Answers

1: C

Rheumatic fever is seldom isolated, as most patients will have involvement of the mitral valve as well. The majority of patients will not have a history of previous rheumatic fever. Calcification occurs at the commissures and when it is present below the commissure between the right and noncoronary cusps, it can result in heart block.

Kouchoukos NT, Blackstone EH, Doty DB, Hanley FL, Karp RB. Kirklin/Barratt-Boyes Cardiac Surgery, 3rd ed. New York: Churchill Livingstone; 2003:556.

Hurst JW, Logue RB. The Heart. 2nd ed. New York: McGraw-Hill; 1970:749-750.

2: B

After the onset of symptoms in patients with aortic stenosis, the average survival is 2 to 3 years. Sudden cardiac death occurs in less than 1% of asymptomatic patients. When chronic heart failure develops, it is most commonly due to decreased contractility and not changes in afterload.

Horskotte D, Loogen F. The natural history of aortic valve stenosis. Eur Heart J. 1988;9(suppl E):57-64.

Frank S, Johnson A, Ross J Jr. Natural history of valvular aortic stenosis. Br Heart J. 1973;35(1):41-46.

3: B

This patient has moderate aortic stenosis, which by itself would not be an indication for valve replacement. However, since the average rate in reduction of valve area is approximately 0.1 cm2 per year, he will likely develop severe aortic stenosis within 5 years. Since it is generally believed that aortic valve replacement following a CABG results in increased morbidity and mortality, patients with moderate aortic stenosis undergoing surgery for another indication should have concomitant aortic valve replacement.

Smith WT, Ferguson TB, Ryan T, et al. Should coronary artery bypass graft surgery patients with mild or moderate aortic stenosis undergo concomitant aortic valve replacement? A decision-analysis approach to the surgical dilemma. J Am Coll Cardiol. 2004;44(6):1241-1247.

Pereira JJ, Balaban K, Lauer MS, et al. Aortic valve replacement in patients with mild or moderate aortic stenosis and coronary bypass surgery. Am J Med. 2005;118(7):735-742.

4: E

Not all patients undergoing aortic valve replacement will require a cardiac catheterization if a cardiac echocardiogram shows all the criteria for significant aortic stenosis. However, catheterization is recommended for all patients with angina, adult onset diabetes, a family history of coronary artery disease, and those >50 years of age.

Bonow RO, Carabello BA, Kanu C, et al. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease. Circulation. 2006;114(5):e84-231.

5: F

Contraindications for percutaneous mitral valvuloplasty include the presence of 3-4+ mitral regurgitation and clot in the left atrium. The presence of atrial fibrillation is not a contraindication. Similarly calcium in the leaflets alone is not a contraindication. The success of this procedure is dependent on the ability to split the fused commissures. A grading score has been developed that takes into account the degree of calcification and fibrosis, which can help to predict the rate of success in individual patients.

Cohen DJ, Kuntz RE, Gordon SP, et al. Predictors of long-term outcome after percutaneous balloon mitral valvuloplasty. N Engl J Med. 1992; 327(19):1329-1335.

6: A

Mitral valve repair is indicated in asymptomatic patients in whom the likelihood of a successful repair is = 90% (Class II recommendation). Residual MR is not likely to occur early after surgery and the highest incidence of reoperation is within 2 years following surgery. In patients with severe ischemic MR, mitral valve repair offers no survival benefit over replacement, in part due to the low ejection fraction and increased cardiovascular comorbidities seen in this group of patients. As in most patients undergoing mitral valve surgery, the most common cause of death is cardiac failure, rather than thromboembolism.

Bonow RO, Carabello BA, Kanu C, et al. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease. Circulation. 2006;114(5):e84-231.

Ling LH, Enriquez-Sarano M, Seward JB, et al. Early surgery in patients with mitral regurgitation due to flail leaflets: a long-term outcome study. Circulation. 1997;96(6):1819-1825.

7: D

The presence of fungal endocarditis, congestive heart failure, and systemic emboli during antibiotic therapy are all absolute indications for surgery in patients with native valve endocarditis. Although patients with a vegetation diameter of .10 mm have a significantly higher incidence of embolization, surgery is not indicated solely on the basis of the size of the vegetation.

Mugge A, Daniel WG, Frank G, Lichtlen PR. Echocardiography in infective endocarditis: reassessment of prognostic implications of vegetative size determined by the transthoracic and transesophageal approach. J Am Coll Cardiol. 1989;14(3):631-638.

Acar J, Michael PL, Varenne O, et al. Surgical treatment of infective endocarditis. Eur Heart J. 1995;16(suppl B):94-98.

8: D

Patients presenting with a descending thoracic aneurysm < 5.5 cm should be managed medically unless there is evidence of symptoms related to the aneurysm, radiological evidence of contained rupture, or an enlarging pseudoaneurysm. Endovascular repair should be considered in patients who are either high risk or not a suitable candidate for open repair. Serial CT scans and optimal medical management is the mainstay for aneurysms <e; .5.5 cm in the descending aorta.

Davies RR, Goldstein LJ, Coady MA, et al. Yearly rupture or dissection rates for thoracic aortic aneurysms: simple prediction based on size. Ann Thorac Surg. 2002;73(1):17-28.

9: E

The 64-slice CT scan is a new diagnostic tool that may help to rapidly screen patients with chest pain in the emergency room and prior to noncardiac surgery. However, certain limitations do exist. For the most optimal results, patients must be in normal sinus rhythm with heart rates < 70. Diagnostic accuracy is diminished in those patients with severe proximal coronary calcification. In order to visualize the full extent of all vessels, higher doses of radiation may be required compared to conventional cardiac catheterization techniques. However, this technology is improving and will ultimately become an important diagnostic screening tool for patients with chest pain.

Mollet NR, Cademartari F, van Meeghem AG, et al. High-resolution spiral computed tomography coronary angiography in patients referred for diagnostic conventional coronary angiography. Circulation. 2005;112(15):2318-2323.

Knez A, Becker CR, Leber A, et al. Usefulness of multislice spiral computer tomography angiography for determination of coronary artery stenoses. Am J Cardiol. 2001;88(10):1191-1194.

10: F

Major determinants of operative mortality in patients with reduced ejection fraction include the quality of the target vessels to be bypassed, the absence of MR, and the extent of viable myocardium. Age is not a major factor unless it is associated with other comorbidities (ie, renal failure, chronic obstructive pulmonary disease, cerebrovascular disease). Chareonthaitawee P, Gersh BJ, Araoz PA, Gibbons RJ. Revascularization in severe left ventricular dysfunction: the role of viability testing. J Am Coll Cardiol. 2005;46(4):567-574.

Di Carli MF, Maddahi J, Rokhsar S, et al. Long-term survival of patients with coronary artery disease and LV dysfunction: implications for the role of myocardial viability assessment in management decisions. J Thorac Cardiovasc Surg. 1998;116(6):997-1004.