AACN Cardiac Surgery Certification (CSC) — Questions and Answers

Question 1: In the Collett and Edwards classification, what defines Type I truncus arteriosus?

Pulmonary arteries arising as collaterals from the descending aorta
A short main pulmonary artery segment arising from the left side of the common truncal root (Correct answer)
Complete atresia of the pulmonary valve with ductal-dependent pulmonary flow
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 2: Heparin-induced thrombocytopenia (HIT) in cardiac surgery patients is managed by substituting heparin with:

No anticoagulation until platelet recovery
Warfarin intraoperatively
Low-molecular-weight heparin
Bivalirudin or argatroban for anticoagulation during CPB (Correct answer)

Correct answer: Bivalirudin or argatroban for anticoagulation during CPB

Bivalirudin is the preferred alternative anticoagulant for CPB in confirmed or suspected HIT, as it does not cross-react with HIT antibodies.

Question 3: In acute Type B aortic dissection, the primary indication for emergency intervention is:

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

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 4: Endarterectomy during CABG is performed when:

The IMA conduit is too short
A coronary artery is diffusely diseased and unsuitable for standard anastomosis without plaque removal (Correct answer)
Off-pump technique is planned
The patient has prior PCI stenting

Correct answer: A coronary artery is diffusely diseased and unsuitable for standard anastomosis without plaque removal

Coronary endarterectomy removes obstructive plaque from a diffusely diseased vessel to create a suitable landing zone for the bypass anastomosis.

Question 5: Which feature of a bioprosthetic heart valve is its primary advantage over a mechanical valve?

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

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

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

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

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

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 8: Which of the following ailments increases the likelihood that patients will experience a postoperative embolic stroke?

Ventricular fibrillation
Ascending aortic manipulation (Correct answer)
Coronary artery atherosclerosis
Renal disease

Correct answer: Ascending aortic manipulation

A primary risk factor for developing intraoperative or postoperative (most common) embolic strokes is manipulation of the ascending aorta. Atrial fibrillation (Afib) is another condition that frequently precedes strokes, especially if it lasts for a long time (48 hours). Heparin usage requires caution because 30% of infarcts have a chance of turning hemorrhagic. Several infarcts of various sizes could develop after cardiac surgery. The initial computed tomography (CT) scan may not be diagnostic, thus subsequent scans may be required. The most sensitive diagnostic is diffusion-weighted magnetic resonance imaging, but it may not be available and could reveal infarcts that weren't known to exist before surgery.

Question 9: 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.

Potts (Correct answer)
Allen
Penfield
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 10: 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 11: Intraoperative TEE after mitral valve repair is used primarily to:

Guide cardioplegia delivery
Determine when to initiate bypass
Assess residual regurgitation and confirm adequate valve function before chest closure (Correct answer)
Monitor pulmonary pressures only

Correct answer: Assess residual regurgitation and confirm adequate valve function before chest closure

Post-repair TEE immediately identifies residual or new regurgitation, stenosis, or systolic anterior motion, allowing the surgeon to revise the repair before leaving the OR.

Question 12: What is the primary advantage of retrograde cardioplegia delivery via the coronary sinus?

Provides more rapid cardiac arrest
Ensures cardioplegia reaches areas with obstructed coronary arteries (Correct answer)
Delivers higher cardioplegia volumes
Avoids aortic cannulation

Correct answer: Ensures cardioplegia reaches areas with obstructed coronary arteries

Retrograde cardioplegia via the coronary sinus ensures uniform myocardial protection even in areas distal to severely stenotic coronary arteries.

Question 13: What is the purpose of a left ventricular vent during cardiopulmonary bypass?

To prevent left ventricular distension and reduce myocardial work (Correct answer)
To measure left ventricular pressure
To assist with deairing only
To deliver cardioplegia to the left ventricle

Correct answer: To prevent left ventricular distension and reduce myocardial work

The LV vent decompresses the left ventricle, preventing distension that can cause myocardial injury when the heart is arrested.

Question 14: At what approximate age is Fontan completion typically performed following the bidirectional Glenn procedure?

2 to 4 years of age (Correct answer)
8 to 12 years of age
1 to 3 months of age
6 to 12 months of age

Correct answer: 2 to 4 years of age

Fontan completion is typically performed between ages 2 and 4 years, after adequate reduction of pulmonary vascular resistance has been achieved following the Glenn procedure.

Question 15: The Ross procedure involves:

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

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 16: What is the most common cause of late failure of saphenous vein coronary bypass grafts beyond 5 years?

Atherosclerosis (Correct answer)
Graft thrombosis
Anastomotic stenosis
Intimal hyperplasia

Correct answer: Atherosclerosis

Beyond 5 years, atherosclerosis within the vein graft is the dominant mechanism of late graft failure, accelerated by the arterial hemodynamic environment.

Question 17: 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)
Blalock-Taussig shunt from the innominate artery to the pulmonary artery
Damus-Kaye-Stansel anastomosis connecting the proximal pulmonary artery to the aorta (Correct answer)
Fontan tunnel connecting the inferior vena cava 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 18: The most common cause of death in patients supported on long-term LVAD therapy is:

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

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 19: Cardiac tamponade after cardiac surgery classically presents with:

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

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

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

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 21: 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 occurs in the fossa ovalis; primum ASD is in the inferior septum adjacent to the AV valves (Correct answer)
Secundum ASD is always associated with a VSD; primum ASD is always isolated

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 22: Radial artery grafts in CABG should be used to bypass coronary targets with:

High-grade stenosis (greater than 70%) to avoid competitive flow-related graft failure (Correct answer)
Total chronic occlusions only
Previously stented lesions
Mild to moderate stenosis

Correct answer: High-grade stenosis (greater than 70%) to avoid competitive flow-related graft failure

Radial artery grafts are prone to spasm and competitive flow failure when bypassing mildly stenosed vessels, requiring targets with ≥70% stenosis for durable patency.

Question 23: Emergency CABG is most commonly indicated after failed PCI in the setting of:

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

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 24: Sternal wound infection after cardiac surgery is most commonly caused by:

Pseudomonas aeruginosa
Enterococcus faecalis
Staphylococcus aureus (Correct answer)
Candida albicans

Correct answer: Staphylococcus aureus

Staphylococcus aureus, including MRSA, is the most frequent pathogen in deep sternal wound infections (mediastinitis) after cardiac surgery.

Question 25: The most critical technical step when implanting a mechanical aortic prosthesis to avoid complications is:

Choosing the largest possible prosthesis size
Avoiding cardioplegia during the procedure
Minimizing cross-clamp time regardless of technique
Secure seating of the sewing ring without paravalvular gaps (Correct answer)

Correct answer: Secure seating of the sewing ring without paravalvular gaps

Ensuring complete annular seating without paravalvular gaps prevents paravalvular leak, which can cause hemolysis, heart failure, and need for reoperation.

Question 26: Which chromosomal abnormality is most strongly associated with complete atrioventricular septal defect?

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

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

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

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

Axillary artery
Carotid 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 29: Spinal cord ischemia is a feared complication of thoracoabdominal aortic aneurysm repair and is reduced by:

Reimplanting intercostal arteries and using cerebrospinal fluid drainage (Correct answer)
Systemic anticoagulation only
Minimizing aortic cross-clamp time regardless of reperfusion
Profound hypothermia alone

Correct answer: Reimplanting intercostal arteries and using cerebrospinal fluid drainage

Reimplanting critical intercostal arteries (T8–T12) and draining cerebrospinal fluid to reduce spinal cord perfusion pressure are the most effective strategies against spinal ischemia.

Question 30: The Rastelli procedure is specifically designed to repair which combination of congenital defects?

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

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

Primary bypass during elective CABG
Routine postoperative monitoring
Long-term destination therapy
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 32: Which complication of aortic valve replacement requires emergency reoperation and presents with severe new aortic regurgitation immediately post-bypass?

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

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

Inhibition of thrombin
Serine protease inhibition reducing fibrinolysis and platelet activation (Correct answer)
Factor Xa inhibition
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 34: Total anomalous pulmonary venous connection (TAPVC) requires urgent surgical repair when which condition is present?

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

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.

Question 35: Delayed sternal closure is most often used after cardiac surgery when:

Bypass time exceeded 2 hours
Bleeding has completely stopped
Significant myocardial edema or hemodynamic instability prevents safe chest closure (Correct answer)
The patient is extubated successfully

Correct answer: Significant myocardial edema or hemodynamic instability prevents safe chest closure

Delayed sternal closure allows the swollen mediastinum to decompress and hemodynamics to stabilize before formal sternal reapproximation.

Question 36: What is the treatment plan if acute renal dysfunction leads to oliguric renal failure?

Dialysis (Correct answer)
Reperfusion
Surgery
Medication

Correct answer: Dialysis

Dialysis Hemofiltration and dialysis are the treatments of choice if acute renal dysfunction leads to oliguric renal failure. This condition is a fatal complication with a death rate of 70% to 100%.

Question 37: Long-term statin therapy after CABG is indicated primarily to:

Improve graft conduit harvesting outcomes
Slow native coronary and vein graft atherosclerosis progression and reduce cardiovascular events (Correct answer)
Reduce sternal wound infection risk
Prevent postoperative atrial fibrillation

Correct answer: Slow native coronary and vein graft atherosclerosis progression and reduce cardiovascular events

Statins reduce lipid-driven atherosclerosis in native coronaries and bypass grafts, cutting long-term MI risk and improving survival after CABG.

Question 38: 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 39: 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?

Endoaortic balloon occlusion catheter (Correct answer)
Intracoronary balloon catheter occlusion
Femoral artery cross-clamp
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 40: Which preoperative medication is typically continued until the day of cardiac surgery to prevent rebound angina?

Beta-blockers (Correct answer)
ACE inhibitors
Metformin
Warfarin

Correct answer: Beta-blockers

Beta-blockers should be continued perioperatively to prevent rebound tachycardia and ischemia in patients undergoing cardiac surgery.

Question 41: 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 42: What is the preferred surgical approach for repair of an acute Type A aortic dissection in a hemodynamically stable patient?

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

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

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

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 44: Competitive flow in a coronary bypass graft occurs when:

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

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

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

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 46: Stanford Type A aortic dissection requires emergency surgery primarily because of the risk of:

Lower limb malperfusion
Renal ischemia alone
Descending aorta rupture
Pericardial tamponade, aortic regurgitation, and coronary ostial involvement (Correct answer)

Correct answer: Pericardial tamponade, aortic regurgitation, and coronary ostial involvement

Type A dissection threatens the proximal aorta, risking rupture into the pericardium (tamponade), aortic valve disruption, and coronary ostial dissection causing acute MI.

Question 47: After mechanical heart valve replacement, the target INR for a bileaflet mechanical aortic valve in a low-risk patient is:

1.5–2.0
4.0–5.0
3.0–4.0
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 48: What are the four components of Tetralogy of Fallot?

Atrial septal defect, pulmonary stenosis, overriding aorta, and left ventricular hypertrophy
Ventricular septal defect, pulmonary stenosis, overriding aorta, and right ventricular hypertrophy (Correct answer)
Ventricular septal defect, pulmonary atresia, transposed great arteries, and right ventricular hypertrophy
Ventricular septal defect, aortic stenosis, overriding pulmonary artery, and right ventricular hypertrophy

Correct answer: Ventricular septal defect, pulmonary stenosis, overriding aorta, and right ventricular hypertrophy

Tetralogy of Fallot consists of VSD, pulmonary stenosis (RVOTO), overriding aorta, and right ventricular hypertrophy — all resulting from anterosuperior displacement of the infundibular septum.

Question 49: The primary indication for the Impella device in cardiac surgery patients is:

Prevention of atrial fibrillation
Mechanical support for cardiogenic shock or high-risk procedures requiring LV unloading (Correct answer)
Temporary pacing
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 50: Which complication is most commonly associated with excessive hemodilution on cardiopulmonary bypass?

Hypercalcemia
Hypertension
Arrhythmia
Coagulopathy and impaired oxygen delivery (Correct answer)

Correct answer: Coagulopathy and impaired oxygen delivery

Excessive hemodilution dilutes clotting factors and reduces hemoglobin concentration, leading to coagulopathy and decreased oxygen-carrying capacity.

Question 51: Maintaining the postoperative pulmonary artery pressure at

More than 25 mm Hg
Less than 15 mm Hg
Less than 25 mm Hg (Correct answer)
Less than 10 mm Hg

Correct answer: Less than 25 mm Hg

Positive airway pressure (PAP) should be maintained at less than 25 mm Hg postoperatively. PAP is measured by a catheter usually fed through the right ventricle to the main pulmonary artery: <br> ‥ Normal PAP is 10–20 mg Hg (mean 15 mm Hg). PAP is usually about 25%–34% the systemic blood pressure rate. Oxygen saturation is usually about 80%. <br> ‥ Increased PAP may indicate pulmonary obstruction or embolus, left-to-right shunt, left ventricular failure, pulmonary hypertension, mitral stenosis, pneumothorax, lung/alveolar hypoplasia, hyperviscosity of blood, or increased left atrial pressure. <br> ‥ Decreased PAP may indicate a decrease in intravascular volume, decreased cardiac output, or obstruction of pulmonary blood flow.

Question 52: The saphenous vein graft failure rate at 10 years is approximately:

5–10%
40–50% (Correct answer)
80–90%
Less than 5%

Correct answer: 40–50%

Saphenous vein graft attrition is significant, with approximately 40–50% of vein grafts occluded by 10 years due to intimal hyperplasia and atherosclerosis.

Question 53: A quick heartbeat called a tachycardia, usually more than ________ beats per minute.

100
180
120 (Correct answer)
110

Correct answer: 120

Tachycardia is a fast heart rate, usually defined as a heart rate of more than 100 beats per minute. Therefore, it is typically considered tachycardia when the heart rate exceeds 100 beats per minute, rather than 120 beats per minute as stated in your response. However, it's important to note that the specific heart rate threshold to classify tachycardia may vary depending on factors such as age, underlying health conditions, and the context in which it occurs.

Question 54: Which conduit has the best long-term patency for coronary artery bypass grafting to the left anterior descending artery?

Right gastroepiploic artery
Radial artery
Saphenous vein graft
Left internal mammary artery (Correct answer)

Correct answer: Left internal mammary artery

The left internal mammary artery (LIMA) to LAD bypass has over 90% patency at 10 years, far superior to vein grafts, making it the gold standard conduit.

Question 55: Which factor most strongly predicts operative mortality in patients undergoing cardiac surgery, as captured by the Society of Thoracic Surgeons (STS) risk score?

Reoperation (redo) status
Urgency of surgery (emergent status) (Correct answer)
Patient age
Preoperative ejection fraction

Correct answer: Urgency of surgery (emergent status)

Emergent surgery status carries the highest weight in STS risk modeling because it reflects hemodynamic instability, inadequate preoperative optimization, and inability to defer to improve patient condition.

Question 56: During weaning from cardiopulmonary bypass, the perfusionist should gradually:

Administer protamine immediately
Lower the venous reservoir level rapidly
Decrease pump flow while the heart fills and cardiac output recovers (Correct answer)
Increase pump flow to maintain MAP

Correct answer: Decrease pump flow while the heart fills and cardiac output recovers

Gradual reduction of pump flow allows the heart to assume progressive responsibility for circulation while venous return fills the cardiac chambers.

Question 57: Which electrolyte abnormality is most commonly associated with cardiac arrhythmias following cardiopulmonary bypass?

Hypocalcemia
Hyperkalemia
Hyponatremia
Hypomagnesemia (Correct answer)

Correct answer: Hypomagnesemia

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

Question 58: 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?

Depolarization of the ventricles
Depolarization of the atria (Correct answer)
Polarization of the atria
Polarization of 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 59: A patient requires redo sternotomy for mitral valve replacement. What is the greatest risk during sternal re-entry?

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

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: 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 61: Which technique can extend the safe duration of circulatory arrest during aortic arch surgery beyond DHCA alone?

Higher pump flow before arrest
Selective antegrade cerebral perfusion (SACP) (Correct answer)
Increased heparin dosing
Retrograde cardioplegia

Correct answer: Selective antegrade cerebral perfusion (SACP)

SACP delivers oxygenated blood directly into the cerebral vessels during circulatory arrest, extending safe arch reconstruction time beyond the limits of DHCA alone.

Question 62: Where might a tumor be present in a patient who experiences irregular heartbeat, lightheadedness, hyperglycemia, and elevated levels of epinephrine?

Adrenal cortex
Pituitary gland
Pancreas
Adrenal medulla (Correct answer)

Correct answer: Adrenal medulla

Adrenal cortex Catecholamines are managed by the adrenal medulla. This controls how we react to stress. Hormone levels will rise as a result of an adrenal medulla tumor, leading to the symptoms listed.

Question 63: Which surgical technique can be used to implant a larger aortic prosthesis in patients with a small aortic root?

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

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 64: 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 65: Which cannulation site is preferred for arterial inflow in patients with severe ascending aortic atherosclerosis?

Axillary artery (Correct answer)
Innominate artery
Femoral artery
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 66: The arterial filter in the CPB circuit is used primarily to:

Regulate flow rate
Monitor blood pressure
Measure oxygen saturation
Remove gaseous and particulate microemboli before arterial return (Correct answer)

Correct answer: Remove gaseous and particulate microemboli before arterial return

The arterial line filter captures microemboli (air bubbles and particulates) to prevent them from reaching the patient's systemic circulation.

Question 67: Which valve lesion typically presents with the longest asymptomatic period, delaying the need for surgery?

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

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 68: In Ebstein anomaly, what is the primary anatomical abnormality of the tricuspid valve?

Apical displacement of the septal and posterior leaflets into the right ventricle (Correct answer)
Absence of the septal leaflet with a single large anterior leaflet
Prolapse of the anterior leaflet into the right atrium during systole
Fusion of all three leaflets causing severe tricuspid stenosis

Correct answer: Apical displacement of the septal and posterior leaflets into the right ventricle

Ebstein anomaly is characterized by downward (apical) displacement of the tricuspid valve's septal and posterior leaflets into the right ventricle, creating an atrialized portion of the RV.

Question 69: Hypothermia during CPB protects organs primarily by:

Enhancing diuresis
Improving blood viscosity
Increasing cardiac output
Reducing metabolic demand and oxygen consumption (Correct answer)

Correct answer: Reducing metabolic demand and oxygen consumption

Hypothermia decreases cellular metabolic rate and oxygen demand, extending the safe ischemic time for organs during CPB.

Question 70: Which intraoperative finding during CABG surgery indicates that a target coronary artery is unsuitable for bypass grafting?

Presence of an endarterectomized segment
Diffuse intramyocardial course (Correct answer)
Vessel diameter of 1.5 mm
Epicardial fat overlying the vessel

Correct answer: Diffuse intramyocardial course

An intramyocardial (tunneled) coronary artery runs within the myocardium rather than the epicardial surface, making anastomosis technically difficult or impossible and often precluding bypass.

Question 71: Which finding on chest X-ray after cardiac surgery suggests tension pneumothorax requiring immediate decompression?

Elevated left hemidiaphragm
Widened mediastinum
Tracheal deviation away from the affected side with absent lung markings and hemodynamic instability (Correct answer)
Small pleural effusion on the left

Correct answer: Tracheal deviation away from the affected side with absent lung markings and hemodynamic instability

Tension pneumothorax causes tracheal deviation away from the collapsed lung, absent breath sounds, and cardiovascular collapse requiring immediate needle decompression.

Question 72: The DeBakey classification of aortic dissection Type I involves:

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

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 73: The most reliable indicator of adequate renal perfusion in the immediate postoperative cardiac surgery patient is:

Normal serum creatinine immediately postoperatively
Urine output greater than 0.5 mL/kg/hour (Correct answer)
Mean arterial pressure above 90 mmHg
Central venous pressure above 15 mmHg

Correct answer: Urine output greater than 0.5 mL/kg/hour

A urine output greater than 0.5 mL/kg/hour is the most practical real-time indicator of adequate renal perfusion in cardiac surgery patients.

Question 74: Aspirin after CABG should be initiated postoperatively primarily to:

Reverse anticoagulation
Treat postoperative fever
Improve saphenous vein graft patency and reduce cardiovascular events (Correct answer)
Prevent sternal wound infection

Correct answer: Improve saphenous vein graft patency and reduce cardiovascular events

Early aspirin initiation (within 6 hours postoperatively) improves vein graft patency by inhibiting platelet aggregation at anastomotic sites.

Question 75: After aortic valve replacement, a patient develops new complete heart block. Which anatomic structure is most likely injured?

Right bundle branch in the moderator band
AV node in the triangle of Koch
SA node near the right atrium
Left bundle branch near the membranous septum (Correct answer)

Correct answer: Left bundle branch near the membranous septum

The left bundle branch courses along the base of the non-coronary and right coronary cusp region of the membranous septum and is at risk during deep suture placement in aortic valve replacement.

Question 76: The internal mammary artery (IMA) is preferred for coronary bypass grafting because:

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

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 77: Which type of oxygenator is most commonly used in modern cardiopulmonary bypass circuits?

Bubble oxygenator
Screen oxygenator
Hollow-fiber membrane oxygenator (Correct answer)
Rotating disk oxygenator

Correct answer: Hollow-fiber membrane oxygenator

Hollow-fiber membrane oxygenators are preferred in modern CPB because they minimize blood trauma and air emboli risk.

Question 78: Off-pump CABG (OPCAB) differs from conventional CABG primarily in that:

Only venous conduits are used
TEE monitoring is not required
The aorta is not cross-clamped
The procedure is performed on a beating heart without cardiopulmonary bypass (Correct answer)

Correct answer: The procedure is performed on a beating heart without cardiopulmonary bypass

OPCAB avoids CPB by using mechanical stabilizers and heart positioners to expose coronary targets while the heart continues beating.

Question 79: Which valve position carries the highest risk of prosthetic valve thrombosis if anticoagulation is subtherapeutic?

Tricuspid bioprosthetic valve
Aortic mechanical valve
Mitral mechanical valve (Correct answer)
Pulmonary 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 80: Neurological complications after cardiac surgery, including stroke, are most often caused by:

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

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 81: Glucose management during cardiopulmonary bypass is important because hyperglycemia:

Decreases heparin effectiveness
Reduces cardiac contractility directly
Worsens neurological outcomes and increases infection risk (Correct answer)
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 82: The diameter threshold that generally triggers surgery for an ascending aortic aneurysm in a patient with a bicuspid aortic valve is:

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

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

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

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 84: Which imaging study is the gold standard for preoperative planning of thoracic aortic surgery?

Transesophageal echocardiography alone
CT angiography (CTA) of the chest, abdomen, and pelvis (Correct answer)
Conventional catheter angiography
Magnetic resonance angiography (MRA) only

Correct answer: CT angiography (CTA) of the chest, abdomen, and pelvis

CTA of the entire aorta provides precise anatomical detail of aortic dimensions, branch involvement, and landing zones essential for surgical or endovascular planning.

Question 85: What is the purpose of the cardiotomy reservoir in the CPB circuit?

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

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

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

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 87: What is the target activated clotting time (ACT) during full cardiopulmonary bypass?

>400 seconds (Correct answer)
>300 seconds
>200 seconds
>500 seconds

Correct answer: >400 seconds

An ACT greater than 400–480 seconds is required during full CPB to prevent clotting within the bypass circuit and ensure adequate anticoagulation.

Question 88: The primary indication for tricuspid valve repair at the time of left-sided valve surgery is:

Tricuspid annular dilation greater than 40 mm or moderate-severe functional tricuspid regurgitation (Correct answer)
Any degree of tricuspid regurgitation
Right ventricular dilation alone
Isolated TR without annular dilation

Correct answer: Tricuspid annular dilation greater than 40 mm or moderate-severe functional tricuspid regurgitation

Current guidelines recommend tricuspid repair concomitantly when the tricuspid annulus is ≥40 mm or functional TR is moderate-to-severe at the time of left-sided surgery.

Question 89: What phase, if any, comes last in a nursing procedure?

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

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.

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%

To Pass

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