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SU26.{1,3-4} | Cardiothoracic Surgery — Practice Quiz
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A 62-year-old man with stable exertional angina is found on coronary angiography to have significant triple-vessel disease, including a tight stenosis of the proximal left anterior descending artery. Medical therapy has not controlled his symptoms. Which surgical procedure is the standard intervention to relieve his ischaemia?
Correct. Fixed obstruction in ischaemic (coronary) disease is bypassed surgically by CABG; the left internal mammary artery to the LAD gives the best long-term patency, supplemented by vein or radial artery conduits.
CABG is the operation for ischaemic heart disease, especially left-main or triple-vessel disease; the LIMA-to-LAD graft is the cornerstone conduit.
Coronary (ischaemic) disease is treated by revascularisation. CABG bypasses the fixed obstruction; valve and transplant operations address different lesions.
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A 35-year-old woman requires aortic valve replacement. After discussion she opts for a MECHANICAL prosthetic valve. Which statement about her subsequent management is correct?
Correct. A mechanical valve is thrombogenic and mandates lifelong warfarin anticoagulation regardless of rhythm.
Mechanical valve = lifelong warfarin (durable but thrombogenic). Bioprosthetic valve = no long-term anticoagulation but limited durability — the trade-off that drives valve choice.
The single most important fact about a prosthetic valve is mechanical versus bioprosthetic: mechanical valves require lifelong warfarin; bioprosthetic valves generally do not but are less durable.
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A 58-year-old man had a bioprosthetic (tissue) aortic valve implanted. Compared with a mechanical valve, the principal disadvantage of his bioprosthetic valve is that it:
Correct. Bioprosthetic valves spare the patient lifelong anticoagulation but degenerate structurally over years, so durability is their key limitation — often favoured in older patients or where anticoagulation is risky.
Bioprosthetic valves: avoid lifelong anticoagulation but wear out — chosen for older patients or those who cannot take warfarin.
The bioprosthetic trade-off is the reverse of the mechanical valve: no lifelong warfarin, but limited durability.
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A newborn is found to have a continuous 'machinery' murmur and a persistent left-to-right shunt due to a patent ductus arteriosus. Into which broad category of congenital heart disease does an isolated PDA fall?
Correct. PDA, ASD and VSD are left-to-right shunts and therefore ACYANOTIC lesions; cyanosis appears later only if Eisenmenger physiology develops.
Acyanotic congenital lesions (PDA, ASD, VSD) shunt left-to-right; cyanotic lesions (e.g. TOF) shunt right-to-left.
PDA, ASD and VSD are left-to-right shunts = acyanotic. Tetralogy of Fallot is the classic cyanotic (right-to-left) lesion.
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A 2-year-old child has cyanotic spells, a boot-shaped heart on chest X-ray, and is found to have a combination of ventricular septal defect, overriding aorta, pulmonary stenosis and right ventricular hypertrophy. This describes:
Correct. The four components — VSD, overriding aorta, pulmonary stenosis, right ventricular hypertrophy — define Tetralogy of Fallot, the classic cyanotic congenital lesion.
Tetralogy of Fallot = VSD + overriding aorta + pulmonary stenosis + RV hypertrophy; the prototypical cyanotic congenital heart disease.
The tetrad of VSD, overriding aorta, pulmonary stenosis and RV hypertrophy is Tetralogy of Fallot — a cyanotic (right-to-left) lesion, unlike the acyanotic ASD/VSD/PDA.
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A 40-year-old woman presents with fatigable ptosis, diplopia and proximal limb weakness. A contrast CT shows an ANTERIOR mediastinal mass. Which mediastinal tumour is most strongly associated with this clinical syndrome?
Correct. An anterior mediastinal mass with myasthenia gravis points to a thymoma — one of the anterior compartment 'four T's' (thymoma, teratoma/germ-cell, thyroid, terrible lymphoma).
Anterior mediastinal masses = the four T's (Thymoma, Teratoma/germ-cell, Thyroid, Terrible lymphoma); thymoma links to myasthenia gravis.
Myasthenia gravis plus an anterior mediastinal mass is the classic thymoma association. Neurogenic tumours arise in the posterior compartment.
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A 30-year-old man has a mass in the POSTERIOR mediastinum on CT. Based on compartment-predicts-pathology reasoning, which type of tumour is most characteristic of this compartment?
Correct. The posterior mediastinum contains the sympathetic chain and nerve roots, so neurogenic tumours are its characteristic masses — the compartment predicts the pathology.
Compartment-based reasoning: posterior mediastinum → neurogenic tumours; anterior → the four T's; middle → lymph nodes, bronchogenic/pericardial cysts.
The compartment predicts the pathology: posterior mediastinum (neural structures) → neurogenic tumours. Thymoma, teratoma and thyroid are anterior masses.
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A 64-year-old heavy smoker has a CENTRAL lung tumour and develops hyponatraemia from inappropriate ADH secretion (SIADH). Biopsy confirms small-cell lung cancer. What is the principal modality of treatment?
Correct. Small-cell lung cancer is typically central, frequently produces paraneoplastic syndromes (SIADH, ectopic ACTH) and is disseminated early — it is treated chemotherapeutically (with radiotherapy), almost never by primary surgery.
Two facts must be on the chart before any lung-cancer operation: histology (SCLC vs NSCLC) and stage. SCLC = chemotherapy; NSCLC = surgery if resectable.
SCLC is rarely an operation: it is central, paraneoplastic-prone and treated with chemotherapy (± radiotherapy). Surgery is reserved mainly for resectable NSCLC.
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A 67-year-old smoker has an apical (superior sulcus) lung tumour and presents with ipsilateral ptosis, miosis and anhidrosis. This Pancoast tumour is causing which named syndrome by invading the sympathetic chain?
Correct. An apical Pancoast tumour invades the sympathetic chain, producing Horner's syndrome (ptosis, miosis, anhidrosis), often with shoulder/arm pain from brachial plexus involvement.
Pancoast (superior sulcus) tumour → Horner's syndrome (ptosis, miosis, anhidrosis) from sympathetic chain invasion.
A Pancoast (apical) tumour invading the sympathetic chain gives Horner's syndrome. SVC obstruction and ectopic-ACTH Cushing's are different paraneoplastic/compressive effects.
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