NCCPA CAQ Cardiovascular and Thoracic Surgery

A 68-year-old man is being evaluated for elective CABG. Which scoring system is most widely used in the United States to predict 30-day operative mortality for cardiac surgery?

• ASTS Adult Cardiac Surgery Risk Score
• BCHA2DS2-VASc
• CHAS-BLED
• DWells score

A patient is scheduled for non-cardiac surgery. Which tool is used to estimate perioperative cardiac risk based on history of ischemic heart disease, heart failure, cerebrovascular disease, insulin-dependent diabetes, creatinine >2.0 mg/dL, and high-risk surgery?

• ARevised Cardiac Risk Index (RCRI)
• BSTS score
• CEuroSCORE II
• DNYHA class

A 75-year-old woman on chronic metoprolol presents for elective CABG. Per ACC/AHA guidance, beta-blocker therapy should be:

• AContinued perioperatively
• BStopped 7 days preop
• CSwitched to clonidine
• DStarted high-dose the morning of surgery if naive

A patient on warfarin for a mechanical mitral valve requires elective CABG. Which is the most appropriate bridging strategy?

• AStop warfarin 5 days preop and bridge with therapeutic heparin
• BContinue warfarin through surgery
• CStop warfarin 24 hours preop, no bridging
• DSwitch to apixaban one week preop

Which preoperative test is most useful for evaluating functional capacity (METs) in a patient considering cardiac surgery?

• ADetailed activity history (e.g., climbing 2 flights of stairs)
• BResting ECG
• CChest x-ray
• DBNP level

An 80-year-old man with severe AS is being evaluated for TAVR vs SAVR. Which assessment tool best quantifies frailty and predicts adverse outcomes?

• AGait speed (5-meter walk test)
• BResting heart rate
• CHand grip duration alone
• DBody mass index

EuroSCORE II differs from the original additive EuroSCORE by:

• AUsing logistic regression with updated contemporary outcomes
• BExcluding patient age
• CBeing limited to off-pump CABG
• DUsing only echocardiographic data

Which preoperative pulmonary function value is most concerning for postoperative respiratory failure after lobectomy?

• APredicted postoperative FEV1 <40%
• BFEV1/FVC ratio of 0.78
• CDLCO of 90% predicted
• DResting SpO2 98% on room air

A patient has stable CAD and is scheduled for elective AAA repair. Recent stress testing shows no inducible ischemia. The next step is:

• AProceed to surgery with optimized medical therapy
• BRoutine preoperative coronary revascularization
• CCancel surgery
• DCardiac catheterization

A patient with a drug-eluting stent placed 9 months ago needs urgent CABG. Per current guidelines, dual antiplatelet therapy management should:

• AContinue aspirin perioperatively, hold P2Y12 inhibitor 5-7 days
• BStop both aspirin and clopidogrel 14 days preop
• CContinue both DAPT through surgery
• DStop aspirin only, continue clopidogrel

Which lab abnormality most strongly predicts adverse outcomes after cardiac surgery and is incorporated into the STS risk model?

• AElevated serum creatinine
• BMild hyponatremia
• CMild hypokalemia
• DElevated alkaline phosphatase

For a patient with severe COPD planned for thoracotomy and lobectomy, which intervention should be optimized preoperatively?

• ASmoking cessation and pulmonary rehabilitation
• BRoutine systemic steroids
• CEmpiric antibiotics
• DDiuresis to dehydration

Which preoperative imaging is most useful to define coronary anatomy before redo cardiac surgery?

• ACoronary angiography with cross-sectional CT for sternal re-entry planning
• BTransthoracic echocardiogram alone
• CChest radiograph alone
• DVentilation-perfusion scan

A patient with poorly controlled diabetes (A1c 11%) is scheduled for elective CABG. The most appropriate plan is:

• ADelay surgery to optimize glycemic control when feasible
• BProceed with no glycemic intervention
• CInitiate sliding-scale insulin only intraoperatively
• DSwitch to oral agents only

Which preoperative finding most strongly suggests need for a Heart Team evaluation in a patient with severe symptomatic aortic stenosis?

• AMultiple comorbidities and intermediate or high surgical risk
• BIsolated AS with low STS score
• CAsymptomatic moderate AS
• DNormal LV ejection fraction with low STS score

In CABG, the gold-standard conduit for the left anterior descending (LAD) artery is:

• ALeft internal mammary artery (LIMA)
• BSaphenous vein
• CRadial artery
• DRight gastroepiploic artery

Compared with on-pump CABG, off-pump CABG is associated with:

• ALower transfusion requirement but possibly lower graft patency
• BHigher mortality in all patients
• CLower stroke rate that is statistically clinically dramatic
• DUniversal superiority in all subgroups

A patient with severe symptomatic AS, age 82, STS score 9%, and significant frailty is best treated with:

• ATAVR
• BSurgical AVR with mechanical valve
• CBalloon valvuloplasty alone as definitive therapy
• DMedical management only

Which valve approach is preferred for a young (35-year-old) patient with severe MR who has degenerative posterior leaflet prolapse?

• AMitral valve repair
• BMechanical mitral valve replacement
• CBioprosthetic mitral replacement
• DMitraClip transcatheter edge-to-edge repair

A patient with mechanical aortic valve has an INR goal of:

• A2.5 (range 2.0-3.0)
• B1.5 (range 1.0-2.0)
• C3.5 (range 3.0-4.0) routinely
• DNo anticoagulation needed

During CABG, after distal anastomoses are completed and the aortic cross-clamp is removed, the patient develops persistent ventricular fibrillation. Initial step is:

• AInternal defibrillation
• BExternal cardioversion at 50 J
• CHigh-dose epinephrine bolus
• DReapply cross-clamp immediately

What is the primary purpose of cardioplegia during cardiac surgery?

• AInduce diastolic arrest and protect the myocardium during ischemia
• BMaintain pulmonary perfusion
• CReplace systemic anticoagulation
• DProvide nutritional support

Which valve procedure carries the highest risk of permanent pacemaker requirement?

• ATAVR (especially self-expanding valves)
• BSurgical AVR with bioprosthesis
• CMitral valve repair
• DCABG

What is the primary indication for the Maze procedure performed at the time of cardiac surgery?

• AAtrial fibrillation
• BVentricular tachycardia
• CSick sinus syndrome
• DComplete heart block

A 60-year-old man undergoing CABG has multiple grafts. The radial artery is harvested. Postoperative management of radial conduits typically includes:

• ACalcium channel blocker (e.g., diltiazem) to reduce spasm
• BLifelong warfarin
• CAspirin avoidance
• DNo special therapy

What is the most appropriate surgical option for a patient with severe symptomatic ischemic functional MR and multivessel CAD?

• ACABG with mitral valve repair or replacement (Heart Team decision)
• BIsolated CABG without mitral intervention
• CIsolated mitral repair
• DMedical therapy only

In the BEST evidence for heart transplantation, the standard immunosuppression regimen typically includes:

• ACalcineurin inhibitor + antimetabolite + corticosteroid
• BSingle-agent cyclosporine
• CMycophenolate alone
• DSteroids alone

During mitral valve surgery, which structure is most at risk of injury during posterior annular suturing?

• ACircumflex coronary artery
• BPhrenic nerve
• CRight coronary artery
• DLeft main coronary artery

A 70-year-old woman undergoes SAVR. On postoperative day 3, she has new complete heart block. Most appropriate management is:

• ATemporary pacing with consideration for permanent pacemaker if persistent
• BReoperation immediately
• CBeta-blocker therapy
• DObservation only

Bioprosthetic valves are generally preferred over mechanical valves in:

• APatients >65-70 years or those with contraindications to anticoagulation
• BPatients <40 years with no comorbidities
• CPatients on lifelong warfarin for other reasons
• DPatients with mechanical valves already in place

A patient undergoes ascending aortic aneurysm repair. The most common indication for elective surgery is an aortic diameter of:

• A>5.5 cm in most patients (lower thresholds in connective tissue disease)
• B3.5 cm regardless of risk
• C8 cm regardless of risk
• DAny size if asymptomatic

Which finding is most consistent with acute Stanford Type A aortic dissection?

• ASevere chest/back pain with mediastinal widening on CXR and intimal flap on CT
• BGradual pleuritic chest pain
• CPain relieved with nitroglycerin
• DBilateral lower extremity weakness as initial presentation

A patient with acute Stanford Type B aortic dissection without complications is best managed initially with:

• AAnti-impulse therapy (IV beta-blocker) and blood pressure control
• BEmergent open repair
• CImmediate TEVAR for all cases
• DThrombolysis

After CABG, which evidence-based therapy reduces graft thrombosis and is recommended within 6-24 hours postop?

• AAspirin
• BWarfarin
• CSubcutaneous LMWH long-term
• DClopidogrel monotherapy

Which is the most common indication for redo cardiac surgery?

• ABioprosthetic valve degeneration
• BMechanical valve thrombosis
• CSuture line infection
• DConduction abnormalities

In TAVR, the most commonly used vascular access is:

• ATransfemoral
• BTransapical
• CDirect aortic
• DSubclavian

Which complication is uniquely associated with paravalvular leak after TAVR?

• AHemolytic anemia and persistent heart failure
• BSternal wound infection
• CPhrenic nerve injury
• DMyasthenia gravis exacerbation

For a young patient with bicuspid aortic valve and severe AR who needs surgery, an option that preserves the native valve is:

• AAortic valve repair with/without root replacement (David or Yacoub procedure)
• BBentall procedure with mechanical valve
• CRoss procedure for all comers
• DTAVR

During cardiopulmonary bypass, the activated clotting time (ACT) is typically maintained above:

• A480 seconds
• B180 seconds
• C60 seconds
• D1200 seconds

What is the antagonist used to reverse heparin after coming off cardiopulmonary bypass?

• AProtamine sulfate
• BVitamin K
• CAndexanet alfa
• DIdarucizumab

What VATS lobectomy advantage compared to open thoracotomy is best supported by data?

• ALess postoperative pain and shorter length of stay
• BHigher 5-year survival in stage I disease
• CLower long-term cancer recurrence in all stages
• DCheaper operating room cost

After lobectomy, persistent air leak from the chest tube on postop day 5 is best managed initially with:

• AContinued chest tube drainage and consideration of water seal
• BImmediate pleurodesis
• CReoperation
• DRemoval of chest tube

For a 2 cm peripheral non-small cell lung cancer in a patient with limited pulmonary reserve, which resection is most appropriate?

• ASublobar resection (segmentectomy or wedge)
• BPneumonectomy
• CBilateral lobectomy
• DTracheal resection

A chest tube placed for pneumothorax is connected to a three-chamber drainage system. Continuous bubbling in the air-leak chamber indicates:

• AAn air leak from the patient or system
• BNormal respiratory variation
• CSystem malfunction with no clinical relevance
• DTube occlusion

An anterior mediastinal mass in a 30-year-old man with elevated AFP and beta-hCG is most likely:

• ANonseminomatous germ cell tumor
• BThymoma
• CLymphoma
• DTeratoma (mature)

The classic '4 T's' of anterior mediastinal masses include thymoma, teratoma, thyroid (substernal goiter), and:

• ATerrible lymphoma
• BTracheal cyst
• CThoracic aortic aneurysm
• DThrombus