CSC (Cardiac Surgery Certification) Demonstrates
specialized expertise in managing cardiac surgery
patients, postoperative care, hemodynamic
monitoring, and recovery processes.
1. A 68-year-old patient with severe aortic stenosis is scheduled for surgical
aortic valve replacement (SAVR). Which of the following preoperative
findings would most increase the risk of postoperative acute kidney injury
(AKI)?
A. Ejection fraction 55%
B. Serum creatinine 1.8 mg/dL (eGFR 35 mL/min/1.73m²)
C. Hemoglobin A1c 6.2%
D. Left ventricular end-diastolic diameter 4.5 cm
Correct Answer: B
Rationale: Pre-existing chronic kidney disease (eGFR <60) is a strong predictor of
postoperative AKI after cardiac surgery. Contrast and cardiopulmonary bypass
(CPB) exacerbate risk.
2. A patient is scheduled for elective coronary artery bypass grafting (CABG)
and takes clopidogrel (Plavix) for a recent drug-eluting stent placed 4 months
ago. The surgeon plans to operate in 5 days. Which medication management is
most appropriate?
A. Continue clopidogrel until day of surgery
B. Discontinue clopidogrel 5-7 days preoperatively after cardiology consultation
(risk of stent thrombosis vs. bleeding)
C. Replace with warfarin
D. Give a loading dose of ticagrelor
Correct Answer: B
Rationale: For DAPT after DES, elective non-cardiac surgery or cardiac surgery
should be postponed if possible. If surgery is necessary, discontinue P2Y12
inhibitor (clopidogrel) 5-7 days preop, with aspirin continued. Risk of stent
thrombosis vs. bleeding is weighed.
3. A patient with severe mitral regurgitation and a history of heparin-induced
thrombocytopenia (HIT) is scheduled for mitral valve repair. Which
,anticoagulant is safe for intraoperative cardiopulmonary bypass?
A. Unfractionated heparin (UFH)
B. Lepirudin (direct thrombin inhibitor, but not available; bivalirudin is used)
C. Fondaparinux
D. Argatroban or bivalirudin
Correct Answer: D
Rationale: In HIT, alternative anticoagulants for CPB include bivalirudin (direct
thrombin inhibitor) or argatroban. Lepirudin is no longer available. UFH is
absolutely contraindicated.
4. A patient scheduled for CABG has a preoperative pulmonary artery
catheter (PAC) placed. Which hemodynamic profile suggests poor left
ventricular function and need for inotropic support on bypass weaning?
A. PAOP 6 mm Hg, CI 2.8 L/min/m²
B. PAOP 22 mm Hg, CI 1.6 L/min/m², SVR 1800
C. PAOP 10 mm Hg, CI 3.2 L/min/m²
D. PAOP 18 mm Hg, CI 2.4 L/min/m²
Correct Answer: B
Rationale: Elevated PAOP (>18) with low cardiac index (<2.2) indicates left
ventricular dysfunction, likely requiring inotropes (milrinone, dobutamine,
epinephrine) to wean from CPB.
5. A patient with severe chronic obstructive pulmonary disease (COPD)
(FEV1 40% predicted) is scheduled for CABG. Which preoperative
intervention is most likely to reduce postoperative pulmonary complications?
A. Routine chest physiotherapy
B. Inhaled corticosteroids alone
C. Smoking cessation at least 4-6 weeks prior, and optimize bronchodilators
D. Preoperative tracheostomy
Correct Answer: C
Rationale: Smoking cessation >4 weeks reduces respiratory complications.
Optimizing bronchodilators and steroids (if indicated) improves lung function.
Chest physiotherapy is postoperative.
6. Which laboratory value is the strongest predictor of adverse outcome after
cardiac surgery?
A. Hemoglobin 12 g/dL
B. Albumin 2.8 g/dL
,C. Platelet count 250,000/µL
D. Sodium 138 mEq/L
Correct Answer: B
Rationale: Preoperative hypoalbuminemia (<3.5 g/dL) is a marker of malnutrition
and frailty, associated with increased infection, prolonged ventilation, and
mortality.
7. A patient with diabetes mellitus (HbA1c 8.9%) is scheduled for elective
CABG. What is the target preoperative glucose control goal to reduce sternal
wound infection?
A. HbA1c <7% (or <8% if high risk)
B. Random glucose <300 mg/dL
C. HbA1c <10%
D. No specific target
Correct Answer: A
Rationale: Improved glycemic control before surgery (HbA1c <7-8%) reduces
deep sternal wound infections. Hyperglycemia on day of surgery is also managed
with insulin infusion.
8. A patient with severe aortic stenosis and a low ejection fraction (25%) is
scheduled for valve replacement. Which preoperative medication should be
discontinued to avoid perioperative hypotension?
A. Beta-blocker (metoprolol)
B. ACE inhibitor (lisinopril) – often held 24 hours pre-op
C. Statin
D. Aspirin
Correct Answer: B
Rationale: ACE inhibitors/ARBs can cause refractory hypotension during
induction of anesthesia due to vasodilation. They are often withheld the day of
surgery. Beta-blockers are continued.
9. A patient with a history of cocaine use within the past 48 hours is scheduled
for urgent CABG. Which intraoperative risk is highest?
A. Hyperthermia
B. Coronary vasospasm, hypertension, and myocardial ischemia
C. Hypoglycemia
D. Prolonged bleeding
Correct Answer: B
, Rationale: Cocaine causes coronary vasoconstriction, hypertension, and
tachycardia, increasing risk of perioperative ischemia and myocardial infarction.
10. Preoperative frailty assessment in a 78-year-old cardiac surgery candidate
includes all of the following EXCEPT:
A. Gait speed (5-meter walk)
B. Hand grip strength
C. Serum albumin level
D. Patient’s favorite color
Correct Answer: D
Rationale: Frailty assessment includes mobility, nutrition, strength, and cognition.
Favorite color is irrelevant.
Domain 2: Intraoperative & Cardiopulmonary Bypass (CPB) Considerations
(Questions 11-20)
11. During cardiopulmonary bypass (CPB), the patient’s mean arterial
pressure (MAP) drops to 45 mm Hg despite adequate pump flow. Which
intervention is most appropriate?
A. Increase pump flow rate
B. Administer a vasopressor (e.g., phenylephrine or norepinephrine)
C. Add a second venous cannula
D. Decrease systemic vascular resistance by deepening anesthesia
Correct Answer: B
Rationale: During CPB, MAP is determined by pump flow and SVR. If flow is
adequate, low MAP indicates low SVR; vasopressors are used to increase MAP
and maintain cerebral perfusion.
12. Which acid-base management strategy during hypothermic CPB is
associated with better preservation of cerebral autoregulation?
A. Alpha-stat (pH maintained at 7.40 without correcting for temperature)
B. pH-stat (CO2 added, pH corrected to 7.40 at patient’s hypothermic temperature)
C. Respiratory alkalosis
D. Metabolic acidosis
Correct Answer: A
Rationale: Alpha-stat management (keeping pH 7.40 at 37°C measured) preserves
cerebral autoregulation. pH-stat increases cerebral blood flow and risk of
microemboli; used in some pediatric or deep hypothermic arrest.
specialized expertise in managing cardiac surgery
patients, postoperative care, hemodynamic
monitoring, and recovery processes.
1. A 68-year-old patient with severe aortic stenosis is scheduled for surgical
aortic valve replacement (SAVR). Which of the following preoperative
findings would most increase the risk of postoperative acute kidney injury
(AKI)?
A. Ejection fraction 55%
B. Serum creatinine 1.8 mg/dL (eGFR 35 mL/min/1.73m²)
C. Hemoglobin A1c 6.2%
D. Left ventricular end-diastolic diameter 4.5 cm
Correct Answer: B
Rationale: Pre-existing chronic kidney disease (eGFR <60) is a strong predictor of
postoperative AKI after cardiac surgery. Contrast and cardiopulmonary bypass
(CPB) exacerbate risk.
2. A patient is scheduled for elective coronary artery bypass grafting (CABG)
and takes clopidogrel (Plavix) for a recent drug-eluting stent placed 4 months
ago. The surgeon plans to operate in 5 days. Which medication management is
most appropriate?
A. Continue clopidogrel until day of surgery
B. Discontinue clopidogrel 5-7 days preoperatively after cardiology consultation
(risk of stent thrombosis vs. bleeding)
C. Replace with warfarin
D. Give a loading dose of ticagrelor
Correct Answer: B
Rationale: For DAPT after DES, elective non-cardiac surgery or cardiac surgery
should be postponed if possible. If surgery is necessary, discontinue P2Y12
inhibitor (clopidogrel) 5-7 days preop, with aspirin continued. Risk of stent
thrombosis vs. bleeding is weighed.
3. A patient with severe mitral regurgitation and a history of heparin-induced
thrombocytopenia (HIT) is scheduled for mitral valve repair. Which
,anticoagulant is safe for intraoperative cardiopulmonary bypass?
A. Unfractionated heparin (UFH)
B. Lepirudin (direct thrombin inhibitor, but not available; bivalirudin is used)
C. Fondaparinux
D. Argatroban or bivalirudin
Correct Answer: D
Rationale: In HIT, alternative anticoagulants for CPB include bivalirudin (direct
thrombin inhibitor) or argatroban. Lepirudin is no longer available. UFH is
absolutely contraindicated.
4. A patient scheduled for CABG has a preoperative pulmonary artery
catheter (PAC) placed. Which hemodynamic profile suggests poor left
ventricular function and need for inotropic support on bypass weaning?
A. PAOP 6 mm Hg, CI 2.8 L/min/m²
B. PAOP 22 mm Hg, CI 1.6 L/min/m², SVR 1800
C. PAOP 10 mm Hg, CI 3.2 L/min/m²
D. PAOP 18 mm Hg, CI 2.4 L/min/m²
Correct Answer: B
Rationale: Elevated PAOP (>18) with low cardiac index (<2.2) indicates left
ventricular dysfunction, likely requiring inotropes (milrinone, dobutamine,
epinephrine) to wean from CPB.
5. A patient with severe chronic obstructive pulmonary disease (COPD)
(FEV1 40% predicted) is scheduled for CABG. Which preoperative
intervention is most likely to reduce postoperative pulmonary complications?
A. Routine chest physiotherapy
B. Inhaled corticosteroids alone
C. Smoking cessation at least 4-6 weeks prior, and optimize bronchodilators
D. Preoperative tracheostomy
Correct Answer: C
Rationale: Smoking cessation >4 weeks reduces respiratory complications.
Optimizing bronchodilators and steroids (if indicated) improves lung function.
Chest physiotherapy is postoperative.
6. Which laboratory value is the strongest predictor of adverse outcome after
cardiac surgery?
A. Hemoglobin 12 g/dL
B. Albumin 2.8 g/dL
,C. Platelet count 250,000/µL
D. Sodium 138 mEq/L
Correct Answer: B
Rationale: Preoperative hypoalbuminemia (<3.5 g/dL) is a marker of malnutrition
and frailty, associated with increased infection, prolonged ventilation, and
mortality.
7. A patient with diabetes mellitus (HbA1c 8.9%) is scheduled for elective
CABG. What is the target preoperative glucose control goal to reduce sternal
wound infection?
A. HbA1c <7% (or <8% if high risk)
B. Random glucose <300 mg/dL
C. HbA1c <10%
D. No specific target
Correct Answer: A
Rationale: Improved glycemic control before surgery (HbA1c <7-8%) reduces
deep sternal wound infections. Hyperglycemia on day of surgery is also managed
with insulin infusion.
8. A patient with severe aortic stenosis and a low ejection fraction (25%) is
scheduled for valve replacement. Which preoperative medication should be
discontinued to avoid perioperative hypotension?
A. Beta-blocker (metoprolol)
B. ACE inhibitor (lisinopril) – often held 24 hours pre-op
C. Statin
D. Aspirin
Correct Answer: B
Rationale: ACE inhibitors/ARBs can cause refractory hypotension during
induction of anesthesia due to vasodilation. They are often withheld the day of
surgery. Beta-blockers are continued.
9. A patient with a history of cocaine use within the past 48 hours is scheduled
for urgent CABG. Which intraoperative risk is highest?
A. Hyperthermia
B. Coronary vasospasm, hypertension, and myocardial ischemia
C. Hypoglycemia
D. Prolonged bleeding
Correct Answer: B
, Rationale: Cocaine causes coronary vasoconstriction, hypertension, and
tachycardia, increasing risk of perioperative ischemia and myocardial infarction.
10. Preoperative frailty assessment in a 78-year-old cardiac surgery candidate
includes all of the following EXCEPT:
A. Gait speed (5-meter walk)
B. Hand grip strength
C. Serum albumin level
D. Patient’s favorite color
Correct Answer: D
Rationale: Frailty assessment includes mobility, nutrition, strength, and cognition.
Favorite color is irrelevant.
Domain 2: Intraoperative & Cardiopulmonary Bypass (CPB) Considerations
(Questions 11-20)
11. During cardiopulmonary bypass (CPB), the patient’s mean arterial
pressure (MAP) drops to 45 mm Hg despite adequate pump flow. Which
intervention is most appropriate?
A. Increase pump flow rate
B. Administer a vasopressor (e.g., phenylephrine or norepinephrine)
C. Add a second venous cannula
D. Decrease systemic vascular resistance by deepening anesthesia
Correct Answer: B
Rationale: During CPB, MAP is determined by pump flow and SVR. If flow is
adequate, low MAP indicates low SVR; vasopressors are used to increase MAP
and maintain cerebral perfusion.
12. Which acid-base management strategy during hypothermic CPB is
associated with better preservation of cerebral autoregulation?
A. Alpha-stat (pH maintained at 7.40 without correcting for temperature)
B. pH-stat (CO2 added, pH corrected to 7.40 at patient’s hypothermic temperature)
C. Respiratory alkalosis
D. Metabolic acidosis
Correct Answer: A
Rationale: Alpha-stat management (keeping pH 7.40 at 37°C measured) preserves
cerebral autoregulation. pH-stat increases cerebral blood flow and risk of
microemboli; used in some pediatric or deep hypothermic arrest.
