
b) renin
c) vasopressin
d) triidothyronine
252) Which of the following is NOT responsible for hyperglycemia during CPB?
a) release of catacholamines
b) decreased levels of corticosteroids
c) decreased insulin response to glucose
d) decreased BMR during hypothermia
253) Platelets are not administered during CPB because
a) platelet transfusion will reduce ACT and produce intravascular clotting
b) platelets will adhere to CPB circuit and will get sequestered
c) platelet dysfunction occurs only in the post CPB period
d) platelet transfusion will produce hemodilution
254 ) Plateletpheresis is a term used to describe
a) increased production of platelets by bone marrow, spleen in response to bleeding
b) loss of platelets during CPB due to adhesion and aggregation to CPB circuitry
c) selective collecting platelets from a donor and transfusing back the remaining blood
d) activation of platelets in response to positively charged surfaces
255) During CPB platelets get sequestered in all of the following organs, except,
a) Lungs
b) bone marrow
c) Liver
d) spleen
256) A line is connected from an arterial filter to cardiotomy reservoir for
a) removal of platelet clumps
b) removal of clot, fibrin shreds and calcium
c) escape of trapped air
d) as a recirculation line to improve oxygenation
e) to collect a sample of arterial blood
257) The reservoir is expected to be ‘full’ in which of the following cases
a) Mod MS. Gross MR, severe TR, normal LV function for MVR
b) Severe AS with mild AR, mild MR, normal LV function for AVR
c) Secundum ASD, with left SVC, IVC interruption for ASD closure
d) IHD, Triple coronary disease, normal LV function for CABG
e) TOF with no collaterals for IC repair
 38

258) The least important factor in deciding the lowest temperature on CPB, is
a) duration of CPB
b) duration of aortic cross time
c) left heart return
d) duration of circulatory arrest
e) type of pump and oxygenator
259) A Capnograph is used for monitoring
a) adequacy of muscle relaxation
b) end-tidal CO2
c) volatile anesthetic gas levels in blood
d) O2 Content of blood
e) pH of blood
260) During partial CPB, the best way of knowing whether the perfusion is pulsatile is by
checking
a) urine output
b) pulse oximeter tracing
c) PA diastolic pressure
d) mean arterial pressure
e) arterial pO2 & pCO2 levels
261) During Intra Cardiac Repair of TOF, a patent BT shunt is managed by
a) leaving it alone and allow natural closure
b) closure of shunt by a separate operation at least a day prior to ICR
c) closure of shunt immediately after sternotomy, even before cannulation
d) closure of shunt on full CPB before cooling
e) leaving it open till the end of operation and close if the hemodynamics are stable
262) During repair of supra cardiac TAPVC, the vertical vein is accidentally left open. This will
result in,
a) low arterial pressure
b) increased left heart return requiring reduced flow
c) venous airlock
d) cerebral air embolism
e) increased venous chattering
263) Which of the following methods would be carried out last while treating massive air
embolism
a) place the patient in Trendelenberg position
b) remove air from aorta and arterial cannula by suction
c) hypothermic retrograde perfusion
d) restart high pressure bypass with 100% oxygen
264) A water to blood leak would give rise to all, except,
a) increase in reservoir volume
b) increase in pH
c) decrease in hemoglobin
d) hemoglobinuria
 39

265) Water to blood leak during CPB is treated by

a) diuresis, adding pack cell to volume
b) stopping rewarming or cooling
c) change of oxygenator
d) maintaining oncotic pressure by priming albumin
266) If CPB is required for construction of an elective Glenn shunt, it is usually
a) a right heart bypass
b) a total CPB without cardiac arrest
c) a left heart bypass
d) under deep hypothermia circulatory arrest
e) only a suction bypass
267) A case of pulmonary atresia with multiple MAPCA will pose the following problem for the
perfusionist:
a) require blood prime
b) low perfusion pressure
c) poor venous return
d) overflowing venous reservoir
e) difficulty in arterial and venous cannulation
268) Which of the following statements about Albumin is true?
Apart from oncotic pressure, Albumin, when used in prime
a) stimulates phagocytosis
b) reduces platelet activation
c) protects clotting factor VII & VIII
d) helps in better warming and cooling
e) improves oxygenation
269) To improve oxygenation capacity of an oxygenator, a manufacturer decides to pack more
hollow fibres in the same space of the oxygenator. The main problem associated with
this measure will be,
a) increased pressure drop across the oxygenator
b) more priming volume
c) more systemic inflammatory response
d) bulkier oxygenator
e) adverse effect on efficiency of heat exchanger
270) To improve oxygenation capacity of an oxygenator, a manufacturer decides to increase
time for diffusion of oxygen by increasing the length of travel of blood around the fibres.
The main problem associated with this measure will be,
a) increased pressure drop across the oxygenator
b) more priming volume
c) more systemic inflammatory response
d) bulkier oxygenator
e) adverse effect on efficiency of heat exchanger
271) Which of the followings is NOT an indication for changing oxygenator
a) persistent metabolic acidosis not responding to correction
b) oxygenator failure, after checking all connections and blender
c) leaking oxygenator at the beginning of CPB
 40

d) water to blood leak in the heat exchanger

272) A meter long tube has OD of 24 mm with a wall thickness of 2mm. The volume in the tube
would be
a) 157 cc
b) 314 cc
c) 628 cc
d) 761cc
e) 1521cc
273) Which of the following causes is most likely if patient develops hematuria within
minutes of going on CPB?
a) small arterial cannula
b) excessive pump occlusion
c) hyperoxia
d) mismatched transfusion
e) excessive cardiotomy suction
274) Which of the following is not an initial response of non-anesthetized human to external
cold?
a) shivering
b) cutaneous vasodilatation
c) vasodilatation of skeletal muscle vascular bed
d) increase in heart rate
e) increase in blood pressure
275) Hypothermia can lead to all of the following, except,
a) decreased renal flow
b) reduction in cerebral metabolism by 50% at 280 C
c) increase in plasma volume
d) hypokalemia
e) hyperglycemia
276) During unilateral antegrade cerebral perfusion, ideally which of the following arteries
should be used for monitoring arterial pressure?
a) innominate artery
b) right radial artery
c) left radial artery
d) right femoral artery
e) left femoral artery
277) ‘Membrane Attack Complex’ or ‘TCC’ is formed during extra corporeal circulation through
a) platelet activation
b) neutrophil activation
c) eosinophil activation
d) lymphocytes activation
e) complement activation
 41

278) Which of the following is not considered as a measure for reducing systemic inflammatory
response during CPB?
a) use of heparin coated circuits and coated oxygenators
b) use of PUF & MUF
c) use of methyl prednisolone or dexamethasone
d) use of aprotinin
e) use of only fresh homologous blood
279) Which of the following parameters should ideally be monitored by a perfusionist ‘to fill the
patient’ while going off CPB in a case for repair of LV aneurysm?
a) mean central venous pressure
b) pulmonary artery systolic pressure
c) pulmonary artery diastolic pressure
d) systemic systolic pressure
e) systemic diastolic pressure
280) The main purpose of lower body perfusion through femoral artery in a case with
descending thoracic aorta aneurysm is to prevent
a) renal failure
b) paraplegia
c) liver cell failure
d) metabolic acidosis
e) lower limb gangrene
281) The maximum acceptable water pressure at inlet of heat exchanger in membrane
oxygenator is
a) < 40psi
b) < 60psi
c) < 80psi
d) < 100psi
282) Venous pressure of above 10 mm of Hg during CPB will result in increased
a) arterial pCO2
b) arterial pressure
c) extravascular fluid
d) urine output
e) arterial pO2
283) Which of the following statements is true?
Systemic vascular resistance during hypothermic CPB
a) remains the same as pre CPB
b) initially rises & then falls at the end
c) keeps on falling throughout the period of CPB
d) keeps on rising throughout
e) initially falls abruptly & then gradually rises throughout
284) In which of the following conditions, SVR is low during CPB?
a) tight mitral stenosis with severe PH
b) coronary artery disease with systemic hypertension
c) severe aortic stenosis in CCF
d) chronic severe aortic regurgitation
e) post infarction VSD
 42

285) Venous pO2 on CPB to ensure adequate perfusion should be, at normothermia
( all values in mm of Hg)
a) 0 - 10
b) 15 – 20
c) 20 – 25
d) 30 – 40
e) 60 – 70
286) Safety of CPB does not depend up on
a) age of the patient
b) duration of CPB
c) type of membrane oxygenator
d) perfusion flow rate
e) temperature of patient during CPB
287) Platelet depletion on CPB can be prevented by priming
a) manitol
b) albumin
c) heta starch
d) penta starch .
288) The most important factor deciding bypass temperature is
a) duration of CPB
b) duration of aortic cross time
c) duration of circulatory arrest
d) pre operative ventricular function
e) type of oxygenator used
289) The least important factor deciding bypass temperature is
a) duration of CPB
b) duration of aortic cross time
c) duration of circulatory arrest
d) pre operative ventricular function
e) type of oxygenator used
290) The site of aortic cannulation should be
a) as near the aortic valve as possible
b) in the middle of ascending aorta
c) proximal to take off of the innominate artery
d) at the base of left carotid artery
e) center of transverse arch
291) Which of the following is NOT a complication of aortic cannulation?
a) aortic arch dissection
b) atherosclerotic plaque embolisation
c) accidental occlusion of cannula during aortic cross clamping
d) retroperitoneal hematoma
e) line blow out
 43

292) A straight plastic cannula is provided with an adjustable collar to

a) facilitate insertion
b) secure snugging
c) facilitate tying and fixing
d) ensure just the right length of cannula is inside
e) direct the tip of the cannula towards the descending aorta
293) In a patient with a recent rise in S. Creatinine to 3.8 mg% has a low pressure on bypass,
then the ideal vasopressor is
a) adrenaline
b) DOPAmine
c) phenylephrine
d) noradrenaline
294) ‘Postperfusion Syndrome’ result in all of the following, EXCEPT,
a) monoplegia
b) attention deficit
c) short term memory loss
d) fine motor function loss
e) slower mental response
295) During CPB, without aortic cross clamping, the greatest decline in blood supply is to ,
a) heart
b) skeletal muscle
c) brain
d) kidneys
e) liver
296) If the inflow of a roller pump becomes limited, it will produce
a) short circuiting
b) venous obstruction
c) cavitation effect
d) cracks in the tube
e) cracks in the oxygenator
297) Blood damage due to cardiotomy suction can be minimised by
a) minimising co-aspiration of air
b) maintaining high arterial pump flow rates
c) using microtip rigid suction
d) filter in the suction line
e) leucocyte filter
298) ‘Performance Index’ of an arterial cannula is
a) Internal diameter / External diameter
b) Flow / External diameter
c) Pressure gradient / External diameter
d) Pressure gradient / Flow
e) External diameter / Flow
 44

299) A pressure gradient excess of 100 mm of Hg across an arterial cannula results in

a) excessive hemolysis
b) particulate embolism
c) jammed pump
d) burst of tubing/connection
300) Jet produced by a small arterial cannula DOES NOT result in
a) damage of aortic wall
b) dislodgment of atheroemboli
c) dissection
d) cavitation
e) decreased flow rates
301) After aortic cannulation, a ‘back bleeding’ from the arterial cannula suggests
a) adequate size of the cannula
b) good systolic arterial pressure
c) presence of gross aortic regurgitation
d) proper intraluminal placement
e) adequate occlusion pressure
302) A depth filter consists of
a) packed dacron wool fibers
b) woven polymer
c) fine membrane
d) dacron micropore mesh
e) knitted polymer thread
303) A depth filter works by
a) ion exchange
b) impaction and adsorption
c) neutralisation
d) interception
e) chelation
304) Which of the followings is NOT a concern about use of salvage blood obtained from
a cell–saver system?
a) increased fragility of RBCs
b) presence of heparin in the blood
c) presence of free hemoglobin
d) slow turn around time
e) tissue debris is unfiltered
305) Efficiency of an ultrafiltration device is inversely proportional to
a) perfusion pressure
b) transmembrane pressure
c) plasma oncotic pressure
d) hydrostatic pressure
e) systemic venous pressure
 45

306) Which of the following operation is performed with a bicaval cannulation

but without caval tourniquets?
a) ASD closure
b) Correction of TAPVC
c) MVR
d) TOF correction
307) The Key to adequate drainage following femoral venous cannulation is
To have the cannula
a) with multiple side-holes
b) metal tipped
c) of short length
d) with an end hole
308) ‘Chattering’ or ‘Fluttering’ around the venous cannulae is due to
a) kinking of venous line
b) air in venous line
c) wedging of cannula
d) too large a cannula
e) excessive negative pressure
309) The narrowest component of venous limb of the circuit is
a) cannula tip
b) body of cannula
c) cannula - venous line connection
d) venous line
e) venous line-reservoir connection
310) In an adult, the ratio of flow from SVC:IVC is
a) 1 : 1
b) 1.5 : 2
c) 1 : 2
d) 2 : 1.5
e) 2 : 1
311) Over several hours of use, the functional capacity of hollow-fibre membrane oxygenator
reduces due to
a) hemolysis
b) condensation of serum on the membrane
c) wash-out of defoamer
d) platelet aggregation on the membrane
e) clotting of blood
312) In a ‘cross – current’ design of membrane oxygenator, the blood flows
a) perpendicular to fiber bundle
b) parallel to fiber bundle and in the direction of gas flow
c) parallel to fiber bundle and in opposite direction of gas flow
d) clock wise in the membrane sheath
e) in a counter clock wise in the membrane sheath
 46

313) In a ‘counter – current’ design of membrane oxygenator, the blood flows

a) perpendicular to fiber bundle
b) parallel to fiber bundle and in the direction of gas flow
c) parallel to fiber bundle and in opposite direction of gas flow
d) clock wise in the membrane sheath
e) in a counter clock wise in the membrane sheath
314) At the end of CPB, if the purge line is also not clamped then, the patient will have
a) high BP with empty reservoir
b) high BP with full reservoir
c) low BP with empty reservoir
d) low BP with full reservoir
315) A ‘True’ membrane oxygenator is one where gas transfer is
a) through micropores in the membrane
b) through colloid channels
c) by passing via diffusion channels
d) by using ionic channels
e) by dissolving in membrane material
316) Which of the following is the slowest way of treating hyperkalemia?
a) glucose -insulin infusion
b) intravenous diuretics
c) intravenous calcium bolus
d) intravenous soda-bi-carbonate bolus
317) Direct contact of gas with blood first results in
a) lipid separation into prothrombotic lipid
b) plasmapheresis
c) denaturation of albumin and globulin
d) gluconeogenesis
e) aggregation of platelets over the gas bubbles
318) CBP tubings are transparent so as to
a) make them flexible
b) make them economical
c) detect early clotting
d) make them compressible
e) allow observation of colour of blood
319) Which of the following was NOT the problem with the obsolete oxygenators like ‘Disc
or Spray’ oxygenators?
a) large priming volume
b) size of the oxygenator
c) CO2 removal
d) hemolysis
e) oxygenation
 47

320) In a bubble oxygenator, oxygen is passed into blood both, as small and large bubbles . The
idea behind ‘small bubbles’ is to,
a) increase oxygenation
b) facilitate CO2 removal
c) avoid inadequate defoaming
d) reduce resistance to venous blood flow
321) If you are conducting a case under deep hypothermia, the important character of the
CPB tubing is
a) should be highly transparent
b) should be of uniform diameter
c) should have an A-V shunt in the circuit
d) should be of Polycarbonate
e) should not harden at low temperatures
322) If on CPB, arterial pressure is not maintained, which of the following causes is not
responsible?
a) inadequate pump occlusion
b) open recirculating line
c) PDA not closed
d) low pCO2 levels
323) On CPB, a leak in the membrane will be indicated by
a) sudden appearance of bubbles in the arterial line
b) sudden decrease in pO2
c) sudden increase in pCO2
d) increase in the arterial line resistance
e) blood in the gas vent
324) A ‘blocked’ MO is indicated by
a) low pO2
b) high pCO2
c) resistance on arterial line
d) resistance on pump head
e) bubble in the arterial line
325) Accidental closure of the gas vent of oxygenator will result in
a) decreased venous return
b) rise in pCO2
c) fall in pCO2
d) fall in pO2
e) bubbles in arterial line
326) Which of the following conditions, if present during CPB, will NOT result in massive LA
return
a) MAPCA
b) PDA
c) patent BT shunt
d) L SVC into CS
 48

327) The ideal way of managing massive LA return is to

a) increase pump out put
b) administer vasoconstrictors
c) administer vasodilators
d) cool the patient & reduce pump out put
e) simply increase cardiotomy suction
328) Over hemodilution results in all of the following EXCEPT
a ) microcytosis of RBCs
b) tissue edema
c) hemolysis
d) low perfusion pressure
329) Which of the following causes of hemodilution is easily avoidable?
a) crystalloid priming
b) frequent administration of cold crystalloid cardioplegia
c) saline washes of cardiac cavities
d) anuria
330) Low oxygen carrying capacity of blood due to excessive hemodilution on bypass is treated
by all of the following , EXCEPT,
a) diuresis
b) hemofiltration
c) adding albumin to prime
d) adding pack cells to prime
331) The major source of particulate emboli during CPB is,
a) venus cannula
b) venous tubings
c) arterial cannula
d) cardiotomy suction
e) oxygenator membrane
332) An IABP results in
a) systolic augmentation
b) systolic & diastolic augmentation
c) diastolic augmentation
d) ventricular augmentation
e) atrio-ventricular augmentation
333) An IABP works on principle of
a) magnetic rotation
b) controlled venturi
c) controlled vortex
d) counter-pulsation
e) eddie currents
334) Which of the following gases can be used for inflating the balloon of an IABP?
a) O2
b) CO2
c) CO
d) NO2
e) NO
 49

335) The relation between resistance (R) offered by a tube and diameter (d) of the tube is,
a) R  1/d
b) R  1/ d2
c) R  1/d4
d) R  d
e) R  ¼d
336) The relation between resistance (R) offered by a tube and the length (L) of a tube is,
a) R  1/L
b) R  1/ L2
c) R 1/L4
d) R  L
e) R  ¼ L
337) The equation regarding factors affecting diffusion of a gas is,
a) PxAxS / d √M.Wt
b) PxAxS / d √sp heat
c) M.Wtx PxAxS / √ d
d) AxS / dxP√M.Wt
e) PxAxS x d / √M.Wt .
338) Glycated hemoglobin or Hb1C level gives you an idea about
a) type of hemoglobinopathy
b) type of diabetes
c) control of diabetes
d) oxygen carried by RBC
e) amount of abnormal hemoglobin in RBC
339) In a mixture of gases if the FiO2 is 60%, then the pO2 of the mixture, in mm of Hg, is
a)75
b)150
c) 200
d) 300
e) 450
340) For a MICS AVR through right upper paramedian incision, which of the following is the
LEAST IMPORTANT character of a venous cannula?
a) thin walled
b) wire-reinforced
c) size
d) two stage
341) Pressure drop across the best oxygenators at a flow of 5litres /min, is ( in mm of Hg)
a) <120
b) <70
c) <40
d) <10
342) In a clinical perfusion, the best ‘heat-exchanger performance’ , at 5 litre blood flow, is
A) 1.25
B) 0.95
C) 0.65
D) 0.35
 50

343) During CPB, which of the following is the least important parameter of adequacy of tissue
perfusion ?
a) urine output
b) rectal- leg skin temperature difference
c) serum lactate level
d) venous saturation
344) If ABG report during CPB indicates pCO2 of 52mmof Hg, pO2 of 234 mm of Hg,
pH of 7.40, then treatment is to
a) increase O2 flow
b) increase the sweep flow
c) increase the pump flow
d) decrease the pump flow
e) add soda bi carbonate
345) Classify the following causes into those which give rise to
A) rapid decrease B) gradual decrease C) no decrease in the reservoir level , while
on CPB
1) aortic dissection by the arterial cannula tip
2) severe diuresis
3) development of interstitial edema
4) soaked surgical sponges
5) small rent in the pleura
6) inadequate occlusion of pump
7) recirculating line open
8) air lock in venous line
9) raising the level of the operation table
10) increase in O2 supply.
346) A higher perfusion pressure, during CPB, is required during CABG mainly
a) to overcome resistance of the atherosclerotic cerebral vessels
b) due to diabetes mellitus
c) to perfuse myocardium
d) to perfuse emphysematous lungs.
347) Hydroxy ethyl starch is used in priming solution for
a) oxygen carrying capacity
b) oncotic pressure
c) chelating agent
d) buffer
e) supplying glucose
348) An ideal patient for Autologous Retrograde Prime is a
a) 4 day old new born for arterial switch with AB negative blood group
b) 9 month, 4.7 Kg baby with VSD with severe PH with Hb of 7.8g%
c) 21 yr old man with Severe valvar AS in sinus rhythm , not in CCF
d) 58 yr old lady with MS MR , TR AF in CCF
 51

349) If ABG report on CPB indicates a persistent pH of 7.23 , HCO3 of 17 meq and pCO2 of 25
mm Hg, pO2 of 321 mm of Hg, then the corrective measure is to
a) increase O2 flow
b) increase the sweep flow
c) increase the pump flow
d) add CO2 to gas mixture
e) add soda-bi-carbonate
350) Heparinised whole blood is preferred over CPD blood for neonatal bypass priming because
of all of the following reasons, EXCEPT,
a) higher platelet count
b) avoids multiple exposure to packed red cells and FFP
c) does not affect ionic calcium levels
d) lower bilirubin load
351) The danger of high arterial pO2 on CPB is development of all of the following, EXCEPT,
a) impaired peripheral perfusion
b) cardiac dysfunction
c) cerebral vasoconstriction
d) cutaneous vasodilatation
352) To avoid hyperoxia, the ideal pO2 during CPB should not be above
a) 350 mm of Hg
b) 300 mm of Hg
c) 250 mm of Hg
d) 200 mm of Hg
353) Which of the following patients is most likely to suffer from the ill-effects of hyperoxia
during CPB?
a) Post functioning BT shunt TOF for intracardiac repair
b) Single ventricle severe PS for Fontan repair
c) Perimembranous VSD for Closure
d) ASD with rt PAPVC for intracardiac repair
354) A crack in the heat exchanger tubings will give rise to all, except,
a) increase in reservoir volume
b) increase in pH
c) decrease in hemoglobin
d) hemoglobinuria
355) In which of the following situations a two-staged, cavo-atrial cannula can be used ?
a) AVR with VSD closure
b) AVR with Repair of ruptured ASOV
c) AVR with CABG
d) AVR with MVR
356) In which of the following operations, a direct SVC cannulation is mandatory
a) MV Repair
b) Primum ASD closure
c) Senning’s operation
d) Tricuspid annuloplastyty
 52

357) Low perfusion pressure during IC repair of TOF cannot be due to

a) circulating PCV 24%
b) MAPCAs
c) inadequate closure of BT shunt
d) perfusate temperature below 250C
358) During CPB, which of the following causes of high arterial line pressure would appear last?
a) cannula tip touching posterior wall of aorta
b) rise in SVR
c) cannula too small
d) cross clamp partly pinching aortic cannula
359) Superoxide desmutase , Catalase , Allopurinol are names of
a) new buffers
b) free radical oxygen scavengers
c) hyperpolarising vasodilators
d) enzymes released by leucocytes in response to stress
360) In a patient with normal coronary arteries, during delivery of antegrade cardioplegia the
aortic root pressure should be less than
a) 50 mm of Hg
b) 90 mm of Hg
c) 135 mm Hg
d) 170 mm Hg
361) What is the maximum molecule size that is filtered by hemoconcentrators or
hemofilters?
a) 10000 Daltons
b) 20000 Daltons
c) 30000 Daltons
d) 40000 Daltons
362) ‘Sieving Coefficient’ for any solute during ultrafiltration, at best, could be
a) 0.5
b) 1.0
c) 2.0
d) 4.0
363) Which of the following has a ‘sieving coefficient’ zero?
a) potassium
b) urea
c) fibrinogen
d) creatinine
e) glucose
364) During deep hypothermia the arterial pump head of a roller pump may stop working due to
a) hardening of arterial line tube
b) increased viscosity of blood
c) rise in SVR
d) cooling of pump motor
 53

365) Which of the following is NOT a feature of A-V shunting on CPB?

a) low systemic arterial pressure
b) high venous pO2
c) high venous pCO2
d) decreased A-V pO2 difference
366) The important addition to the Priming fluid for a 4yr,10Kg, deeply cyanosed TOF with Hb
22g% is
a) fresh whole blood
b) mannitol
c) albumin
d) sodabicarb
e) plasma free- packed cells
367) Normal value of pO2 in mixed venous blood is (in mm of Hg)
a) 15
b) 20
c) 35
d) 50
368) Platelet activation during CPB can be reduced by all of the following , EXCEPT,
a) Aprotenin
b) CO2 insufflation
c) Nitric Oxide
d) PGE1
369) Raised levels of plasma free hemoglobin & potassium, during CPB, are due to all of the
following, EXCEPT,
a) excessive cardiotomy suction
b) tight arterial line occlusion
c) persistent aspiration of blood collected in pericardium
d) severe renal & liver cell failure
370) Which of the following measures DOES NOT reduce prime or reservoir volume during
CPB?
a) low PCV at initiation of CPB
b) hemofilter
c) retrograde autologous prime
d) vacuum assisted venous drainage
371) Which of the following is NOT a feature of Laminar Flow?
a) concentric layers of blood moving in a parallel way
b) highest velocity of fluid at the centre
c) from side walls to centre flow pattern is hyperbolic
d) no cross-currents perpendicular to direction of flow
372) Which of the following factors in a circuit, is NOT DETRIMENTAL to blood?
a) low shear stress
b) stagnation
c) negative pressure
d) turbulence
 54

373) Chance of gaseous micro embolism is highest during which of the following events?
a) aortic cannulation
b) aortic cross-clamping
c) rewarming
d) decannulation
374) Which of the following situations is NOT a contributor to gaseous micro embolism?
a) high pCO2 levels at the time of starting CPB
b) continued use of nitrous oxide till CPB starts
c) of Hg vacuum pressure > - 40 mm during VAVD
d) high pO2 levels at the time of starting CPB
375) During a conventional CPB, which of the following gases is the most likely component of
gaseous micro emboli?
a) Oxygen
b) Nitrogen
c) Carbon dioxide
d) Carbon monoxide
376) After starting unilateral antegrade cerebral perfusion, cerebral SaO2 monitored on left side
falls by > 20%. Which of the following is the most appropriate measure?
a) increase FiO2
b) increase flows through the arterial cannula
c) give head low
d) institute bilateral cerebral perfusion
377) Which of the following is required to be frequently checked when patient is on CUF ?
a) potassium
b) sodium
c) heparin
d) glucose
e) calcium
378) Shunt fraction of a clinically used oxygenator should be below
a) 15%
b) 25%
c) 35%
d) 45%
379) Which of the following is NOT considered as a safety device during CPB?
a) arterial line filter
b) cardioplegia line pressure manometers
c) gas line filters
d) rapid priming port
380) Which of the following is a classic feature of laminar flow ?
a) all the layers of blood, from periphery to centre , move parallel at the same speed
b) all blood layers move parallel & velocity increases towards the center .
c) velocity of blood decreases by V2/d as one moves from periphery to center
d) all the layers of blood move forward in micro turbulent channels
 55

381) The role played by procaine in St. Thomas cardioplegia is

a) provide substrate
b) immediate diastolic arrest
c) prevention of reperfusion edema
d) membrane stabilisation
382) The role played by glutamate in St. Thomas cardioplegia is
a) provide substrate
b) immediate diastolic arrest
c) prevention of reperfusion edema
d) membrane stabilisation
383) Which of the following ions is agonist to Potassium in cardioplegia?
a) calcium
b) magnesium
c) sodium
d) bicarbonate
e) noradrenaline
384) If surgeon suddenly demands an urgent extra dose 1L of St. Thomas sanguineous
cardioplegia, the first thing to check is
a) serum potassium level
b) circulating PCV
c) reservoir level
d) urine output
385) During rewarming, blood gas analysis is mainly to check
a) pO2
b) pCO2
c) pH
d) K+
386) On CPB, if patient is well perfused at normothermia, the arteriovenous oxygen saturation
difference should be
a) 10%
b) 25%
c) 40%
d) 55%
387) On CPB, if the pump flows are below the rated flow of the oxygenator, the arterial oxygen
saturation should be
a) 100%
b) 96%
c) 92%
d) 90%
388) On CPB, the colloidal osmotic pressure should be at least (in mm of Hg)
a) 24
b) 20
c) 16
d) 10
 56

389) At 40% FiO2, the partial pressure of oxygen in arterial blood gas, on CPB, should be
a) 150 mm of Hg
b) 200 mm of Hg
c) 250 mm of Hg
d) 300 mm of Hg
390) The majority of currently used CPB tubings are made of
a) Poly propylene
b) Polyvinyl chloride
c) Poly sulphone
d) Polyurethane
e) Polycarbonate
391) Presence of which of the following situations is a contraindication for IABP use ?
a) aortic stenosis
b) post infarct VSD
c) aortic regurgitation
d) mitral regurgitation
392) For a ½” tubing, the volume per cm length is
a) 1.05 ml
b) 1.65 ml
c) 2.05 ml
d) 2.65 ml
393) For 3/8 ” tubing volume per cm length is
a) 1.65 ml
b) 1.05 ml
c) 0.72 ml
d) 0.45 ml
394) For 1/4” tubing volume per cm length is
a) 1.05 ml
b) 0.65 ml
c) 0.62 ml
d) 0.32 ml
395) The base of del Nido Cardioplegia is
a) Ringer Chloride
b) Rehydral P
c) Plasmalyte A
d) Isolyte E
396) The calcium content of del Nido cardioplegia is
a) zero
b) trace
c) 5.1 mEq/L
d) 6.2 mEq/L
397) Histidine in HTK Custodial Cardioplegia acts as
a) an enhancer of buffering capacity
b) a cell membrane stabilizer
c) improves ATP production during reperfusion
d) an inhibitor of lactate production
 57

398) Ketoglutarate in HTK Custodial Cardioplegia acts as

a) an enhancer of buffering capacity
b) a cell membrane stabilizer
c) improves ATP production during reperfusion
d) an inhibitor of lactate production
399) Trptophan in HTK Custodial Cardioplegia acts as
a) an enhancer of buffering capacity
b) a cell membrane stabilizer
c) improves ATP production during reperfusion
d) an inhibitor of lactate production
400) Which of the following is NOT a concern associated with use of Custodial HTK
cardioplegia for routine CPB cases?
a) hyponatremia
b) hypo-osmolarity
c) acidosis
d) hyperkalemia
401) After setting oxygenator and tubing circuitry, the first step before priming is,
a) to switch on power and check for ‘run away’ pump
b) to start the gas flow at 4 litters / min
c) to start water flow through heat exchanger
d) to add 50000 units of heparin to reservoir
402) Veno-venous bypass without oxygenator is required in all of the following situations,
EXCEPT,
a) carinal tumour excision
b) IVC resection for renal cell carcinoma
c) liver transplant
d) extra cardiac Fontan operation
403) Which of the following is NOT associated after CPB if the priming fluid is hypotonic?
a) cerebral edema
b) rise in plasma free hemoglobin
c) increased lung water
d) hypernatremia
404) Trans-Esophageal Echo is useful in the operation theatre in all of the following ways,
EXCEPT,
a) adequacy of deairing the heart
b) filling of the heart while coming off CPB
c) adequacy of perfusion on CPB
d) placement of aortic and venous cannule
405) The principle on which an on-line filters work is
a) ion exchange
b) strain filtration & adsorption
c) catalytic conversion
d) neutralization
 58

406) Which of the following is NOT a correct step for retrograde cerebral perfusion?
a) Head low with ice around the head
b) IVC snugged
c) BP cuff on both arms inflated partially
d) perfusion through isolated SVC cannula
407) In which of the following cases retrograde cerebral perfusion was first used?
a) arch aneurysm
b) ascending aortic dissection
c) cerebral air embolism
d) brain tumour operation
e) vehicular accident
408) Which of the following is NOT a problem during deep hypothermia?
a) hypokalemia
b) hypocarbia
c) hypoglycemia
d) hyperviscocity
409) Which of the following problems is typically faced with a total miniaturised CPB circuit?
a) small venous cannule
b) difficulty in maintaining pCO2
c) air trapped in the circuit
d) high arterial line resistance
410) All the following statements about the use of IABP in children is true, EXCEPT,
a) children do not ever develop LVF
b) there are size constraints of device and balloon
c) difficulty is experienced in synchronising the balloon cycles due to faster heart rates
d) increased elasticity of aorta makes the counter pulsations difficult
411) Which of the following complications of IABP is NOT likely?
a) aortic dissection
b) air embolism following rupture of balloon
c) limb ischemia
d) arterial thrombosis
412) Which of the following is NOT a method to reduce air embolism during CPB ?
a) use of arterial filters
b) avoidance of large temperature gradients during rewarming
c) use of Propofol for anesthesia
d) avoidance of low reservoir levels
413) Which of the following statements about venous reservoir is FALSE?
a) every CPB circuit has to incorporate a reservoir
b) all current hard shell reservoirs have an integrated cardiotomy reservoir
c) holding of blood in reservoir results in removal of gaseous micro emboli
d) reservoirs contain two filters: one ~200 capacity and another with ~ 40  capacity
 59

414) Accurate pump occlusion setting of a roller pump is required for all of the following ,
EXCEPT,
a) avoid tubing wear
b) avoid hardening of tubing
c) correct pump out put
d) avoid blood damage
415) Accepted roller pump head occlusion is fall in arterial line level the at a rate of
a) 1cm/ 1second
b) 1cm / 1min
c) 1inch/ 1sec
d) 1inch / 5min
416) ‘Spallation’ means
a) spilling of prime fluid through a crack in the tube developed during cooling
b)generation & releasing into blood of microparticles of tubing material
c) generation of micro gas bubbles due to cavitation as a result of over occlusion
d) adsorption of blood proteins on the surface of the tubes
417) Which of the following must be used with a non- occlusive pump?
a) online pO2/pCO2 monitor
b) online pressure monitor
c) online flow monitor
d) vacuum assisted venous drainage
418) Which of the following features does not pertain to a centrifugal pump?
a) they are non occlusive
b) they are afterload dependent
c) they produce spallation
d) they are based on the principle of ‘controlled vortex’
419) Pulsatile flow is associated with all of the followings, EXCEPT,
a) increased cerebral and renal capillary perfusion
b) decreased metabolic acidosis
c) increased delivery of nutrients
d) increased peripheral vascular resistance
420) Which of the following DOES NOT contribute to failure in delivering pulsatile flow?
a) soft long venous tubings
b) transmembrane resistance of oxygenator
c) soft walled arterial line
d) narrow tipped arterial cannula
421) Which of the following complements is an anaphylatoxin ?
a) C1a
b) C2b
c) C3a
d) C4b
422) Which of the following is NOT a stimulus for complement activation?
a) contact with non endothelial surface
b) ischemia- reperfusion
c) protamine administration
d) starting of inotropic support- Adrenaline
 60

423) Membrane attack complex or Terminal Complement Complex is

a) C5-7
b) C5-8
c) C5-9
d) C5-12
424) Membrane attack complex or Terminal Complement Complex acts by
a) allowing influx of water and ions into the cell
b) degranulation of leucocytes
c) triggering other complements like C1& C2
d) stimulating mast cells and monocytes
425) Which of the following statements about calcium ion is FALSE?
a) calcium plays a role in reperfusion injury
b) in serum, about 40% calcium is bound to protein
c) calcium participates in neurotransmitter release
d) calcium is responsible for actin-myocin coupling
426) All of the following can give rise to platelet activation, EXCEPT
a) surface contact
b) terminal complement complex
c) thromboxane A2
d) thrombin
427) Which of the following statement about Endothelin -1 is true?
Endothelin-1
a) is a myocardial stimulant
b) is a vasoconstrictor
c) causes leucocytosis
d) is a natural endothelial nourisher
428) Low root pressure during delivery of antegrade root cardioplegia is observed in patients
with
a) severe LM stenosis with RCA ostial stenosis
b) tight MS with grade I-II AR
c) gross MR with TR
d) tight MS with severe AS
429) Promotion of ‘secondary flows’ in an oxygenator mainly are used for
a) improvement of oxygenation
b) decreasing the shear stress
c) destruction of formed elements
d) better CO2 removal
430) Recirculating line in an MO should not be used for
a) collecting blood for blood cardioplegia
b) deairing the MO
c) preventing clotting of membrane during circulatory arrest
d) reduce the high arterial pressure during CPB
e) improving pO2 levels during CPB
 61

431) Air and oxygen entering the air-O2 blender should be supplied at which of the following
pressure values for optimum working of blender?
a) 100-120 psi
b) 80-100 psi
c) 40-60 psi
d) 20-40 psi
432) Gas filters used in CPB circuits have a filtration capacity , in microns,
a) 200
b) 20
c) 2
d) 0.2
433) In case of a trans RA appendage IVC cannulation, the tip of an IVC is cannula can get
malplaced in all of the following, except
a) coronary sinus
b) RA
c) RV inflow
d) hepatic veins
434) A patient, on IABP for many days, is for open heart surgery. Which of the following is
least expected in the case ?
a) heparin resistance
b) stroke
c) Serum creatinine = 1.5mg%
d) lower limb ischemia
435) Which of the following is not a requisite for defining an ‘Oxygenator Failure’?
a) rising arterial pCO2
b) falling arterial pO2
c) FiO2 delivered should be 100%
d) pump flows should be at clinical levels
436) The first thing to check in case of suspected ‘Oxygenator Failure’ is,
a) change the oxygenator immediately
b) check the entire oxygen supply line
c) recheck arterial blood gas
d) cool the patient rapidly
437) An ‘ on-line arterial filter’ will be associated with all of the following , EXCEPT,
a) more priming volume
b) more pressure drop
c) a chance of air embolisation
d) more time for rewarming
438) Which of the following parameters is NOT a feature of protamine shock?
a) fall in systemic arterial pressure
b) fall in pulmonary arterial pressure
c) fall in the heart rate
d) rise in CVP
 62

439) Which of the following property of a roller pump is important while operating a pediatric
case?
a) should be battery operable for 4hours continuously
b) should be light in weight and easily transportable
c) should deliver accurate flows and display digitally
d) should have a noiseless function
e) should not generate heat in a long run
440) Conversion of One KiloPascal (KPa) of pressure to Pound per square inch ( PSI) is,
a) 1.45 psi
b) 0.145 psi
c) 7.5 psi
d) 75 psi
441) Hemolysis during CPB is suspected if
a) low pO2
b) low Hb
c) low serum potassium levels
d) high serum sodium levels
e) hematuria
442) If severe hemolysis is suspected within minutes of going on CPB , then the cause is
a) cardiotomy suction
b) narrow arterial cannula
c) mismatch blood priming
d) over hemodilution
e) excessive pump occlusion
443) Which of the following arteries is NEVER used for Antegrade Cerebral Perfusion?
a) right subclavian artery
b) innominate artery
c) right axillary artery
d) left common carotid artery
e) left subclavian artery
444) Which of the following is the least important feature of a femoral venous cannula during
MICS surgery through mini right thoracotomy?
a) flexibility
b) thin walled
c) multiple side holes
d) radio-opaque markers
e) adequate length
445) On full bypass , before cross clamping aorta a surgeon notices full and tense MPA with
RA empty. The cause is
a) ASD
b) VSD
c) AV canal defect
d) PDA
 63

446) On CPB, the danger of venting LA before cross-clamping of aorta is

a) air embolism
b) loss of blood volume
c) hemodilution
d) difficulty in cross clamping
447) Which of the following cases hemodilution could occur during surgery due to use of saline
wash by surgical team?
a) a case with MR for MVR and cuspal preservation
b) a case with MS for open mitral valvotomy with clot removal
c) a case with gross AR for aortic valve replacement for
d) a case with TS and TR for tricuspid valve replacement
448) Which of the following operations can not be performed on CPB after removing aortic
cross clamp?
a) RVOT patching of TOF
b) tricuspid valve replacement
c) DeVega’s annuloplasty of tricuspid valve
d) excision of subaortic membrane
449) Which of the following does not result in hemodilution during bypass?
a) hypothermia
b) frequent administration of crystalloid cardioplegia
c) saline washes of cardiac cavities
d) topical cooling of heart with ice
e) anuria
450) Excessive hemodilution on bypass is treated on ‘ urgent basis’ by
a) administering diuretics
b) hemofiltration
c) increasing pump flow
d) starting infusion of 3mcg/kg/min DOPAmine
e) starting infusion of vasodilators
451) Which of the following will counter the ill effects of hyperkalemia in a rapid manner ?
a) diuretic
b) GI drip
c) hemofiltration
d) sardolate
e) IV calcium bolus
452) Which of the following substances is not filtered by a hemofiltration ?
a) creatinine
b) urea
c) fibrinogen
d) glucose
453) After SVC cannulation which of the following signs indicates a proper cannulation?
a) blood overflowing through the cannula
b) a column of blood in the cannula moving with ventilation
c) a small fall in the arterial blood pressure
d) a rise in the CVP by 3-4 mm on the monitor
 64

454) Which of the following should be the most important consideration while choosing an
arterial filter for an adult?
a) bubble trap directing air to exit port
b) maximum rated flow
c) ease of assembly and deairing
d) priming volume
455) In a membrane oxygenator, the usual gradient between the pump-head and cannula tip, in
mm of Hg, is
a) zero
b) 10-20
c) 50-60
d) 80-100
e)150-170
456) Which of the following is not a criterion of an ideal aortic cannula?
a) short tip
b) wire reinforced
c) transparent
d) single-cast
e) sudden tapering
457) Major disadvantage of a cavo-atrial or two-stage cannula is
a) early rewarming of the heart
b) cost
c) large purse string required
d) easy kinking
e) poor drainage
458) Increased arterial line pressure with a high aortic pressure is due to
a) arterial perfusion line kink
b) high SVR
c) aortic dissection
d) cannula tip jutting against aortic wall
e) choked filter
459) Low aortic pressure with a high reservoir volume(level) is due to
a) low circulating PCV
b) low SVR
c) inadequate pump occlusion
d) aortic dissection
e) small sized heart
460) In a 1yr - 6.5kg patient with VSD, severe PH, the aortic pressure on CPB is low with a
massive left heart return. The cause of this problem is,
a) missed patent ductus arteriosus
b) incompletely closed BT shunt
c) undetected MAPCAs
d) interrupted IVC
 65

461) Multiple doses of St. Thomas cardioplegia results in

a) hyperglycemia
b) Na+ overload
c) hemodilution
d) metabolic acidosis
462) Which of the following is NOT a favourable quality of soda-bicarbonate as a buffer?
a) available
b) cost
c) pKof 6.1
d) excretion of neutralised product
463) If arterial pCO2 decreases by 10 mm of Hg, pH of blood will change by
a) +0.4
b) +0.3
c) + 0.1
d) +0.05
464) If arterial pCO2 increases by 20 mm of Hg, pH of blood will change by
a) --0.4
b) --0.3
c) --0.1
d) --0.05
465) The last measure to be taken in case of a rapid decrease in venous return is to
a) adjust venous cannula
b) check for air lock
c) check kink in the venous line
d) raise the table level
e) decrease the pump flow
466) Gas bubbles in the arterial line can never be because
a) loss of antifoam A in a bubble oxygenator
b) low blood levels in the reservoir/arterial chamber
c) high blood pO2 levels
d) leak in the membrane
467) Hypomagnesemia during CPB is due to all of the following EXCEPT
a) poor preop health
b) use of albumin in prime
c) use of mannitol in prime
d) use of citrated blood
468) The minimum platelet count , per cmm, required for performing a cardiac operation is
a) 40,000
b) 80,000
c) 150,000
d) 300,000
 66

469) Which of the following is NOT a feature of ‘Pump lung syndrome ’ or ‘Post perfusion
lung syndrome’ ?
a) intra-alveolar edema
b) interstitial edema
c) atelectasis
d) hemothorax
470) Which of the following worsens ‘pump lung’ syndrome?
a) reduced colloidal osmotic pressure on CPB
b) arterial line filter
c) leucocyte depleting filter
d) blood priming
471) Out of the following priming solutions, which is the odd solution in the group?
a) albumin
b) gelatin polymer
c) hydroxyethyl starch
d) fresh frozen plasma
e) Ringer lactate
472) ‘Alfa stat’ strategy during hypothermia is to
a) add aminocaproic acid to prime for cerebral protection
b) add  statin to prime for uniform cooling
c) maintain blood pH at 7.4 at all temperatures
d) maintain temperature corrected alkalosis with hypocarbia
e) maintain a temperature corrected acidosis with hypothermia
473) ‘Luxury perfusion’ is
a) to calculate flows at a rate more than 3.1 L/M2 BSA
b) an organ receiving more flow than the tissue O2 demand
c) stagnation of blood in an organ due to gravity
d) excessive flow to an organ due to a shunt
e) slow cooling of patient at a rate of 6minutes / 0C
474) Which of the following does not affect urine out put on bypass ?
a) perfusion pressure
b) pump out put
c) use of centrifugal pump
d) pulsatile flow
e) hemodilution
475) In a patient for MVR, aorta is cross-clamped at 350C, & cardioplegia is delivered through
root. Heart undergoes a quick electro-mechanical arrest but recovers electrical activity in
less than 6minutes. The cause would be
a) left coronary ostial stenosis
b) underestimated associated gr II AR
c) inadequately applied aortic cross clamp
d) failure to add potassium to cardioplegic solution
 67

476) Inadequate occlusion of the arterial head of roller pump results in all of the following,
except,
a) low perfusion pressure
b) metabolic alkalosis
c) raised blood levels in venous reservoir
d) low urine output
477) A patient for ASD closure surgery receives 300units/kg of heparin intravenously, prior to
cannulation . Five minutes later, the ACT of the patient is 376seconds.What should be
done next?
a) go ahead with surgery as this a short case and ACT would rise later
b) wait for 3 more minutes, repeat ACT
c) give 2units of fresh frozen plasma
d) repeat heparin dose of 300 units/ kg
478) A patient at the end of CPB receives a test dose of Protamine. Three minutes later, due to
stable hemodynamics anesthesiologist starts heparin reversal by starting a protamine
drip. BUT, within seconds develops features of protamine shock and the patient is
required to put back again on CPB. Strategy regarding anticoagulation would be
a) no need of heparin as shock has developed within seconds of starting protamine drip
b) give only a minimal or topping dose of heparin 100 units / Kg
c) first check ACT and then decide about the dose of heparin
d) administer 300 units / Kg of heparin straight-away
479) Which of the following conditions is NOT associated with higher chance for protamine
allergy ?
a) insulin dependent diabetics
b) sea food allergy
c) vasectomised patient
d) tubectomised patient
480) The shell of a hard shell reservoir is made up of
a) poly carbonate
b) poly urinate
c) polyethylene
d) polyalthylene
481) Which of the following is not a feature of a cardiotomy reservoir?
a) defoamer
b) polypropylene fibres
c) depth filter
d) screen filter
482) The diameter of a hollow fiber in an oxygenator is
a) 50 to 100 
b) 200 to 300 
c) 400 to 500 
d) 600 to 700 
 68

483) The pore size of a hollow fiber in an oxygenator is

a) 0.01 to 0.07
b) 0.1 to 0.3 
c) 0.3 to 0.7 
d) 0.7 to 1.0 
484) The criteria for selection of an oxygenator are all of the following EXCEPT,
a) low priming volume
b) low pressure drop
c) low gas transfer rate
d) low complement release
485) Which of the following materials is not used for manufacturing ‘membrane’ of an
oxygenators?
a) polypropylene
b) polymethylpentene
c) polycarbonate
d) silicone
486) Which of the following materials now widely used for manufacturing ECMO?
a) polypropylene
b) polymethylpentene
c) polycarbonate
d) silicone
487) If the gas vent of reservoir is accidentally closed , which of the following should happen
first?
a) pressure valve will give-away
b) gas bubble will be noticed in arterial line
c) froth will collect in the reservoir
d) froth in the gas outlet of oxygenator
488) On CPB, anesthesiologists stop ventilation ,
a) soon after CPB is started
b) after total CPB is established
c) after desired temperature is reached
d) after delivery of cardioplegia
489) During intermittent aortic clamping technique for CABG, the temperature of patient
should not be below,
a) 28˚C
b) 30˚C
c) 32˚C
d) 34˚C
490) A head low position on CPB with a two-stage venous cannula will result in all of the
following, except ,
a) rise in CVP
b) rise in reservoir levels
c) decrease venous return
d) decreased urine output
 69

491) Which of the following ions is not present in Ringer Lactate solution?
a) potassium
b) calcium
c) magnesium
d) chloride
492) The principle on which an arterial filters works is,
a) ion exchange
b) catalytic conversion
c) strain filtration & adsorption
d) neutralization
493) Apart from danger of hemolysis, danger of ‘over-occlusion’ of a roller pump is
a) use of increased electrical power and heating
b) higher arterial line pressure
c) skidding
d) accelerated tubing wear
494) To prevent formation of gaseous micro-emboli during rewarming , it is recommended to
maintain a maximal temperature gradient of < 100C, between water bath and
a) rectal temperature
b) nasopharyngeal temperature
c) venous blood temperature
d) arterial blood temperature
495) To prevent formation of gaseous micro-emboli during cooling , it is recommended to
maintain a maximal temperature gradient of < 100C, between
a) water bath and rectal temperature
b) water bath and nasopharyngeal temperature
c) venous blood and nasopharyngeal temperature
d) arterial blood and nasopharyngeal temperature
496) In case of a roller pump, the ‘minute pump output’ depends on all of the following,
EXCEPT,
a) OD of the tubing
b) ID of the tubing
c) length of raceway
d) RPM of pump
497) A perfusionist calculated BSA as 1.1M2 instead of 1.5 M2. During CPB ,this will result in
a) low reservoir levels
b) hyper lactatemia
c) low pCO2
d) high pO2
498) pCO2 during cooling is low because of all of the following, except,
a) less production of CO2
b) increased solubility of CO2
c) proportionately large gas sweep flow
d) increased conversion of CO2 to HCO3 ions
 70

499) During CPB, pCO2 levels should not be allowed to fall below 25 mm of Hg , so as to ensure
a) alkalotic pH
b) adequate blood supply to brain
c) proper utilization of glucose
d) stable potassium level
500) On CPB, anesthesiologists should re-start ventilating
a) during rewarming, when temperature is more than 320C
b) after release of cross clamp and at 340C
c) when heart starts partially beating and ejecting
d) just before coming off CPB
501) In which of the following cases, emergency establishment of CPB will be required
following sternotomy?
a) large ascending aortic aneurysm
b) dysfunction of biological valve in mitral position
c) critical left main artery disease
d) ischemic LV aneurysm
502) A 66 yrs old patient is undergoing On-Pump CABG with a single venous cannula. If during
delivery of retrograde cardioplegia, cannula slips back out of the coronary sinus, the
pressure tracing will show
a) a continuous rise
b) a rise and plateau
c) a RV pressure trace
d) no change
e) a fall to a negative value
503) Which of the following is not a part of ‘Miniaturised CPB Circuit’
a) heparinised tubings
b) heparinised oxygenator
c) cardiotomy reservoir
d) centrifugal pump
504) Which of the following is THE essential part of a total ‘miniaturised CPB circuit’?
a) lateral thoracotomy incision
b) percutaneous SVC/ IVC cannulation
c) no venous reservoir and cardiotomy suctions
d) endoscopic surgery
505) Inadequate venous return while going on bypass cannot be due to
a)venous cannula tip wedged in a tributary
b) too small venous cannula
c) low gravity force
d) 3rd space loss
e) kinking of cannula
506) Which of the following is not a buffer present in blood?
a) hemoglobin
b) lactates
c) phosphates
d) histidine
 71

507) 11yr old patient is for ASD closure. Within seconds of starting CPB a ‘small’ leak in
oxygenator is noticed. The ideal next step to take is to,
a) As the case is a ‘short case’ & the leak is ‘small’, ignore and quickly finish the surgery
b) quickly cool the patient, arrest the circulation and change the oxygenator
c) apply wax to close off the leak and continue CPB
d) refill the patient, terminate CPB at normothermia and change the oxygenator
e) continue CPB and keep on priming extra volume to compensate for the loss
508) A slow decrease in the reservoir level is due to the following, except due to
a) urinary loss
b) blood loss during surgery
c) development of cellular edema
d) third space loss
e) dissection of aorta
509) A complication peculiar to a straight tip cannula used for aortic cannulation is
a) innominate artery cannulation
b) dissection of aorta
c) hematoma at the cannulation site
d) high resistance
510) Which of the following drugs does not have action on SIR ?
a) aprotinin
b) calcium gluconate
c) methyl prednisolone
d) dexamethasone
511) The minimal essential measure/s to be taken by a perfusionist in case of disconnection of
an arterial line from arterial cannula is to,
a) stop the pump
b) clamp the arterial line
c) stop the pump and clamp the venous line
d) stop the pump and clamp arterial and venous line
512) In adults, conventional CPB is associated with
a) hyperglycemia & impaired insulin response
b) hyperglycemia & normal insulin response
c) hyperglycemia & increased insulin response
d) hypoglycemia & decreased insulin response
e) hypoglycemia & increased insulin response.
513) Transient hypotension at the initiation of bypass is due to
a) dilution of catacholamines
b) empty heart
c) inadequate pump occlusion
d) stoppage of ventilation
514) Which of the following is NOT a desirable parameter of a roller pump ?
a) accurately calibrated
b) adjustable occlusion
c) adjustable tube size
d) specific about tube quality
 72

515) The proven advantage of PVC tubing over Silicon rubber tubing is
a) it has better thermal stability
b) truer stroke volume
c) less spallation
d) decreased thrombin production
e) decreased platelet deposition
516) The formula for calculating trans-membrane pressure in a hemofilter is
Pa: Arterial inlet pressure, Pv: Venous outlet pressure, Pn: Negative pressure placed on effluent side of membrane
a) ( Pn + Pv ) / 2 + Pa
b) ( Pa – Pv ) / 2 x Pn
c) ( Pa + Pv ) / 2 + Pn
d) ( Pn + Pv) /2 x Pa
517) The minimum venous reservoir operating level should be
a) 5% of systemic blood flow
b) 15% of systemic blood flow
c) 25% of systemic blood flow
d) 50% of systemic blood flow
518) In ‘Port Access’ system, the cannula passed through the femoral artery takes care of which
of the following ?
a) cardioplegia
b) arterial return and left heart return
c) cardioplegia and arterial return
d) arterial return aortic cross clamp
e) cardioplegia and arterial return and aortic cross clamp
519) Selection of prime is least dependent on
a) osmolality of the prime
b) patients serum electrolyte levels
c) calculated circulating PCV
d) blood glucose level
520) Which of the following is NOT used as an activator in any ACT machine?
a) diatomaceous earth [Celite]
b) kaolin
c) glass beads
d) chalk powder
e) ellagic acid
521) Activators in an ACT cuvette activate
a) factor VIII
b) factor XII
c) factor X
d) factor IX
522) Which of the following factors DOES NOT affect ACT ?
a) hemodilution
b) hypothermia
c) tranexamic acid
d) severe thrombocytopenia
 73

523) The most important advantage of a metal tipped cannula over a plastic tipped cannula is
a) the ease of insertion of a metal tipped cannula
b) better ID/OD ratio of a metal tipped cannula
c) metal cannula can have side holes
d) only metal tip could be short & curved.
524) Which of the following characteristics of a venous cannula helps in unobstructed drainage?
a) thin walled
b) oval body
c) light house tip
d) straight cannula
525) Tight packing of fibres in an oxygenator results in all of the following, EXCEPT,
a) improved oxygenation
b) increased priming volume
c) increased gradients
d) improved filtration
526) Which of the following statements is FALSE?
As compared to Axial flow, Radial blood flow in an oxygenator results in,
a) less blood contact with foreign surfaces
b) decreased trans-membrane pressure gradient
c) poor CO2 removal
d) decreased prime volume
527) As compared to crystalloid cardioplegia, blood cardioplegia is better on all the following
counts, EXCEPT,
a) O2 carrying capacity
b) buffering capacity
c) oncotic pressure
d) capillary distribution
e) antioxidant capacity
528) High root pressure during delivery of root cardioplegia is observed in patients with
a) tight MS with severe TS
b) unprotected LM stenosis
c) severe AS
d) post infarct VSD
529) Repeating cardioplegia results in all except
a) lowering of myocardial temperature
b) increases myocardial pH
c) restoration of myocardial substrates
d) intermittent coronary vasodilatation
530) Multiple doses of St.Thomas cardioplegia is likely to produce all , EXCEPT,
a) hyperkalemia
b) increase in reservoir volume
c) fall in circulating PCV
d) rise in the perfusion pressure
 74

531) Another technique to deliver retrograde cardioplegia is by injecting cardioplegia into ,

a) IVC
b) RA
c) RV
d) coronary sinus from outside
532) Retrograde cardioplegia, as the ONLY mode of arresting heart, is not commonly used as
a) this technique cannot arrest the heart
b) a different than the usual cannula is required
c) a special type of pump is required
d) it takes a long time to arrest the heart in this manner
e) this technique results in distension of heart.
533) Longer arterial tubing length is associated with all of the following , EXCEPT,
a) increased resistance
b) priming volume
c) increased pump head pressure
d) increased pCO2
534) Heat exchanger is on venous side so as to avoid
a) gas embolisation
b) damage to platelets
c) damage to RBCs
d) uneven cooling
e) improper oxygenation.
535) Which of the following makes heat transfer inefficient
a) low specific heat of the coil material
b) thick walled coils
c) more coils in the space
d) slower speed of blood
536) Which of the following is NOT an advantage of hemodilution during CPB?
a) maintains capillary circulation even at low mean arterial pressure
b) facilitates operation in patient with hemophilia A
c) offsets increased viscosity due to hypothermia
d) increases oxygen carrying capacity of blood
537) Which of the following hormones, released during CPB, is NOT a vasoconstrictor?
a) anti-diuretic hormone
b) epinephrine
c) ACTH
d) norepinephrine
538) Which of the following is NOT a desirable character of an arterial tubing ?
a) resilient
b) expandable
c) tough
d) low spallation rate
 75

539) The advantages of retrograded cardioplegia over antegrade cardioplegia during aortic
valve surgery are all of the following, EXCEPT,
a) uninterrupted surgery
b) aortic annulus visibility is better
c) shortened anoxic period
d) can be delivered after lowering of aortic valve
540) The dreaded complications of retrograde cardioplegia is
a) coronary sinus rupture
b) coronary artery dissection
c) acute ostial occlusion
d) IVC rupture
541) Which of the following would most likely have metabolic acidosis prior to CPB?
a) Gross AR , LVEF 40% for Aortic Valve replacement
b) Post infarct VSD for early closure of VSD
c) RHD , tight calcific MS ,AF for mitral valve replacement
d) Chronic stable angina, triple vessel disease for CABG
542) Which of the following drugs CANNOT be used for treating hyperkalemia on CPB?
a) insulin with glucose
b) calcium gluconate
c) sodium polystyrene sulfonate
d) sodium bicarbonate
543) Which of the following is NOT an acute reaction to blood transfusion?
a) febrile non-hemolytic reaction
b) graft vs host disease
c) hemolytic reaction
d) anaphylactic
544) The LAST measure to be taken for treating oliguria on CPB is,
a) administer injection Frusemide
b) increase flow for adequate perfusion pressure
c) start NTG infusion
d) rule out mechanical block in the catheter and draining tube
545) Which of the following is the LEAST important quality of an aortic cannula for a
conventional CPB?
a) Wire reinforced
b) smooth tapering
c) ID/OD ratio as near 1 as possible
d) gradient across cannula less than 100 mm of Hg
546) Which of the following is an odd cause with respect to venous reservoir level?
a) use of ultrafiltration
b) development of interstitial edema
c) soaked surgical sponges
d) inadequate occlusion of pump
e) small rent in the pleura
 76

547) A pump output of mere 2.4L/m2min is adequate on CPB due to all of the following
reasons, EXCEPT,
a) anesthesia
b) muscle relaxation
c) nonpulsatile flow
d) hypothermia
548) Gas flow is increased during rewarming because of,
a) decreased solubility of gas at higher temperatures
b) increased oxygen consumption during rewarming
c) increased blood flow during rewarming
d) decreased CO2 clearance
549) Which of the following statements is most accurate ?
a) nasopharyngeal temperature is always higher than rectal temperature
b) nasopharyngeal temperature is always lower than rectal temperature
c) rectal temperature trails behind nasopharyngeal temperature
d) rectal and nasopharyngeal temperatures are always equal on CPB
 77

Cardiac Anesthesia / Surgery

550) On full CPB, prior to aortic cross clamping, RA is not completely empty. Which of the
following causes is NOT responsible for the clinical situation?
a) patient has an additional ASD
b) inadequate gravity force for drainage
c) venous line partly kinked
d) IVC cannula wedged into hepatic vein
e) small sized venous cannulae used
551) Immediately after being on total CPB, before aortic cross clamping, heart fibrillates and
LV distends. Which of the following causes is NOT responsible for the clinical situation?
a) more than grade I AR
b) more than grade I MR
c) presence of PDA
d) large number of broncho-pulmonary collaterals
552) Almost empty reservoir, low arterial pressure with empty heart on CPB is diagnostic of
which of the following conditions?
a) incomplete occlusion of roller pump-head
b) wrong calculation of body surface area , hence wrong flows
c) recirculating line open
d) retroperitoneal dissection due to femoral cannula
553) During a redo AVR with normal coronary arteries, a surgeon insists on delivering the
first dose of cardioplegia by retrograde route rather than by ostia cardioplegia route,
mainly because,
a) visualise annulus well
b) unhindered surgery
c) previous prosthesis obstructs view of ostium
d) it offers a better myocardial protection
554) In a case with ASD, on total CPB, prior to cross-clamping of aorta, RA is empty but on
snaring SVC & IVC, RA becomes full immediately. This suggests which of the following
clinical situations?
a) IVC cannula wedged into hepatic vein
b) too small IVC cannula
c) presence of L-SVC
d) venous line kinked
555) Following an open heart surgery, a patient is shifted to intensive care . Two hours later,
patient is found to have excessive drainage and is required to placed on CPB again to
control hemorrhage. Which of the followings will be the perfusionist’s main concern
a) availability of blood for priming
b) possibility of heparin resistance
c) Serum creatinine levels
d) Serum potassium levels
 78

556) Sudden air-locking of venous line can occur during what stage of MV replacement
surgery?
a) during longitudinal paraseptal left atriotomy
b) after excising calcific mitral valve
c) while suturing prosthetic valve
d) while suturing lower angle of left atriotomy
557) Which of the following operations is performed with a bicaval cannulation
but without caval tourniquets?
a) ASD closure
b) Correction of TAPVC
c) TOF correction
d) Open Mitral Valvotomy with LA clot removal
558) If a patient is operated immediately following a complication of coronary angioplasty, the
perfusionist should be concerned about
a) dissection during aortic cannulation
b) urine out put
c) cerebral perfusion
d) accelerated leucocyte activation
559) A patient with MSMR , ASAR with severe PH is being operated for MVR + AVR. While
coming off CPB, patient is in NSR, SpO2 is 100%, CVP of 1mm of Hg, ABP of 88/54 of
Hg. To bring up ABP , one should FIRST
a) start DOPAmine drip
b) start adrenaline drip
c) return volume via arterial line
d) give head low of 25 degree
e) start phenylephrine drip
560) During On-Pump CABG using LIMA & RIMA , at near end of CPB, the reservoir level is
very low. The loss of volume must be in
a) 1st space
b) 2nd space
c) 3rd space
d) 4th space
e) 5th space
561) After repair of TOF, patient is just off CPB. The surgeon wishes to lift heart to check
bleeding. The bleeding is likely from
a) cardioplegia cannulation site
b) RSPV vent
c) right atriotomy
d) RVOT patching
562) Which of the following is an indication of redoing LIMA –LAD distal anastomosis?
a) Pulmonary artery diastolic pressure = 20 mm of Hg
b) Gr I-II MR on TEE
c) 2 mm ST elevation in lead I
d) hypokinesia of postero-lateral segment on TEE
e) Systemic diastolic pressure < 80 mm of Hg
 79

563) Pulse oximeter cannot be used on a conventional CPB to monitor arterial saturation
because of ,
a) hypothermia
b) hemodilution
c) alkalosis
d) flow is not pulsatile
e) use of cautery
564) On total CPB, RA & MPA are full. The measure that should NOT be taken is, to
a) search for PDA
b) adjust the venous cannula position
c) increase the gravity force
d) vent the heart
e) quickly cross-clamp the aorta
565) Trans-Esophageal Echocardiography is NOT useful in assessing
a) mitral valve area
b) LVEF
c) coronary blocks
d) chamber dimensions
e) LV wall motion
566) Swan – Ganz catheter provides information about
a) JVP
b) RA pressure
c) RVEDP
d) LVEDP
e) aortic diastolic pressure
567) For which of the following conditions temporary epicardial pacing is required in the
operation room?
a) repeated ventricular tachycardia
b) complete atrio-ventricular dissociation
c) sudden onset atrial fibrillation
d) repeated ventricular fibrillation
568) A surgeon wishes to insert retrograde cardioplegia cannula only after instituting CPB.
During insertion of the retrograde cardioplegia cannula, perfusionist should
a) reduce arterial flows
b) cool the patient quickly
c) keep heart partly filled
d) keep the cardiotomy suctions at full speed
569) While delivering retrograde cardioplegia with cannula (RCC) through coronary sinus
(CS), at a rate of 200ml/ min, the CS pressure is 75 mm of Hg. The cause of pressure of
75 mm of Hg is,
a) too fast delivery of cardioplegia
b) RCC is in one of the tributary of coronary sinus
c) diffuse atherosclerotic disease of coronary veins
d) CS ostial stenosis
 80

570) On CPB, anesthetist stops ventilation ,

a) immediately after CPB is started
b) after ‘total’ CPB is established
c) after desired temperature is reached
d) after cardioplegically stopping the heart
571) All of following is expected in Robotic surgery EXCEPT,
a) no incision , only ports
b) assisted venous drainage
c) percutaneous arterial cannulation
d) very short CPB and cross clamp times
572) A case of VSD with severe PH, has an excessive return through the vent passed through
RSPV during VSD closure surgery. The suspected cause is,
a) additional PDA
b) MAPCA
c) additional AR
d) incomplete aortic cross clamping
573) Which of the following structures can never be damaged during median sternotomy?
a) left Innominate vein
b) ascending aorta
c) RV
d) LV
e) RA
574 ) In a case with TOF, surgeon will ask to reduce the flows
a) so as to insert the RSPV vent
b) while delivering cardioplegia
c) during VSD closure
d) during RVOT patching
575) Bilateral pulmonary thrombo-endarterectomy is performed with which of the following
techniques?
a) Pump standby, on IABP and cell saver
b) Deep hypothermia circulatory arrest
c) On Pump, Cardioplegically arrested heart at 280 C
d) On pump, Beating heart at 370 C
576) During operation of which of the following conditions cardioplegic arrest by root
injection will be possible ?
a) A-P window
b) Ascending aortic aneurysm
c) RSOV into RA without AR
d) RSOV into RV without AR
577) The technique of “cross circulation” is attributed to
a) Gibbon
b) Lillehei
c) Debakey
d) Buckberg
e) Melrose
 81

578) Blood cardioplegia was re introduced and popularised by

a) Gibbon
b) Lillehei
c) Debakey
d) Buckberg
e) Melrose
579) The roller pump was invented by
a) Gibbon
b) Lillehei
c) Debakey
d) Buckberg
e) Melrose
580) In a case with multiple L to R shunts, PDA is closed
a) before commencing CPB
b) only after on full CPB, before cooling
c) after aortic cross-clamping, just before cardiotomy
d) on achieving hemodynamics off CPB
581) Ascending aorta should be cannulated as distally as possible in all of the following cases,
except,
a) severe AS with IHD for AVR with CABG
b) severe MR for MV repair
c) AP window repair
d) on pump CABG
582) In Off-Pump CABG surgery, the first distal anastomosis is placed on LAD . Which of the
following facts is the least important reason for doing so?
a) in patients referred for surgery, it is usually significantly blocked
b) it is an important artery as it supplies 5 out of 10 segments of heart
c) its exposure requires least manipulation of heart
d) it is on the anterior surface of heart in ‘side on’ position
583) A ‘well controlled’ patient following MVR with a mechanical valve should have an INR of
a) 1.1
b) 2.0
c) 2.7
d) 3.8
584) A ‘well controlled’ patient following AVR with mechanical valve will have an INR of
a) 1.2
b) 2.2
c) 3.5
d) 4.5
585) A patient with 4day old post infarct VSD is for closure of VSD . Which of the following
statements is the least likely statement?
a) PCW mean pressure of the patient is 8mm of Hg
b) femoral artery cannulation is not required for conducting CPB
c) patient will be on ventilator for pulmonary edema
d) bicaval venous cannulation with snugging of cave will be required
 82

586) A head-low position is given in all of the following situations, except,

a) off-pump OM anastomosis
b) retrograde cerebral perfusion
c) retrograde coronary sinus perfusion
d) circulatory arrest during arch replacement
587) Which of the following events is expected on CPB after closing a patent BT shunt in a case
with TOF,
a) CVP drops to zero
b) mean arterial pressure increases
c) arterial pCO2 improves
d) arterial pO2 improves
588) Which of the following is the least likely complication following cross clamping of
descending thoracic aorta for a thoracoabdominal aneurysm ?
a) renal failure
b) paraplegia
c) lower limb gangrene
d) mesenteric ischemia
589) A Surgeon confirms ‘proper’ placement of aortic cannula by checking all of the followings
EXCEPT,
a) marker on body of the cannula
b) adjusting the collar of the cannula
c) free flow of blood through the cannula
d) feeling the tip of the cannula through the aorta
590) Ventricular fibrillation, on CPB prior to aortic cross clamping is most damaging in which of
the following conditions?
a) ASD closure
b) AR for AVR
c) CAD for CABG
d) MR for MVR
591)The danger of repeating cardioplegia during mitral valve surgery is
a) right coronary air embolism
b) increased venous return to LA
c) wet operating field
d) calcium particulate embolism
592) Which of the following strategies DOES NOT protect spinal cord, during surgery for
thoracoabdominal aneurysm?
a) CSF drainage
b) distal aortic perfusion
c) selective celiac artery perfusion
d) mild hypothermia
593) For which of the following associated procedures with CABG, bicaval cannulation will be
required?
a) ascending aortic aneurysm repair
b) MV Repair
c) LV aneurysm repair
d) aortic valve replacement
 83

594) In which of the following conditions the aorta will be cross clamped very early to avoid
distension of heart?
a) severe aortic stenosis
b) aorto-pulmonary window
c) large VSD
d) severe mitral stenosis
595) If the surgeon proposes to cross-clamp the aorta early in a case, then the perfusionists duty
is to
a) prime extra volume particularly with blood
b) never to cool the case and keep the temperature above 320C
c) to keep cardioplegia ready right at start of CPB
d) keep aortic pressure high by starting phenylephrine
596) Accidental sucking of saline in the cardiotomy suctions should be watched during which of
the following steps of MV replacement surgery?
a) during dissecting the inter atrial septum
b) after excising mitral valve
c) while suturing prosthetic valve
d) while suturing left atriotomy
597) During a secundum ASD closure operation, the venous reservoir level suddenly falls on
opening the RA due to venous line airlock & the blood is drained only through
cardiotomy suctions. The cause is,
a) aortic dissection by the cannula tip
b) venous line kink
c) inadequate snaring of venous cannule
d) missed PDA
598) The outlet of retrograde cardioplegia is all of the following , EXCEPT,
a) RCA into aorta
b) LCA into aorta
c) Thebesian veins into RA, RV
d) Thebesian veins into IVC
599) In a case for excision of LA myxoma, the left heart is vented through
a) RSPV
b) LA
c) MPA
d) aortic root
600) Which of the following indicates an improper delivery of antegrade cold blood
cardioplegia by coronary ostial cannulation?
a) coronary arteries distend
b) coronary veins become turgid
c) absence of reflux from the opposite coronary ostium
d) the hand, holding the cannula, becomes cold
 84

Answers
1) C
2) D
The heart is drained by 3sets of venous systems. 1) Great cardiac system: draining LV
and forming coronary sinus. 2) Anterior system : draining RV and opening directly into
RA & 3) Vene cordis minimis or Thebesian veins.

Thebesian veins open directly into all the chambers of the heart. Their openings are
maximally numbered in RA and the least in LV.
3) D
4) C
Pulmonary artery-Pulmonary capillary-Pulmonary vein – LA – LV is a continuous
system with only one valve: mitral valve. During diastole, when the mitral valve is open,
LV cavity is in communication with pulmonary artery, pressure wise. Thus, pulmonary
diastolic pressure also reflects LVEDP
5) A
Equivalent weight is calculated by the following steps
1) Find the atomic weights for each element in the molecule: Locate this number under
the atomic symbol on the periodic table. For example, Potassium (K) has an atomic
weight of 40 grams per mole and Chloride is 35.5 grams per mole
2) Calculate the molecular weight of the substance: Hence molecular weight of KCl is
40 x1(one K) + 35.5 x1(one Cl) = 75.5 gram per mole. 3) Calculate equivalent weight :
Divide the molecular weight by the number of hydrogen protons it donates as acid or the
number of hydroxide (OH) anions it produces as a base. As one molecule of Potassium
would react with one molecule of Hydroxide (OH), valence of KCl is one. Thus, a 7.5g%
solution of KCl provides 1 meq of Potassium per ml, and a 15g% solution will provide 2
meq of Potassium per ml.
6) A
7) B
8) A
SVC is formed by joining of right and left innominate or brachiocephalic veins. The
azygos vein joins it posteriorly, almost at the midpoint of SVC .
 85

Azygos ( meaning without a duplicate on the opposite side) vein forms an important
communication between SVC and IVC and is very dilated in the presence of IVC
interruption.
9) C
Please refer to the answer to MCQ 8 and picture provided along with.
10) B

IVC is to the right of spine. Hence, the right femoral vein is more in line with the IVC
than the left femoral vein. Also, right iliac artery crosses the left common iliac vein.
11) D
(When ever in an MCQ ‘except’ appears, only one answer does not match the statement .
The answer not matching is the correct answer)
 86

Femoral artery is the continuation of external iliac artery. Common iliac and external
iliac arteries are in the abdomen. Hence due to depth, their exposure takes longer time.
Also, ureter crosses common iliac artery and requires careful dissection.

12) D
Longitudinal section through aortic root

1= aortic annulus , 2=aortic cusp, 3= sinus of Valsalva , 4= sinutubular junction

5= ascending aorta, 6= coronary artery
The initial part of ascending aorta housing the aortic valve mechanism is called aortic
root and it consists of structures mentioned above.
13) E
pK of a buffer indicates the pH at which base and acid components are equally balanced
in concentration. This is the pH at which the buffer is most efficient, as it can neutralise
acids and bases equally well. More near is this pK to blood pH ( 7.4), better is the buffer
efficiency.
 87

14) D
As blood pH is 7.4 , bicarb is not considered as an efficient buffer.
15) A
16) A
Due to low oncotic pressure RBCs becomes turgid and biconcave. These RBCs are
distended and, hence, are fragile.
17) D
Due to their large size, colloids do not get filtered through - renal or artificial filters
18) A
19) C
20) A
21) C
Finding of RBC in urine is abnormal. ‘ Microscopic hematuria’ is hematuria that is
detectable only on microscopic examination of urine. Inflammation of or injury to the
glomeruli can cause leakage of RBCs. It could be also due to renal infarcts, urinary tract
infection , tumours or trauma to urothelium by stones. Perfusionists should be aware of
glomerular causes as they pose problems during CPB.
22)C
This is the reason for administering GI drip to treat hyperkalemia.
23) B
Circulation time increases with sluggish circulations ( e.g. mitral stenosis ) and is shorter
in hyperdynamic states (e.g. PDA, pregnancy ).
Circulation time gives you an idea how early the effect of an intravenous drug could be
expected.
24) C.
Shown in the picture as ‘AM’. The acute marginal is also called Right marginal Artery .

The branches of LCA are: LAD, Diagonal ( anterolateral surface ) and Septal
LCx, Obtuse Marginal ( on posterior surface)

The branches of RCA are: SA nodal artery, RA br, RV br , Acute marginal ( these are not
grafted as they are small in caliber and do not supply LV).
 88

PD and PLV could be branches of RCA ( then it is called right dominant

circulation) or of LCA ( then it is called left dominant circulation)

Some times the Left Main artery trifurcates into LAD-Ramus intermedius – Left
circumflex.
25) B
ADP helps in aggregation of a platelet to damaged endothelium and to other platelets and
helps formation of a platelet plug.
26)C
27)B
Basophils and mast cells produce heparin. Heparin is stored in these cells around the
capillaries of lung and liver.
28) B
Viscosity of blood, instead of describing in absolute terms, is described in comparison to
that of water, with water viscosity considered as 1. Proteins (mainly fibrinogen) and all
the cells (but, mainly RBC) increase blood viscosity. As regards RBCs, RBC count,
RBC rigidity (i.e. deformability) and RBC aggregation increases viscosity. Viscosity of
plasma is 1.8 and that of blood is between 3 & 4, depending upon the hematocrit.

Blood being a ‘non-Newtonian fluid’, its viscosity changes inversely with its speed.
And with special reference to CPB, viscosity increases about 2% for each degree
centigrade decrease in temperature.
29) D
Diffusion of gas is directly proportional to area of diffusion , pressure difference and
solubility. Diffusion is inversely proportional to distance between the two gases or
thickness of membrane. Diffusion of gas is also inversely proportional to square root of
molecular weight of gas ( i.e. heavier the gas more difficult to diffuse).
30) D
The answer is not a) or b) because systole and diastole are not of equal duration. Also, a
systolic pressure of 120 is not throughout the systole and so is diastolic pressure of 80
is not throughout the diastole. Other accepted formula for mean pressure is
(Systolic Pressure + 2x Diastolic Pressure) / 3
31) E
Aggregation of platelets helps in the formation of a platelet plug which initiates clotting.
Hence the platelet-plug is called primary hemostasis or ‘white clot’
32) B
 89

Roughly, For acidosis, pH should be below 7.3. If HCO3 levels are below 25 with normal
or subnormal pCO2 levels then it is metabolic acidosis . High pCO2 with normal or
higher HCO3 levels indicate respiratory acidosis.
33) C
pK of a buffer indicates the pH at which the buffering action is the best. pK of bicarb
buffer is 6.1, while that of blood is 7.4.
Other wise bicarb buffer is the cheapest buffer available , it does not precipitate in blood
and through lungs ( by exhaling the CO2 produced ) and kidneys ( by excreting H+, Na+
and HCO-3 ions ) pH-homeostasis is well maintained.
34) A
When hemoglobin combines with carbon monoxide (CO) Carboxyhemoglobin is
formed.
Carbon dioxide is transported as 1) dissolved CO2. CO2 is 20 times more soluble than
oxygen. But, this form is only a small part of CO2 transport. 2) 20% of transport is in
combination with hemoglobin as carbaminohemoglobin 3) more than 75%
transport is a HCO3 ions – either in RBC or in plasma.
Approximately 75% of carbon dioxide is transport in the red blood cell and 25% in the
plasma .
35) D
36) B
Biconcave shape becomes spherical when plasma oncotic pressure is low.

37) E
Please refer to diagram in answer to MCQ no 12
38) A
The left subclavian artery is the last of the arch vessels and is difficult to approach
through a median sternotomy. From point of view of cerebral circulation, left
vertebral artery is the only branch it contributes . Hence this artery is not used for
antegrade cerebral circulation.
 90

39) B
Rarely, in complex congenital heart diseases, the left SVC opens into the roof of LA.
40) A
Thus, RA receives 99% of the systemic venous return through SVC, IVC and coronary
sinus.
41) B
Please refer to answer of MCQ 24. Obtuse Marginal arteries , also called Marginal
arteries, are shown as ‘M’ in the picture.
42) B
Infundibulum, literally, means a hollow funnel shaped cavity. So, there is an
Infundibulum, each, in brain, nose & uterus .
In heart, only RV has infundibulum and is also called ‘RV outlet’. As it is the outlet, it
is just below the pulmonary valve.
( Infundibulum is shown in the diagram below as ‘ conus arteriosus)

43) E
OM being a posterior vessel, the heart (i.e. LV) requires lifting towards the surgeon, i.e.
towards right, during the anastomosis . This lifting of heart towards right results in
obstruction to IVC venous drainage into RA.
A ‘head low’ position during this anastomosis also reduces venous return.

LAD and Diagonals are anterior vessels and venous return is least disturbed during
anastomosis to these vessels
44) B
 91

Please refer to answer to MCQ 24. Diagonal 2 only is shown in the diagram.

45)A
Node of Arantius is part of aortic valve leaflet.

46) D
Basilar oxygen consumption of myocardium is 9ml/100g/min. For an empty beating
heart it is 3ml. For an arrested heart it is 0.9 ml. Arrested and cooled heart it is 0.3 ml.
Thus major reduction (1/10) in oxygen consumption is by arresting heart. Reduction of
1/3 is by cooling.
47) A
The p50 value of pO2 is 26-28 mm of Hg. The p50 value is inversely related to affinity of
Hb for oxygen.
48) C
80% of the colloidal osmotic pressure is by albumen.
49) C
Depending on the osmolarity a solution is considered as iso, hyper or hypotonic
IV fluid solutions 270-300 mOsm/L = Isotonic (e.g. 0.9% Sodium Chloride)
IV fluid solutions >300 mOsm/L = Hypertonic (e.g. 10 % dextrose in water or 5%
Dextrose in Normal saline )
IV fluid solutions <270 mOsm/L = Hypotonic (e.g. 2.5% dextrose or 0.45%Sodium
Chloride)
Ringer Lactate is isotonic
50) C
Hence, IVC cannula is larger than a SVC cannula. If IVC is interrupted , it continues
through various azygos systems . As all the azygos systems finally join SVC, if IVC is
interrupted, SVC is dilated. ( see below and also ref to picture in MCQ 8).

In an infant SVC and IVC flows are almost equal due to relative large supply to brain .
 92

51) B
Thus, cannulation of right subclavian artery ensures adequate antegrade cerebral
circulation ( ref to answer to MCQ 38)

52)A
LCx artery is in the left a-v groove, which is posterior. Being in a ‘groove’ it is deep,
too. In addition, the artery is covered by great cardiac vein on the epicardial surface. All
these three causes makes direct grafting of LCx very difficult.

Other ‘non-graftable’ arteries are : LM, initial part of LAD, all the septals, 1st and 2nd part
of RCA
53) B
As cerebral blood flow is constant over a wide range of mean arterial pressure ( 60-160)
one way of increasing cerebral perfusion pressure is by draining CSF and reducing
intracranial pressure.
54) D
55) A
It is 7% of the previous metabolic rate, at each degree. The decrease is non-linear with
greater fall in the initial period. Q10 is the ratio of metabolic rates at a temperature
difference of 100C. In a rat experiment, the ratio was 12.1 for temperatures between 380
and 300C (i.e. 12.1 times or 1210% fall over initial 8degrees); But, the ratio was only 2.8
between 300 and 280 C temperatures.
56) B
In pH stat strategy for hypothermia, there is extra blood flow to brain (luxury perfusion).
Cerebral microembolism with particulate and gaseous emboli is the fear in such cases.
57) C
Brain and liver do not require insulin for glucose uptake.
58) B
Of all the neck vessels, both the external carotid arteries supply blood to face, mouth, etc
(i.e. parts outside the cranium)
 93

59) B
60) C
Following injury , blood vessel undergoes reflex vasospasm , which is further aided by
serotonin, ADP and thromboxane A2, released by platelets. Noradrenaline is a
vasoconstrictor but released by sympathetic system.
61) B
Sodium and Potassium are cations ( positively charged ions). Of these, Potassium is in
abundance (140 meq/L) intracellularly, in all animals and plants!! Hence, hemolysis of
blood during CPB results in hyperkalemia. In patients with renal failure, soups, tea, etc
( which are extracts of cells) are prohibited to avoid hyperkalemia.
 94

62) C
Hydrostatic pressure pushes fluid out of a compartment while colloidal osmotic pressure
retains fluid in the compartment. Hence, increased plasma proteins help reducing cellular
edema by retaining fluid in the intravascular compartment.

63) A

Anterior cardiac veins drain the anterior surface of RV, cross the right a-v groove and
open directly into RA. They do not open into coronary sinus. Hence, retrograde-
cardioplegia delivered through coronary sinus does not perfuse anterior surface of RV.

64) A
Explanation as above in MCQ 63
65) A

66) A
 95

67) C

68) A

69) B
The essentials for the maturation of red blood cells are vitamin B12 (cobalamin) and
vitamin B9 (folic acid). Their deficiency results in megaloblastic anemia. In
megaloblastic anemia RBCs aren’t produced properly. Because the cells are too large,
they may not be able to exit the bone marrow to enter the bloodstream and deliver
oxygen.
70) B
Some of the causes of aplastic anemia are : 1) Radiation and chemotherapy treatments
2) Exposure to toxic chemicals like pesticides and insecticides 3) Use of certain drugs,
like, chloramphenicol, carbamazepine, phenytoin, quinine, and phenylbutazone
4) Autoimmune disorders 5) Viral infection 6) Pregnancy.

71) D
The life span of an adult RBC is 120 days. RBCs in a fullterm neonate survive
between 60 and 90 days. RBCs from premature neonates have considerably shorter life
span, ranging from 35 to 50 days.
 96

CPB reduces the RBC lifespan significantly and, this is a major cause of post operative
anemia or failure. Blood storage also reduces RBC life span.
72) D
73) C
The hepatic veins open into IVC just below the diaphragm. In a case with congestive
failure, the hepatic veins are dilated too.

74) A

The right brachiocephalic vein is in line with the SVC and drains through the end
hole; while, the others are side branches and drain through side holes.
75) A
( see diagram above, also). Azygos vein opens into SVC posteriorly, at the spot where
extrapericardial SVC becomes intrapericardial. Azygos vein is an important
communication of SVC with IVC and is prominent in cases with IVC interruption.
 97

76) D

Spinal cord blood supply is derived from one Anterior spinal artery ( branch of vertebral
artery) and two posterior spinal arteries ( branches of either the posterior inferior
cerebellar or vertebral arteries) . The arteries are usually discontinuous and are reinforced
by branches of posterior intercostal arteries - radicular arteries. Posterior intercostal
arteries are branches of descending thoracic aorta. One of the radicular arteries could be
 98

prominent and is called arteria radicularis magna or artery of Adamciewicz. The spinal
cord ends at L1-L2 vertebral level. Hence, clamping below L1-L2, i.e. infrarenal
clamping never results in paraplegia.
77) B

78)B
or blood volume
79) B

80) D
81) D
Thromboxane A2 is produced by activated platelets and has prothrombotic properties: it
stimulates activation of new platelets as well as increases platelet aggregation. It is a
vasoconstrictor, too.
Basophils appear in many specific kinds of inflammatory reactions, particularly those that
cause allergic symptoms. Basophils contain heparin. They also contain the vasodilator
histamine, which promotes blood flow to tissues.
Monocytes are responsible for immunity.
B cells, also known as B lymphocytes, are a type of WBCs. They function in the humoral
immunity component of the adaptive immune system by secreting antibodies.
82) B
83) A
The free radicals produced are O-2, HOCl- ( hypochlorite radical), OH- ( hydroxyl
radical). Apart from free radical oxygen ,enzymes produced by neutrophils during SIR
are myeloperoxidase , elastase & proteases; which basically damage cell wall or
interstitium.
84)B
The venous oxygen content depends upon 1) cardiac output 2) hemoglobin of the blood.
 99

Hence in a given case, with a steady hemoglobin , venous pO2 is a parameter of cardiac
output .
85) D
86) B
Thus, out of 20 ml of oxygen in 100 ml of blood only 0.3 ml (0.003x pO2) is in dissolved
state and the rest is bound to hemoglobin ( Hb x 1.34 x saturation ).
87) A
Activated factor XII ( XIIa) simultaneously stimulates clotting , fibrinolytic and
complement systems.
88) Valves which close during ventricular diastole: pulmonary and aortic valves
Valves which open during ventricular diastole: tricuspid and mitral valves
Valves which open during ventricular systole : pulmonary and aortic valves
Valves which close during ventricular systole : tricuspid and mitral valves
89) Shift of the oxygen dissociation curve to right indicates less affinity for oxygen( normally
occurs at tissue level) and occurs with lower pH, higher temperature and higher DPG.

Shift of the oxygen dissociation curve to left indicates more affinity for oxygen (
normally occurs at the lung) and occurs with higher pH, lower temperature and lower
DPG.

90) The pressures favoring exudation out of fluid a capillary are: higher capillary hydrostatic
and tissue oncotic pressures.
The pressures favoring retention of fluid in a capillary are: Higher capillary oncotic and
tissue hydrostatic pressures.( Please see answer to Q 62)

91) Low platelet count is due to hemodilution, aggregation and sequestration of platelets.

92) a = c, b= e, c= f, d= d, e = b, f = g, g= a

93) carbonic unhydrase

94) hepatic veins

95) increases

96) +0.0142/C

97) SVC

98) Left common iliac artery

99) 20 times

100) A
The hepatitis A virus (HAV) is transmitted through ingestion of contaminated food and
water or through direct contact with an infectious person.
 100

101) B
This the nature’s method of managing hypercoagulability of blood due to high PCV.
Patients also have a low clotting factor ( II, VII, IX and V) levels and fibrinogen levels.
There could be a subclinical DIC and these patients could have fibrinogen degradation
products ( FDP) in blood.

The other complications mentioned in A and D could be present but are not related to
high PCV. LV dysfunction in TOF is rare.
102) A
Obligatory shunts are the shunts which are required to sustain the life of a patient with
congenital cyanotic heart disease. ASD is essential to sustain the life of a patient with
tricuspid atresia. Similarly, in a case with TAPVC and d-TGA, ASD is essential to
sustain life . Similarly, an additional VSD or PDA is obligatory to re-establish flow to
pulmonary circuit .

103) B
Staphylococcus aureus is a gram-positive coccus and is frequently found in the nose,
respiratory tract, and on the skin. It is a facultative anaerobe that can grow without the
need for oxygen. The emergence of antibiotic-resistant strains of S. aureus such as
methicillin-resistant S. aureus (MRSA) is a worldwide problem.

S. aureus and S. epidermidis are commonly transmitted from ‘health care workers’
(doctors, nurses, perfusionists) to patients and are responsible for sternal wound
infection as well as infective endocarditis.

104) D
 101

In any type of TAPVC, all the four pulmonary veins join to form a common chamber
(CC). CC is situated behind LA. In a normal person, CC gets incorporated or merges with
LA. In a case with TAPVC, The CC opens into one of the systemic veins or chamber. If
the systemic vein is superior to heart (left innominate vein or SVC ), it is called
supracardiac TAPVC (A). If it is in the heart ( RA or coronary sinus) ,it is called
intracardiac TAPVC (B) . If it is below the heart ( IVC, hepatic vein, portal vein ),
it is called infracardiac TAPVC (C).

A B C

105) A
The complement system is a part of the immune system that enhances (hence, called
‘complement’) the ability of antibodies and phagocytic cells to clear microbes and
damaged cells from an organism & promotes inflammation. It consists of a number
(about 30) of proteins. These proteins stimulate in a cascading manner. C3a, C5a and
C5b-9 are some of the active complements.
C3a causes T cell activation, angiogenesis stimulation, chemotaxis , mast cell
degranulation and, macrophage activation.
C5a acts as a highly inflammatory peptide, encouraging further complement activation,
formation of the membrane attack complex (MAC) and attraction of nonspecific immune
cells.
C5b-9 is called terminal complement complex and destroys bacterial cell by severely
damaging cell membrane.
106) D
Cardiac cirrhosis (congestive hepatopathy) includes a spectrum of hepatic derangements
that occur in the setting of right-sided heart failure. Clinically, the signs and symptoms of
congestive heart failure dominate the disorder.
Chronic and gross RV failure causes transmission of elevated RA pressure to the liver via
the IVC and hepatic veins. Chronic venous congestion ultimately results in liver cell
atrophy, necrosis, and, fibrosis.
The most common liver enzyme abnormality is an elevation of serum bilirubin, modest
elevations in SGOT and SGPT, alkaline phosphatase, and total bilirubin , as well as mild
decreases in albumin.
107) B
 102

Atherosclerosis affects high pressure vessels. Hence, pulmonary arteries are not affected.
Another group of arteries not affected by atherosclerosis are Right and Left Internal
Thoracic Arteries (LITA and RITA, previously called LIMA & RIMA).
108) B
SGPT, now called, alanine aminotransferase (ALT) test measures the amount of this
enzyme in the blood. ALT is found mainly in the liver, but also in smaller amounts in the
kidneys , heart, muscles, and pancreas . Low levels of ALT are normally found in the
blood. High ALT levels are caused by liver damage.

The ALT test is often done along with aspartate aminotransferase (AST). AST is in
significant amounts in cardiac and skeletal muscle.

Hemolysis raises LDH and free hemoglobin. Myocardial cell damage would raise AST
and Troponins.
109) A
Marfan’s syndrome is a genetic disorder of the connective tissue. It involves a mutation
to the gene that makes fibrillin which results in abnormal connective tissue. The
connective tissue is weak and is unable to withstand pressure due to cystic medial
necrosis. A patient with Marfan’s syndrome is tall with long arms, legs, fingers. The
joints are extra flexible and scoliosis could be present. In cardiovascular system, they can
have mitral valve prolapse and aortic regurgitation due to dilated annulus and aneurysm
or dissection of any part of the aorta .
Stenotic lesions of any valve or artery are not known.
110) B
111) E
Storage destroys fragile cells like platelets. Continued metabolism of remaining cells
results in fall in blood sugar, fall in pH and rise in ammonia.
112) D
Oxygen carrying capacity of blood = (1.34 x Hb x Saturation) + Dissolved oxygen
Polycythemia, or increased hemoglobin is a natural body compensation for decreased
oxygen carrying capacity when there is decreased saturation due to R to L shunt.
In a patient with valvar PS without ASD or VSD there is no shunt, so there is no
cyanosis or desaturation.
113) B
In a PDA with L to R shunt, there is volume (and pressure) over load of pulmonary
circulation. The volume overload is carried forward to pulmonary veins, LA (LAVO),
LV( LVVO) and ascending and arch of the aorta .Overloading of ascending and arch of
the aorta results in their dilatation . RAVO is typically, a feature of ASD.
114) D
The connections in a d-TGA are:
 103

a) RA-RV- Aorta- systemic circulation –systemic veins-RA

b) LA-LV-MPA-pulmonary circulation- Pulmonary veins –LA
Thus, there are two parallel circulations. Hence, an ASD is an obligatory shunt.
Blood flows through ASD L to R as well as R to L; and, is called ‘mixing’.
As systemic venous blood reaches Aorta, patient is cyanosed .

115) E
TOF is a condition where, due to aortic override and RVOT obstruction, excess blood
flows into ascending and arch of aorta. Excess of flow of blood precludes development of
aortic stenosis or coarctation. An adult TOF can develop aortic regurgitation.

116) E
Bilateral SVC is associated with congenital heart disease.
117) A
Rheumatic fever results from pharyngitis caused by group A- hemolytic streptococci. It
is due to an immune responses occurring 1-3 weeks after the onset of streptococcal
pharyngitis. The underlying mechanism is believed to involve the production of
antibodies against streptococcal protein which also attack person’s own connective
tissues in joints, heart, brain and skin.
118) E
Serum level of Troponin increases within 3-12 hours from the onset of chest pain, and
peaks at 24-48 hours, and returns to baseline over 5-14 days. CK-MB is less specific and
sensitive.
 104

119) D
In ASD with left to right shunt, RA, in addition to blood from SVC, IVC and CS;
receives blood from LA resulting in RA volume overload ( RAVO ) . This volume
overload is carried forward resulting in RVVO .

120) D
Ref to 104 for details
121) B
In a case with VSD with L to R shunt the RV receives blood from RA as well as from
LV, resulting in volume overload (RVVO)) .This volume over load is carried forward to
pulmonary circulation. In a large VSD there is a transmission of LV systolic pressure to
RV (RVPO). This RV pressure over load is carried forward to pulmonary circulation.
Thus, the pulmonary circulation is volume overloaded as well as pressure overloaded.
 105

122) A
In a case with mitral stenosis normal or less blood is pumped into aorta and systemic
circulation. Hence, the aorta is normal or small in size. Choices b) to d) are result of back
pressure effect due to the stenotic mitral valve.
123) A
In a case with mitral regurgitation the regurgitant volume produces LAVO and LVVO.
The forward output from LV is always normal or subnormal. Choices c),d) and e) are
result of back pressure effect due to LA pressure overload.
124) B
Methemeglobin results from the presence of iron in the ferric form , instead of, in ferrous
form. This results in decreased availability of oxygen to tissues. Methemeglobinemia
occurs when RBC contain methemeglobin at levels higher than 1%.
125) B
Pulmonary artery to LV is a continuous tubal system with only one valve –mitral valve.
Hence, in a person without mitral valve disease, during diastole, when the mitral valve is
open and the flow is passive all the pressures are almost equal. Hence, Pulmonary
Diastolic Pressure = LVED pressure.
126) A
In a patient with HLHS, it is the pulmonary artery which is maintaining supply to
systemic circulation via PDA. If there is an additional pulmonary atresia, the patient
won’t survive. Hypoplastic ‘left heart’ implies, hypoplasia of mitral valve, LV, aortic
valve and ascending aorta.

127) D
HIT is a procoagulant state and is due to a vicious cycle of
platelet activation- PF4 release- PF4-heparin IgG complex- stimulation of platelets.
Treatment is to stop all heparin exposures, initiate an alternative anticoagulant ,and, not
to transfuse platelets.
128) A
Focal brain damage is due to a small embolus blocking one artery in brain. Causes b) &
c) give rise to diffuse brain damage. Choice d) does not produce one single gas bubble
but produces a large gas-blood jell, which, crosses over to arterial side to produce diffuse
brain damage.
129) A
Basophils appear in many specific kinds of inflammatory reactions, particularly those that
cause allergic symptoms.
 106

130) D
131) C
Calcium in blood exists in three fractions: ionized (~50%), protein bound (~ 40%), and
chelated (~10%).Changes in the total and ionised calcium fractions during and after
CPB are influenced by the inclusion of exogenous calcium salts or blood products in the
pump priming solution and by the frequent administration of calcium salts at
discontinuation of CPB. Other aspects of CPB prime solution such as protein (albumen)
content and acidity have been shown to influence ionised calcium.
A fall in ionised calcium concentration occurs upon initiation of CPB due to
hemodilution. Reabsorption of the calcium in the kidney is thought to be inhibited by the
influence of hypothermia.
132) A
Whole blood is stored at a temperature of 40 to 60C. At this temperature the platelets lose
their viability. Also, platelets adsorb to the transfusion set. Platelets should be stored at
220C in 50 ml of plasma.
WBCs lose their phagocytic and bactericidal property within 4-6 hrs of collection and
become non-functional after 24 hrs of storage. Over a period of time, potassium level
rises and Albumen level falls.
133) C
Syphilis affects cardiovascular system in tertiary stage. Invasion of aortic wall by
Treponema pallidum results in aortitis. Inflammation causes obliteration of vasa vasorum
resulting in periaortitis and necrosis of the elastic fibres and connective tissue in the
tunica media .The replacement of tunica media with fibrous tissue leads to weakening of
the aortic walls and saccular or fusiform aneurysm formation. The infection and
inflammation may extend into the root of the aorta causing dilatation of the aortic annulus
resulting in aortic regurgitation. There is no cuspal involvement to cause stenosis. There
could be coronary ostial stenosis.
134) A
Prothrombin time (PT) test performed with a weaker agent, yields a raised PT and PT test
done with a potent agent yields a lower PT. To counter this problem, the reagent
potency is ‘weighted’ as International Standardisation Index (ISI). A potent agent has a
higher ISI value and compensates for the lower PT value.
135) D
Ischemic MR was originally been thought to be due to ”papillary muscle dysfunction.”
Experimental and clinical imaging studies have confirmed that the main trigger for
ischemic MR is not papillary muscle dysfunction, but lateral and apical displacement of
the papillary muscle with resultant restricted leaflet motion.
 107

136) C
Please read 133
137) A
VSD, RVOT obstruction, RVH and overriding aorta ( i.e. partly facing LV and partly
facing RV) are the classically four components of TOF.

Diagnostic features of other mentioned CHDs are

TAPVC= Common chamber , vertical vein
Truncus Arteriosus = single trunk giving rise to arch of aorta and both pulmonary arteries
Truncal valve, which could be quadricuspid
Tricuspid atresia = hypoplastic RV inflow and body
138) B

( CT scan (caudal) view)

139) B
Circulation in a case with tricuspid atresia is as shown below
 108

140) C
CPB circuit provides a non endothelial surface which stimulates ‘alternate pathway’.

141) A
142) E
 109

143)
% of normal kidney left

S. Cr value in mg%
144) A
Due to MR, the forward flow is reduced. This keeps the ascending aorta small in size.
Patients with VSD, ASD or Mitral stenosis have a small aorta , requiring adjustments
with cannula size.
145) C
146) B
147) A
Hepatitis A virus is transmitted primarily by the fecal-oral route; i.e., when an uninfected
person ingests food or water that has been contaminated with the faeces of an infected
person.
148) C
CPB is commonly associated with hypothermia, hypoxia, hypoperfusion, and acidosis.
These are pre-disposing factors that can lead to severe RBC aggregation, vascular
occlusion and thrombosis.

149) Troponin T, Troponin I, CPK-MB, B-type natriuretic peptide (BNP) , Myoglobin.

Also, please read answer to Q 116
150) Human immunodeficiency virus (HIV) , Hepatitis B & C viruses.
Species of Plasmodium ( causing malaria)

151) Match the following

Group A Group B
(CHD) (Typical pathological feature)

a) complete AV canal a) MAPCA (e)

b) supra cardiac TAPVC b) parallel circulation (c)
c) d TGA c) common valve annulus (a)
d) tricuspid atresia d) vertical vein (b)
e) Pulmonary atresia e) obligatory ASD (d)
 110

152) Match the following

Group C Group D
(Disease) (Peculiar problems)

a) TOF a) severe PH (d)

b) MS with AF b) cleft mitral valve (e)
c) AR due to Marfan’s syndrome c) ascending aortic aneurysm (c)
d) Non restrictive VSD d) polycythemia (a)
e) Primum ASD e) LA clots (b)
g) calcific aorta ( )
h) calcific mitral valve ( )

153) Match the following

Group E Group F
(Pathology) (important aspect related to CPB)

1. MSMR+ TSTR+ AR, CCF 1.Right heart bypass (8)

2. Critical MS with AF 2. Bicaval Cannulation (10)
3. Arch aneurysm 3.IABP (7)
4. Multiple A-P collaterals 4. LA clot (2)
5. Operation on an infant 5.Coronary cannulation for cardioplegia (6)
6. Rupture of ASOV 6. pH-stat strategy while cooling (5)
7. Acute VSD 7. closure of vert. vein before cardiotomy (9)
8. Extra cardiac TCPC 8. Antegrade cerebral perfusion (3)
9. Supra cardiac TAPVC 9. Cavoatrial venous cannula (11)
10.Gross AR with small VSD 10.Large venous return (1)
11. LV aneurysm repair 11.Trickle flow (4)
12. CABG with MVR 12. Extracardiac shunt closed prior to CPB (13)
13. ASD+ VSD + PDA 13. Distal coronary anastomoses first (12)

154) D
Heparin is a heterogeneous polysaccharide chain. One third of the polysaccharide chain
contains a specific antithrombin binding pentasaccharide sequence. A pentsaccharide in
heparin binds to antithrombin III to bring a conformational change in AT III (also called
heparin cofactor).
a) The activated AT III inhibits conversion of fibrinogen to fibrin by thrombin.
b) Heparin also acts indirectly at multiple sites in both the intrinsic and extrinsic blood
clotting systems to potentiate the inhibitory action of AT III on several activated
coagulation factors IXa, Xa, XIa, and XIIa. Inhibition of activated factor Xa interferes
with thrombin generation and thereby inhibits the various actions of thrombin in
coagulation.
c) Heparin also accelerates the formation of an AT III–thrombin complex, thereby
inactivating thrombin and preventing the conversion of fibrinogen to fibrin; these actions
prevent extension of existing thrombin.
 111

d) Heparin also prevents formation of a stable fibrin clot by inhibiting the activation of
the fibrin stabilising factor by thrombin. Heparin has no fibrinolytic activity.
155) B
Heparin is metabolised in liver and reticulo-endothelial cells by heparinase.
156) C
In vivo means in body.
157) B
This is irrespective of concentration.
158) C
7.5 g% of KCL will have 7500mg of KCl /100 ml.
= 75 mg of KCl /ml
Molecular weight of potassium is 40 and that of Chloide is 35. Hence molecular
weight of KCl would be 75. Valence of KCl is one.
mEq = mg x valence/formula weight
=75 mg x 1/75
=1
( similarly please find milliequivalents of other commonly used solutions like 0.9%
NaCl, NaHCO3, CaCl2)
159) B
side effects include low blood pressure related to vasodilation, transient apnea following
induction doses, and cerebrovascular effects. Reports of blood pressure drops of 30% or
more are thought to be at least partially due to inhibition of sympathetic nerve activity.
This effect is related to dose and rate of propofol administration. Propofol can also cause
decreased systemic vascular resistance, myocardial blood flow, and oxygen
consumption, possibly through direct vasodilation.
160) D
161) B
Etomidate has a rapid onset of action and a safe cardiovascular risk profile, and therefore
is less likely to cause a significant drop in blood pressure than other induction agents. In
addition, etomidate is often used because of its easy dosing profile, limited suppression of
ventilation, lack of histamine liberation and protection from myocardial and cerebral
ischemia. Etomidate is a good induction agent for people who are hemodynamically
unstable. Etomidate is one of the only anesthetic agents able to decrease intracranial
pressure and maintain a normal arterial pressure.
162) B
The onset of action following an intravenous dose is within 5 minutes
163) C
Midazolam is a benzodiazepine & works in the CNS to cause sleepiness, muscle
relaxation, short-term memory loss, and reduces anxiety.
164) C
The calcium concentration is 2–3 mEq /L equal to 1.5 mmol/L.
(also see below)
165) A
The lactate is metabolised into bicarbonate by the liver, which can help correct metabolic
acidosis.
166) C
 112

Rest all are vasoconstrictors .

167) D
1 to 5 microgram/Kg/min dose of DOPAmine stimulates DOPAminergic receptors in
kidney producing diuresis.
168) A
Mannitol is a sugar. It is not absorbed by the gut. When administered IV, mannitol is
confined to the extracellular space, only slightly metabolised and rapidly excreted by the
kidney. Approximately 80% of a 100 g dose appears in the urine in 3 hours. The drug is
freely filtered by the glomeruli with less than 10% tubular reabsorption ; it is not secreted
by tubular cells. Mannitol induces diuresis by elevating the osmolarity of the glomerular
filtrate and thereby hindering tubular reabsorption of water. Excretion of sodium and
chloride is also enhanced. A 20% solution of mannitol is approximately 4.5 times
hyperosmolar.
169) A
All the choices are true actions of adenosine. But for myocardial protection during CPB,
choice (a) is of no use. Also, other useful actions of Adenosine for myocardial protection
are, i) slowing of heart rate ii) negative inotropic action.
170) D
Argatroban is an anticoagulant with a direct thrombin inhibitor property (unlike heparin
which acts through antithrombin III).
Argatroban is given intravenously and plasma concentrations reach steady state in 1–3
hours. Argatroban is metabolised in the liver and has a half-life of about 50 minutes. It is
monitored by PTT. Because of its hepatic metabolism, it may be used in patients with
renal dysfunction. (This is in contrast to lepirudin, another direct thrombin inhibitor that
is primarily renally cleared).

Due to the lack of a reversal agent, dosing of argatroban during CPB is complex. ACT
has been reported to be a reliable measure of the degree of anticoagulation during
argatroban therapy. Furthermore, it has been proposed that ACT levels should be
maintained between 500 and 600 s during CPB.
171) A
Hydroxyethyl starch ( HES) is a nonionic starch derivative. It is a volume expander.
HES is a general term and are sub-classified according to average molecular weight
(typically around 130 to 200 kDa), molar substitution(what proportion of the glucose
units on the starch molecule have been modified with hydroxyethyl units: typically
around 0.35 to 0.5). A solution of HES may further be described by its concentration
in % (i.e. grams per 100ml). So for example, one commercially available HES (Voluven)
is described as 6% HES 130 / 0.4.

The elimination depends on molar substitution degree. Molecules smaller than the renal
threshold (60–70 kDa) are readily excreted in the urine while a small part of the larger
molecules are metabolized by plasma α–amylase before those degradation products are
renally excreted. However HES is only partly degraded and excreted, while for a large
amount, the metabolism remains unclear. Administered HES accumulates in large
quantities within diverse tissues where it can persist for periods of several years.
Therefore, HES should not be administered for longer than 24 hours.
 113

172) D
Losartan and its longer acting metabolite, E-3174, lower blood pressure by antagonizing
the renin-angiotensin-aldosterone system (RAAS); they compete with angiotensin II for
binding to the type-1 angiotensin II receptor (AT1) subtype and prevent the blood
pressure increasing effects of angiotensin II.
173) D
Telmisartan is more potent than Losartan in lowering systolic and diastolic hypertension.

174) A
N-acetylcysteine (NAC) administration has been shown to improve acute renal failure
induced by ischemia-reflow, and was found to prevent radiocontrast nephropathy in high-
risk patients. The protective effect of NAC has been primarily attributed to scavenging
oxygen free radicals & improving renal microcirculation.
175) C
Adenosine has an extremely short half life of < 30 seconds and is metabolised by
adenosine deaminase, present in RBCs & vessel wall . So adding adenosine to blood is
of no use. Adenosine should be administered as a ‘pretreatment’ through clear fluids.
176) A
Multiple studies with various doses have evaluated the effects of allopurinol on
outcomes in CABG patients. These studies found that allopurinol can reduce
in-hospital mortality, improve cardiac performance, reduce incidence of arrhythmias,
reduce markers of ischemia and free-radical generation, and reduce the need for inotropic
support. However, these findings were not consistent between all studies. Although the
optimal dose has not been determined, reviewed literature suggests that patients should
receive at least 600 mg one day prior to surgery, as well as at least 600 mg on the day of
surgery.
177) B
Heparin resistance can be seen as early as 24 hours of treatment with heparin.
In non-CPB cases, it is diagnosed if dose >35000 units of heparin is required in 24 hours
to maintain aPTT.
It can be seen in patients on IABP & on LVAD
Other than post CPB acquired ATIII deficiency, it can also be seen with
a) accelerated ATIII consumption: IE, IABP, LVAD
b) decreased ATIII production: hereditary , liver disease
c) increased heparin clearance: nephropathies
d) elevation of heparin binding proteins:
e) high levels of fibrinogen or factor VIII, or platelets > 300000/cmm
178) B
It is the strongest acid present in the body with a strong negative charge.
Chemically it is a nonuniform mixture of straight chain mucoplysaccharides with weight
10000 to 20000 Daltons. (Also, please read answer to MCQ 154)
179) B
Should be avoided in patients with preoperative renal and liver dysfunction.
180) B
Sodium content is same as 1 N NaCl i.e. 154 mEq/L
181) C
 114

Protamine is a highly cationic (positively charged) peptide that binds to heparin

(negative charged) to form a stable ion pair. Neutralisation of heparin occurs in < 5
minutes. The Protamine –Heparin complex does not have anticoagulant activity. The
ionic complex is then removed and broken down by the RE system, or may be partially
metabolised by fibrinolysin, freeing heparin.

Protamine does not bind to the low molecular weight fragments within LMW heparin
preparations resulting in incomplete neutralisation of anti-factor Xa activity when
protamine is used to treat overdosage of LMW heparins.

In large doses, protamine sulfate may also have an independent—however weak—

anticoagulant effect.
Half-life of protamine , without heparin in healthy individuals is 7.4 minutes. Half-life
following CPB is 4.5 minutes. Thus, at the end of CPB, protamine should be continued
till all primed blood is returned back.

Protamine was originally isolated from the sperm or mature testes of salmon and other
species of fish but is now produced primarily through recombinant biotechnology.

Protamine has been reported to cause allergic reactions in patients who are allergic to
fish, diabetics using insulin preparations containing protamine, and vasectomised or
infertile men. Allergic reactions occur at rates ranging from 0.28% to 6%. The adverse
reactions can be avoided by slow infusion of protamine sulfate and pre-treating at-risk
patients with histamine receptor antagonists (H1 and H2) and steroids.

Non allergic systemic hypotension with rise in PA pressures also occurs after protamine
administration due to release of vasoactive mediators (e.g., histamine, bradykinin,
thromboxane, and nitric oxide), complement activation, and antibody production.

A 5–10 mg test dose is recommended following pretreatment before administering the

full dose. Dosage for heparin reversal is 1.0 -to- 1.5 mg protamine sulfate IV for every
100 IU of active heparin. Protamine also has been used to neutralise low molecular
weight heparin and heparin analogous.
182) C
Please see answer to MCQ 181 for details
183) B
Abciximab is a glycoprotein IIb/IIIa receptor antagonist resulting in platelet aggregation
inhibition. It is mainly used during and after coronary angioplasty. GPIIb/IIIa is an
integrin complex found on platelets. It is a receptor for fibrinogen and von Willebrand
factor and aids platelet activation.

While abciximab has a short plasma half-life, due to its strong affinity for its receptor on
the platelets, it may occupy some receptors for weeks. In practice, platelet aggregation
gradually returns to normal about 96 to 120 hours after discontinuation of the drug.

Other drugs in the same group are eptifibatide, tirofiban.

 115

184) B
Barbiturates (Thiopentone) and Propofol are by far the best for neuro-protection
185) D
186) A
Diltiazem is a calcium channel blocker that can be used alone or in combination for the
treatment of hypertension & angina. It acts by blocking Ca influx in myocardium and
smooth muscle cells of vessels. It prevents extracellular Ca influx into target cells,
decreases intracellular calcium and produces dilatation in systemic arteries.

Diltiazem or other calcium channel blockers like Nifedipine with or without

nitroglycerine (NTG) are used to dilate arterial conduits. Diltiazem is shown to increase
flow in all types of arterial grafts.

They reduce SVR and if used with NTG increase venous capacitance resulting in reduced
venous return.
187) A
Nitroglycerin is primarily a venodilator, though dilation of arterial smooth muscle also
occurs with high doses. Once nitroglycerin is converted to nitric oxide, it activates
guanylate cyclase and stimulates the production of cyclic GMP (cGMP). This produces
smooth muscle relaxation, mainly in the venous system, and reduces myocardial preload.
On CPB, pooling of blood in veins results in decreased venous return.
188) C
20% Albumen has 20 gm of Albumen in 100 ml. Thus 5ml ( 1/20) of Albumen will have
( 20/20 =1) 1 gm of Albumen.
189) B
Ivabradine lowers heart rate by acting on sinus node. It does not decrease muscle
contractility.
190) C
Please refer to answer to MCQ 168
191)
Noradrenaline: 1)  (1& 2) adrenergic receptor agonist: a power full vasoconstrictor
and constricts both veins (capacitance) and resistance ( arterioles) blood vessels.
It increases systolic, diastolic and mean blood pressure.
2)  adrenergic receptor agonist :positive inotropic drug through its1 action and
causes cardiac stimulation. It increases stroke volume and improves coronary
blood flow.
Aprotenin: 1) Aprotinin is a competitive inhibitor of several serine proteases, specifically
of plasmin and kallikrein. Its action on kallikrein leads to the inhibition of the
formation of factor XIIa. As a result, both the intrinsic pathway of coagulation
and fibrinolysis are inhibited during CPB.
2) Its action on plasmin independently and slows fibrinolysis.
Atenolol: 1) is a beta-adrenergic blocking agent. It reduces the force of contraction of
heart muscle and lowers blood pressure.
Captopril: 1) prevents the conversion of angiotensin I to angiotensin II by inhibition of
Angiotensin Converting Enzyme. Angiotensin II is a powerful vasoconstrictor
 116

and stimulator of Aldosterone secretion. Prevention of ATII results in fall in

systemic pressure.
Aspirin: 1) irreversibly inactivates platelet- cyclooxygenase resulting in inhibition of the
formation of a highly effective platelet aggregator and a vasoconstrictor
thromboxane A2. Since the platelets do not synthesize proteins, the effect remains
demonstrable as long as the affected platelets live (7-10 days).
Isosorbide 5 mononitrate: 1) is the long-acting metabolite of isosorbide dinitrate. By
dilating the vessels, it lowers the blood pressure and reduces the LV preload and
afterload, therefore, leads to a reduction of myocardial oxygen requirement.
Vecuranium : 1) is a neuro muscular blocking agent resulting in skeletal muscle
relaxation .
Nifedepine: 1) is a long- and short-acting calcium channel blocker. It acts primarily on
vascular smooth muscle cell calcium channels. By inhibiting the influx of
calcium in smooth muscle cells, calcium-dependent myocyte contraction and
vasoconstriction is prevented.
192) Nitroprusside , Nitroglycerine , Isoflurane , Sevoflurane
193) Mephentine , Phenylephrine
194)
A) Drug Commonest Use
1.Clopidogrel 1. to reduce HR during OPCAB (6)
2.Cefotaxime 2. to preop stabilise post MI VSD (11)
3.Chlorhexidine 3. to dilate conduits during CABG ( 7)
4.Diltiazem 4. to preserve clotting mechanism during CPB (15)
5.Propofol 5. a lipid lowering agent ( 8)
6.Esmolol 6. to prevent angina pectoris (9)
7.Nicorandil 7. to prevent plaque/stent thrombosis ( 1)
8.Simvastatin 8. as a short acting IV anesthetic agent (5)
9. Monotrate 9. artery dilatation as well as an anti arrhythmic agent (4)
10.Isofurane 10. to prevent prosthetic valve thrombosis (14)
11. Nitroprusside 11. an inhalational anesthetic (10 )
12.Losartan 12. treatment of acute AF (13 )
13.Amiodorone 13. oral antihypertensive (12)
14.Coumarin 14. an antiseptic hand wash (3)
15.Tranexamic acid 15. an antibiotic (2)
195) B
In a two stage or ‘Cavo –Atrial’ cannula, the atrial port drains SVC. Even in an ideal
 117

situation, the warmer ( 320-280C) systemic venous blood from SVC comes in contact
with RA and IAS ( cooler myocardium at 40- 100C). This results in early rewarming of
heart.
Even with bicaval cannulation , if cave are not snugged or snared , then the warmer
venous blood always seeps around the cannule into RA-RV and rewarms myocardium.

196) D
Excessive hemodilution results in low osmotic pressure. The RBCs swell and rupture.
A narrow tip aortic cannula causes excessive turbulence resulting in hemolysis. Old ( >
10days) banked blood increases fragility of RBCs.
Other causes of hemolysis on CPB are blood group mismatching, excessive use of
cardiotomy suction.
The absolute physical factors responsible for hemolysis are regions of flow stasis,
cavitation, extremely high shear forces, and elevated Reynolds number for shear stress.
197) C
Any cell rupture results in release of potassium, which is high intracellularly.
Free hemoglobin binds to nitric oxide and ‘endothelium derived relaxing factor’ (which
are natural vasodilators) and inactivates them.
Free hemoglobin precipitates in the acidic urine and mechanically blocks the renal
tubules.
Hemolysis can also cause hypercoagulation, CNS damage and intravascular thrombosis.
198) D
Low intravascular osmotic pressure results in tissue edema.
Low pack cell volume (PCV) results in low viscosity and low perfusion pressure.
Swelling of RBC due to excess of water makes a biconcave RBC biconvex (spherocyte).
199)B
Choice a), c), and d) involve trans atrial approach for the operation. Total Cavo
Pulmonary Connection( TCPC) operation involves clamping & dividing of SVC and
suturing it to RPA . Innominate vein cannulation provides a complete access to SVC.

200) D
Higher flows are required because oxygen consumption at normothermia in infants is 6-8
ml/kg/min as against 2-3 ml/kg/min in infants .
201) C
All the neck vessels ( innominate artery, left common carotid artery and left subclavian
artery) are liable for accidental selective cannulation. Innominate artery is the nearest
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artery and is in continuity with the axis of ascending aorta , so is most likely to get
selectively cannulated.
This complication is more likely to be with straight, aortic cannula than with a curved
tip cannula with a flange ( designed to prevent excessive insertion).
Another complication associated with cannula introduced excessively in aorta is blockage
of cannula outlet by the posterior wall of aorta.

202) D
Bevel directed towards descending aorta has the lowest incidence of post CPB CNS
complications. The particulate and gaseous emboli are directed towards the ‘silent area’
( branches of descending thoracic and abdominal aorta) .

203) D
204) D
205) C
In an asanguineous prime, when aortic cannula is connected to arterial line (tubing) a
column of blood from aortic cannula flows slightly backwards (towards the pump) .This
is called ‘back bleeding’.
 119

Excessive back bleeding can also be seen when recirculation line is open (i.e. occlusion
not checked).
206) B
In a centrifugal pump forward-flow is dependent on after load or systemic vascular
resistance. In a DeBakey pump, which is a positive displacement pump, rotation of pump
head ensures forward flow. But, in a centrifugal pump rotational movement of impeller
does not mean a forward flow. Hence, a flow meter is essential.
207) C
Microporous membranes, at least at the start of perfusion, allow a transitory interface
between gas and blood. After some time a proteic lining is built up on the membrane
which isolates the blood from the gas, but permits diffusion through micropores. The
surface tension of the blood impedes leaking through the tiny pores of the capillary
membrane. The micropores, in truth, function as ducts through a polypropylene
membrane, providing the sufficient capacity of diffusion to both gases, O2 and CO2.
After some hours of use, the functional capacity of microporous membrane oxygenators
is reduced due to evaporation and subsequent condensation of serum that passes through
the micropores. The diameter of the pores of microporous membranes is smaller than 1
micron, although the exact size depends on the manufacturing process. It is always
necessary that the micropores have less than 1 micron to inhibit leakage of liquid or gas
through the surface of the membranes.
208) C
A classic ‘light house’ tip venous cannula provides a minimally obstructive, streamlined

venous blood drainage. (Above : ‘Side’ view and ‘end-on’ view of the ‘lighthouse’ tipped
cannula).
209) D
Cardiac contractility worsens below 350C, spontaneous VF is common below 320C, and
clotting requires normal blood temperature.
Arterial blood pO2 value is a function of lung and is not dependent on temperature.
210) C
CO2 is 20-25 times more diffusible than O2. Hence, even in historical oxygenators CO2
removal was never a problem. Due to poor oxygenating efficiency, a large contact
volume ( i.e. priming volume) was required. In many oxygenators, blood was broken
into multiple small drops to increase area for diffusion. This produced hemolysis.
211) B
Insulin shifts potassium intracellularly and lowers serum potassium. Correction of
acidosis and increase in serum calcium levels corrects hyperkalemia.
212) A
A focal neurological injury , like impaired vision in one eye, suggests a particulate ( gas
or solid) embolism. Choices b, c, and d are causes of diffuse neurological damage during
CPB.
213) A
 120

Dissection is classically associated with empty patient- empty reservoir- zero perfusion
pressure. Choices b, c and, d are causes of slow and late decrease in reservoir volume.

Other causes of sudden decrease in reservoir volume, any time during CPB, are venous
air lock ( missed ASD , accidental opening of RA during MVR), venous cannula or
venous line kinking, venous cannula dislodgement, inadequate SVC or IVC snugging. All
these causes result in making heart full and blood overflowing in the operating field.
214) C
Inadequate snugging of caval cannula results in airlock on opening RA. A missed LSVC
or PDA will result in large return in RA without an airlock.

Another cause of venous airlock on opening RA is IVC cannula placed or displaced in

RA or RV across the tricuspid valve. This occurs with large RAs.
215) B
Glenn Shunt (SVC anastomosed to RPA, end to side) is performed as a stage 1
operation, prior to final correction ( Fontan operation ) in cases with functional single
ventricle.
The rest of the choices are systemic artery – pulmonary artery shunts which, if left open,
pose massive problems during CPB. Hence, they all require closure (‘take down’) prior
to the final repair.
216) A

217) C
Atherosclerosis affects almost all the arteries of the body. The most common operation in
a patient with atherosclerosis is CABG. During CABG the attention is on improving
myocardial blood supply. There always will be some amount of concomitant disease of
cerebral arteries and or of renal arteries resulting in hypoperfusion of the organs during
CPB. Atherosclerosis makes arteries hard and hence, less distensibility. This results in
higher perfusion pressure at a given flow.

Large left heart return is a typical feature of CHD, that too, in a patient with cyanotic
heart disease.
218) A
Root venting in a case with VSD will only result in sucking of air ( operating field – VSD
– root). Also, LA return would be still passing through VSD (LA-- LV-- VSD – RV--
RA) making difficult to visualize VSD margins.
Once VSD is closed root vent can be used to decompress the left heart.
 121

219) D
Femoral venous cannula produced by Biomedicus is extra long ( 60 cm) and provides
ports for SVC, RA and IVC drainage.

220) D
Extra corporeal support for any aneurysm is mainly required to perfuse and protect either
whole body ( ascending aneurysm) or brain ( ascending and arch aneurysm) or spinal
chord ( thoracic and thoracoabdominal aneurysms) . Infra renal aneurysms are situated
below L1 vertebral level by which level branches supplying spinal chord or important
abdominal viscera have already taken off. Hence no form of support is required.
221) C
‘bridging innominate vein’ is the left innominate vein joining the bilateral SVCs. A large
bridging innominate vein drains and decompresses the left jugular vein and subclavian
vein adequately and there is no need for cannulating the left SVC.
 122

222) A
In a case with RA myxoma, an IVC cannula can pass through the myxoma tumour and
fragment/ embolise it. Hence, IVC blood is drained through femoral venous cannulation.
IVC is not snared/ snugged till tumour extension is visualised.
223) D
On full CPB, the heart is empty beating (ECG as preop). As cooling starts, the heart rate
slows down, QRS broadens and VPCs may start appearing. Below 320C, the heart may
spontaneously fibrillate. A complete electrical stand-still (‘straight line’) is achieved
only after cardioplegically arresting the heart. All types of cardioplegia give rise to
‘electrical stand-still’.
224) E
CO2 concentration in air is 0.04%. As per ‘Law of Gases’, partial pressure exerted by an
individual gas (in this case, CO2) in a mixture of gases (in this case, Air) is proportional
to its concentration in the mixture. So, pCO2 will contribute 0.04% of 750 mm of Hg
pressure = 0.04/100 x 750=0.3mm of Hg

225) C
Trans Membrane Pressure = {Inlet Pressure + Outlet Pressure}/2 + Vacuum Pressure
Increasing the flow increases inlet pressure.
226) B
Suffix ‘index’ indicates relation to body surface area. Hence,
Pump Index = Pump Flow / BSA = 4.5/1.8 = 2.5L/ m2/ min
227) E
Trickle flow of 0.5 to 1.0 liters /min /m2 is offered at 180 to 200C temperature to extend
the duration of hypothermic arrest at the same time to maintain a ‘dry’ field. In terms of
kilogram it is 20ml/kg/min.
228) E
Another special attributes for a pediatric pump would be pump with a digital read-out for
accurate output delivery and accepting 1/8” line in the arterial pump head.
229) C
In a bubble oxygenator (e.g. VT 2000 or 5000 or 7000 . Picture below is of RK 5000 a
previous version of VT5000) blood and gas are mixed right at the inlet of the
 123

oxygenator. The direct contact of gas with blood created ‘foam’. This foam was
‘broken’ by 1) keeping the venous column long 2) spreading the blood over a large
surface area in a defoaming chamber. 3) coating the chamber with a material called
‘Antifoam A’.
This antifoam got washed away during the bypass, restricting the use of oxygenator.
230) D
Collateral flow to lower limb prevents lower limb gangrene. ( Please refer to answer to
MCQ 220)
231) D
Various books have mentioned various values of hypothermia . Some have classified
hypothermia only into Mild( upto 32), Moderate( 28-32), and Deep( < 28).

The value of profound hypothermia mentioned in this MCQ is chosen from a book
written by John Brodie & Ronald Johnson, second edition, Glendale Medical Corp,
Augusta GA 1997.
232) C
In a case with a descending thoracic aortic aneurysm, balloon will not be able to occlude
aorta to augment ascending aortic filling .
Other contraindication is more than mild AR.
233) D
Leucocytes are responsible for ischemia-reperfusion injuries. Hence, for enhancing the
myocardial protection afforded by blood cardioplegia, leukocytes are removed from the
perfusate. Usually, more than 90% of leukocytes are removed by this filter. However, it is
also shown that these filters may begin to fail after a threshold filtered volume in the
vicinity of 1000–1300 ml.
234) A
Generally in the body, blood flow is laminar. However, under certain conditions,
laminar flow can be disrupted and become turbulent. When this occurs, blood does not
flow linearly and smoothly in adjacent layers, but instead the flow can be described as
being chaotic.
 124

turbulence occurs when a critical Reynolds number (Re) is exceeded. Reynolds number is
a way to predict, under ideal conditions, when turbulence will occur. The equation for
Reynolds number is:

Where v = mean velocity, D = vessel diameter, ρ = blood density, and η = blood viscosity

As can be seen in this equation, high velocities and low blood viscosity (as occurs with
anemia due to hemodilution on CPB) are more likely to cause turbulence. An increase in
diameter without a change in velocity also increases Re and the likelihood of turbulence;
Turbulent flow also occurs in large arteries at branch points, in diseased and narrowed
(stenotic) arteries (see figure above), and across stenotic heart valves.
235) C
236) D
Gas filters remove 99.999% bacteria found in the gas stream and reduces cross
contamination between the equipment and the patient.
237) B
238) A
There is no unanimity of definition of hyperoxia, though pO2 > 300 mm of Hg is the
accepted by all.
Hyperoxia exposure is especially damaging to the brain. In comparison to other cells,
neurons have increased susceptibility to free-radical damage due to their high oxygen
consumption rate, large lipid content, and lower levels of antioxidant defenses.
The problems of hyperoxia are less in adults, hypothermic CPB, conventional CPB
(versus circulatory arrest).
239) A
In a case requiring circulatory arrest, an A-V bridge in circulation allows blood in
oxygenator brought to an alkalotic state with low pCO2 before flows are resumed.
240) B
Bag is collapsible and as the reservoir volume falls, the walls of the bag collapse and
avoid any air embolism.
241) C
Diffusion of gas =  P x Area x Solubility of gas
Distance x  Molecular wt
Solubility and molecular weight are unmodifiable for a gas. Area of membrane and
thickness (= distance of separation of two gases) of membrane are decided by the
 125

manufacturer, hence fixed for an oxygenator. So, a perfusionist can modify gas levels
only by changing the concentration.
242) C
243) B
The efficiency of screen filters depend upon the pore size.
244) C
The main function of arterial output is to deliver an output, adequate & appropriate for
the patient BSA and core temperature. In an adult circuit (as compared to a pediatric
circuit) priming volume of filter is less important. As arterial flow by full pump force,
pressure drop upto 50mm of Hg, too, is less important.
245) B
246) A
247) B
( intentionally, a tracing with 2:1 inflation is provided for comparison )

248) A
249) B
Cerebral blood flow in pediatric group is 15 to 20% of the cardiac output. Some other
relevant figures about cerebral blood flow are:
Blood flow through whole brain (adult) = 750 -1000 ml/min
 126

Blood flow through whole brain (adult) = 54 ml/100 g of brain tissue/min

Blood flow through whole brain (child) = 105 ml/100 g of brain tissue/min

Rengachary , S.S. and Ellenbogen , R.G., editors, Principles of Neurosurgery, Edinburgh: Elsevier
Mosby, 2005)
250) B
251) D
abnormalities in the circulating thyroid hormone levels are found in the absence of
primary thyroid disease; this is collectively called the sick euthyroid syndrome (SES).
The most common pattern is a decrease in total and unbound triiodothyronin (T3) with
normal levels of thyroid stimulating hormone (TSH) and thyroxin (T4). This is classified
as SES type 1 (SES-1) or low-T3 syndrome. The de-ionidation from T4 to T3 via
peripheral (hepatic) enzymes is impaired, leading to a decrease of T3 and an increase in
reverse T3 that is biologically inactive. Inflammatory cytokines have been linked to the
development of SES and the levels of cytokines seem to influence the severity of SES.
Elevated serum levels of steroids as part of a stress response may influence the
de-ionidase activity and TSH and T3 response in SES.
252) B
253) B
Platelets will get immediately activated during CPB and aggregate to the CPB circuit
sites. Also, the activated platelets will release various granules which would add to the
systemic inflammatory response.
254) C
Platelets collected by this method are called ‘single donor platelets’( SDP).
Platelets has been collected from the ‘buffy coat’ or platelet rich plasma of multiple
(usually 6-8) donors. The platelets thus collected are called Random Donor Platelets -
RDP. This method is more cost effective than the SDP but exposes patient to multiple
donors, the transfusion has higher concentration of leucocytes (poorly leucodepleted ) &
RBCs. SDP has 1000 times more concentration of platelets than the RDP.
255) B
256) C
257) A
Moderate MS with MR, severe TR is a condition where all the four chambers as well as
the pulmonary and systemic venous bed are volume overloaded. Hence, after going on
CPB as well as on opening LA, large amount of blood will be drained into the reservoir.

In a patient with AS or with an IHD with good LV function the heart is small and there is
no venous congestion. In a patient with ASD, though there is RAVO and RVVO, due to
lack of any form of venous congestion, the venous return is not excessive.
258) E
Lower temperature during CPB, allows lower pump flows and reducing blood damage.
Lower temperature slows rewarming and improves myocardial protection. In the
presence of large left heart return, lower temperature allows lowering pump flow to
improve surgical visibility. Duration of circulatory arrest depends on temperature.
259) B
During CPB, the oxygenator exhaust outlet can be connected to a capnograph sensor for
continuous monitoring of exhaust CO2. A 100-cm length of anesthetic tubing is required
 127

to be attached behind the capnograph adaptor to act as a reservoir for the exhaust gases
and thus prevent entrainment of room air.

260) B
A pulse oximeter depends on flow of blood through capillaries and hence gives a good
idea about perfusion. Hence, if a pulse oximeter probe is attached to great toe, observing
‘sine wave’ form tracings on the pulse oximeter guarantees that, not only the flow on
CPB is pulsatile but perfusion too, is excellent.

Pulmonary artery pressure tracing is another way of knowing pulsatile flow.

261) D
A patent BT shunt (also, MAPCA, aorto-pulmonary collaterals and PDA), during CPB,
results in a preferential flow of blood to lungs from systemic artery (subclavian artery).
This is due to the low resistance of pulmonary circuit. This shunt results in low perfusion
pressure, large left heart return resulting n poor surgical visibility, distension of heart and
early rewarming of heart. Hence, BT shunt should be closed prior to cooling and arresting
the heart.
At the same time, in a case with TOF with patent BT shunt, BT shunt flow could be the
sole source of pulmonary blood flow. Hence, it should be closed only after CPB has
taken over oxygenation of blood completely.
262) C
In supracardiac TAPVC, the vertical vein joins the common chamber to the left
innominate vein (see answer to MCQ 104). During surgery the common chamber is
opened and is anastomosed to the LA. Thus, if the vertical vein is not snugged during
surgery, air from the common chamber would be sucked into the –ve pressure systemic
vein ( left innominate vein).
263) D
264) B
Water to blood leak occurs due to a crack in the heat exchanger. Higher water pressure in
the heat-exchanger results in the leak of water from heat exchanger to oxygenator,
resulting in an unexpected increase in the reservoir volume. Water with a pH of 7.0
should bring down the pH. Dilution brings down the hemoglobin. Lowering of the
oncotic pressure results in RBCs becoming turgid and rupturing. The free hemoglobin
gives rise to hemoglobinuria.
265) C
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This water is unsterile; hence, the oxygenator should be changed. The leak is detected by
starting the water flow through the heat exchanger prior to prime.
266) A
Glenn shunt requires clamping of SVC and RPA. High pressure SVC, due to clamping ,is
decompressed by a right heart bypass ( Innominate vein- reservoir-pump-MPA).

Other off-Pump techniques are : 1) Lamberti and associates first reported a technique for
performing BDG without CPB by establishing a temporary venoatrial shunt between the
SVC and right atrium in 1990. 2) Murthy and colleagues described a different technique,
the venopulmonary shunt. 3) No shunt. Just clamp SVC and perform the anastomosis.

267) B
( Please read answer to MCQ 261)
268) B
Albumin is cationic ( i.e. positively charged) and binds with negatively charged CPB
circuit sites and reduces blood cellular ( WBC + Platelets) response to exposure to
foreign surface.
269) A
In a hard shell oxygenator space available for oxygenation is fixed. In all modern hollow
fiber oxygenators the blood is outside the fiber. Hence, to increase area available for gas
diffusion, more fibres are packed. This reduces the distance between the two fibres and
increases the resistance and pressure drop across the oxygenator.
270) B
In a hard shell oxygenator space available for oxygenation is fixed. In all modern hollow
fiber oxygenators the blood is outside the fiber. Oxygenation can be improved by
increasing the contact-time between the blood and the membrane. This is achieved by
running the blood axially along the fiber. This increases the volume of the oxygenator.
 129

[ It can be appreciated that with a better quality membrane, the distance of travel of blood
(left ) in a radial flow oxygenator is reduced by about 7 times as compared to an axial
flow oxygenator( right)]
271) A.
A metabolic event during CPB is never related to gas diffusion capacity of oxygenator. A
metabolic acidosis during CPB, points out to pump output or renal status.
272) B
The ID of the tube = OD – Thickness = 24 -2-2 = 20 mm
Radius = 10 mm = 1 cm
R2 = 12 =1
Volume of a tube = x R2 x Length
= 3.14 x 1x 100
= 314
273) D
Choices a,b & c, too, are causes of hematuria but the develop later.
274) B
Humans are homeotherms i.e. they maintain their internal temperature all the time.
Hence, the normal initial responses to external cold are, a) to prevent heat-loss b) to
generate more heat. The heat loss is prevented by cutaneous vasoconstriction, by which
the core heat is prevented from reaching skin. Muscles generate heat. Hence, blood
supply to muscle is increased and to circulate this heat as well as to provide more energy
to muscles heart rate and BP is increased.
275) C
Hypothermia causes increase in vascular resistance due to increase in blood viscosity and
catecholamines, hemoconcentration, cell swelling. The increase in blood viscosity occurs
because of fluid shifts, with loss of plasma volume from capillary leak and cell swelling.
The red blood cell volume remains unchanged even though the hematocrit rises. Red
blood cell aggregation and rouleaux formation can occur, further impeding blood flow.
These changes can be somewhat attenuated by adequate anesthesia, hemodilution,
heparinisation, and the use of vasodilators.

The kidneys show the largest proportional decrease in blood flow of all the organs. This
is because increased renal vascular resistance, with diminished outer and inner cortex
blood flow. Tubular transport of sodium, water, and chloride are decreased, and
concentrating ability becomes impaired. Tubular reabsorption is decreased. Urine flow
 130

may be increased with hypothermia, but this effect can be masked by the stress-induced
release of arginine vasopressin and antidiuretic hormone. The ability of the hypothermic
kidney to handle glucose is impaired, and glucose often appears in the urine.
Hemodilution in combination with hypothermic CPB improves renal blood flow and
protects the integrity of the renal tubules postoperatively.

Hyperglycemia is due to decreased endogenous insulin production. In addition,

glycogenolysis and gluconeogenesis may be increased because of increases in
catecholamines.

Cell swelling and edema occur, which may be related to an accumulation of sodium and
chloride within cells secondary to a decrease in reaction rates of membrane Na+-K+-
ATPase . Hypothermia decreases free water clearance and causes a decrease in plasma
potassium and an increase in osmolarity.
276) C
Unilateral cerebral perfusion (UCP) is performed by cannulating innominate artery or
right subclavian/ axillary artery. Adequacy of cerebral perfusion in UCP is based on the
assumption that the circle of Willis is intact to feed the opposite left hemisphere. This can
be confirmed only by cannulating an artery related to left cerebral circulation.

(dark red shading indicates the path of blood from arterial cannula to left radial artery)
277) E
Please refer to answer to MCQ 140
 131

278) E
Activation of cellular & humoral response due to contact with non endothelial surfaces is
the key to stimulation of SIR. Measures a), c) & d) are useful in preventing that. PUF
and MUF filterout the complements and reduce the intensity.
279) C
Patients with LV aneurysm have a poor LV function. After the surgery the LV cavity
may be compromised, or be less compliant. Hence the filling of LV should be done with
PA diastolic pressure as guide.
280) B
Please refer to answer to MCQ 76
281) A
282) C
Venous pressure on CPB is equal to capillary hydrostatic pressure. Higher is this pressure
on CPB, more chance of development of tissue edema (increased interstitial water). Due
to the lower oncotic pressure during CPB, tissue edema can develop at lower levels of
venous pressure.
283) E
Transient decreased SVR is the predominant cause of hypotension following initiation of
CPB (secondary to reduced blood viscosity, dilution of endogenous catecholamines in
priming solution). As CPB progresses, SVR gradually increases, eventually to
supranormal levels. This is presumably due to hypothermia (leading to vasoconstriction
and catecholamine release), stress response (also leading to vasoconstriction and
catecholamine release), and vessel closure (i.e. maldistribution of flow).

SVR falls during rewarming and with establishment of pulsatile perfusion.

284) D
As a compensatory mechanism, in a case with chronic AR, the SVR is low so that more
blood will pass to the periphery rather than regurgitate back into LV.
In mitral stenosis and aortic stenosis the SVR is high, as a compensatory mechanism. Due
to systemic hypertension, in IHD the SVR is high. Post infact VSD is an acute low output
state and the SVR is always high.
285) D
Venous pO2 and venous saturation are parameters of adequate perfusion. Venous
saturation of 60-65% indicates adequate perfusion. Both the values depend on circulating
hemoglobin (i.e. oxygen carrying capacity). Oxygen saturation of blood also depends
upon pH of blood.
286) C
287) B
Ref to answer to MCQ 268.
288) C
Brain is the least tolerant organ for ischemia. Hence circulatory arrest or periods of
reducing flows (which reduces left heart return and improves intracardiac visibility) are
more important in deciding CPB temperature.

289) E
 132

Some oxygenators may have a heat exchanger with poor ‘performance factor’ (< 0.6). In
such cases, the rewarming should be started early.
290)C
The aortic cannulation site should such that i) it is easily visible for cannulation and
surgeon can tackle any complications associated with cannulation ii) rest of the ascending
aorta is available for cross-clamping, root cardioplegia cannulation and aortotomy if
required.
Choices d & e are not easily visible. Choices a & b don’t fulfill criterion ii).
291) D
It is a complication peculiar to lower limb artery cannulation.
292) D

The danger of straight aortic cannula is of placing excessive length intra aortically,
resulting in tip occluded by aortic wall or selective cannulation ( Innominate / left
common carotid artery). The collar ensures just adequate length of cannula intra
aortically.
293) C
Phenylephrine is an 1 agonist with a mild renal vasoconstrictor effect. Rise in blood
pressure offsets this renal vasoconstrictor effect and there is an increase in renal blood
flow. In this case of acute renal failure (‘recent rise in S. Creatinine’) increase in renal
blood flow is very useful.
294) A
Postperfusion syndrome, also known as ‘pumphead’, is a group of neurocognitive
impairments attributed to CPB. Symptoms are subtle and include defects associated with
attention, concentration, short term memory, fine motor function, and speed of mental
and motor responses. Studies have shown a high incidence of neurocognitive deficit soon
after surgery, but the deficits are often transient with no permanent neurological
impairment.
295) B
296) C
Roller pumps are positive displacement pumps. Due to displacement of fluid, the outflow
part has positive pressure and the inflow has negative pressure. If inflow becomes
limited, the roller pumps will develop high negative pressures within the tubing
producing cavitation, microbubbles, and hemolysis.
If the outflow becomes occluded, pressure in the line will progressively rise until the
tubing in the pump ruptures or connectors and tubing separate.
297) A
cardiotomy suction and reservoir have been found to be a major source of hemolysis,
particulate and gaseous microemboli (GME), fat globule formation, activation of
coagulation and fibrinolysis, cellular aggregation, and platelet injury and loss. A major
contributor to these adverse effects is the amount of room air that is aspirated along with
 133

the blood. Not only does this add GME to the blood, but the air–blood mixture causes
turbulence and high shear stresses that can damage red blood cells and platelets.

Other methods to avoid blood damage are : 1) use largest suction tips possible
2) avoiding generation of high degrees of negative pressure by not occluding the sucker
tip and using a controlled vacuum suction rather than a roller pump.
298) C
The value of performance index will change with blood flow and design of the cannula.
It is not a fixed value.
299) A
A gradient more than 100 mm of Hg result in hemolysis and protein denaturation.
300) E
Roller pump, which is a positive displacement pump, resistance does not result in
decreased flow.
The complications mentioned in the choices a) to c) are called ‘sand blasting’ effect and
are due to breakdown of an atheromatous plaque in the aorta due to jet from the arterial
cannula.
301) D

302) A
303) B
 134

The depth filter has no defined pore size, but presents a tortuous large wetted surface that
filters by impaction and adsorption. The efficiency of depth filter depends upon the
density of wool packing and the distance between inlet and outlet ( i.e. the depth).Most of
the modern oxygentors are depth filters
304) D
305) C
Oncotic pressure holds water in its compartment. A high plasma oncotic pressure would
hold water in the intravascular compartment and reduce urine formation or ultrafiltration .
Please also refer to answer to MCQ 225
306) C
Intracardiac correction of an ASD or VSD requires opening of a right sided chamber
(RA/RV/PA). To avoid airlock , tourniquets ( snares/ snuggers) are required around the
venous cannule. MVR is performed through a trans LA approach. But, if transseptal
approach is adopted then SVC, IVC snaring will be required.
307) A

Tributaries join IVC all around and all along the course of IVC. Hence the side holes
should all around and all along the cannula. (ref to answer to MCQ 10)
Another requirement of adequate drainage through a peripheral venous cannulation is
cannula long enough to reach RA.
308) E
Excessive negative pressure (caused by gravity or by active suction) causes the
compliant vein walls to collapse around the ends of the venous cannulae ( "chattering" or
"fluttering") and intermittent reduction of venous drainage.
Chattering can be reduced by partially occluding the clamp on the venous line, which
may paradoxically increase venous drainage, or by increasing the systemic blood flow.
309) A
310) C
Hence the SVC cannula is smaller than the IVC cannula. In a pediatric case the sizes are
equal.
311) B
Microporous membranes allow at least transient direct blood–gas interfacing at the
initiation of CPB. After a short time, protein coating of the membrane and gas interface
takes place, and no further direct blood and gas contact exists. Typically, the surface
tension of the blood prevents large amounts of fluid from traversing the small micropores
during CPB. The micropores provide conduits through the polypropylene membrane that
give sufficient diffusion capability to the membrane for both oxygen and carbon dioxide
exchange. However, over several hours of use, the functional capacity of micropore
membrane oxygenators decreases because of evaporation and subsequent condensation of
serum that leaks through the micropores.
 135

A B

A) Typical hollow fiber design with a direct gas to blood interface through an open pore.
B) Gas exchange by diffusion through a semi-permeable membrane.

Hemolysis ( choice A) is never a limiting factor of modern oxygenators. Washout of

defoamer ( choice C) is a classic limiting factor of bubble oxygenator.
312) A

313)C
 136

Counter current principle is used in heat exchangers also

314) D
315) E

True membrane oxygenators are expensive, difficult to produce, frequently require large
areas of membrane and a large volume for priming. These oxygenators can maintain gas
exchange of O2 and CO2 in satisfactory conditions for long periods (even weeks),
without losing efficiency, hence, used for ECMO.
316) B
Others act fast by immediately changing the serum ionic calcium level.
317) E
Direct gas-blood interface is perceived as a nonendothelial surface and platelet aggregate
on it. Direct gas-blood interface is also a stimulus for stimulation of Complement system.
318) E
Transparency of arterial line also permits detection of air bubble.
319) C
CO2 is easily diffusible and CO2 removal has never been a problem. Disc oxygenators
required a large priming volume and Spray oxygenators were notorious for hemolysis.
320) A
A volume of gas broken into small bubbles provides more surface area and, there by
improve oxygenation. Large bubbles ( more volume) facilitate CO2 removal.
321) E
To avoid jamming of roller pump (‘stuck’ pump head) due to hardened tubings, separate
siliconised rubber tubing is used only for the pump-head raceway.
322) D
 137

323) E
The pressure on the blood side is always more than pressure on gas side. Hence blood
will appear in the gas vent.
324) C
Or the pressure drop across the oxygenator will increase.
325)E
326)D
LSVC usually drains into coronary sinus, which opens into RA. This poses no
problem to left heart return. Only when LSVC opens into roof of LA (usually in a
complex cyanotic heart disease case), it can result in increased LA return.
327) D
Increasing pump flow only increases the LA return. Drugs have no effect on left heart
return. Increasing cardiotomy suction is an initial measure to be taken but, it results in
significant blood damage. Lowering of temperature should be as per the pump flow.
Cause of massive LH return , like a missed PDA, should be searched for.
328) A
Hemodilution lowers hematocrit (and there by, also lowers viscosity and resistance ) and
plasma oncotic pressure. Due to low plasma oncotic pressure the biconcave RBCs
become spherical, distend and become turgid. Such RBCs rupture easily producing
hemolysis. Tissue edema is due to low plasma oncotic pressure. Low viscosity results in
low perfusion pressure.
329) C
Washing of cardiac cavities is generously done after removal of LA clots and after
excision of calcified valves.
A large volume of intra-cavitary saline is also used to test repaired valves.
Some centers use topical ice slush for additional myocardial protection. This slush melts
and enters cardiac chambers (LA or RA), if they are open.
330) C
Adding albumen increases only the oncotic pressure.
331) D
Hence, the cardiotomy filter in the reservoir is more powerful (30- 40) than the venous
filter (200).
During CPB, the cardiotomy suction and reservoir have been found to be a major source
of hemolysis, particulate and gaseous microemboli (GME), fat globule formation,
activation of coagulation and fibrinolysis, cellular aggregation, and platelet injury and
loss. A major contributor to these adverse effects is the amount of room air that is
aspirated along with the blood. Not only does this add GME to the blood, but the air–
blood mixture causes turbulence and high shear stresses that can damage red blood cells
and platelets.
332) C
Please ref to answer to MCQ 247
333) D
Please ref to answer to MCQ 247
334) B
The gases used for inflation of IABP are, helium or carbon dioxide.
 138

The advantage of helium is its lower density and therefore a better diffusion
coefficient. It facilitates balloon cycling. Whereas carbon dioxide has an increased
solubility in blood and thereby reduces the potential consequences of gas embolisation
following a balloon rupture.
All the other gases mentioned have a poor solubility, hence a fear of gas embolisation in
a situation of balloon rupture.
335) C
336) D
337) A
P= difference in partial pressures of gas
A= area available for diffusion
S= solubility of the gas
d= distance of separation between the two
M.Wt = molecular weight of the gas

Of these, the modifiable factors are

1) partial pressure of gas, 2) area available for diffusion ( area of membrane in an
oxygenator) and 3) distance of separation ( thickness of membrane). Factors 2 & 3 are
built-in factors and are decided by the manufacturer of the oxygenator. A perfusionist can
alter the partial pressure only by changing the concentration (FiO2) of the gas.

338) C
Glycated hemoglobin (hemoglobin A1c, HbA1c, A1C, or Hb1c; sometimes also referred to
as being Hb1c or HGBA1C) is a form of hemoglobin that is measured primarily to
identify the three-month average plasma glucose concentration. The test is limited to a
3 month average because the lifespan of a red blood cell is four months. However, since
RBCs do not all undergo lysis at the same time, HbA1C is taken as a limited measure of
3 months. It is formed in a non-enzymatic glycation pathway by hemoglobin's exposure
to plasma glucose. HbA1c is a measure of the beta-N-1-deoxy fructosyl component of
Hb. As the average amount of plasma glucose increases, the fraction of glycated Hb
increases in a predictable way. This serves as a marker for average blood glucose levels
over the previous three months before the measurement as this is the lifespan of red blood
cells.
For people without diabetes, the normal range for the HbA1c level is between 4% and
5.6%. HbA1c levels between 5.7% and 6.4% mean you have a higher chance of getting
of diabetes. Levels of 6.5% or higher mean you have diabetes.
The levels don’t dictate insulin dose.
339) D
(Please refer to answer to MCQ 224)
340) A
For a MICS AVR through right upper sternotomy RA appendage is used for venous
cannulation. Hence, ‘thin walled cannula’ ( for a better ID/OD ratio) is not a criterian.
It is an important criterion for femoral venous cannulation.
341) B
342) C
 139

Heat exchanger performance

= actual temperature change in blood / Temperature gradient offered by heat exchanger
= Temp of blood in ~ Temp of blood out/ Temp of water in ~ Temp of blood in
A performance factor of 0.7 means when water-blood gradient is 1degree centigrade, the
blood temperature changes by 0.7degree centigrade
343) A
Urine output on CPB also depends upon pump output, preoperative renal function,
hemodilution, diuretics administered. With a ‘satisfactory’ urine out, perfusion , still,
could be inadequate. But with ‘poor’ urine output, perfusion is certainly inadequate.

Rectal-skin temperature difference is an indicator of adequate vasodilatation on CPB.

With adequate perfusion, vasoconstrictor response to CPB is less severe, resulting in
reduction in the temperature difference.

Venous oxygen saturation or venous pO2 levels are better parameter of cardiac output.
However, hemoglobin levels (i.e. oxygen carrying capacity) and pH determine oxygen
saturations.
Lactic acid level is now the best parameter of perfusion but , may not be available at all
the centers.
344) B
CO2 is easily diffusible and reaches equilibrium quickly. Hence, CO2 removal is
dependent on minute volume or sweep flow (i.e. rate at which the gas is replaced).
345) 1 & 8 are causes of rapid decrease in the reservoir level
7&10 are causes of no change in reservoir level
Rest are causes for a rapid decrease in reservoir level
346) A
Atherosclerosis is a generalised disease. Coronary artery disease is just one of the
manifestations. A patient for CABG could have simultaneous subclinical arterial blocks
in all the systemic arteries. Of all the systemic arteries, cerebral arteries are important
from point of cerebral protection.
347) B
Hydroxyethyl starch (HES/HAES) is a nonionic starch derivative. Hydroxyethyl starches
are synthetic colloids commonly used for fluid resuscitation to replace intravascular
volume. HES is a general term and can be sub-classified according to average molecular
weight, molar substitution, concentration.
348) D
Retrograde autologous prime ( RAP) is performed to avoid homologous blood
transfusions. Its success depends on patient’s total RBC mass, i.e., preCPB hematocrit &
patient blood volume . Blood volume is depend on patient’s BSA & on patient status
w.r.t. CCF. Hence RAP, is possible in adult patients and in patients with CCF.
349) C
An acidic pH and low bicarb levels indicate metabolic acidosis. The treatment of a
persistent metabolic acidosis on CPB is to increase pump flow, administer vasodilators
and ensure adequate urine output (hemofiltration + diuretics). Administering sodabicarb
is only a temporary measure.
350) A
 140

Platelet count decreases within hours of collection and there is no difference in the
platelet count of CPD and fresh heparinised blood.
351) D

352) D
353) B
Hyperoxic damage is most pronounced in severely cyanosed patients. The patient in
choice a) is a shunted patient with a functioning shunt , while, patients in choice c) & d)
are with a L to R shunt. Thus the case with single ventricle severe PS (choice b) is
expected to have severe cyanosis.
In cyanotic patients normoxic bypass is recommended.
354) B
As water circulating through heat exchanger leaks into reservoir, the reservoir volume
increases, mixing of water with blood causes hemodilution. Lowering of oncotic pressure
causes RBCs to swell up and rupture. The pH of water is ~7.0. Hence the pH of the
blood will decrease.
355) C
a) & b) are cases with intra cardiac shunts. Use of a 2-staged cannula will result in air
lock. During MVR, use of a two-stage cannula will not permit adequate LA retraction
and the Cooley’s LA retractor would occlude the RA port and thus, obstruct SVC
drainage.
356) C
Mandatory means absolute necessary. Except C, in all other conditions mentioned, SVC
can be ‘indirectly’ cannulated through RA.
Senning’s operation ( and, also, Mustard Operation ) is an ‘atrial switch’ operation where,
RA –the systemic venous atrium becomes pulmonary venous atrium and LA – the
pulmonary venous atrium becomes systemic venous atrium. To facilitate the operation,
SVC opening is diverted into morphological LA. This is possible only if the SVC
opening is free of any cannula. Hence SVC is cannulated directly.
Some other operations , where direct SVC cannulation is mandatory are: Glenn Shunt ,
Total Cavo-Pulmonary Connection ( TCPC) , TAPVC into SVC, and , Cardiac
Transplant.
357) D
 141

In fact, at low temperatures there is vasoconstriction.

a) to c) are correct causes of low pressure on CPB
358) B
Decreased SVR is the predominant cause of hypotension following initiation of CPB
(secondary to reduced blood viscosity, dilution of endogenous catecholamines in priming
solution, and differences in pO2, pH, and electrolyte concentrations between the priming
solution and native blood). As CPB progresses, SVR gradually increases, eventually to
supranormal levels. This is presumably due to hypothermia (leading to vasoconstriction
and catecholamine release), stress response (also leading to vasoconstriction and
catecholamine release), and vessel closure (i.e. maldistribution of flow).
Causes a, c, and d will be obvious within minutes of initiation of CPB.
359) B
Free radicals are molecules with unpaired electrons making them highly reactive. They
can be derived from oxygen, nitrogen, or sulfur molecules. Free radicals derived from
oxygen are usually called reactive oxygen species (ROS). The main forms of cardiac
ROS are superoxide (O2-, hydrogen peroxide, hydroxyl radicals( OH−) , and
peroxynitrite (ONOO−). Although hydrogen peroxide is not a free radical it is considered
a ROS due to its highly reactive nature. Free radicals are produced during oxidative
metabolism, ischemia and reperfusion, and CPB. When OFR production exceeds
scavenging capacity, peroxidation of structural lipids in cell membranes can occur with
potentially injurious consequences.
The effects of ROS are counteracted under physiological conditions by antioxidants
which are molecules that are capable of neutralizing free radicals. The antioxidant
molecules may directly react with the reactive radicals and destroy them, or, they may
become new free radicals which are less active, longer-lived, and less dangerous than
those radicals they have neutralised.
Superoxide dismutase is an endogenous antioxidant and acts directly with free radicals.
Allopurinol is a xanthine oxidase inhibitor drug and it inhibits superoxidation.
Catalase is an endogenous antioxidant and converts H2O2 to water and oxygen.
360) A
This is to avoid myocardial capillary damage by high pressure.
361) B
Membrane pore size is important for determining what soluble plasma molecules will be
removed with the plasma fluid. The pore size normally ranges between 10 and 35 Å
allowing molecules up to 20,000 Da to undergo ultrafiltration. (Å Angstrom is named for
the 19th-century Swedish physicist Anders Jonas Ångström. 1 micron = 10000 Å).
362) B
Sieving coefficient = concentration in filtrate/ concentration in blood. As there is no
active secretion of any substance, the sieving coefficient is always < 1.
363) C
The efficiency of an ultrafiltration device to remove a soluble molecule is called the
sieving coefficient and is directly related to molecular size. The larger the molecular size
of a substance, the less efficient the ultrafiltration device will be in its removal. Small
molecules with molecular weight below 10,000 Da, such as sodium, potassium,
chloride, urea, creatinine and glucose, have a sieving coefficient of 1, meaning, they are
filtered at a rate equal to their concentration in the plasma. Large molecules, such as
 142

albumin (69,000 Da), hemoglobin (68,000 Da), and fibrinogen (341,000 Da) and the
cellular components of blood (leukocytes, platelets, and red blood cells) are too large to
traverse the pores and therefore remain within the blood. The result is a higher blood
concentration of the nonfiltered elements after a period of ultrafiltration.
As regards heparin, it is a mucopolysaccharide between 6,000 and 25,000 Da, should be
expected to be removed during ultrafiltration. Because of this, intensified anticoagulation
monitoring has been suggested when ultrafiltration is used in conjunction with CPB.
However, some investigators have found that no additional heparin supplementation is
required. Recent evidence suggests that ultrafiltration actually leads to heparin
concentration within the patient rather than heparin loss. This is an unexpected
observation considering the relatively small size of the heparin molecule. One hypothesis
for the concentrating effect of ultrafiltration on heparin is the presence of many negative
charges on the heparin molecule that promote interaction of the heparin molecule with
serum proteins. The binding of the heparin molecule to proteins may inhibit its ability to
be filtered. Because the effect of ultrafiltration on heparin concentration is not totally
predictable, a possible concentrating effect must be anticipated when reinfusing blood
that has undergone ultrafiltration from the CPB circuit.
364) A
365) C
Due to nonpulsatile flow and other circulatory changes during CPB, at capillary level, the
blood bypasses cell and returns to the venous side producing a-v shunt. Venous blood
saturation > 80% suggests shunting.
366) C
Due to high prebypass PCV, adequate circulating PCV (=24% to 28%) is not a problem
in this case. Total plasma volume in this patient is low (due to high hematocrit) hence,
hemodilution results in low oncotic pressure. Albumin provides oncotic pressure.
367) C
368) B
369) D
High free hemoglobin and raised potassium indicate hemolysis. Choice a, b& c are
causes of hemolysis on CPB.
370) D
Low PCV on CPB goes hand-in-hand with low oncotic pressure. Low oncotic pressure
results in fluid from intravascular compartment to move into interstitial compartment
resulting in third-space loss.
Use of hemofilter results in removal of volume (filtrate) from circulation.
RAP uses patient volume for priming the circuit, hence less prime volume is required.
371) C
The pattern is parabolic. Please refer to the answer to MCQ 234.
372) A
Stagnation results in platelet deposition and clot formation.
Negative pressure areas cause spontaneous gas bubble formation.
Turbulence increases resistance and damages cellular elements.
373) C
 143

Increase in temperature reduces solubility of gases and gases bubble out. Hence,
rewarming should be done gradually (10C in 4 minutes) with a gradient of less than 100C
between bucket temperature and the patient core temperature
Choices a,b & d ( all because of handling of aorta ) are known for particulate embolism.
Other causes of gaseous embolism are
i) air trapped in oxygenator and circuit
ii) air trapped in cardiac cavities during surgery e.g. LA in a case with MR
This cause is least likely in an on pump CABG where a cardiac chamber is not
opened.
iii) perfusionist interventions to administer drugs and collect blood samples
iv) vacuum assisted drainage
374) A
CO2 has high solubility and low partial pressure. This makes its contribution to gaseous
emboli the least.
375) B
Nitrogen has the highest partial pressure, both in the air ( 595 mm of Hg) and in the
blood, and has a low coefficient of solubility ( 0.56, if oxygen is 1.0). These
characteristics make it as the main gas inside the bubbles formed in the blood.
376) D
Unilateral cerebral perfusion is performed through innominate artery or the right
subclavian artery. It is based on the assumption that through the circle of Willis, the
opposite, i.e. the left, cerebral hemisphere will be perfused adequately. A fall in tissue
saturation of >20% indicates poor perfusion and it is an indication to switch to bilateral
cerebral perfusion through left common carotid artery.

Circle of Willis
 144

A= Unilateral cerebral Perfusion

B & C = Bilateral cerebral Perfusion

377) C
Please read answer to MCQ 363.
378) A
379) D
380) B
Please refer to answer to MCQ 234.
381) D
Procaine is used to stabilise the myocardial membrane and provides benefits like
decreasing the occurrence of arrhythmias and other rhythm disorders. Procaine has a
depolarising effect and it enhances Endothelin-Derived Hyperpolerising Factor
mediated relaxation.
382) A
The cardiac consumption of glutamate( and also aspartate) increases in the setting of
hypoxia. During the first 4 hours following CPB, the heart does not use lipids or
carbohydrate substrates and takes up amino acids, mainly glutamate. The amino acids
glutamate and aspartate are Kreb cycle precursors that are used in cardioplegia solutions
to improve myocardial metabolism. These amino acids can be metabolised in anaerobic
conditions for energy production as well as to counteract the depletion of Kreb cycle
intermediates during ischemia.
383) B
IV Mg2+ after CABG surgery prevents postoperative arrhythmia atrial fibrillation .
Mg2+ may exert a cardioprotective effect during ischemia and reperfusion through a
beneficial effect on Ca2+ transport. Hyperkalemic cardioplegic solutions partially
depolarise the membrane and may open the L-type Ca2+ channels. Mg2+ blocks the L-type
Ca2+ channels, reduces Ca2+ loading and energy demands and preserves myocardial
metabolites.
384) C
 145

Inadequate volume of blood in reservoir is the only factor that will prevent from
preparing cardioplegia urgently. Other factors can be addressed later.
385) A
As per law of solubility of gases, solubility of gas decreases with increase in temperature.
CO2 is 20 times more soluble than O2. Hence pO2 level during rewarming is the main
concern. In almost all oxygenators, gas flow is increased 1.5 to 2.0 times blood flow
during rewarming.
386) C
A venous saturation of 60% indicates a well perfused patient. Hence an a-v saturation
difference of 40% (100% - 60%) indicates a good perfusion.
387) A
‘Rated Flow’ of an oxygenator is that flow till which an oxygenator can oxygenate fully
(100% saturated) a normally desaturated venous blood (saturation of 60-65%). So, if the
pump flows are more than the rated flow, the arterial blood would be less than 100%
saturated.
388) C
There is no definite value mentioned. The optimum levels of perfusate oncotic pressure
and protein content during experimental CPB are 16 mm Hg and 4.2 g%, respectively, to
avoid tissue edema and acidosis.
Low oncotic pressures on CPB are associated with prolonged ventilation and lower
survival.
389) D
Please refer to answer to MCQ 224.
390) B
PVC tubings are durable and have acceptable rates of hemolysis. They have a high
transparency for safe and easy debubbling and excellent flow visibility. They have a high
mechanical resistance, excellent elasticity and anti-kinking properties. They provide
easy connection to connectors.
However PVC tubings do have a tendency to induce spallation and stiffen during
hypothermia.
391) C
During diastolic augmentation the AR will increase and will worsen the LVF
392) B
Volume of a tube =  x R2 x h (here ½” is the outer diameter of the tube , so for
calculation of volume, the inner radius should be considered)
393) C
394) D
395) C
Plasma-Lyte A has an electrolyte composition similar to EC Fluid. The concentrations of
electrolytes before addition of additives are (in mEq/L)140 sodium, 5 potassium, 3
magnesium, 98 chloride, 27 acetate, and 23 gluconate. The pH value is 7.4. The
cardioplegia additives to this base solution are: Mannitol 20% 16.3 mL, Magnesium
sulfate 50% 4 mL, Sodium bicarbonate 8.4% 13 mL, Potassium chloride 15% 13 mL ,
Lidocaine 1%, 13 mL . This formulation is mixed then with blood from CPB circuit in a
ratio of 4:1. It is important to note that there is no calcium in the base solution. The final
calcium concentration of this cardioplegia can be described as trace because 20% of the
 146

delivered volume contains patient blood. This is an important consideration because trace
calcium in cardioplegic solutions has been shown to be preferable as compared to
acalcemic or hypercalcemic levels.
396) B
Please refer to answer to MCQ 395
397) A
398) C
399) B
HTK cardioplegia was described by Bretschneider in the 1970s. ‘Custodial’ is the name
given by the manufacturer. The cardioplegia is classified as an intracellular, crystalloid
cardioplegia due to its low sodium and calcium content. Sodium depletion of the
extracellular space causes a hyperpolarisation of the myocyte plasma membrane,
inducing cardiac arrest in diastole. This is a different mechanism of action from
conventional ‘extracellular’ cardioplegic solutions, which are high in potassium content
and cause arrest by membrane depolarization.
400) D

401) C
Leaking heat-exchanger is a dangerous complication (see answer to MCQ 264) and is
difficult to detect once priming is even started completed. Hence should be checked when
the circuitry is totally dry.
402) A
A veno-venous bypass is without the use of oxygenator. In a veno-venous bypass, blood
is drawn from distal cava and is pumped back into RA or opposite cava. V-V bypass is
used when caval (IVC or SVC) clamping is required. Caval clamping causes hypotension
(due to decrease in preload) and distal venous hypertension, resulting in severe
splanchnic or cerebral congestion, decreased renal perfusion (incase of IVC) and
accumulation of acidotic products.
 147

In a case with a carinal tumour, lungs cannot be ventilated and hence an oxygenator will
be required.
Various circuitries for V-V bypass are:

Single centrifugal pump, no reservoir Two pumps & one reservoir

Single Pump, with heat exchanger and filter

403) D
Hyponatremia is associated with hypotonic priming.
404) C
TEE is particularly useful for placement of cannule during surgery by minimally invasive
technique.
405) B
406) B
60% blood perfused through SVC returns back to heart via IVC. Hence, the IVC should
not be snugged.
Head low improves cerebral perfusion pressure. Ice around the head cools brain.
Blood pumped through SVC is prevented from entering both subclavian veins by
partially inflating (just above the SVC pressure) the blood pressure cuffs.
407) C
In 1980, Mills and Ochsner originally used RCP to treat accidental air embolisms during
CPB.
408) C
 148

Hypothermia causes hyperglycemia. It is due to decreased consumption, less insulin and

induced stress the blood sugar levels rise (please refer to answer to MCQ 275).
Hypokalemia is due to intracellular movement of potassium.
Hypocarbia is due to decreased production and increased solubility of CO2.
Hyperviscosity is in accordance with hemoglobin level .( please refer to the answer to
MCQ no 28).
409) C
In a conventional bypass, air sucked through venous purse-string holes or loose snuggers
is trapped in the venous reservoir. In a miniaturised circuit, due to the absence of a
reservoir, trapping of this air is a concern. Also, many a times the venous drainage is
kinetic, which increases the sucking of the air.

410) A
Acute LV failure occurs in children following surgical correction of congenital anomalies
or following myocarditis.
Other important points regarding use of IABP in children are:
i) systolic unloading of LV, during balloon deflation, is more important.
ii) open femoral artery technique or trans-thoracic technique of insertion is used.
iii) 2.5 to 7.0 ml balloons are available for infants and children
iv) pediatric catheters do not have central pressure monitoring channel
v) limb and mesenteric ischemia should be carefully monitored.
411) B
(please refer to answer to MCQ 334)
412) C
Propofol is an intravenous anesthetic agent and has no effect on formation or prevention
of gas bubbles.
 149

Warmth reduces solubility of a gas. Hence during rewarming, in the heat-exchanger and
during cooling in the aorta gas bubbles are formed.
Pores of screen filter are filled with liquid that is maintained by surface active forces
which prevent passage of gas microbubbles at clinical pressures.
High reservoir levels allows blood to remain in reservoir for a little longer time, allowing
gas to vent out.
413) A
Miniaturised CPB circuits do not incorporate a reservoir.
Maximum particulate embolism is from cardiotomy suction. Hence, the filter in the
cardiotomy chamber is 40  while the filter in the venous compartment is 200.
414) B
Pump occlusion does not increase hardening of a tube.
415) B
There is no unanimity regarding what is an ‘adequate’ occlusion. Occlusion is
accomplished by holding the divided or open outflow line vertically so the top of the
fluid is at patient chest level (about 100cm) above the pump and then gradually
decreasing the occlusiveness until the fluid level falls at a rate of 1 cm every 5 seconds or
1 inch/min ( 2.5 cm / min) or 1 cm/min ( as per various references). KEM Hospital,
Mumbai, India; adjust occlusion till there is NO fall!
416) B
Quality of tubings, occlusion and flow rates affect spallation. It is known to occur in the
raceway of the roller pump during normal pump operation. Spallation is a known cause
of systemic particulate embolism during CPB. Exposure to plasticiser phthalates
(di-2-ethylhexyl phthalate- DEHP) poses risk to reproduction, causes hepatomegaly, and
can result in acute immune system response in patient.
417) C
Blood flow through a non-occlusive pump is bidirectional and is preload and afterload
dependant. Flow is not determined by rotational rate alone. Hence, a flow meter is
essential.
Some other points about centrifugal pumps are :
i) the outflow must be clamped after stopping the pump.
ii) if the arterial line becomes occluded, these pumps will not generate excessive
pressure (maximum pressure ~ 800 mm Hg) and the arterial line will not rupture.
iii) as compared to a roller pump, they do not generate as much negative pressure
(maximum ~ 500 mm Hg) and produce less cavitation and microembolus .
418) C
419) D
Nonpulsatile flow increases the secretion of Renin, Plasma vasopressin. It reduces tissue
oxygen consumption and produces metabolic acidosis. Enhanced energy delivered by
pulsatile perfusion keeps the microcirculation open and improves the delivery of
nutrients. Investigations suggest that hepatic, pancreatic, and gut function are better
preserved during pulsatile flow.
420) A
Obstacles to transmitting pulsatile flow from a pump into the patient include,
 150

i) resistance and damping imposed by membrane oxygenators, arterial filters, and arterial
infusion cannulae that intervene between the source of pulsatility and the patient's
arterial circulation.
ii) distensibility of the arterial tubing : a distensible tubing absorbs the pulsatile energy.
iii) small size of the aortic cannula in relation to the arterial tubing creates the
extracorporeal equivalent of severe aortic stenosis, resulting in loss of pulsatility
and possible hemolysis when sufficient energy is transmitted across the cannula to
induce architecturally physiologic intra-arterial pulsatility.
421) C
Anaphylatoxins or complement peptides, are fragments (C3a, C4a and C5a) that are
produced as a part of the activation of the complement system. They cause smooth
muscle contraction, histamine release from mast cells, and enhanced vascular
permeability. They also mediate chemotaxis, inflammation, and generation of cytotoxic
oxygen radicals.
422) D
At the end of CPB, the classic pathway is activated a second time when heparin is
neutralised by protamine; the heparin–protamine complex strongly activates complement
via the classic pathway. Surface contact in the perfusion system activates the classic
pathway. The alternative pathway, involving factors B and D and C3b is the predominant
pathway during CPB.

423) C
424) A
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425) B
(please refer to answer to MCQ 131)
426) C
Platelets are activated during CPB and OHS by surface contact, heparin, circulating
thrombin, and platelet-activating factor formed by a variety of cells. Heparin increases
the sensitivity of platelets to soluble agonists. Initially, platelets are most likely activated
by circulating thrombin, which is a powerful agonist and binds with a specific thrombin
receptor. As CPB continues, activated complement (C5b–9), plasmin, hypothermia, PAF,
interleukin-6 , cathepsin G, serotonin, epinephrine, and other agonists also activate
platelets and contribute to their loss and dysfunction.
427) B
Endothelins derived the name from the fact that they were derived and secreted from
cultured endothelial cells. There are three isoforms , identified as ET-1, -2, -3.
Endothelins are peptides and are the most potent vasoconstrictors known. Endothelial
cells are activated during CPB and OHS by a variety of agonists, including thrombin,
C5a, and various cytokines [e.g., IL-1, tumor necrosis factor (TNF)]. Endothelial cells
also produce a vasodilator - prostacyclin (PGI2). Prostacyclin concentrations increase
rapidly at the beginning of CPB and then begin to decrease. ET-1 peaks several hours
after CPB ends.
428) B
Low root pressure is due to leakage of cardioplegia into LV due to AR.
In coronary artery disease and particularly in LM stenosis the root pressure is high.
MR, TR or AS have no effect to root pressure.
429) A
Between CO2 and O2 it is the O2 which has poor diffusibility. The primary methods for
enhancing gas diffusion are
i) increasing the driving gradient : is limited to 760 mm Hg minus the oxygen tension in
the blood, because pressures above atmospheric pressure is not practical and risks
bulk gas transport across the membrane with resultant gas embolisation.
 152

ii) increasing dwell time: limited by the requirement for increased priming volume as the
size of the oxygenator increases.
iii) decreasing the diffusion path: has been used very successfully to enhance gas transfer.
First, the blood path thickness has been minimized as much as technically feasible
by placing the membranes as close together as possible without causing an
excessive pressure drop across the oxygenator. The major advance has been the
utilisation of induced eddies or secondary flows of the blood from the primary
stream (figure below) into the diffusion boundary layer, thus decreasing the
thickness of this layer and increasing the gas transfer. ‘Boundary layer’ is the
stagnant saturated layer along a membrane and is a great hindrance to diffusion.

Eddies have been generated in several different ways. Some possible methods
include making the surface of the membrane irregular (e.g., dimpled) or
positioning the elements within the flow stream to disrupt the smooth flow (figure
below).

430) D
High arterial pressure during CPB is, almost always, due to severe vasoconstriction. The
correct way to this is with use of vasodilators. Another wrongly used method to treat
hypertension during CPB is to reduce pump-flows, disproportionate to temperature.
431) C
432) D
433) A
Coronary sinus opening is close to IVC opening but is too small as compared to the size
of the IVC cannula. (IVC carries 2/3 systemic blood, in adults).
b) RA: venous drainage will be affected during retraction (e.g. MVR). Snugger below the
marker on the cannula.
 153

c) RV inflow: venous drainage affected and RA will be full on CPB, even without
retraction. Purse string could be between the two markers.
d) Hepatic vein: RA full on CPB, inadequate venous return. Second marker in the RA
( below the purse string).
434) B
Choices a, c and d are valid complications of long term use of IABP.
435) A
A rise in transmembrane pressure above 200mm of Hg or a premembrane pressure of >
500 mm of Hg is also reported.
436) B
Oxygenator failure is suspected when there is a dark-coloured blood in the arterial line.
Oxygenator failure could be i) due to manufacturing defect (causes 1, 2 &5 mentioned
below) or acquired (causes 3, 4 & 6). Acquired causes are related to a perfusionist and
should be easily and immediately correctable.
In an article studying oxygenator failure, the causes found were,
1) a hollow fiber membrane that circumferentially ruptured between the heat exchanger
and oxygenation compartment when over pressurised 2) two bubble oxygenators that had
no defoamer agent 3) 2 cases of leaks in the gas delivery line due to either a hole in a
high pressure line or a cracked oxygen line filter 4) misconnected gas supply lines
5) failure due to a part missing inside an oxygenator that was not detected before bypass
6) failure of an oxygen/air blender 7) structural failure due to leakage of a volatile
anesthetic (Forane) onto the oxygenator.
437) D
Micropore arterial filters are excellent gross bubble traps. If they are used for this
purpose, however, they must have (unless they are self-venting) a continuously open
purge line, which includes a one-way valve, that goes from the filter to the cardiotomy or
venous reservoir to allow escape of trapped air. It is also recommended by filter
manufacturers that a bypass line should be incorporated around the filter, which is
clamped but can be opened in case the filter becomes obstructed. Limitations of arterial
 154

line microfilters include that they add to the cost, may obstruct, are harder to de-air (and
therefore may be a source of gaseous microemboli), may generate microemboli, and
cause hemolysis and platelet loss and complement activation.
Arterial line filters have a pressure drop of 24 to 34 mm Hg at a flow of 5 L/min.
438) B
439) C
Another quality for a pediatric pump would be, able to accept 1/4” and 1/8” tubings.
440) B
The pascal (named after the French polymath Blaise Pascal & symbol is Pa) is the
International System of Units (SI) derived unit of pressure used to quantify internal
pressure, stress, etc. It is defined as one newton force per square metre. One newton force
is the force required to carry 1 Kg weight through a distance of 1meter at a speed of
1m/sec for one second.
1 Atm or Atmospheric Pressure ( 760mm of Hg) is 101.325kPa.In some blood gas
machines, gas values are reported in KPa. One KPa = 7.5 mm of Hg
441) E
The urine is ‘tea water’ coloured or ‘coca cola’ coloured and is uniformly mixed with
blood.
442) C
All are true causes of hematuria but occur at different times during bypass.
443) E
The left subclavian artery takes origin from the arch of the aorta and its contribution to
cerebral circulation is through the left vertebral artery. While, all the arteries mentioned
in the choices a to d establish continuity with carotid system and perfuse brain n a better
manner. Also, the left subclavian artery is difficult to approach through median
sternotomy.
444) D
Flexibility allows negotiation of the cannula. Thin walled cannula helps in a better ID/OD
ratio. Multiple side holes ensure drainage from lateral tributaries of IVC. Length ensures
cannula reaches RA. Appropriate placement of cannula is found by manual palpation or
on USG.
445) D
446) A
If the heart is beating, it can still suck air through the RSPV vent and eject into aorta.
Hence, RSPV is vented when contractions are weaker, and during venting, perfusionist
keeps the heart slightly full and anesthesiologist keeps the lungs semi inflated.
447) B
Washing LA following clot removal helps is removing fibrin shreds & small clots which
float in saline.
Intracavitary washes are also given in a case with calcified valves ( typically, mitral
stenosis or aortic stenosis), and during testing of repaired valves ( typically, mitral and
tricuspid).
448) D
Choices a, b & c are right sided operations and can be performed on a perfused heart
(fibrillating or beating) on CPB , without a fear of air embolism. As the heart is perfused
coronary venous return from the coronary sinus obstructs the operating field. This
 155

requires a judicious use of cardiotomy suction. In case of RVOT patching, return from
distal MPA also hinders suturing.
449) A
450) B
Other choices mentioned are also accepted methods of treating hemodilution, but are not
the fastest.
451) E
IV calcium (as a chloride or gluconate) does not lower potassium levels but acts by
directly countering the ill effects of hyperkalemia on myocardium . GI drip moves
potassium intracellularly and lowers serum potassium level. Loop diuretics lower levels
through urinary loss. Ultrafiltration filtrate will contain potassium in a concentration little
less than that of serum. Sardolate prevents gastro-intestinal absorption and is the slowest
to act.
452) C
Please refer to answer to MCQ 363
453) B
The height of the column of blood in the cannula should be equal to the CVP.
a) indicates the cannula is fitting too tight, i.e. is large for the SVC size.
Choice c) & d) are not related to SVC cannulation .
454) B
In an adult patient, priming volume of the filter is not important. Features a) & c) are
common in all filters.
455) E
Gradient from pump head to cannula tip = Gradient across the oxygenator 50 mm Hg
+ gradient across arterial filter and tubing 20 mmHg
+ gradient across arterial cannula 80 mm Hg
456) E
Smooth tapering cannula results in maintenance of streamline flow. Sudden tapering
gives rise to turbulence. The cannula should be
1) Short: so the tip does not jut against the posterior aortic wall or accidentally enter a
nearby artery, like the innominate artery.
2) Wire-reinforced: to avoid kinking.
3) Transparent: to check air bubbles during cannulation and colour of blood.
4) Single-cast: means without any joint or seam. Single cast ensures no leaks or bursts.
457) A
In a two stage-cavoatrial- cannula, the SVC drainage is through the atrial port. So, blood
with perfusate temperature (usually 320C ) comes in contact with RA and there by
rewarms the heart ( which, due to cardioplegia is at about 8- 100C) .
Also, as IVC is not snared, some blood seeps around the cannula into RA, and rewarms
the heart.
 156

458) B
The rest of the choices are causes of high arterial line pressure with low aortic pressure,
the causes of which are related to cannula position or arterial circuitry (pump head to
arterial cannula tip).
459) C
a) & b) are causes of low aortic pressure with normal reservoir volume.
d) & e) are the causes of low reservoir volume with normal aortic pressure.
Another cause of low aortic pressure with a high reservoir volume is ‘recirculation line
open’.
460) A
A patient with VSD is never operated for BT shunt nor has MAPCAs. Interrupted IVC
never results in increased left heart return.
461) C
The PCV of any blood cardioplegia is around 10%-15%, hence, causes hemodilution.
As St. Thomas cardioplegia has normal sugar & sodium levels, and has a pH >7.8,
the other choices are not correct.
462) C
pK of a buffer is a pH value at which the base and acid of the buffer system are of equal
concentration and hence, the buffer works most efficiently. So, a buffer system with pH
near to blood pH ( =7.4) works most efficiently. Due to pK of 6.1, bicarbonate to
carbonic acid ratio is 20:1. Hence, bicarbonate buffer works mainly in neutralising
acids.
Another negative feature of bicarbonate buffer is it corrects only extra cellular
acidosis.
Other wise soda-bicarb is easily available, is cheap, and the product of neutralsation
H2CO3 is easily excreted as CO2( through lungs) and H2O ( lungs and kidneys).
463) C
464) C
465) E
a) to d) are the causes of rapid decrease in venous return and should be ruled out first.
Pump flow should be reduced when reservoir level is dangerously low.
466) D
 157

Pressure on the blood side is always higher than that on the gas side. Hence, in case of
leak in the membrane, blood leaks on the gas side resulting in noticing blood in the gas
vent.
467) C
Magnesium is the second most abundant intracellular cation ,after potassium. It is a key
cofactor in a variety of enzyme systems and hormone secretion and action (e.g., insulin
and parathormone).
Much like calcium, magnesium in the blood exists in three fractions: ionized
(approximately 55%), chelated (approximately 15% . chelated means metal in
combination with an organic substance), and protein bound (approximately 30%). The
ultrafiltrable fraction includes only the ionized and chelated fractions and, due to the
small contribution from the chelated ions, approximates the ionized fraction.

Cardiac surgery patients frequently develop hypomagnesemia, which may be due to

insufficient dietary intake, increased excretion (secondary to diuretics), diabetes,
aminoglycoside antibiotics, cardiac glycosides, ethanol abuse, pancreatic disease, or
administration of citrated blood products or albumin. Blood magnesium concentrations
decrease during and after CPB in adults and children. During CPB, total magnesium
concentration declines in relation with the ultrafiltrable fraction as a consequence of
chelation by albumin and other blood products and hemodilution. Urinary excretion of
magnesium during bypass is not increased. Magnesium concentrations, unlike calcium
concentrations, once reduced during CPB, return to normal only slowly because of the
lack of a specific hormonal regulatory system

Hypomagnesemia in the post-bypass period commonly contributes to cardiac

dysrhythmias. Infusion of magnesium salts prevents hypomagnesemia and its
complications during and after CPB. During CPB, cardiac muscle is preferentially
depleted of magnesium (compared with skeletal muscle).

Moderate magnesium supplementation (1 to 2 g magnesium sulfate intravenously per

hour of CPB maintains serum magnesium concentrations greater than 1 mM) has minimal
effects on blood pressure in normotensive patients. Renal insufficiency may predispose to
magnesium toxicity. Overall, magnesium salts are safe & effective low-cost therapy that
may be used on a routine basis for prevention or treatment of many atrial and ventricular
arrhythmias. The routine occurrence of hypomagnesemia during CPB and rapid renal
excretion of magnesium allows the clinician to administer moderate doses of magnesium
salts empirically without the need for frequent measurement of magnesium blood
concentrations.

468) B
There is no definite rule, though most of the articles mention this value. Also, it is equally
important to know quality of platelets. Following aspirin- clopidogrel therapy count is
normal but the platelets aggregation is poor.
Patients with high PCV (e.g. TOF), and patients on prolonged heparin therapy have low
platelet count.
469) D
 158

Acute respiratory distress syndrome (ARDS), also known as adult respiratory distress
syndrome, or shock lung, is a fatal pulmonary parenchymal disorder as a result of
respiratory infection, trauma, or stress (e.g. CPB) triggered by cytokine release (by
WBCs). It results in impaired endothelial barriers (resulting in increased permeability)
and surfactant deficiency (promoting alveolar collapse). Fluid accumulation in the distal
airspaces results in impaired gas exchange.
The ARDS that developing early after CPB is known as post-perfusion or post-pump
syndrome. The affection is mainly intraparenchymal. Pleural affection, like hemothorax,
is not seen.
470) A
(Please read answer to MCQ 469) Hemodilution reducing oncotic pressure worsens
interstitial edema and there by pump lung problems. Elevated pulmonary capillary wedge
pressure (PCWP) due inadequate venting on CPB or due to over filling of LV also
worsens pump lung picture.
471) E
Except Ringer rest all are colloids
472) D
Normal values for arterial blood pH and PCO2 are 7.40 and 40 mm Hg, respectively, at
37°C in blood. There is a temperature-dependent spectrum of "normal" values.

This change in PCO2 with temperature is a consequence of the change in solubility of

gases in liquids with temperature change. As a general rule, decreasing the temperature of
a solution increases the solubility of a given gas in that solution and therefore decreases
the partial pressure of that gas.
The neutral pH of water increases by 0.0147/0C. Cold blooded or ectothermic animals
like frog & turtles, during hibernation maintain a blood pH alkaline corresponding

to the temperature ( see graph above) . So, if temperature has fallen by 200C, then the
neutral pH of water would be 7.0 + (20 x 0.0147) = 7.0 + 0.294 =7.294 and neutral pH of
blood would be 7.694.
A major buffering system responsible for this constant relationship of blood and tissue
fluid pH to pN( neutral pH) with temperature change is the imidazole moiety of the
amino acid histidine, which is commonly found in body proteins.
The ratio of the unprotonated histidine imidazole groups to H+, a value known in the
chemistry world as alpha, remains constant; total CO2 remains constant; and pH
changes as temperature changes.
The term alpha-stat has come to indicate an acid–base management strategy in which the
net charge (dissociation) of proteins remains constant as temperature changes. Typically
during CPB, this is managed by keeping total CO2 stores constant and allowing pH and
 159

PaCO2 to follow their thermodynamically mediated dissociation changes with

temperature change.

The alternative method of acid–base strategy is termed pH-stat. With this method, pH is
the value that is maintained constant at varying temperatures. Obviously, if the pH-stat
strategy is used as blood is cooled, CO2 must be added to maintain a PaCO2 of 40 and a
pH of 7.40.
473) B
This typically occurs with respect to cerebral blood flow when pH stat strategy is
adopted.
474) C
475) C
The fact that the heart has undergone a quick arrest means coronary arteries are normal,
there is no AR and the potassium content of cardioplegia is appropriate. Perfusate blood
which is warm and is with normal potassium levels, leaks through the inadequately
clamped aorta in to the root and washes away cardioplegia and the heart activity returns.
476) B
In adequate pump head occlusion results in 1) decreased forward flow 2) back flow nto
the reservoir. Decreased forward flow should give rise to metabolic acidosis, low
pressure and decreased urine output. Back flow gives rise to higher reservoir levels and
low perfusion pressure.
477) D
Heparin resistance can be defined as a need for higher than usual doses of heparin to
achieve adequate anticoagulation. This may be due to ATIII deficiency or increased
protein binding of heparin. Protein binding is variable and increases in acute illness.
ATIII deficiency may be either inherited or acquired. Inherited ATIII deficiency follows
an autosomal dominant pattern with a prevalence of 1:2000–20000. Affected individuals
usually have ATIII levels below 50% of normal and are prone to venous thrombosis.
Acquired ATIII deficiency is more common and is usually due to recent heparin
administration.
Additional heparin is usually all that is required for heparin resistance, but ATIII
deficiency should be suspected if an ACT > 480 s cannot be achieved after
administration of more than 600 IU of heparin/kg. Transfusion of recombinant ATIII
concentrates is the treatment of choice. Fresh frozen plasma (FFP) contains normal
concentrations of ATIII and is a cheaper alternative, but carries the risks associated with
transfusion.
478) D
Protamine shock is first treated by administering volume, steroids, IV calcium or
inotropes. Going on CPB for protamine shock is the last measure and patient is usually in
a very bad hemodynamics. There is no time to wait and check ACT. It is best to be safe
by administering 300 units of heparin.
479) D
Please refer to answer to MCQ 181.
480) A
481) B
 160

The essential components of a cardiotomy reservoir are 1) an air-fluid separation

chamber (for which a defoamer is required ) 2) a temporary storage reservoir for
priming solutions ( conical shape with a false bottom) 3) filtration of particulate
materials (clots, blood cell aggregates, etc.) from banked blood, the storage and filtration
of blood aspirated from the surgical field ( for which screen and depth filters are
required) 4) addition of fluids and pharmacological agents to the perfusion circuit ( for
which ports are required).

482) B
483) A
484) C
‘Gas transfer rate’ usually pertains to O2 transfer. It should be high. Otherwise, a large
membrane area will be required.
485) C
Polycarbonate is used for making hardshell of reservoir & oxygenators.
Polymethylpentene is particularly used for making ECMOs. Silicon was initially used for
manufacturing ECMOs, but, now is being phased out.
486) B
Read answer to MCQ 485.
487) A
This is an essential safety mechanism of any reservoir. The bursting of valve relieves the
excess pressure developed.
488) B
With total CPB, all the blood is diverted away from pulmonary circulation. So, there is no
venous blood is available for oxygenation. Also, the oxygenator has totally taken over the
responsibility of oxygenating blood.
489) C
In ‘intermittent cross clamp technique’ for CABG, conventional CPB is established.
Temperature is lowered to 320C. Heart is fibrillated with an electrical fibrillator. The
aorta is cross clamped. No cardioplegia is administered. One distal coronary anastomosis
 161

is performed. Aorta is unclamped. Heart is defibrillated. On empty beating heart the

corresponding proximal anastomosis is performed. This cycle of ‘fibrillating heart –
distal anastomosis – defibrillating heart—proximal anastomosis’ is repeated to achieve
complete myocardial revascularisation. Temperature of patient should not drift below
320C so as to ensure defibrillation of heart and achieve empty beating heart .
490) B
IVC and SVC are valveless systems. Hence, with head low, venous blood pools in the
upper half of the body. Two stage venous cannula drains SVC through its RA port ( ref to
answer to MCQ 457). As RA is now at a higher position, gravity point of view, RA
remains full and venous drainage decreases.
491) C
Lactated Ringer's is composed of sodium chloride 6 g/L, sodium lactate 3.1 g/L,
potassium chloride 0.3 g/L, and calcium chloride 0.2 g/L. Lactated Ringer's contains ions
of sodium 130 mEq/L, potassium 4 mEq/L, calcium 2.7 mEq/L, chloride 109 mEq/L, and
lactate 28 mEq/L.
492) C
On line filters have an outer screen filter , which works by straining, and an inner depth
filter, which works by adsorption.
493) D
This complication is important when a roller pump is used for ECMO.
494) C
During rewarming, patient is cooler and heat exchanger is warmer. So as per law of
solubility of gases, bubbles will form in the warmer heat-exchanger which is in contact
with venous blood.
495) D
During cooling, patient is warmer and blood exiting from oxygenator is cooler. So as per
low of solubility of gases, bubbles will form in the warmer patient (aorta) when cool
arterial blood enters a warmer patient .
496) A
Flow rate depends on the ID of the tubing, length of the raceway, and rpm of the rollers.
497) B
Due to lower assumed BSA, less flows will be delivered. This would produce metabolic
acidosis exhibited in arterial blood gas report as low pH, low bicarb ion levels with
normal pCO2 levels. Venous saturations and venous pO2 levels, too, will be low.
498) D
499) B
Cerebral autoregulation for blood supply stops when pCO2 levels fall below 25 mm of
Hg.
500) C
Please refer to answer to MCQ 488.
501) A
Left innominate vein, ascending aorta, RA and RV are anterior structures . Dilatation of
these structures (aortic aneurysm, dilated RA due to TR or CCF, dilated RV due to severe
PH) carries a good chance of these structures suffering injury during sternotomy. A Redo
sternotomy or intrapericardial adhesions increases the risk further.
 162

A CT scan can provide accurate information ( arrow in photo below).

A surgeon may cannulate femoral artery and vein prior to sternotomy, in such situation.
502) E
Venous pressure on CPB is negative. Hence, the pressure will become negative.

The delivered cardioplegia will straight away drain into IVC cannula or into two-stage
venous cannula. The negative pressure will be equal to CVP pressure on CPB.
503) C
504) C
( Also see answer to MCQ 409).
In an effort to minimise the detrimental effects of CPB, a miniaturised CPB (M-CPB)
closed circuit system also known as closed circuit extracorporeal circulation (CCECC)
has been developed . Miniaturised CPB reduces the artificial surface for blood contact
with less resulting inflammatory reaction .
Though there is no official definition of what is a ‘miniature’ circuit , there are a number
of common features that various M-CPB circuits utilise.
1) A heparin/ phosphorylcholine /polymer coated tubing to reduce protein adsorption and
platelet activation
2) low prime volumes (500- 800 cc) so that a combination of reduced tubing area and
reduced priming volume can minimise hemodilution. Hemodilution during CPB leads to
reduced levels of coagulation and fibrinolytic proteins, increases transfusions, and, is
responsible for organ dysfunction, short-term mortality, and long-term morbidity.
3) The lack of a venous cardiotomy reservoir removes the foreign blood-air interface and
avoids stasis in the reservoir thus reducing clotting factor and inflammatory mediator
activation. Reinfusion of cardiotomy suction blood exposed to pericardial surfaces is
associated with postoperative neurologic injury secondary to increased levels of
hemolysis and fat in scavenged blood
4) a centrifugal pump actively draining the right atrium to reduce platelet aggregation and
cellular damage.
 163

5) Cell salvage so that all bloodshed from the operative field is removed by a cell saver
system. This blood can then be washed and re-transfused.
6) kinetic assist to augment venous drainage coupled with venous line air handling
devices and arterial line filters to reduce venous air entrapment add safety to the circuit
by reducing the chance of air embolisation.
505) D
Third space loss or loss of fluid into interstitial space, occurs with hemodilution or low
oncotic pressure. The shifting of fluid from intravascular to intercellular compartment
takes time. Other delayed volume losses are 1) loss into pleural or peritoneal cavity
(4th space) 2) surgical loss into sponges and drapes 3) urine or ultrafiltration loss
506) B
507) D
An oxygenator leak is managed according to the timing of leak and the amount of leak.
Leak of any sort right at the beginning of CPB, should be managed by immediate
termination of CPB, by appropriate manner and changing the oxygenator.
508) E
Aortic or arterial dissection due to cannula is a catastrophic complication. It occurs right
at the beginning of CPB. It results is a rapid decrease the reservoir volume.
Please also refer to answer to MCQ 505.
509) A
Other complications are common to aortic cannulation with any type of cannula.
510) B
Aprotinin prevents systemic inflammatory response by preventing the formation of factor
XIIa, which is the basic stimulation for contact activation.
Methyl prednisolone and dexamethasone are steroids and prevent inflammatory ill effects
by stabilising cell membrane.

511) D
512) A
Carbohydrate metabolism is regulated by insulin, glucagon, cortisol, growth hormone,
and epinephrine, the concentrations of which are generally perturbed during and after
CPB. After onset of CPB, blood glucose concentrations rise steadily. Despite marked
hyperglycemia, insulin concentrations decline from their control values during
hypothermic bypass. Normoglycemia can be maintained only with great difficulty during
hypothermic nonpulsatile CPB in nondiabetic adults, even with large doses of insulin.
Thus, hyperglycemia, hypoinsulinemia, and insulin resistance are produced by
hypothermic nonpulsatile CPB in adults.
With rewarming, insulin concentrations rise spontaneously to appropriate high levels;
nonetheless, blood glucose remains elevated.
513) A
Hypotension ( mean pressure of 40-50 mm of Hg) is due to hemodilution, as well.
Hemodilution reduces viscosity disproportionately.
514) D
515) C
516) C
 164

Thus, ultrafiltration is improved by more arterial flow, partially clamping the venous
outlet of the filter and by increasing the negative pressure.
517) C
The answer is based on ‘reaction time’ of a perfusionist. Fall of volume in the reservoir
should be anticipated so that appropriate changes in systemic blood flow can be made in
a timely manner before a dangerously low volume situation occurs. It has been suggested
that the venous reservoir volume should be equal to 25% of the systemic blood flow
(L/min) to allow for a 15-second reaction time. Recommendations from device
manufacturers on minimum blood levels for safe operation to avoid entrainment of air
should be considered as well. The graph below suggests the reaction time available at a
particular flow and reservoir level.

518) E

519) A
All the priming solutions are iso-osmolar. There is nothing to chose based on osmolarity.
520) D
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ACT depends up on the material used. Hence, ‘normal’ values vary from machine to
machine.
521) B
ACT reflects time of clot formation via the intrinsic coagulation pathway by the addition
of factor XII activators. ACT increases linearly to relation to the heparin concentration.
Clotting times may also vary between ACT analysers manufactured by different (or the
same) vendors, depending on the source and the formula of the activator, the amount of
activator relative to the sample volume, or the method of clot detection. Therefore,
instrument-specific protocols should be established and validated for each type of clinical
procedure.
522) C
Drugs like, warfarin, aprotinin, GPIIb/IIIa inhibitors (e.g. abciximab) prolong ACT.
Aspirin & clopidogrel appear to have a variable effect upon the ACT.
523) B
524) C
Please refer to MCQ 208.
525) B
In a modern hollow fiber oxygenator, blood flows on the outer side of the fiber and gas
inside. More fibers in a space a) increases surface area and improves gas diffusion
2) reduces space between the fibers and they work like a depth filter 3) but the reduced
space increases resistance to flow of blood.
526) C
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527) A
Theoretically, oxygen carried by RBC (blood cardioplegia) is more than the dissolved
oxygen (crystalloid cardioplegia). But at low temperatures of cardioplegia, the O2-Hb
dissociation curve shifts to left and less O2 is released for tissue. Also, due to
hypothermia, oxygen requirement of myocardium is decreased by 1/30th , hence, a so
called better oxygen carrying capacity is of no value.
528) B
Unprotected LM stenosis is a condition where, even, the RCA is dominant and is having
significant proximal block ( extreme right figure below). As all the outlets of root
cardioplegia have significant blocks, root pressure is high.

529) D
As the aims of repeating cardioplegia are a, b,& c but not arresting the heart, potassium
content of repeat cardioplegia need not be high.
530) D
531) B
Fabini and Carpantier described this technique.
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Technique of retrograde cardioplegia delivery through RA: RA is punctured directly

after caval and pulmonary artery exclusion. Retrieval of the cardioplegic solution is
obtained directly in the aortic root. Arrows represent direction of flow.
Anterior coronary veins and Thebesian veins open into RA directly and therefore, this
technique perfuses anterior coronary vein and Thebesian veins .Thus, this technique has a
better myocardial distribution of the cardioplegia.
The coronary veins (read answer to MCQ2) have an extensive inter- venous
communication. Approximately 33% cardioplegia delivered through CS drains back into
cardiac chambers, without reaching myocardium, as the chambers are at low pressure.
532) D
533) D
534) A
Heat exchangers are usually located proximal to the gas exchanging section of the circuit
to minimize the risk of releasing microbubbles of gas from the blood, which could occur
if the blood is warmed after being saturated with gas.
535) B
Heat transfer laws are similar to gas transfer laws. Thick walled coils increases the
distance between blood and water and slows heat transfer. Specific heat of a material is
change (rise or fall) in temperature of material in centigrade per calorie of heat transfer
(heated or cooled). So, materials with low specific heat (e.g. aluminum) temperature
rises quickly even by offering little heat.
536) D
Oxygen is mainly carried by hemoglobin. So, dilution reduces the oxygen carrying
capacity.
537) C
ACTH has no action what so ever on blood vessels.
ADH is same as Vasopressin and its action is as shown below.
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538) B
Thin wall makes the tube expandable which will absorb all the pump energy.

Desirable tubing characteristics include: transparent; resilient (reexpands after

compression); flexible ; kink resistant; hard enough to resist collapse ; tough to resist
cracking and rupture ; low spallation rate (the release of particles from the inner surface
of tubing); made of inert material; smooth and nonwettable inner surface; tolerance for
heat sterilisation; and blood compatibility. Medical-grade polyvinyl chloride seems to
meet these standards.
539) B
Retrograde cardioplegia exits through coronary ostia. As the ostia are close to RCC and
NCC annulus, the visibility is poor.
540) A
In one study, over 4 years 1500 cases were operated using retrograde cardioplegia.
Fifteen cases had rupture of coronary sinus. In all 15 cases, a retrograde cannula with a
self-inflatable balloon was used and 12 patients were woman with low body mass index.
Forceful insertion due to coronary sinus web, fragility of sinus in thin patients, or a
small coronary sinus causes rupture.
The injury could be due to the catheter, stylet or balloon.
The other disadvantages of retrograde cardioplegia include, myocardial injury with
edema and hemorrhage if cardioplegia is delivered at a pressure higher than 50 mmHg,
and the possibility of inadequate protection of the RV.
541) B
A case with Post infarct VSD is equivalent of ‘rupture of heart’. Poor LV function( due to
akinesia of IVS) and pulmonary volume overload are concomitant. The margins of VSD
are necrotic and suturing patch is difficult. Hence, patient is stablised first on afterload
reducing agents, IABP and ventilator for 7-10 days and then operated.
Other case which could have metabolic acidosis perioperatively is one with chronic renal
failure.
542) C
Cation exchange resins such as sodium polystyrene sulfonate (SPS) increase
gastrointestinal excretion. SPS can be administered only orally or rectally (as a retention
enema). Because the major site of action for this drug is the colon, rectal administration is
preferred for hyperkalemic emergencies. SPS is not useful for acute control of
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hyperkalemia, because its effect on potassium is delayed for at least 2 hours, peaking at
4-6 hours. SPS can decrease serum potassium by 2 mEq/L.
Another resin is Kayexalate, a nonspecific sodium-cation exchange resin originally
approved in 1958.
However, two potassium-binding agents, sodium zirconium cyclosilicate (ZS-9) and
patiromer (Veltassa), appear to have the potential to challenge the dominance of SPS
as hyperkalemia treatment.

543) B

Reactions 7,9 & 10 are delayed reactions.

544) A
For urine production renal blood flow should be adequate ( cardiac / pump output &
dilated renal arteries i.e., low SVR ) and perfusion pressure should be adequate ( > 40-50
mm of Hg). A diuretic should be administered only after ensuring above factors.
545) A
During a conventional CPB, aortic cannula once inserted and connected to an arterial line
is fixed without kinking and is not moved around. Hence, wire reinforcement to prevent
kinking is not an essential criterion.
546) D
All other cause a slow decrease in reservoir level. In adequate pump occlusion causes a
rise in reservoir level.
547) C
General anesthesia ( induced with drugs like Etomdate & Propofol) , muscle relaxation
and hypothermia reduce metabolic requirement and permit reduction of blood flows.
548) A
As solubility of all gases is less at higher temperatures, to maintain partial pressure of
gas, the ratio of Gas flow: Blood flow should be increased ( typically, from 1:1 to 2:1).
549) C
Trails mean ‘remain behind’. During cooling (downward trend), nasopharyngeal
temperature (due to excellent blood supply of nasopharynx) is lower and rectal
temperature is higher. During warming (upward trend) the nasopharyngeal temperature
is higher than the rectal temperature.
550) A
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On CPB, an ASD , per se, does not give rise to full RA . If at all , as the heart is still
beating, it will vent full RA.
551) B
AR causes LV distension due to aortic regurgitation. PDA and collaterals will cause LV
distention due to increased return.
MR, infact, will delay LV distension as , due to MR, LV is vented into LA and
pulmonary veins.
552) D
Retroperitonium can accommodate large volume of fluid (2-3 litres) without any external
evidence .
Other causes mentioned give rise to a full reservoir.
553) C
Presence of any type of prosthesis makes visualisation of left coronary ostium impossible
till the prosthesis is fully excised. A bioprosthesis makes visualisation of RCA ostium
also very difficult.
554) C
As RA is totally empty on full CPB, causes a, b& d are ruled out.

555) A
Due to a massive blood loss patient would be in a hypovolemic shock and the
hemoglobin would be low.
Duration is too short for heparin resistance to develop.
This is a life threatening emergency and instituting CPB is the prime concern.
556) A

The longitudinal paraseptal left atriotomy is just behind Waterston groove , which
separates RA from LA. Indistinct groove can result in accidental opening of RA.
The opening in RA is temporarily occluded by a side biting clamp, venous air lock is
removed and CPB is restarted. The rent in RA is now sutured , and RA unclamped.
557) D
MVR is usually performed by longitudinal left atriotomy (see above 556). For an
adequate drainage, not affected by LA retraction, bicaval cannulation is required. RA is
not opened , hence SVC, IVC tourniquets are not required.
558) B
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The commonest complication of angioplasty is dissection or rupture of coronary artery.

This requires urgent CABG. Patient could be in metabolic acidosis due to cardiogenic
shock. Urine out-put( > 0.5ml/kg/min) is one of the parameters of cardiac output.
Also, The contrast used during angioplasty causes kidney damage, especially in people
who already have kidney problems (in addition, atherosclerosis and diabetes can damage
kidneys, too). Ultra filtration will be required during CPB.
559) C
A patient like this, with severe PH, usually has post operative RV dysfunction, requiring
higher ( >7-8 mm of Hg) CVP.
Another way of judging the amount of fluid to be returned is by PAD pressure or by
PCW pressure.
560) D
During LIMA and RIMA harvesting, pleura is opened surgically or accidentally. Each
pleural space can ‘store’2-3 liters of fluid till it is detectable.
Also please refer to answer to MCQ 505.
561) D
To check bleeding from left superior part of a transannular RVOT patch (shown in red
colour), heart is lifted as, this part of the patch margin is not visible atall . A surgeon may
go on partial or full bypass to stop bleeding .

562) C
This is the earliest change and indicates severe ischemia in the anterior territory (supplied
by LAD) of heart. PA diastolic pressure reflects LV function and does not diagnose
specific cause of LV dysfunction. Causes b & d are unrelated to the LAD territory.
563) D
CPB induced vasoconstriction is also responsible.
564) E
However ‘good’ quality cardioplegia may be, cross clamp time should be used for
intracardiac correction only. Cross clamp time should not be spent in correcting CPB
related problems. Prior to cross clamping, the right heart should be completely
collapsed. A collapsed RA ensures complete systemic venous drainage and an empty
MPA indicates a minimal left heart return. Aorta should be cross clamped only after these
two things.
565) C
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Echocardiography is useful in assessing valves, walls ( including IVS & IAS) and
chamber dimensions. Distal pulmonary arteries, coronary arteries are not assessable by
echo.
566) D
Beyond pulmonary valve the pulmonary vascular system is without a valve. The only
valve till LV cavity is the mitral valve. Hence, if the mitral valve is normal
physiologically, during diastole, LVEDP is reflected backward. On wedging the catheter
one knows capillary wedge mean pressure.
Without wedging, pulmonary diastolic pressure gives an idea about LV end-diastolic
pressure.
567) B
Complete A-V dissociation is equal to complete heart block (CHB). It is, initially, treated
by correcting hypothermia, acidosis and hyperkalemia. Preoperative use of drugs like
betablockers, digoxin and cordarone increase the chance of temporary CHB.

All other conditions( a,c,d), during surgery, are treated by drugs or by a DC shock.
568) C
Full RA keeps the opening of coronary sinus wide open and facilitates insertion. Full RA
avoids air sucked into venous cannula through cannula purse string. As heart is kept full,
cooling is avoided, till RCP is inserted.
569) A
Retrograde cardioplegia should be delivered at a rate of 50ml/min.
RCC rarely gets wedged in a tributary as all the tributaries are at right angle to the
coronary sinus.
Coronary veins never undergo atherosclerotic damage.
The very fact that catheter could be introduced into coronary sinus, rules out CS ostial
obstruction.
570) B
Total CPB means, all the blood reaching RA is diverted into heart lung machine, and no
blood is entering MPA for oxygenation. Oxygenator is oxygenating all the blood. Hence,
ventilation is stopped.
Vice versa, while coming off CPB, ventilation is restarted on ‘partial bypass’ when
clamping of one venous cannula results in blood entering pulmonary circuit. Also, when
pulsatile flow is established (as seen on pulse oximeter tracings or on pressure tracings)
ventilation is restarted.
571) D
As robotic technique is still evolving, robotic surgery or MICS involves longer duration
of cross-clamp times and bypass.
572) A
In a patient with severe PH, PDA could be missed even on 2D Echo examination.
Return from PV suggests PDA. MAPCAs are not present in a patient with VSD.
AR poses problems w.r.t. arresting heart, not related to left heart return.
If cross clamp is inadequate, blood comes from VSD via LV, also comes through CS,
but not from RSPV vent.
573) D
LA & LV are posterior structures and are never injured during median sternotomy.
 173

574) C
A case with TOF has many naturally developed systemic artery- pulmonary artery ( also
called broncho-pulmonary) collaterals. These collaterals give rise to excessive left heart
return. This left heart return is usually vented through LA (RSPV or IAS/ PFO vent). If
this venting is inadequate, the blood flows from LV to RV through VSD. This makes
VSD closure very difficult. To reduce LV return, arterial flows are reduced. It is essential
to keep appropriate low temperature to permit lowering of flows.
575) B
This technique is adopted to obtain a totally dry operating field.
576) B
In all other conditions, the cardioplegia will drain away .
577) B

In March 1954, Dr Lillehei and his associates—Morley Cohen, Herb Warden, and
Richard Varco—used controlled cross-circulation to correct a VSD in an 11-year-old
boy. The boy’s anesthetised father served as the oxygenator. They shared the same blood
group. Blood flow was routed from the patient’s caval system to the father’s femoral vein
and lungs, where it was oxygenated and then returned to the patient’s carotid artery. The
cardiac defect was repaired with a total pump time of 19 minutes.
Over the ensuing 15 months, Lillehei operated on 45 patients with otherwise irreparable
complex interventricular defects; most of these patients were less than 2 years old.
Although cross-circulation was a major advance, it was not adopted for widespread use
because it posed a serious risk to the “donor.” Nevertheless, this method paved the way
for the open heart surgery era. It also won Drs Lillehei, Cohen, Warden, and Varco the
1955 Albert Lasker Award in medical research.
578) D
Blood cardioplegia, as practiced today, was reintroduced in 1977 by Gerald Buckburg. It
was first used by Melrose and associates in 1955 . Melrose used potassium
concentrations in the range of 245 mEq/L, which were subsequently found to cause
myocardial damage . This injury might have been avoided had hypothermia, rather
than normothermia, been used.
Though reintroduced in 1977, blood cardioplegia was not widely employed till 1986.
 174

Its use has been expanded coincident with 1) a better understanding of the physiology of
blood as a vehicle for cardioplegia, 2) randomised clinical studies favoring blood
cardioplegia, and 3) development of adjunctive measures to enhance blood cardioplegia.
579) C
In 1932 , at the age of 23, while still in medical school, DeBakey devised a continuous-
flow roller pump, which was a modification of a pump invented by Porter –Bradley in
1885, for blood transfusions. The full significance of this invention was not realised for
another two decades, when it became a major component of the heart-lung machine in the
first successful open-heart operation.
580) A
In a case with multiple L to R shunts, PDA shunt is non life-saving (non-obligatory), and
is closed prior to starting CPB, through the same median sternotomy incision.
581) B
Ascending aorta is cannulated as distally as possible so as to make space on ascending
aorta available for cross-clamping , cardioplegia cannulation , aortotomy for AVR and
proximal coronary anastomosis.
582) A
LAD is a major artery supplying 5 out of 10 segments of the heart. The hemodynamics of
an off-pump case become very stable once LIMA- LAD anastomosis is performed. LAD
is on the anterior surface of heart and runs left to right of surgeon ( called side on view).
This makes visibility and suturing easy with least disturbance to the hemodynamics.

In the picture below is surgeon’s view and LAD is easily exposed with just one sponge
and is seen on the anterior surface of heart running left to right ( side on view) .

It is true that a case is not referred for surgery unless LAD is significantly blocked ( >
50% & in proximal part) but that is not the reason why it should be grafted first.
583) C
584) B
INR values mentioned in MCQ 583 and 584 were evolved initially for Medtronic Hall
valve.
585) A
Post infarct VSD is a type of ‘rupture of heart’. Following a massive septal infarct, the
IVS muscle ruptures and results in an acute and massive L to R shunt, resulting in
 175

pulmonary edema. Hence PCWP cannot be normal at 8 mm of Hg. Patient is on

inotropes, due to poor LVEF. Vasodilators and IABP are instituted to reduce afterload
and increase forward flow to body. In case of pulmonary edema, the patient could be on
ventilator.

As there is severe necrosis of muscle, VSD sutures may not hold. For a better quality of
VSD margin, patient is intentionally conserved for 7-10 days and operated for VSD
closure.

To avoid airlock on CPB after cardiotomy, bicaval cannulation and snaring of SVC /IVC
is essential. The VSD is closed through LV infarct area.
586) C
A head low position during a) off-pump OM anastomosis to improve venous return and
BP b) retrograde cerebral perfusion to increase perfusion pressure and avoid air entering
cerebral arteries d) to avoid air entering ‘neck vessels’ and arch.
No such benefit is served by head-low during RCP.
587) B
A patent BT shunt connects high resistance systemic circuit to low resistance pulmonary
circuit. Take-down of shunt (i.e. closure of shunt) closes this communication and all the
arterial return blood, now, flows into systemic circuit.
As shunt is closed on full bypass before starting cooling, changes in pO2 and pCO2 don’t
take place.
588) C
589) D
It is not feasible to feel the tip of an aortic cannula.
590) B
LV distends due to AR. Distention of LV is detrimental to the myocardial integrity.
591) A
During conventional MVR in supine position, aorta is superior to LA. On opening LA for
MVR, air enters aortic root ( LA-LV-Ao). Hence, during a repeat cardioplegia aortic root
requires deairing, otherwise air will enter the anteriorly placed RCA.
 176

592) C
In a thoracoabdominal aneurysm, the main fear is of paraplegia due to spinal cord
ischemia. Spinal cord ischemia is prevented by reducing oxygen demand (hypothermia)
or by improving perfusion (reduce CSF pressure, distal aortic perfusion). Celiac artery
supplies stomach, spleen and liver and has no role in supplying blood to spinal cord.
593) B
MVR through conventional sternotomy should be performed with bicaval cannulation so
as to ensure adequate venous drainage during LA retraction for exposing mitral valve.
As ischemic MR is acute and LA is small, making it difficult to expose the mitral valve.
594) B
Aorto-pulmonary window is a communication between ascending aorta and MPA. There
is a large left to right shunt. During surgery, on full CPB, the arterial flow is diverted into
low resistance pulmonary circuit, resulting in large left heart return. As cooling is
instituted on CPB, the LV contractility decreases resulting in LV distension. Hence, aorta
is cross-clamped immediately on full bypass.
Other conditions when aorta is cross-clamped early are a) rupture of aneurysm of sinus of
Valsalva into RV: to avoid RV distention b) gross AR

Cardioplegia delivery can be by root cannula but RPA and LPA should be snared prior.
APW is closed through an aortotomy. Second cardioplegia , if required, is always by
ostial cannulation.
595) C
See above.
596) B
After excising any calcified valve, a surgeon gives cold saline washes to suck-out any
fine, particulate calcium.
597) C
The condition a) will cause low reservoir, low BP, RA empty on opening & no venous
airlock. The condition b) will cause low reservoir, normal BP, RA empty on opening &
no venous airlock. The condition d) will cause normal reservoir levels, low BP, RA full
due to high left heart return & no airlock.

In an ASD, due to large RA , the IVC cannula tip may remain in RA, instead of IVC,
and result in the same problem of airlock on opening RA.
598) D
 177

Major part of retrograde cardioplegia finds outlet through veno-venous connections into
RA & RV.
IVC has no openings of Thebesian veins.
599) C
RSPV or LA vent gets blocked by myxoma.
On opening LA the root-vent sucks air and is not useful.
600) C
Due to extensive inter-coronary anastomosis, cardioplegia delivered in one ostium
refluxes through the other ostium.
If cardioplegia delivery is proper, coronary veins initially turn jet black ( acidic blood is
washed out ) and later improve to pink red colour as oxygen saturation equilibrates.

Causes of inadequate ostial delivery are : 1) ostial stenosis not allowing engagement of
catheter 2) tip touching coronary artery wall, if cannula is not aligned with the direction
of the artery 3) short LM, cannula selectively perfusing LAD.