AACN Cardiac Surgery Certification (CSC) — Questions and Answers

Question 1: The 'elephant trunk' technique in staged total aortic replacement is performed to:

Bypass the coronary arteries during arch replacement
Leave a free-floating graft segment in the descending aorta to facilitate the second-stage repair (Correct answer)
Enable percutaneous completion of the arch repair
Repair the descending aorta in a single stage

Correct answer: Leave a free-floating graft segment in the descending aorta to facilitate the second-stage repair

The elephant trunk leaves a graft tail hanging in the descending aorta after Stage 1 arch repair, providing a landing zone for Stage 2 descending aortic repair.

Question 2: Which valve position carries the highest risk of prosthetic valve thrombosis if anticoagulation is subtherapeutic?

Aortic mechanical valve
Mitral mechanical valve (Correct answer)
Pulmonary bioprosthetic valve
Tricuspid bioprosthetic valve

Correct answer: Mitral mechanical valve

Mitral mechanical valves have the highest thrombotic risk among prosthetic valves due to lower transvalvular gradients and higher stagnation of blood flow, requiring stricter INR targets.

Question 3: Neurological complications after cardiac surgery, including stroke, are most often caused by:

Anesthesia neurotoxicity
Cerebral embolism from atheromatous aortic debris or air (Correct answer)
Cerebral vasospasm
Prolonged hypotension alone

Correct answer: Cerebral embolism from atheromatous aortic debris or air

Macroemboli from atheromatous aortic plaque dislodged during cannulation/clamping and air introduced during bypass are the leading causes of perioperative stroke.

Question 4: Competitive flow in a coronary bypass graft occurs when:

Two grafts are placed to the same coronary territory
The bypass graft flow is greater than native coronary flow
The graft is kinked near the anastomosis
A native coronary with moderate stenosis provides sufficient native flow to outcompete the graft (Correct answer)

Correct answer: A native coronary with moderate stenosis provides sufficient native flow to outcompete the graft

Competitive flow occurs when the native coronary is not critically stenosed, allowing antegrade native flow to compete with graft flow and potentially causing graft failure.

Question 5: How sleepy does Azatadine normally make you feel?

Extreme
Little to none
Moderate (Correct answer)
Some

Correct answer: Moderate

One of the antihistamines with a modest level of sleepiness is azatadine. Additionally, it has mild anticholinergic properties. Confusion, dry mouth, impaired vision, and constipation are just a few of the side effects of anticholinergics.

Question 6: During mitral valve repair, the P2 scallop of the posterior leaflet is resected and reapproximated. What additional step is routinely performed to prevent systolic anterior motion (SAM)?

Ring annuloplasty (Correct answer)
Anterior leaflet augmentation
Chordal transfer
Commissurotomy

Correct answer: Ring annuloplasty

Ring annuloplasty reduces the annular diameter and remodels the mitral valve, which is essential to prevent SAM and ensure durable repair after posterior leaflet resection.

Question 7: What is the preferred surgical option for mitral regurgitation due to posterior leaflet prolapse with good tissue quality?

Mitral valve repair (Correct answer)
Mechanical valve replacement
Bioprosthetic valve replacement
Transcatheter edge-to-edge repair

Correct answer: Mitral valve repair

Mitral valve repair is the gold standard for posterior leaflet prolapse because it preserves native tissue, avoids prosthetic valve risks, and provides excellent long-term outcomes.

Question 8: Which flow rate is considered the standard index flow for normothermic cardiopulmonary bypass in adults?

1.0–1.2 L/min/m²
3.5–4.0 L/min/m²
0.5–0.8 L/min/m²
2.2–2.4 L/min/m² (Correct answer)

Correct answer: 2.2–2.4 L/min/m²

An index flow of 2.2–2.4 L/min/m² is the standard for normothermic CPB, approximating normal cardiac index and ensuring adequate systemic oxygen delivery.

Question 9: Which surgical technique for Ebstein anomaly repair involves detaching and rotating the available leaflet tissue to create a cone-shaped valve?

Damus-Kaye-Stansel anastomosis
Konno-Rastan aortoventriculoplasty
Cone reconstruction (da Silva technique) (Correct answer)
Danielson repair with posterior plication

Correct answer: Cone reconstruction (da Silva technique)

The cone reconstruction (da Silva technique) detaches, rotates, and reattaches the leaflet tissue to create a three-dimensional cone resembling a normal tricuspid valve, with superior long-term outcomes.

Question 10: The Konno-Rastan procedure (aortoventriculoplasty) is indicated for which condition?

Subaortic membrane with a mild 20 mmHg gradient
Bicuspid aortic valve with moderate stenosis and adequate annulus size
Severe tunnel-type subaortic stenosis with an annulus too small for adequate prosthesis (Correct answer)
Supravalvular aortic stenosis associated with Williams syndrome

Correct answer: Severe tunnel-type subaortic stenosis with an annulus too small for adequate prosthesis

The Konno-Rastan procedure enlarges the aortic annulus and LVOT by incising the interventricular septum, indicated when severe subaortic obstruction is accompanied by a small annulus inadequate for a standard prosthesis.

Question 11: Which of the following criteria is true when weaning patients off of artificial ventilation during the early postoperative period?

Slight arrhythmia
Core temperature of 35.2 C
Heart rate of 124 bpm
Chest tube drainage of 40 mL/hr (Correct answer)

Correct answer: Chest tube drainage of 40 mL/hr

The criteria ( 50 mL/hr) for weaning from ventilation in the initial postoperative period are met by chest tube drainage of 40 mL/hr. Awakens without stimulation and a sufficient reversal of neuromuscular inhibition are further requirements. The ideal core temperature is greater than 35.5°C. With a cardiac index of over 2.2 L/min/m2, a systolic blood pressure of 100–140 mm Hg, a heart rate of less than 120 bpm, and no arrhythmias, hemodynamic status should be stable. The pH of the blood should be between 7.30 and 7.50, the partial pressure of carbon dioxide should be under 50 torr, the partial pressure of oxygen in the arterial blood should be over 75 torr, and the fraction of inspired oxygen (FiO2) should be at or above 0.5.

Question 12: To reduce the risk of a wound infection, early postoperative blood glucose levels should be kept below which of the following values?

110/mg/dL
180 mg/dL (Correct answer)
160 mg/dL
140 mg/dL

Correct answer: 180 mg/dL

For the first 48 hours following surgery, blood glucose levels should be kept below 180 mg/dL to lower the risk of wound infection in both diabetics and non-diabetics. The most popular insulin is Novolin R, which is administered as a bolus and is then followed by a 100 U/100 mL normal saline infusion. It is not advised to lower blood sugar to fewer than 120 mg/dL. Increased insulin resistance brought on by a stress reaction, total parenteral feeding without an appropriate insulin response, and sepsis may result in hyperglycemia following surgery.

Question 13: What are the two classifications of aneurysm?

Cranial and Caudal
Saccular Aneurysm
Aortic and Ventricular
Saccular and Fusiform (Correct answer)

Correct answer: Saccular and Fusiform

Aneurysms are classified by shape into saccular (a pouch-like outpouching on one side of the vessel) and fusiform (a diffuse, spindle-shaped dilation around the whole circumference). The other pairings either name only one type or use anatomical terms that aren't standard aneurysm shape classifications.

Question 14: The internal mammary artery (IMA) is preferred for coronary bypass grafting because:

It has greater diameter matching all coronary targets
It is easier to harvest
It has superior long-term patency compared to saphenous vein grafts (Correct answer)
It requires less anticoagulation

Correct answer: It has superior long-term patency compared to saphenous vein grafts

The left internal mammary artery has a 10-year patency rate exceeding 90%, far superior to saphenous vein grafts (50–60%), making it the gold-standard conduit.

Question 15: The primary indication for the Impella device in cardiac surgery patients is:

Temporary pacing
Mechanical support for cardiogenic shock or high-risk procedures requiring LV unloading (Correct answer)
Prevention of atrial fibrillation
Treatment of aortic stenosis

Correct answer: Mechanical support for cardiogenic shock or high-risk procedures requiring LV unloading

The Impella is an axial flow pump placed across the aortic valve to actively unload the LV and provide hemodynamic support in cardiogenic shock or high-risk interventions.

Question 16: The diameter threshold that generally triggers surgery for an ascending aortic aneurysm in a patient with a bicuspid aortic valve is:

4.0 cm
5.5 cm (or 5.0 cm with additional risk factors) (Correct answer)
7.0 cm
6.5 cm

Correct answer: 5.5 cm (or 5.0 cm with additional risk factors)

Current guidelines recommend surgery for bicuspid aortic valve-associated ascending aneurysms at 5.5 cm, or at 5.0 cm when risk factors such as rapid growth or family history are present.

Question 17: Which suture technique is associated with the lowest risk of perivalvular leak in aortic valve replacement?

Horizontal mattress sutures with pledgets (Correct answer)
Continuous running suture
Figure-of-eight sutures
Simple interrupted sutures

Correct answer: Horizontal mattress sutures with pledgets

Horizontal mattress sutures buttressed with Teflon pledgets distribute tension and improve tissue sealing at the annulus, reducing the incidence of perivalvular leakage.

Question 18: Perioperative myocardial infarction after CABG is most often caused by:

Early graft occlusion or technical anastomotic failure (Correct answer)
Postoperative atrial fibrillation
Prolonged CPB time alone
Anesthesia complication

Correct answer: Early graft occlusion or technical anastomotic failure

Early graft occlusion due to technical anastomotic issues, thrombosis, or spasm is the most common cause of perioperative MI after CABG.

Question 19: What phase, if any, comes last in a nursing procedure?

Remove protective equipment
Record and report the procedure (Correct answer)
Restore the unit by removing used equipment, cleaning items, and storing them properly
Check the patient's chart

Correct answer: Record and report the procedure

Any nursing procedure must be documented and reported in accordance with the chosen charting technique as the last step. The charge nurse or doctor should be informed of any irregularities.

Question 20: Which hemodynamic finding is characteristic of severe aortic stenosis requiring surgical intervention?

Mean gradient less than 20 mmHg with preserved ejection fraction
Pulmonary capillary wedge pressure below 10 mmHg
Aortic valve area greater than 1.5 cm²
Mean aortic valve gradient greater than 40 mmHg with valve area less than 1.0 cm² (Correct answer)

Correct answer: Mean aortic valve gradient greater than 40 mmHg with valve area less than 1.0 cm²

Severe AS is defined by a mean gradient >40 mmHg and aortic valve area <1.0 cm², indicating the need for intervention.

Question 21: The proximal anastomosis of a saphenous vein graft in conventional CABG is most commonly placed on:

The internal mammary artery as a Y-graft
The ascending aorta (Correct answer)
The subclavian artery
The descending thoracic aorta

Correct answer: The ascending aorta

Proximal vein graft anastomoses are most commonly placed on the ascending aorta, though no-touch aortic techniques are increasingly used to reduce embolic risk.

Question 22: The primary goal of glucose management in the cardiac surgery ICU is to maintain blood glucose between:

140–180 mg/dL (Correct answer)
100–110 mg/dL
70–100 mg/dL
200–250 mg/dL

Correct answer: 140–180 mg/dL

Current evidence supports maintaining blood glucose between 140–180 mg/dL in cardiac surgery ICU patients, balancing infection risk against hypoglycemia harm.

Question 23: The most common causes of acute renal failure and the need for renal replacement therapy include

Hypovolemia, metabolic, alkalosis, and hypokalemia
Increasing levels of serum creatinine
Initial signs of oliguria
Fluid overload, metabolic acidosis, and hyperkalemia (Correct answer)

Correct answer: Fluid overload, metabolic acidosis, and hyperkalemia

Indications for renal replacement therapy (RRT) include metabolic acidosis, fluid overload, and hyperkalemia. Increased disorientation, pericarditis, or gastrointestinal bleeding are some further warning signs. Increased oliguria and serum creatinine necessitate further analysis and could initiate RRT to stop further kidney damage. For patients needing RRT following heart surgery, intermittent hemodialysis (given over 3–4 hours three times a week) and continuous venovenous hemofiltration are frequently employed. Slow continuous ultrafiltration, continuous venovenous hemofiltration, and continuous venovenous hemodiafiltration are all examples of continuous venovenous systems.

Question 24: The #11 knife blade is used to cut open the coronary artery (or Beaver blade), and the incision is extended with Dietrich or fine _______ coronary scissors.

Penfield
Allen
Potts (Correct answer)
Lowman

Correct answer: Potts

The correct term to complete the sentence is "Potts." The incision made in the coronary artery with a #11 knife blade is extended using Dietrich or fine Potts coronary scissors. Potts coronary scissors are a specific type of surgical scissors designed for delicate dissection and cutting in cardiovascular procedures, including coronary artery surgeries. They are commonly used in cardiac surgery to precisely extend the incision in the coronary artery for various interventions, such as bypass grafting or other procedures involving the coronary arteries.

Question 25: Which blood product is most effective for reversing coagulopathy due to dilutional platelet loss after prolonged cardiopulmonary bypass?

Packed red blood cells
Cryoprecipitate
Fresh frozen plasma (FFP)
Platelet concentrate (Correct answer)

Correct answer: Platelet concentrate

Platelet transfusion directly replaces the diluted platelets and is first-line treatment for platelet-related coagulopathy after prolonged CPB.

Question 26: Chest tubes are inserted into the mediastinum and right pleural cavity of a patient recovering after mitral valve replacement and cardiopulmonary bypass, with suction adjusted at -20 cm H2O. 120 mL of bloody discharge was produced in the first four hours; however, when the patient is shifted to the side, 70 mL of dark red blood instantly drains out the chest tube, followed by a slowing of the flow. Currently, hemodynamic condition is stable. The most probable reason for the elevated discharge is

Pooling of blood (Correct answer)
Repositioning of the chest tube
Acute onset of bleeding
Inadequate protamine dosing

Correct answer: Pooling of blood

The pooling of blood may produce higher outflow from the chest tube when the patient is moved. Bright crimson blood and a steady stream of discharge are signs of acute onset bleeding. In particular, if discharge slows down after first speeding up, dark red blood signifies older blood rather than recent bleeding. No more than 200 mL in 2–6 hours of chest tube drainage should be used. A transesophageal echocardiography may be necessary if there is a suspicion of cardiac tamponade in addition to coagulation testing, repeat chest x-rays to measure the width of the mediastinum, and excessive bleeding.

Question 27: During the Norwood Stage I procedure for hypoplastic left heart syndrome, which key anastomosis creates unobstructed systemic outflow?

Superior vena cava to right pulmonary artery (Glenn anastomosis)
Fontan tunnel connecting the inferior vena cava to the pulmonary artery
Damus-Kaye-Stansel anastomosis connecting the proximal pulmonary artery to the aorta (Correct answer)
Blalock-Taussig shunt from the innominate artery to the pulmonary artery

Correct answer: Damus-Kaye-Stansel anastomosis connecting the proximal pulmonary artery to the aorta

The Damus-Kaye-Stansel anastomosis connects the proximal main pulmonary artery to the hypoplastic ascending aorta, creating an unobstructed outflow from the single right ventricle to the systemic circulation.

Question 28: The internal mammary artery receives its blood supply primarily from the:

Aortic arch directly
Intercostal arteries
Axillary artery
Subclavian artery (Correct answer)

Correct answer: Subclavian artery

The internal mammary (internal thoracic) artery arises from the first portion of the subclavian artery bilaterally, making subclavian stenosis an important preoperative consideration.

Question 29: Glucose management during cardiopulmonary bypass is important because hyperglycemia:

Worsens neurological outcomes and increases infection risk (Correct answer)
Reduces cardiac contractility directly
Decreases heparin effectiveness
Causes hypotension

Correct answer: Worsens neurological outcomes and increases infection risk

Hyperglycemia during CPB is associated with impaired neurological outcomes and increased risk of wound infection, necessitating tight glycemic control.

Question 30: The most common cause of death in patients supported on long-term LVAD therapy is:

Device thrombosis
Right heart failure
Device infection
Stroke (neurological events) (Correct answer)

Correct answer: Stroke (neurological events)

Stroke is the leading cause of death and disability in long-term LVAD patients, resulting from thromboembolic or hemorrhagic events related to the device.

Question 31: What is the preferred surgical approach for repair of an acute Type A aortic dissection in a hemodynamically stable patient?

Emergency open repair via median sternotomy (Correct answer)
Fenestration via catheter-based technique
Thoracic endovascular aortic repair (TEVAR)
Medical management with beta-blockers

Correct answer: Emergency open repair via median sternotomy

Acute Type A aortic dissection is a surgical emergency; emergency open replacement of the ascending aorta via sternotomy is the only definitive treatment to prevent rupture and malperfusion.

Question 32: Deep hypothermic circulatory arrest (DHCA) is used in aortic arch surgery primarily to:

Allow higher pump flow rates
Prevent coagulopathy
Enable off-pump arch reconstruction
Provide a bloodless operative field while protecting the brain and organs during circulatory pause (Correct answer)

Correct answer: Provide a bloodless operative field while protecting the brain and organs during circulatory pause

DHCA cools the patient to 15–20°C, dramatically reducing cerebral metabolic demand and allowing safe cessation of circulation for arch reconstruction.

Question 33: What is the standard target activated clotting time (ACT) before initiating cardiopulmonary bypass?

Greater than 400 seconds (Correct answer)
Greater than 300 seconds
Greater than 200 seconds
Greater than 150 seconds

Correct answer: Greater than 400 seconds

An ACT greater than 400 seconds is required before initiating CPB to prevent clot formation in the bypass circuit.

Question 34: The left ventricular assist device (LVAD) as destination therapy is indicated for patients with:

Reversible cardiogenic shock
Isolated right heart failure
Moderate heart failure with LVEF 35–45%
End-stage heart failure ineligible for transplantation requiring permanent mechanical support (Correct answer)

Correct answer: End-stage heart failure ineligible for transplantation requiring permanent mechanical support

Destination LVAD therapy provides permanent support for end-stage HF patients who are not transplant candidates, improving survival and quality of life.

Question 35: The most prevalent arrhythmia is atrial fibrillation. It can happen after heart surgery and with a variety of coronary illnesses. Atrial fibrillation: what is it?

Polarization of the atria
Polarization of ventricles
Depolarization of the atria (Correct answer)
Depolarization of the ventricles

Correct answer: Depolarization of the atria

Atrial depolarization patterns that occur quickly and erratically are the hallmarks of the arrhythmia known as atrial fibrillation. Multiple circuit reentries in the atria are the most likely culprits for this occurrence.

Question 36: Which of the following laboratory examinations examines platelet clumping potential?

Platelet count
CBC
PT
Platelet aggregation (Correct answer)

Correct answer: Platelet aggregation

To determine whether and how well platelets clump together, a platelet aggregation test is conducted. A blood disease and an elevated risk of bleeding can be suggested by ineffective clumping.

Question 37: Cardiac tamponade after cardiac surgery classically presents with:

Normal hemodynamics with chest pain only
Hypotension, elevated CVP, and equalization of filling pressures (Correct answer)
Hypertension, low CVP, and wide pulse pressure
Bradycardia and high cardiac output

Correct answer: Hypotension, elevated CVP, and equalization of filling pressures

Cardiac tamponade produces the classic triad of hypotension, elevated central venous pressure, and equalization of diastolic pressures across cardiac chambers.

Question 38: The hybrid coronary revascularization approach combines:

Robotic CABG with open sternotomy
CABG with transcatheter valve replacement
Off-pump CABG with intra-aortic balloon pump
LIMA-to-LAD CABG with percutaneous coronary intervention (PCI) for non-LAD lesions (Correct answer)

Correct answer: LIMA-to-LAD CABG with percutaneous coronary intervention (PCI) for non-LAD lesions

Hybrid revascularization uses the durable LIMA-LAD surgical graft for the LAD territory and PCI stenting for other vessels, combining the best of both approaches.

Question 39: Extracorporeal membrane oxygenation (ECMO) in adult cardiac surgery is used primarily as:

Primary bypass during elective CABG
Long-term destination therapy
Routine postoperative monitoring
Rescue therapy for refractory cardiogenic shock or cardiac arrest unresponsive to conventional support (Correct answer)

Correct answer: Rescue therapy for refractory cardiogenic shock or cardiac arrest unresponsive to conventional support

VA-ECMO provides both cardiac and respiratory support as a bridge to recovery or decision in patients with refractory cardiogenic shock after cardiac surgery.

Question 40: The most important complication to monitor for in patients on veno-arterial ECMO after cardiac surgery is:

Atrial septal defect
Hyperkalemia alone
Limb ischemia from the femoral arterial cannula and left ventricular distension (Correct answer)
Hypertension

Correct answer: Limb ischemia from the femoral arterial cannula and left ventricular distension

Femoral arterial cannulation can cause distal limb ischemia, and the ECMO circuit's retrograde flow can distend the non-ejecting LV, both requiring active monitoring.

Question 41: A pacemaker is a device that produces electrical impulses that stimulate the heart. This process is called _____________.

Stabilizing the heart
Pulmonary veins into the left atrium
Internal mammary artery
Pacing the heart (Correct answer)

Correct answer: Pacing the heart

The process of producing electrical impulses that stimulate the heart using a pacemaker is called "pacing the heart."

Question 42: What is the primary physiologic benefit of antegrade cerebral perfusion during deep hypothermic circulatory arrest?

It provides continuous metabolic substrate delivery to the brain (Correct answer)
It reduces systemic cooling requirements
It prevents air embolism
It maintains renal perfusion

Correct answer: It provides continuous metabolic substrate delivery to the brain

Antegrade cerebral perfusion via the carotid or axillary artery delivers oxygenated blood continuously to the brain, extending the safe circulatory arrest time beyond the limits of hypothermia alone.

Question 43: When a patient is discharged, you instruct her on how to take care of her PICC line. How frequently should you inform the patient that she needs to have her dressing changed?

Every 24 hours
Every 3 days
Every 7 days (Correct answer)
Only when soiled

Correct answer: Every 7 days

A clean dressing will be essential for protecting a patient's PICC line when she returns home. Every seven days, the dressing should be replaced. Patients should be instructed on how to change their own dressings and should also be informed that a helpful friend or family member should also be instructed on how to change dressings.

Question 44: During surgical repair of supracardiac total anomalous pulmonary venous connection, what is the critical anastomosis performed?

Ligation of the vertical vein with direct individual pulmonary vein reimplantation
Creation of a baffle directing pulmonary venous blood through the coronary sinus to the left atrium
Connection of the innominate vein directly to the left atrial appendage
Wide anastomosis between the posterior common pulmonary venous confluence and the posterior left atrium (Correct answer)

Correct answer: Wide anastomosis between the posterior common pulmonary venous confluence and the posterior left atrium

TAPVC repair requires creating a wide, tension-free posterior anastomosis between the common pulmonary venous confluence and the left atrium to restore normal pulmonary venous drainage without obstruction.

Question 45: Which cannulation site is preferred for arterial inflow in patients with severe ascending aortic atherosclerosis?

Femoral artery
Innominate artery
Axillary artery (Correct answer)
Ascending aorta

Correct answer: Axillary artery

The axillary artery is preferred in patients with porcelain aorta or severe ascending aortic atherosclerosis because it provides antegrade flow and avoids the diseased aorta.

Question 46: An intra-aortic balloon pump (IABP) improves cardiac function by:

Increasing heart rate to improve cardiac output
Inflating in diastole to augment coronary perfusion and deflating before systole to reduce afterload (Correct answer)
Pacing the ventricle during diastole
Providing continuous flow bypass of the left ventricle

Correct answer: Inflating in diastole to augment coronary perfusion and deflating before systole to reduce afterload

IABP counterpulsation inflates during diastole (augmenting coronary perfusion) and deflates just before systole (reducing LV afterload via aortic unloading).

Question 47: Low cardiac output syndrome after cardiac surgery is best initially managed with:

Anticoagulation
Immediate reoperation
Inotropic support and optimization of preload and afterload (Correct answer)
High-dose diuresis

Correct answer: Inotropic support and optimization of preload and afterload

Low cardiac output syndrome is managed by optimizing preload, reducing afterload, and adding inotropes to improve myocardial contractility.

Question 48: Which chromosomal abnormality is most strongly associated with complete atrioventricular septal defect?

Trisomy 21 (Down syndrome) (Correct answer)
Turner syndrome (45, X)
22q11.2 deletion (DiGeorge syndrome)
7q11.23 deletion (Williams syndrome)

Correct answer: Trisomy 21 (Down syndrome)

Trisomy 21 (Down syndrome) is present in approximately 70% of patients with complete AVSD, making it by far the most common chromosomal association with endocardial cushion defects.

Question 49: Which vessel is the preferred conduit when total arterial revascularization is planned for a bilateral CABG strategy?

Bilateral radial arteries
Bilateral internal mammary arteries (BIMA) (Correct answer)
Combined IMA and gastroepiploic artery
Bilateral saphenous veins

Correct answer: Bilateral internal mammary arteries (BIMA)

Bilateral IMA grafting provides the highest long-term patency rates for total arterial revascularization, though it increases the risk of sternal wound complications in diabetics.

Question 50: A bicuspid aortic valve is most commonly associated with which concomitant aortic pathology?

Infrarenal aortic aneurysm
Aortic arch hypoplasia
Ascending aortic dilation (Correct answer)
Aortic root aneurysm

Correct answer: Ascending aortic dilation

Bicuspid aortic valve is strongly associated with ascending aortic dilation due to shared genetic abnormalities in the aortic wall, independent of hemodynamic effects of valve dysfunction.

Question 51: Which cannulation site is most commonly used for arterial return during standard cardiopulmonary bypass?

Carotid artery
Axillary artery
Femoral artery
Ascending aorta (Correct answer)

Correct answer: Ascending aorta

The ascending aorta is the most common arterial cannulation site for CPB because it provides optimal flow and avoids retrograde perfusion risks.

Question 52: During minimally invasive mitral valve surgery via right mini-thoracotomy, what is the preferred method of aortic occlusion when the surgeon cannot reach the ascending aorta directly?

Intracoronary balloon catheter occlusion
Femoral artery cross-clamp
Endoaortic balloon occlusion catheter (Correct answer)
No aortic occlusion is needed

Correct answer: Endoaortic balloon occlusion catheter

An endoaortic balloon occlusion catheter (Heartport) placed via the femoral artery allows intraluminal aortic occlusion and antegrade cardioplegia delivery without direct aortic cross-clamping.

Question 53: In aortic valve replacement, what is the primary advantage of a sutureless bioprosthetic valve?

Better hemodynamics at large sizes
Lower cost
Reduced cross-clamp time (Correct answer)
Longer durability

Correct answer: Reduced cross-clamp time

Sutureless valves are secured without individual sutures, significantly reducing aortic cross-clamp and cardiopulmonary bypass times, which benefits high-risk patients.

Question 54: The Ross procedure involves:

Transferring the patient's own pulmonary valve to the aortic position with a homograft in the pulmonary position (Correct answer)
Implanting a transcatheter aortic valve via the femoral artery
Repairing the aortic valve leaflets using autologous pericardium
Replacing the aortic valve with a bovine pericardial bioprosthesis

Correct answer: Transferring the patient's own pulmonary valve to the aortic position with a homograft in the pulmonary position

The Ross procedure replaces the aortic valve with the patient's own pulmonary valve (autograft) and reconstructs the right ventricular outflow with a homograft, providing a living autograft without anticoagulation.

Question 55: In acute Type B aortic dissection, the primary indication for emergency intervention is:

Mild back pain without hemodynamic compromise
Hypertension alone
Malperfusion syndrome, rapid expansion, or impending rupture (Correct answer)
Any dissection extending below the renal arteries

Correct answer: Malperfusion syndrome, rapid expansion, or impending rupture

Uncomplicated Type B dissection is initially managed medically, but malperfusion, rapid aneurysmal expansion, or rupture mandate urgent TEVAR or open surgery.

Question 56: What is the primary long-term consequence of leaving a large, unrestrictive VSD untreated beyond early childhood?

Progressive right ventricular pressure overload causing right heart failure
Development of complete atrioventricular block from septal fibrosis
Spontaneous closure with formation of a ventricular aneurysm
Eisenmenger syndrome with irreversible pulmonary vascular obstructive disease (Correct answer)

Correct answer: Eisenmenger syndrome with irreversible pulmonary vascular obstructive disease

A large unrestrictive VSD causes sustained high-pressure, high-flow pulmonary hypertension, eventually leading to irreversible pulmonary vascular obstructive disease and shunt reversal (Eisenmenger syndrome).

Question 57: The DeBakey classification of aortic dissection Type I involves:

Dissection confined to the descending aorta
Dissection involving only the aortic arch
Dissection confined to the ascending aorta only
Dissection originating in the ascending aorta and extending into the descending aorta (Correct answer)

Correct answer: Dissection originating in the ascending aorta and extending into the descending aorta

DeBakey Type I dissection begins in the ascending aorta and propagates distally through the arch and into the descending aorta, requiring emergency surgery.

Question 58: Which intraoperative finding most commonly prompts conversion from off-pump to on-pump CABG?

Anesthesia failure
Hemodynamic instability during cardiac displacement (Correct answer)
Absence of epicardial fat
Inadequate conduit length

Correct answer: Hemodynamic instability during cardiac displacement

Hemodynamic instability when the heart is displaced to expose posterior targets is the most common reason for urgent conversion to CPB during OPCAB.

Question 59: A patient requires redo sternotomy for mitral valve replacement. What is the greatest risk during sternal re-entry?

Internal mammary artery transection
Injury to adherent right ventricle (Correct answer)
Aortic injury
Pulmonary artery laceration

Correct answer: Injury to adherent right ventricle

After prior cardiac surgery, the right ventricle commonly adheres to the posterior table of the sternum, making it vulnerable to laceration during oscillating saw re-entry.

Question 60: The Rastelli procedure is specifically designed to repair which combination of congenital defects?

Tetralogy of Fallot with absent pulmonary valve syndrome
Hypoplastic left heart syndrome with aortic atresia
D-TGA with VSD and left ventricular outflow tract obstruction (Correct answer)
Tricuspid atresia with normally related great arteries

Correct answer: D-TGA with VSD and left ventricular outflow tract obstruction

The Rastelli procedure repairs D-TGA with VSD and LVOT obstruction by creating an intracardiac LV-to-aorta tunnel through the VSD and placing an extracardiac RV-to-PA conduit.

Question 61: Which finding on intraoperative TEE after mitral valve repair suggests systolic anterior motion (SAM) of the mitral valve?

Anterior displacement of the anterior mitral leaflet into the LVOT with dynamic obstruction (Correct answer)
Aortic regurgitation
Mitral annular calcification
Posterior leaflet coaptation failure

Correct answer: Anterior displacement of the anterior mitral leaflet into the LVOT with dynamic obstruction

SAM occurs when a redundant or anteriorly displaced leaflet is drawn into the LVOT during systole by the Venturi effect, causing dynamic outflow obstruction.

Question 62: Which surgical technique can be used to implant a larger aortic prosthesis in patients with a small aortic root?

Mechanical valve downsizing
Aortic root enlargement (Nicks or Manouguian procedure) (Correct answer)
Sutureless valve implantation
Pulmonary autograft (Ross) only

Correct answer: Aortic root enlargement (Nicks or Manouguian procedure)

Root enlargement procedures like Nicks (extending into the anterior mitral leaflet) or Manouguian (into the aorto-mitral curtain) allow placement of a larger prosthesis.

Question 63: Which intraoperative monitoring is considered standard for major cardiac surgery requiring CPB?

Pulmonary artery catheter alone
Intracranial pressure monitoring
Electroencephalography
Transesophageal echocardiography (TEE) (Correct answer)

Correct answer: Transesophageal echocardiography (TEE)

TEE is standard during cardiac surgery because it provides real-time assessment of cardiac function, valve repair quality, air removal, and filling status.

Question 64: Which electrolyte abnormality is most commonly associated with cardiac arrhythmias following cardiopulmonary bypass?

Hyperkalemia
Hypomagnesemia (Correct answer)
Hypocalcemia
Hyponatremia

Correct answer: Hypomagnesemia

Hypomagnesemia is very common after CPB due to hemodilution and urinary losses, and predisposes patients to atrial and ventricular arrhythmias.

Question 65: Which feature of a bioprosthetic heart valve is its primary advantage over a mechanical valve?

Easier to implant
Does not require lifelong anticoagulation (Correct answer)
Lower cost
Greater durability beyond 20 years

Correct answer: Does not require lifelong anticoagulation

Bioprosthetic valves do not require long-term anticoagulation after the initial postoperative period, reducing hemorrhagic risks for appropriate patients.

Question 66: What is the most common indication for surgical repair of a ventricular septal defect (VSD) in adults?

Eisenmenger syndrome
Qp:Qs ratio >1.5:1 with symptoms (Correct answer)
Isolated murmur without shunt
Small membranous VSD with Qp:Qs <1.5:1

Correct answer: Qp:Qs ratio >1.5:1 with symptoms

Adult VSD repair is indicated when the pulmonary-to-systemic flow ratio (Qp:Qs) exceeds 1.5:1 and is accompanied by symptoms or progressive ventricular enlargement.

Question 67: Emergency CABG is most commonly indicated after failed PCI in the setting of:

Stable angina with preserved EF
Asymptomatic three-vessel disease
Isolated left main disease in an elective patient
Acute coronary occlusion with hemodynamic compromise unresponsive to catheter-based intervention (Correct answer)

Correct answer: Acute coronary occlusion with hemodynamic compromise unresponsive to catheter-based intervention

Emergency surgical revascularization is indicated when PCI fails to restore flow and ongoing ischemia with hemodynamic instability persists, requiring immediate coronary bypass.

Question 68: Which parameter best indicates adequate systemic oxygen delivery during cardiopulmonary bypass?

Heart rate
Central venous pressure
Systemic blood pressure alone
Mixed venous oxygen saturation (SvO2) (Correct answer)

Correct answer: Mixed venous oxygen saturation (SvO2)

Mixed venous oxygen saturation reflects the balance between oxygen delivery and consumption, making it the best indicator of systemic perfusion adequacy during CPB.

Question 69: What is the most common cause of bioprosthetic valve failure requiring reoperation?

Paravalvular leak
Thrombosis
Prosthetic valve endocarditis
Structural valve deterioration (calcification and leaflet tears) (Correct answer)

Correct answer: Structural valve deterioration (calcification and leaflet tears)

Structural valve deterioration due to progressive calcification and leaflet degeneration is the leading cause of bioprosthetic valve failure over time.

Question 70: What is the primary purpose of pulmonary artery banding as a palliative procedure in congenital heart surgery?

To create a controlled atrial-level communication for mixing
To augment pulmonary blood flow in cyanotic heart defects
To restrict excessive pulmonary blood flow and protect pulmonary vasculature from hypertensive injury (Correct answer)
To provide systemic blood flow when the ductus arteriosus closes

Correct answer: To restrict excessive pulmonary blood flow and protect pulmonary vasculature from hypertensive injury

Pulmonary artery banding reduces pulmonary blood flow and pressure in defects with excessive left-to-right shunting, protecting the pulmonary vasculature from progressive hypertensive obstructive disease.

Question 71: After mechanical heart valve replacement, the target INR for a bileaflet mechanical aortic valve in a low-risk patient is:

3.0–4.0
1.5–2.0
4.0–5.0
2.0–3.0 (Correct answer)

Correct answer: 2.0–3.0

Current guidelines recommend an INR of 2.0–3.0 for bileaflet mechanical aortic valves in patients without additional risk factors.

Question 72: What is the primary hemodynamic indication for surgical closure of a ventricular septal defect (VSD)?

VSD diameter exceeding 3 mm on echocardiography
Presence of any audible murmur regardless of shunt size
Detection of VSD in any newborn before 6 months of age
Qp:Qs ratio greater than 1.5:1 with symptoms or evidence of volume overload (Correct answer)

Correct answer: Qp:Qs ratio greater than 1.5:1 with symptoms or evidence of volume overload

Surgical closure is indicated when the pulmonary-to-systemic flow ratio exceeds 1.5:1, particularly when accompanied by symptoms, recurrent infections, or ventricular volume overload.

Question 73: In a complete atrioventricular septal defect (AVSD), how many leaflets does the common AV valve typically contain?

Four leaflets with a secundum ASD and perimembranous VSD
Three leaflets functioning exclusively as a right-sided valve
Five leaflets spanning both the tricuspid and mitral annuli (Correct answer)
Two leaflets with a single central orifice

Correct answer: Five leaflets spanning both the tricuspid and mitral annuli

Complete AVSD features a common five-leaflet AV valve (two bridging leaflets and three mural leaflets) that spans both ventricles, associated with a primum ASD and inlet VSD.

Question 74: The Carpentier functional classification Type I mitral regurgitation is characterized by:

Normal leaflet motion with annular dilation or leaflet perforation (Correct answer)
Restricted leaflet motion due to rheumatic disease
Ischemic tethering of the leaflets
Leaflet prolapse with excess motion

Correct answer: Normal leaflet motion with annular dilation or leaflet perforation

Carpentier Type I MR involves normal leaflet excursion, with regurgitation caused by annular dilation or leaflet perforation (e.g., from endocarditis).

Question 75: What is the purpose of the cardiotomy reservoir in the CPB circuit?

To warm or cool the perfusate
To collect blood suctioned from the operative field (Correct answer)
To regulate systemic flow rate
To oxygenate the blood

Correct answer: To collect blood suctioned from the operative field

The cardiotomy reservoir collects blood suctioned from the operative field so it can be filtered and returned to the patient.

Question 76: A patient on cardiopulmonary bypass develops a sudden increase in arterial line pressure with decreased venous return. What is the most likely cause?

Oxygenator failure
Venous air lock (Correct answer)
Pump failure
Aortic dissection

Correct answer: Venous air lock

Air entrained into the venous line creates a vapor lock that obstructs venous drainage, leading to high arterial pressure and decreased venous return to the pump.

Question 77: During a Bentall procedure, what are the three components that are replaced?

Aortic root, coronary arteries, and descending aorta
Aortic valve, ascending aorta, and coronary ostia reimplantation (Correct answer)
Mitral valve, ascending aorta, and coronary arteries
Aortic valve, ascending aorta, and aortic arch

Correct answer: Aortic valve, ascending aorta, and coronary ostia reimplantation

The Bentall procedure replaces the aortic root and ascending aorta with a composite graft containing a prosthetic valve, with reimplantation of the coronary ostia as buttons.

Question 78: The most common coronary artery target for the left internal mammary artery (LIMA) graft in CABG is:

Right coronary artery (RCA)
Left anterior descending (LAD) artery (Correct answer)
Obtuse marginal (OM) artery
Posterior descending artery (PDA)

Correct answer: Left anterior descending (LAD) artery

LIMA-to-LAD grafting is the cornerstone of CABG because the LAD supplies the largest territory and the LIMA-LAD anastomosis has the best long-term outcomes.

Question 79: The main purpose of temporary epicardial pacing wires placed at the end of cardiac surgery is:

To monitor ST-segment changes
To measure intracardiac pressures
To deliver cardioplegia
To manage postoperative bradyarrhythmias and heart block (Correct answer)

Correct answer: To manage postoperative bradyarrhythmias and heart block

Epicardial pacing wires provide immediate access to pacing capability should bradycardia or heart block occur in the early postoperative period.

Question 80: A patient undergoing cardiac surgery develops diffuse microvascular bleeding refractory to FFP and platelets. Thromboelastography (TEG) shows a long clot formation time and low maximum amplitude. What agent should be administered?

Vitamin K
Cryoprecipitate (Correct answer)
Tranexamic acid
Protamine

Correct answer: Cryoprecipitate

Low maximum amplitude on TEG indicates platelet dysfunction or fibrinogen deficiency; cryoprecipitate provides concentrated fibrinogen and factor VIII to address this specific coagulopathy.

Question 81: The classic Blalock-Taussig (BT) shunt anastomoses which two structures?

Right ventricle to pulmonary artery via a conduit
Subclavian artery to ipsilateral pulmonary artery (Correct answer)
Superior vena cava to right pulmonary artery
Ascending aorta to main pulmonary artery

Correct answer: Subclavian artery to ipsilateral pulmonary artery

The classic BT shunt connects the subclavian artery end-to-side to the ipsilateral pulmonary artery, increasing pulmonary blood flow in cyanotic congenital heart disease.

Question 82: Which anatomical feature distinguishes a secundum ASD from a primum ASD?

Secundum ASD is in the inferior atrial septum; primum ASD is in the fossa ovalis
Secundum ASD involves the coronary sinus; primum ASD involves the superior vena cava
Secundum ASD is always associated with a VSD; primum ASD is always isolated
Secundum ASD occurs in the fossa ovalis; primum ASD is in the inferior septum adjacent to the AV valves (Correct answer)

Correct answer: Secundum ASD occurs in the fossa ovalis; primum ASD is in the inferior septum adjacent to the AV valves

Secundum ASDs occur centrally at the fossa ovalis, while primum ASDs are located in the inferior atrial septum adjacent to the AV valves and are part of the atrioventricular septal defect spectrum.

Question 83: Which valve lesion typically presents with the longest asymptomatic period, delaying the need for surgery?

Acute mitral regurgitation
Severe aortic stenosis
Severe mitral stenosis
Chronic aortic regurgitation (Correct answer)

Correct answer: Chronic aortic regurgitation

Chronic aortic regurgitation allows the LV to dilate gradually and adapt over years, often remaining asymptomatic despite severe regurgitation until LV dysfunction develops.

Question 84: Coarctation of the aorta most commonly occurs at which anatomical location?

Ascending aorta proximal to the innominate artery origin
Aortic arch between the left common carotid and left subclavian arteries
Juxtaductal position near the insertion of the ligamentum arteriosum (Correct answer)
Descending thoracic aorta at the level of the diaphragm

Correct answer: Juxtaductal position near the insertion of the ligamentum arteriosum

Coarctation most commonly occurs at the juxtaductal position in the proximal descending thoracic aorta, near the insertion of the ligamentum arteriosum (remnant of the ductus arteriosus).

Question 85: Which complication of aortic valve replacement requires emergency reoperation and presents with severe new aortic regurgitation immediately post-bypass?

Sternal wound dehiscence
Pericardial effusion
Prosthetic valve malposition or paravalvular leak (Correct answer)
Atrial fibrillation

Correct answer: Prosthetic valve malposition or paravalvular leak

Significant paravalvular leak or prosthetic malposition producing severe acute aortic regurgitation after bypass requires immediate return to CPB for revision.

Question 86: In the Collett and Edwards classification, what defines Type I truncus arteriosus?

Pulmonary arteries arising as collaterals from the descending aorta
Complete atresia of the pulmonary valve with ductal-dependent pulmonary flow
A short main pulmonary artery segment arising from the left side of the common truncal root (Correct answer)
Separate pulmonary arteries arising from the posterior truncus with no main pulmonary artery segment

Correct answer: A short main pulmonary artery segment arising from the left side of the common truncal root

Type I truncus (most common) features a short main pulmonary artery segment arising from the common truncal root before dividing into left and right pulmonary arteries.

Question 87: Which repair technique for hypertrophic obstructive cardiomyopathy (HOCM) involves resecting basal septal muscle?

Konno procedure
Dor procedure
Ross procedure
Morrow myectomy (Correct answer)

Correct answer: Morrow myectomy

The Morrow (septal) myectomy involves surgical resection of hypertrophied basal septal muscle through the aortic valve to relieve left ventricular outflow tract obstruction.

Question 88: What is the mechanism of action of aprotinin in cardiac surgery?

Serine protease inhibition reducing fibrinolysis and platelet activation (Correct answer)
Factor Xa inhibition
Inhibition of thrombin
Reversal of heparin anticoagulation

Correct answer: Serine protease inhibition reducing fibrinolysis and platelet activation

Aprotinin is a broad-spectrum serine protease inhibitor that attenuates fibrinolysis, inflammatory activation, and platelet dysfunction associated with cardiopulmonary bypass.

Question 89: Total anomalous pulmonary venous connection (TAPVC) requires urgent surgical repair when which condition is present?

Pulmonary venous obstruction causing severe cyanosis and pulmonary edema (Correct answer)
Bidirectional shunting at the atrial level
Pulmonary artery pressure equal to 50% of systemic pressure
Mild right ventricular dilation on echocardiogram

Correct answer: Pulmonary venous obstruction causing severe cyanosis and pulmonary edema

Obstructed TAPVC is a surgical emergency because pulmonary venous obstruction causes severe pulmonary edema, profound hypoxemia, and cardiovascular collapse without urgent repair.

AACN Cardiac Surgery Certification (CSC)

The CSC certification validates expert nursing knowledge in post-operative care for adult cardiac surgery patients within the first 48 hours, covering surgical procedures, complications, therapeutic interventions, and monitoring/diagnostics.

Questions

120 min

Time Limit

73%

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