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Review Questions Choose the single BEST option. 3. A 45-year-old man was referred for surgical evalua- tion after a 4.6 cm ascending aortic aneurysm was 1. In the Arterial Revascularization Trial (ART), found. Cardiac catheterization demonstrated no sig- patients were randomly assigned to receive either nificant coronary artery disease. He has a murmur bilateral internal thoracic artery grafts or a standard heard best in the right second interspace and echo single left internal thoracic artery graft during coro- showed a bicuspid aortic valve with a valve area of nary artery bypass grafting. The intention-to-treat 0.9 cm2. With respect to the patient’s care, which of analysis at 10 years follow-up reported the following statements is true? A. significantly improved all-cause mortality in the A. Aortic pathology is anticipated to show increased bilateral internal thoracic artery grafts group. fibrillin 1 content and decreased matrix metallopro- B. significant between-group difference in the rate of teinase 2 activity. repeat revascularization. B. Aortic valve replacement alone is the appropriate C. no significant differences between the two groups recommendation for this patient. for the composite outcomes of death from any cause, C. A Bentall procedure should be performed if the aor- myocardial infarction, or stroke. tic root is dilated. D. significant between-group differences in cardiac D. Expectant followup of this patient is expected to mortality. show an aortic dilation rate equivalent to patients E. significant between-group differences in stroke rate. with tricuspid aortic valves. 2. A 60-year-old otherwise healthy man underwent suc- E. Reduction aortoplasty and supracoronary tube graft- cessful aortic valve replacement for severe aortic ste- ing (in addition to AVR) yield comparable long-term nosis with mild insufficiency. Preoperative angiogram results. showed minimal coronary disease. During the opera- 4. One week ago a 40-year-old man patient on chronic tion initial arrest was with cold antegrade cardiople- hemodialysis underwent AVR with a mechanical gia though an aortic cannula, and maintenance was valve for calcific aortic stenosis. Preoperative ven- with intermittent cold retrograde cardioplegia. A left tricular function was normal. A routine followup ventricular vent was used. Several hours postop as he transthoracic echo identified a paravalvular leak in was waking up there were multiple witnessed grand the non-coronary sinus with a vena contracta of mal seizures and hemodynamic evidence of right 0.6 cm. Discharge plans are complete and the patient ventricular dysfunction with several episodes of non-­ is asymptomatic. Blood cultures are negative, there is sustained ventricular tachycardia. no evidence of hemolysis and the ejection fraction is The most appropriate management is 45%. Which of the following is the best treatment A. Hundred percent oxygen, induced hypertension and option? hyperdynamic condition, and avoidance of A. Observation until spontaneous resolution or devel- hyperthermia. opment of symptoms. B. Emergent cardiac catheterization and possible per- B. Percutaneous catheter intervention to place an cutaneous interventions. occlude device. C. Hyperbaric therapy with 50% oxygen and 50% C. Reoperation for valve re-replacement using a bio- nitrogen at a pressure of 3 atm. prosthetic valve. D. Immediate reoperation to place multiple coronary D. Reoperation for valve re-replacement using another artery grafts with saphenous vein segments. mechanical valve. E. IV anticonvulsant therapy, emergent CT scan of the E. Reoperation to close the defect with pledgeted chest and neurosurgical consultation. sutures. © Springer Nature Switzerland AG 2020 1011 S. G. Raja (ed.), Cardiac Surgery, https://doi.org/10.1007/978-3-030-24174-2 1012 Review Questions 5. A 78-year-old man with diabetes, high cholesterol, operative transthoracic echocardiography shows and well controlled hypertension presented with exer- severe ischemic mitral valve regurgitation with LVEF tional chest pain and shortness of breath. He has 35% and moderate-to-severe tricuspid valve regurgi- never had a stroke or TIA, he lives independently and tation. Pre-bypass TEE now shows mild mitral regur- remains active. Non-specific ECG changes and crite- gitation and mild tricuspid valve regurgitation. ria for left ventricular hypertrophy were present on Which of the following statements is correct? ECG. Cardiac catheterization demonstrated severe A. CABG and mitral valve repair will lower PA pres- multivessel disease with an ejection fraction of 50%, sure, so concomitant tricuspid annuloplasty is not and a carotid duplex showed a 50–70% and 60–75% indicated. stenoses of the right and left internal carotid arteries, B. A complete tricuspid ring annuloplasty is preferred respectively. At the time of surgery the initial TEE to avoid future dilatation of the posterior annulus. demonstrates an aortic valve area of 1.15 cm2 and C. A flexible mitral annuloplasty ring is best to pre- heavy calcification of the annulus and leaflets. serve mitral annular mobility and ventricular Which of the following is the best operation for contractility. this patient? D. The patient’s poor left ventricular function suggests A. Off-pump multivessel bypass grafting alone and sur- that concomitant tricuspid valve repair is prudent. veillance of the carotid stenoses and aortic stenosis E. The present TEE findings indicate that CABG alone B. Off-pump multivessel bypass grafting with antici- is adequate—mitral annuloplasty is not required. pated percutaneous transcatheter aortic valve 8. A 63-year-old woman presented to the emergency replacement in the near future. department complaining of shortness of breath and C. On-pump multivessel bypass grafting and surveil- recurrent chest pain. Five days before she had acute lance of the carotid stenoses and aortic stenosis. chest pain that spontaneously resolved. Her past med- D. On-pump multivessel bypass grafting and replace- ical history was notable only for hypertension. Physical ment of the aortic valve with a bioprosthetic valve. examination confirms dyspnoea at rest. Blood pres- E. On-pump multivessel bypass grafting, bioprosthetic sure is 80/50, heart rate is 100, and her skin is cool and AVR and left carotid endarterectomy. clammy. An ECG shows sinus tachycardia with ST 6. Fifteen years ago a 75-year-old woman underwent elevations in the anterior leads. This woman’s echo- coronary artery bypass grafting with saphenous vein cardiogram shows a large anterior effusion with dia- grafts to the LAD, obtuse marginal, and posterior stolic RV collapse and impaired LV function with descending arteries. She developed unstable angina posterior akinesis suggesting postinfarction free wall and a cath revealed a 90% left main stenosis and ventricular rupture. This patient is best managed by occlusions of the native right coronary and the OM A. Angioplasty, bare metal stenting of the LAD, and and PDA grafts. There was a 90% stenosis of the delayed coronary artery bypass grafting. saphenous vein graft to the LAD. At reoperation, a B. Beta blockers, IV fluids, and septal myomectomy LIMA was placed to the LAD and the old saphenous when stable. vein graft was ligated. New saphenous vein grafts C. Emergent circumflex CABG and myocardial rein- were placed to the obtuse marginal and PDA. The forcement with sutures and felt pledgets. patient cannot be weaned from bypass because of left D. Pericardiocentesis, intra-aortic balloon placement, heart failure and anterior akinesis. TEE shows no and inotropic support. valve pathology, and ultrasonic flow measurements E. Prompt surgical intervention with a glued epicardial of the LAD, OM and PDA grafts are 26, 50, and patch. 35 mL/min respectively. Which of the following is the 9. A 56-year-old man underwent a 3-vessel coronary most appropriate action to take? artery bypass following a recent myocardial infarction. A. Go back on bypass and re-do the LIMA-LAD Grafts included LIMA to LAD, radial artery graft to anastomosis. OM1, and saphenous vein graft to the PDA. This was B. Place a left ventricular assist device. done on cardiopulmonary bypass with a warm beating C. Remove the ligature from the saphenous vein graft heart. Thirty-six hours postoperatively the patient is to the LAD. noted to be in severe respiratory distress with increased D. Place an intra-aortic balloon pump and add inotropic work of breathing. He is on a face mask with 100% support. inspired oxygen. Pulmonary artery pressure is 55/35, E. Return to bypass and place a saphenous vein graft to cardiac index is 1.7, and mean arterial pressure is the LAD. 50 mmHg. Physical exam reveals significant rales and 7. A 68-year-old man is about to undergo coronary a systolic murmur. His chest radiograph shows severe bypass grafting and mitral valve surgery. Coronary pulmonary edema. Which of the following is the next angiography reveals severe 3-vessel disease and pre- step in the management of this patient? Review Questions 1013 A. Begin an epinephrine (adrenaline) infusion ular function with anteroapical wall akinesis. A saphe- B. Do a stat coronary catheterization nous vein graft was placed to the LAD distal to the C. Initiate a furosemide infusion LIMA anastomosis to no avail. A short-term LVAD D. Obtain a stat echocardiogram was placed with left atrial inflow via the right superior E. Start a phenylephrine infusion pulmonary vein and an outflow graft anastomosed to 10. Three months ago a 56-year-old man suffered an the ascending aorta. The next day his hemodynamics anterior wall myocardial infarction. An echocardio- included: LVAD flow 4.0 L/min, PA 33/25 (mean 29), gram shows an apical aneurysm. Which of the fol- RA 27, heart rate 95. His urine output was 20 mL/h on lowing statements about his condition is true? a furosemide drip at 20 mg/h. Serum creatinine was A. All lesions of this type that exceed 3 cm should be 2.5 mg/dL (rising), and he remained coagulopathic repaired regardless of symptoms. despite massive blood component transfusion.

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