Anesthesia for Cardiothoracic and Vascular Surgery

Questions

DIRECTIONS (Questions 94-174): Each of the numbered items or incomplete statements in this section is followed by answers or by completions of the statement. Select the ONE lettered answer or completion that is BEST in each case.

94. A 72-year-old patient who underwent successful CABG is extubated 2 hours after arrival in the ICU. The next morning, the patient experiences the acute onset of sinus bradycardia with associated hypotension. The next best step in management is to

(A) initiate artificial cardiac pacing

(B) start isoproterenol

(D) perform a stat TTE

(E) administer adenosine

95. Afterload is reduced while diastolic perfusion pressure is increased by

(A) dopamine

(B) epinephrine

(D) nitroprusside

(E) intraaortic balloon counterpulsation

96. Ischemia from a right coronary artery lesion would most likely be evident on electrocardiographic lead

(A) I

(B) II

(D) AVL

(E) V5

97. Increased amplitude of v waves in a central venous pressure recording indicates

(A) junctional rhythm

(B) atrial fibrillation

(D) hypovolemia

(E) heart block

98. At 17°C

(A) EEG activity is unchanged

(B) cellular integrity is lost

(D) cerebral metabolic rate of oxygen consumption (CMRO₂) is less than 10% of normothermic value

(E) the brain switches to anaerobic metabolism

99. Which one of the following modalities for artificial pacing will result in ventricular, as opposed to atrial, pacing only?

(A) Transvenous endocardial leads

(B) Epicardial leads

(D) Esophageal electrodes

100. A 62-year-old male with a past medical history of alcohol abuse, smoking, and COPD is admitted to the hospital with severe substernal chest pain after an episode of binge drinking during which he reportedly threw up violently. He is brought to the operating room for emergent exploration of the chest for suspected esophageal rupture. His physical examination is notable for signs and symptoms consistent with severe sepsis, tachypnea, and SpO₂ of 89% while breathing O₂ through a nonrebreather facemask. Airway exam is notable for a Mallampati III score and a full beard. The surgeon informs you that one-lung ventilation will be required to facilitate esophageal repair. The anesthetic plan most likely to result in safe induction of anesthesia and adequate lung separation in addition to rapid-sequence induction includes

(A) placement of right-sided double-lumen tube

(B) placement of left-sided double-lumen tube

(D) placement of Univent tube followed by selective bronchial blockade

(E) placement of single-lumen tube followed by left mainstem intubation

101. The best drying effect before fiberoptic endoscopy is performed is achieved by the administration of

(A) neostigmine

(B) pyridostigmine

(D) atropine

(E) glycopyrrolate

102. A patient undergoing right upper lobectomy for lung cancer in the left lateral decubitus position is experiencing hypoxemia while receiving an FIO₂ of 1.0 during one-lung anesthesia with a double-lumen tube. Which one of the following options is the most appropriate next step in the treatment of hypoxemia?

(A) Application of continuous positive airway pressure (CPAP) to the nondependent lung

(B) Application of PEEP to the dependent lung

(D) Reinstitute two-lung ventilation

(E) Administration of oxygen via suction catheter to the collapsed lung

103. During cardiopulmonary bypass, patients

(A) need large doses of muscle relaxants at 25°C

(B) require neuromuscular blockade during cooling and warming

(D) should have their lungs hyperinflated

(E) should have continued pulmonary ventilation

104. Nitroglycerin causes vasodilation that is markedly potentiated by

(A) metoprolol

(B) remifentanil

(D) magnesium sulfate

(E) sildenafil

105. An 82-year-old patient with a cardiac rhythm-management device (ICD/pacemaker) in place requires surgery that entails the use of electrocautery. Which one of the following statements is true?

(A) The cutaneous electrode (skin pad) of a unipolar electrocautery unit should be as close to the pulse generator as possible.

(B) Electrocardiographic monitoring is necessary only if the patient is being paced.

(D) The risk for interference is negligible if the pacer is a demand unit.

(E) Electrocautery can electrically reset the pacemaker.

DIRECTIONS: Use the following scenario to answer Questions 106-107: A 42-year-old woman is referred by a thoracic surgeon from the clinic for mediastinoscopy. On evaluation, the patient is sitting up on the stretcher, and the respiratory pattern is notable for tachypnea that according to the patient has been present for the past two weeks. The patient’s voice sounds hoarse, and she tells you that she sleeps with two pillows at night.

106. Based on the description of symptoms, which one of the following findings is likely to be present on physical exam?

(A) Pain of the shoulder and medial aspect of forearm

(B) Rubor of face, and arm veins fail to empty on elevation

(D) Pursed lips, prolonged expirium, and bilateral wheezing on auscultation

(E) Paraesthesias, tetany, and dizziness

107. Based on the patients’ presentation, which one of the following is the safest approach to induction of anesthesia?

(A) Upper extremity IV access and rapid-sequence induction with placement of a single-lumen tube

(B) Upper extremity IV access and rapid-sequence induction with placement of double-lumen tube

(D) Lower extremity IV access, placement of arterial blood pressure monitor, maintenance of spontaneous breathing, placement of single-lumen tube

(E) Upper extremity IV access, placement of arterial blood pressure monitor, maintenance of spontaneous breathing, placement of single-lumen tube

108. The patient with a pacemaker in place may develop competing rhythms when a normal sinus rhythm is present and the unit has been converted to the asynchronous mode. If the pacing stimuli fall on the T wave of the previously conducted beats,

(A) ventricular fibrillation will follow

(B) there is little danger, since the energy output is low with current pulse generators

(D) ventricular fibrillation is less likely with catecholamine release

(E) ventricular fibrillation is less likely with myocardial infarction

109. Intraaortic balloon counterpulsation is a circulatory assist method that

(A) is used for patients with aortic aneurysms

(B) is used for patients with aortic insufficiency

(D) increases coronary blood flow

(E) increases impedance to the opening of the left ventricle

110. The clamping of the thoracic aorta in aneurysm repair is followed by

(A) immediate hypotension

(B) immediate hypertension

(D) no change

(E) loss of blood pressure in the right arm

111. A 72-year-old patient is undergoing thoracic aortic surgery. When the patient is extubated on the first postoperative day, he is noted to have paraplegia on neurological exam. This complication of aortic surgery is most commonly due to

(A) pressure on the spinal cord during surgery

(B) long periods of hypotension

(D) spinal cord ischemia

(E) loss of cerebrospinal fluid

112. Hypovolemia may occur during abdominal aneurysm procedures as a result of all of the following EXCEPT

(A) blood loss

(B) inadequate fluid replacement

(D) loss of fluid into the bowel

(E) expansion of the vascular bed during occlusion

113. The blood flow rate for an adult on total cardiopulmonary bypass is generally

(A) 15 mL/kg/min

(B) 35 mL/kg/min

(D) 85 mL/kg/min

(E) 115 mL/kg/min

114. When an adult patient is on total cardiopulmonary bypass,

(A) arterial pressure is generally maintained above 50 mm Hg

(B) blood is pumped from the venae cava and drains by gravity into the aorta for circulation

(D) venous pressure elevation is of no consequence

(E) venous return to the pump is always started before arterial infusion

115. A 48-year-old female with a history of 40 pack-years of smoking, hypertension, and hypercholesterolemia is to undergo right carotid endarterectomy for symptomatic, high-grade stenosis. Which one of the following statements regarding the anesthetic care for carotid artery surgery in this patient is true?

(A) Blood pressure during carotid occlusion should be maintained at, or above the patient’s baseline.

(B) The use of a BIS monitor will reliably detect intraoperative cerebral ischemia.

(D) The surgical procedure should be preceded by tests to show if carotid clamping can be tolerated.

(E) The use of regional anesthesia would minimize the risk of perioperative stroke.

116. The most reliable monitor for detection of intraoperative myocardial ischemia is

(A) creatine phosphokinase levels

(B) changes in the ST-T segment on ECG

(D) troponin concentrations

(E) exhaled nitric oxide

117. A 72-year-old male is presenting for endovascular stent graft repair of a 6.8 cm descending thoracic aortic aneurysm. The patient’s past medical history is significant for insulin dependent diabetes, hypertension, hypercholesterolemia, coronary artery disease, and myocardial infarction. The patient’s past surgical history is significant for infrarenal aortic aneurysm repair. In order to decrease the risk of spinal cord ischemia, part of the anesthetic management should be

(A) the preoperative placement of a lumbar drain

(B) intraoperative EEG monitoring

(D) deliberate hypotension

(E) a “high-dose narcotic” technique

118. An 84-year-old female with known severe mitral stenosis is to undergo urgent left hip hemiarthroplasty after suffering a femur fracture after a fall. The patient had a failed spinal anesthetic in the past and is refusing neuraxial anesthesia. The hemodynamic goal after induction of anesthesia should include

(A) increased heart rate

(B) increased contractility

(D) decreased contractility

(E) increased afterload

119. In comparing patients undergoing esophagectomy against those undergoing pulmonary resection, it is generally TRUE that esophagectomy patients

(A) have better nutritional status

(B) have less risk of aspiration

(D) are less likely to be hypoxic during single lung ventilation

(E) are less likely to need postoperative ventilation

120. The human larynx

(A) lies at the level of the 1st through 4th cervical vertebrae

(B) in the adult is narrowest at the level of the cricoid cartilage

(D) is protected anteriorly by the wide expanse of the cricoid cartilage

(E) lies within the thyroid cartilage

121. A patient is undergoing a mediastinoscopy when there is a sudden loss of pulse and pressure wave being monitored at the right wrist. The mediastinoscope is withdrawn, with resumption of normal vital signs. The most likely cause of the problem is

(A) cardiac arrest

(B) superior vena cava obstruction

(D) compression of the innominate artery

(E) anesthetic overdose

122. A 71-year-old man is admitted with a complaint of hoarseness and sore throat. On indirect laryngoscopy, a supraglottic mass is noted with edema of the cords. He is scheduled for a direct laryngoscopy under general anesthesia. The approach to this procedure should be

(A) kept simple, since it is a short procedure

(B) induction, paralysis, and laryngoscopy

(D) paralysis, intubation, induction, and laryngoscopy

(E) to establish an airway before paralysis or instrumentation

123. A patient with esophageal obstruction is to have a general anesthetic for esophagoscopy. He has had a barium swallow on the previous day. One of the greatest dangers of the planned procedure is

(A) bleeding

(B) hypotension

(D) aspiration

(E) arrhythmia

DIRECTIONS: Use the following figure to answer Questions 124-127:

124. The figure shows a view of a patient with a double-lumen tube viewed from the head of the bed. To ventilate the right lung and deflate the left lung, one should

(A) clamp at 1 and uncap at 3

(B) clamp at 6 and uncap at 3

(D) clamp at 5 and uncap at 4

(E) clamp at 1 and 6 and uncap at 3

125. After the tube has been correctly positioned, a bronchoscope is used. By opening at 4 and looking down the lumen of 2, one should see

(A) the left upper lobe with a right-sided tube

(B) the carina with a right-sided tube

(D) the carina with a left-sided tube

(E) the left upper lobe with a left-sided tube

126. To lavage the right lung while ventilating the left lung, one would perform all the following EXCEPT

(A) clamp at 6

(B) clamp at 2

(D) inflate the bronchial cuff

(E) inflate the tracheal cuff

127. All of the following are true about the double-lumen tube in the figure EXCEPT

(A) lumen 1 is the bronchial lumen in a left-sided tube

(B) the pressures are equal at 1 and 2 when no clamps are applied

(D) clamping at 6 isolates the left lung from the anesthesia circuit

(E) clamping at 5 and uncapping at 3 will allow the left lung to collapse

DIRECTIONS: Use the following figure to answer Questions 128-129:

128. The device depicted in the figure is

(A) a Univent bronchial blocker tube

(B) a Fogarty catheter

(D) an independent (Arndt) endobronchial blocker

(E) an airway exchange catheter

129. Which one of the following statements about the device depicted is true?

(A) It is useful to obtain one-lung ventilation in patients who are already intubated or have a difficult airway.

(B) Positive pressure ventilation has to be interrupted for proper placement.

(D) It can only be used in patients undergoing right sided surgery.

(E) With this device, the endotracheal tube has to be exchanged at the end of surgery if the patient is to remain intubated.

130. During apneic oxygenation

(A) the time elapsed before desaturation occurs is independent of the patient’s pulmonary status

(B) all arrhythmias are due to hypoxemia

(D) the carbon dioxide level rises about 3-6 mm Hg/min

(E) pulse oximetry is not helpful

131. The bronchial venous systems drains into all of the following vascular beds EXCEPT

(A) Thebesian veins

(B) hemiazygos veins

(D) pulmonary veins

(E) mediastinal veins

132. A 58-year-old male with past medical history significant for moderate to severe aortic regurgitation is undergoing laparoscopic ventral hernia repair under general anesthesia. Assuming that the patient’s blood pressure is normal and at baseline, administration of which one of the following drugs is likely to result in improved forward flow?

(A) Norepinephrine

(B) Glycopyrrolate

(D) Phenylephrine

(E) Vasopressin

133. The administration of fentanyl in large doses (0.1 mg/kg) generally results in

(A) increased pulmonary vascular resistance

(B) decreased heart rate

(D) more profound hypotension than is seen with morphine (1 mg/kg)

134. Which one of the following interventions is most likely to result in preservation of renal function during aortic aneurysm surgery?

(A) Administration of furosemide

(B) Keeping aortic cross clamp time less than 120 min

(D) Endovascular approach to aortic aneurysm repair

(E) Administration of mannitol

DIRECTIONS: Use the following scenario to answer Questions 135-136: A 75-kg patient is undergoing elective repair of an aortic aneurysm. Twenty minutes after incision the patient develops tachycardia, hypotension, and subsequent ST elevations in lead V, as well as a rise in the pulmonary artery (PA) pressures. An infusion of vasopressor is started to correct hypotension.

135. In addition to correcting the hypotension, the most effective intervention for the treatment of elevated PA pressures in this scenario is

(A) infusion of milrinone

(B) addition of inhaled nitric oxide

(D) start hyperventilation

(E) increase in FIO₂ to 1.0

136. With respect to the patient’s tachycardia, the next best step in management is

(A) observation only

(B) administration of metoprolol

(D) administration of neostigmine

(E) administration of glycopyrrolate

137. A 72-year-old patient underwent an uncomplicated CABG for severe three-vessel coronary artery disease four hours ago and is now requiring increasing levels of hemodynamic support. The patient was started on an epinephrine infusion, currently at 2 mcg/kg/min. Vital signs are blood pressure (BP) 80/50, heart rate 130, pulmonary artery pressure 50/25, central venous pressure 24, cardiac index 1.6, and the ECG shows variations in amplitude. A bedside transthoracic echocardiogram shows right atrial collapse and abnormal ventricular septal motion. Based on the patient’s presentation, the next best step in management is to

(A) add norepinephrine

(B) stop epinephrine and start milrinone

(D) add nitroglycerin

(E) stat CT of the chest with pulmonary embolism protocol

138. An anesthetic consideration for Marfan syndrome is

(A) atlanto-axial instability

(B) aortic stenosis

(D) mitral regurgitation

(E) ventricular septal defect (VSD)

139. A 29-year-old male suffered a motorcycle crash and is undergoing intramedullary nailing of the left femur. The accident occurred 24 h ago. Shortly after intramedullary reaming, the patient develops tachycardia, hypotension and hypoxemia. There are no ST-segment changes on the five-lead EKG. What is the most likely finding on the patient’s transesophageal echocardiogram?

(A) Fluid collection around the heart without any diastolic collapse

(B) Regional wall motion abnormalities in the anterolateral wall of the left ventricle

(D) Distended right atrium and ventricle, collapsed left atrium and ventricle

(E) Large color flow via the intraventricular septum

140. When PaCO₂ and pH are managed by the alpha-stat method during hypothermic cardiopulmonary bypass,

(A) the corrected pH is 7.4

(B) ABG results will be corrected to current patient temperature

(D) the corrected PaCO₂ is 40 mm Hg

141. A 77-year-old woman with coronary artery disease and significant aortic stenosis develops myocardial ischemia shortly after induction of anesthesia. She is being treated with beta blockers and nitroglycerin, and her blood pressure is being supported with an infusion of norepinephrine. Throughout this event the patient’s oxygen saturation is 100%. The patient continues to be ischemic. What statement about the use of an intraaortic balloon pump (IABP) in this patient is true?

(A) An IABP is not indicated and the patient should be put on cardiopulmonary bypass.

(B) An IABP is contraindicated because the patient has aortic stenosis.

(D) The tip of the IABP balloon has to be placed just distal to the coronary arteries.

(E) An IABP is contraindicated due to the risk of leg ischemia.

142. A 65-year-old female with a history of severe aortic stenosis requires urgent laparoscopic cholecystectomy. An important hemodynamic goal during anesthetic care is

(A) decreased afterload

(B) slow heart rate

(D) high heart rate

(E) decreased contractility

143. Cannon waves in the central venous pressure tracing

(A) are caused by atrial fibrillation

(B) can be seen with atrioventricular nodal rhythms

(D) will resolve with ventricular pacing

(E) represent an artifact caused by air in the pressure transducer system

144. The right lung, in the upright position

(A) is the smaller of the two

(B) has a single fissure

(D) receives 45% of total lung blood flow

(E) is less frequently involved in aspiration compared to the left

145. A 74-year-old patient is to undergo for right-sided thoracotomy for resection of lung cancer. The patient’s past medical history is significant for myocardial infarction four months ago at which time the patient underwent the placement of two drug-eluting stents and was started on antiplatelet therapy with clopidogrel. According to the patient’s cardiologist, the patient is to continue clopidogrel throughout the perioperative period. The surgeon is requesting an analgesic strategy that would provide the patient with about 36 h of postoperative pain control to facilitate extubation and early mobilization. Which one of the following is the most effective and safest method of analgesia for this patient?

(A) postoperative right intercostal block

(B) lumbar epidural catheter

(D) thoracic epidural catheter

(E) right paravertebral block via continuous catheter

146. A patient with severe COPD and severe pulmonary hypertension is to undergo bilateral lung transplant. The en-bloc double-lung transplant, as compared to bilateral sequential single-lung transplantation

(A) has a decreased need for blood transfusions

(B) has a lower incidence of ischemia at the site of tracheal anastomosis

(D) is technically easier

(E) does not require cardiac arrest

147. A 68-year-old patient is to undergo a Whipple procedure for resection of a tumor of the head of the pancreas. The patient’s past medical history is significant for myocardial infarction and the placement of a bare metal stent, hypertension, hypercholesterolemia, and COPD secondary to tobacco abuse. The preoperative ECG is significant for a right bundle branch block, and the preoperative TTE is significant for diastolic dysfunction with an ejection fraction of 45% as well as moderate to severe aortic regurgitation. In addition to arterial blood pressure, a decision is made for intraoperative monitoring with a pulmonary artery catheter for estimation of left ventricular preload. Based on this patient’s presentation, left ventricular preload as assessed by pulmonary artery catheter measurements will likely be

(A) underestimated because of aortic regurgitation

(B) overestimated due to the right bundle branch block

(D) underestimated because the patient will be on positive pressure ventilation

(E) accurately reflected by LAP, LVEDP, and PAOP

DIRECTIONS: Use the following figure to answer Questions 148-149:

148. A 58-year-old male comes to the emergency department with diffuse chest pain that is radiating into his back. His past medical history is significant for tobacco and alcohol abuse, hypertension, and hypercholesterolemia, as well as peripheral vascular disease. A workup for acute coronary syndrome is negative, and the patient undergoes CT imaging of chest and abdomen with IV contrast that reveals a thoracoabdominal aneurysm that is deemed symptomatic and the patient is scheduled to undergo urgent surgical repair. Based on the drawing, which one of the following classifications of this patient’s aneurysm is accurate?

(A) Stanford A

(B) DeBakey II

(D) Crawford I

(E) Crawford II

149. The risk of spinal cord ischemia with surgical repair of this type of lesion is approximately

(A) 2%

(B) 10%

(D) 30%

(E) 40%

150. An 82-year-old patient with anterior two-vessel coronary artery disease and unstable angina is referred by the cardiologist for CABG. Her past medical history is otherwise significant for type I diabetes, chronic renal insufficiency, peripheral vascular disease, COPD, and atherosclerotic ascending aortic disease. The cardiac surgeon decides to perform off-pump CABG to the LAD and the RCA. Considering this patient’s comorbidities and the proposed procedure, it is true that

(A) minimally invasive coronary artery bypass grafting would be a suitable alternative

(B) the surgeon will require a stabilization device for the distal anastomoses

(D) hemodynamic goals are easier to achieve as compared to CABG with cardiopulmonary bypass

(E) the use of propofol for maintenance of anesthesia will result in equivalent myocardial protection as compared to volatile anesthetics

151. The patient population most likely to benefit from transcatheter aortic valve implantation is

(A) children and young adults with congenital, noncalcific aortic stenosis

(B) adult patients with severe aortic regurgitation

(D) adult patients with symptomatic severe aortic stenosis deemed too high risk for surgery

(E) adult patients with symptomatic severe aortic stenosis without other associated comorbidities

152. A 60-year-old female was admitted with a large goiter and a history of hoarseness. An incidental finding on the chest x-ray was tracheal deviation with questionable narrowing of the tracheal lumen. After induction was complicated by a difficult intubation requiring multiple attempts, the thyroid was removed with some difficulty and at the end of the procedure the patient was breathing spontaneously. Immediately after extubation, breathing was labored and retraction was noted. Causes of this may include all of the following EXCEPT

(A) bilateral recurrent laryngeal nerve injury

(B) laryngospasm

(D) bronchospasm

(E) thyrotoxicosis

153. Hypoxic pulmonary vasoconstriction

(A) occurs when regional atelectasis mechanically obstructs blood flow

(B) is primarily triggered by alveolar carbon dioxide tension

(D) is potentiated by administration of nitrous oxide

(E) is augmented by an increase in pulmonary artery pressure

154. At the conclusion of an aortic aneurysm repair associated with significant blood loss, diffuse bleeding and the absence of clot formation is noted in the surgical field. A thromboelastogram shows decreased maximum amplitude. The appropriate treatment includes administration of which one of the following?

(A) Protamine

(B) Cryoprecipitate

(D) Aminocaproic acid

(E) Platelets

155. Structures that pass anteriorly to the trachea include all of the following EXCEPT

(A) pulmonary artery

(B) thyroid isthmus

(D) aortic arch

(E) left brachiocephalic vein

156. Indications for one-lung ventilation include all of the following EXCEPT

(A) infection with purulent secretions

(B) massive pulmonary hemorrhage

(D) unilateral bronchopulmonary lavage for alveolar proteinosis

(E) Ivor-Lewis esophagectomy

157. During awake, closed chest ventilation in the lateral decubitus position,

(A) the lung relationships are the same as in the semirecumbent position, i.e., the apex is in zone 1 and the bases are in zone 3

(B) ventilation is highest at the apex

(D) compliance is unequal in the two lungs

(E) the nondependent lung receives most of the tidal ventilation

158. A 35-year-old man is admitted to the emergency department following an automobile accident. It is noted that there is a contusion over the anterior thorax, he is tachypneic, and he has a scaphoid abdomen. Auscultation reveals poor breath sounds on the left side. Chest x-ray shows a large air cavity in the left side of the thorax. Blood pressure is 80/60, and heart rate is 120 per minute. Diagnoses that must be considered include all of the following EXCEPT

(A) ruptured spleen

(B) pneumothorax

(D) cardiac contusion

(E) fat embolism syndrome

159. A 69-year-old woman is scheduled for routine CABG. Since her preoperative cardiac catheterization, her platelet count has dropped from 312 to 252 × 10³/mm³. A heparin-induced thrombocytopenia (HIT) immunoassay has been ordered and it resulted in a positive HIT antibody. She has a large bruise at the site of her catheterization. There are no signs of deep venous thrombus or any other thrombotic events. You should

(A) delay surgery for 2 months

(B) proceed with surgery and use a direct thrombin inhibitor instead of heparin

(D) use only 50% of the regular heparin dose and proceed with surgery

(E) use a combination of warfarin and low-dose heparin to achieve adequate anticoagulation

160. A 73-year-old patient is undergoing emergent three-vessel CABG for symptomatic left main coronary artery disease. Upon completion of the surgical procedure, the patient develops the need for high dose inotropic support, and the decision is made to implant a left ventricular assist device (LVAD) to facilitate weaning from cardiopulmonary bypass (CPB). After discontinuation of CPB, the patient is noted to be hypotensive with low pump flow rates apparent on the LVAD device. Immediate TEE examination does not show any evidence of inflow cannula obstruction, but is significant for systolic collapse of the right atrium and diastolic collapse of the right ventricle. The ECG shows low QRS voltage. The most likely cause for this patient’s hypotension is

(A) graft failure

(B) acute hypovolemia

(D) pulmonary embolus

(E) pericardial tamponade

161. The advantages of ultrasound-guided central venous catheter placement, as compared to the landmark technique, include all of the following EXCEPT

(A) prevention of arterial injury

(B) direct visualization of the target vessel

(D) decreased number of attempts required

(E) decreased overall complication rate

DIRECTIONS (Questions 162-164): Each group of items below consists of lettered headings followed by a list of numbered phrases or statements. For each numbered phrase or statement, select the ONE lettered heading or component that is most closely associated with it and fill in the circle containing the corresponding letter on the answer sheet. Each lettered heading or component may be selected once, more than once, or not at all.

For each patient, select the appropriate diagram of the heart sounds.

162. A 64-year-old patient with a history of rheumatic fever presenting for elective aortic valve replacement.

163. A 21-year-old female with Down syndrome and echocardiographic evidence of right ventricular overload.

164. A 70-year-old male with a 60 pack-year history of smoking and a history of pneumonectomy for lung cancer with mild respiratory insufficiency and evidence of right ventricular strain on echocardiography.

DIRECTIONS (Questions 165-174): Each group of items below consists of lettered headings followed by a list of numbered phrases or statements. For each numbered phrase or statement, select the ONE lettered heading or component that is most closely associated with it. Each lettered heading or component may be selected once, more than once, or not at all.

(A) Mid-esophageal four chamber

(B) Mid-esophageal two chamber

(D) Transgastric two chamber

(E) Transgastric mid-papillary short axis

(F) Mid-esophageal aortic valve short axis

(G) Mid-esophageal aortic valve long axis

(H) Mid-esophageal bicaval

(I) Mid-esophageal right ventricular inflow-outflow

(J) Deep transgastric long axis

(K) Upper esophageal aortic valve short axis

(L) Upper esophageal aortic valve long axis

(M) Transgastric long axis