CHAPTER 13

Ane s the s ia fo r Cardio tho rac ic and

Vas c ular S urg e ry
Que s tions

DIRECTION S (Qu estions 94-174): Each of the nu m - 97. Increased am p litu d e of v w aves in a central
bered item s or incom p lete statem ents in this section venou s pressure record ing ind icates
is follow ed by answ ers or by com p letions of the
(A) ju nctional rhythm
statem ent. Select the ON E lettered answ er or com -
p letion that is BEST in each case. (B) atrial fibrillation
(C) tricu sp id regu rgitation
94. A 72-year-old p atient w ho u nd erw ent su ccess- (D) hyp ovolem ia
fu l CABG is extu bated 2 hou rs after arrival in (E) heart block
the ICU. The next m orning, the patient experi-
ences the acute onset of sinus brad ycard ia w ith 98. At 17°C
associated hyp otension. The next best step in
m anagem ent is to (A) EEG activity is u nchanged
(B) cellu lar integrity is lost
(A) initiate artificial card iac p acing
(C) cerebral blood flow increases
(B) start isop roterenol
(D) cerebral m etabolic rate of oxygen con-
(C) start ep inep hrine su m ption (CMRO 2) is less than 10% of
(D) p erform a stat TTE norm otherm ic value
(E) ad m inister ad enosine (E) the brain sw itches to anaerobic
m etabolism
95. Afterload is red u ced w hile d iastolic p erfu sion
pressu re is increased by 99. Which one of the follow ing m od alities for arti-
(A) d op am ine ficial p acin g w ill resu lt in ven tricu lar, as
opposed to atrial, pacing only?
(B) ep inep hrine
(C) nitroglycerin (A) Transvenou s end ocard ial lead s
(D) nitrop ru ssid e (B) Ep icard ial lead s
(E) intraaortic balloon cou nterp u lsation (C) External noninvasive electrod es
(D) Esop hageal electrod es
96. Ischem ia from a right coronary artery lesion
w ou ld m ost likely be evid ent on electrocard io-
grap hic lead
(A) I
(B) II
(C) VR
(D) AVL
(E) V5

215
216 13: Ane s the s ia for Ca rdiothora cic a nd Va s cula r S urge ry
100. A 62-year-old m ale w ith a p ast m ed ical history
of alcohol abuse, smoking, and COPD is ad mit-
ted to the hospital w ith severe substernal chest
p ain after an ep isod e of binge d rinking d u ring
w hich he rep orted ly threw u p violently. H e is
brou ght to the op erating room for em ergent
exploration of the chest for su spected esop ha-
geal rup tu re. H is physical exam ination is nota-
ble for signs and sym p tom s consistent w ith
severe sep sis, tachyp nea, and Sp O 2 of 89%
w hile breathing O 2 throu gh a nonrebreather
facem ask. Airw ay exam is n otable for a
Mallam pati III score and a fu ll beard . The sur-
geon inform s you that one-lu ng ventilation
w ill be requ ired to facilitate esop hageal rep air.
The anesthetic p lan most likely to resu lt in safe
ind u ction of anesthesia and ad equ ate lu ng
sep aration in ad d ition to rap id -sequ ence
ind u ction inclu d es
(A) p lacem ent of right-sid ed d ou ble-lu m en
tube
(B) p lacem ent of left-sid ed d ou ble-lu m en
tube
(C) p lacem ent of single-lu m en tu be fol-
low ed by right m ainstem intu bation
(D) p lacem ent of Univent tu be follow ed by
selective bronchial blockad e
(E) p lacem ent of single-lu m en tu be fol-
low ed by left m ainstem intu bation
101. The best d rying effect before fiberop tic end os-
copy is perform ed is achieved by the ad m inis-
tration of
(A) neostigm ine
(B) p yrid ostigm ine
(C) ed rop honiu m
(D) atrop ine
(E) glycop yrrolate
102. A patient und ergoing right upp er lobectom y
for lu ng cancer in the left lateral d ecu bitu s
p osition is exp eriencin g h yp oxem ia w h ile
receiving an FIO 2 of 1.0 d u ring one-lu ng anes-
thesia w ith a d ouble-lum en tube. Which one of
the follow ing options is the m ost app rop riate
next step in the treatm ent of hypoxem ia?
(A) Ap p lication of continu ou s p ositive
airw ay p ressu re (CPAP) to the non-
d epend ent lu ng
(B) Ap p lication of PEEP to the d ep end ent
lu ng
(C) Interm ittent reinflation of the non-
d epend ent lu ng
(D) Reinstitu te tw o-lu ng ventilation
(E) Ad m inistration of oxygen via su ction
catheter to the collapsed lu ng
103. Du ring card iop u lm onary byp ass, p atients
(A) need large d oses of m u scle relaxants at
25°C
(B) requ ire neu rom u scu lar blockad e d u ring
cooling and w arm ing
(C) shou ld have Pa CO 2 m aintained at abou t
30 m m H g
(D) shou ld have their lu ngs hyp erinflated
(E) shou ld have continu ed p u lm onary
ventilation
104. N itroglycerin causes vasod ilation that is m ark-
ed ly p otentiated by
(A) m etop rolol
(B) rem ifentanil
(C) labetalol
(D) m agnesiu m su lfate
(E) sild enafil
105. An 82-year-old p atient w ith a card iac rhythm -
management d evice (ICD/ pacemaker) in place
requ ires su rgery that entails the u se of electro-
cautery. Which one of the follow ing statem ents
is tru e?
(A) The cutaneous electrod e (skin pad) of a
unipolar electrocautery unit should be as
close to the pulse generator as possible.
(B) Electrocard iograp hic m onitoring is nec-
essary only if the patient is being p aced .
(C) Placing a magnet over the device can
deactivate the pacing function of an ICD.
(D) The risk for interference is negligible if
the pacer is a d em and unit.
(E) Electrocau tery can electrically reset the
pacem aker.

DIRECTION S: Use the follow ing scenario to answ er
Qu estions 106-107: A 42-year-old w om an is referred
by a thoracic su rgeon from the clinic for m ed iasti-
noscopy. On evalu ation, the patient is sitting u p on
the stretcher, and the respiratory p attern is notable
for tachyp nea that accord ing to the p atient has been
p resent for the p ast tw o w eeks. The p atient's voice
sou nd s hoarse, and she tells you that she sleeps
w ith tw o p illow s at night.
106. Based on the d escrip tion of sym p tom s, w hich
one of the follow ing find ings is likely to be
p resent on p hysical exam ?
(A) Pain of the shou ld er and m ed ial asp ect
of forearm
(B) Ru bor of face, and arm veins fail to
em p ty on elevation
(C) Low er extrem ity ed em a, and rales on
au scu ltation
(D) Pu rsed lip s, p rolonged exp iriu m , and
bilateral w heezing on au scu ltation
(E) Paraesthesias, tetany, and d izziness
107. Based on the p atients' p resentation, w hich one
of the follow ing is the safest approach to ind uc-
tion of anesthesia?
(A) Up p er extrem ity IV access and rap id -
sequ ence ind u ction w ith placem ent of a
single-lu m en tu be
(B) Up p er extrem ity IV access and rap id -
sequ ence ind u ction w ith placem ent of
d ou ble-lu m en tube
(C) Low er extrem ity IV access, stand ard IV
ind u ction, m ask ventilation, p lacem ent
of single-lu m en tu be
(D) Low er extrem ity IV access, p lacem ent of
arterial blood p ressu re m onitor, m ainte-
nance of sp ontaneou s breathing, place-
m ent of single-lu m en tu be
(E) Up p er extrem ity IV access, p lacem ent of
arterial blood p ressu re m onitor, m ainte-
nance of sp ontaneou s breathing, place-
m ent of single-lu m en tu be
108. The p atient w ith a p acem aker in p lace m ay
d evelop com p eting rhythm s w hen a norm al
sinu s rhythm is present and the unit has been
converted to the asynchronou s m od e. If the
Que s tions : 100–111 217
p acing stim u li fall on the T w ave of the previ-
ously cond u cted beats,
(A) ventricu lar fibrillation w ill follow
(B) there is little d anger, since the energy
ou tput is low w ith cu rrent pu lse
generators
(C) ventricu lar fibrillation is less likely if
hyp oxem ia is p resent
(D) ventricu lar fibrillation is less likely w ith
catecholam ine release
(E) ventricu lar fibrillation is less likely w ith
m yocard ial infarction
109. Intraaortic balloon cou nterp u lsation is a circu -
latory assist m ethod that
(A) is u sed for p atients w ith aortic
aneu rysm s
(B) is u sed for p atients w ith aortic
insu fficiency
(C) cau ses an intraaortic balloon to be
inflated d u ring systole
(D) increases coronary blood flow
(E) increases im p ed ance to the op ening of
the left ventricle
110. The clam p ing of the thoracic aorta in aneu -
rysm rep air is follow ed by
(A) im m ed iate hypotension
(B) im m ed iate hypertension
(C) card iac stand still
(D) no change
(E) loss of blood pressu re in the right arm
111. A 72-year-old p atient is u nd ergoing thoracic
aortic su rgery. When the p atient is extubated
on the first postoperative d ay, he is noted to
have p arap legia on neu rological exam . This
com p lication of aortic su rgery is m ost com -
m only d u e to
(A) p ressu re on the sp inal cord d u ring
su rgery
(B) long p eriod s of hyp otension
(C) hypothermia associated with the surgery
(D) sp inal cord ischem ia
(E) loss of cerebrosp inal flu id
218 13: Ane s the s ia for Ca rdiothora cic a nd Va s cula r S urge ry

112. H yp ovolem ia m ay occu r d u ring abd om inal (C) The u se of volatile anesthetics w ou ld
aneu rysm p roced ures as a resu lt of all of the resu lt in su p erior brain p rotection as
follow ing EXCEPT com pared to propofol.
(A) blood loss (D) The su rgical p roced u re shou ld be p re-
ced ed by tests to show if carotid clam p-
(B) inad equ ate flu id rep lacem ent
ing can be tolerated .
(C) u se of vasod ilators
(E) The u se of regional anesthesia w ou ld
(D) loss of flu id into the bow el m inim ize the risk of perioperative
(E) exp ansion of the vascu lar bed d u ring stroke.
occlu sion
116. The m ost reliable m onitor for d etection of
113. The blood flow rate for an ad u lt on total car- intraop erative m yocard ial ischem ia is
d iopu lm onary byp ass is generally
(A) creatine p hosp hokinase levels
(A) 15 m L/ kg/ m in (B) changes in the ST-T segm ent on ECG
(B) 35 m L/ kg/ m in (C) transesop hageal echocard iograp hy
(C) 55 m L/ kg/ m in (D) trop onin concentrations
(D) 85 m L/ kg/ m in (E) exhaled nitric oxid e
(E) 115 m L/ kg/ m in
117. A 72-year-old m ale is p resenting for end ovas-
114. When an ad u lt patient is on total card iopu lmo- cu lar stent graft rep air of a 6.8 cm d escend ing
nary bypass, thoracic aortic aneu rysm . The p atient's p ast
(A) arterial p ressu re is generally m aintained med ical history is significant for insulin d epen-
above 50 m m H g d ent d iabetes, hypertension, hypercholesterol-
em ia, coronary artery d isease, and m yocard ial
(B) blood is p u m p ed from the venae cava
infarction. The p atient's p ast su rgical history is
and d rains by gravity into the aorta for
significan t for in fraren al aortic an eu rysm
circu lation
rep air. In ord er to d ecrease the risk of sp inal
(C) the level of blood in the venou s reser- cord ischem ia, p art of the anesthetic m anage-
voir of the pu m p reflects the central m ent shou ld be
venous pressu re of the patient
(D) venou s p ressu re elevation is of no (A) the p reop erative p lacem ent of a lu m bar
consequ ence d rain
(E) venou s retu rn to the p u m p is alw ays (B) intraop erative EEG m onitoring
started before arterial infu sion (C) d eep hyp otherm ic circu latory arrest
(DH CA)
115. A 48-year-old fem ale w ith a history of 40 p ack- (D) d eliberate hyp otension
years of sm oking, hyp ertension, and hyp er- (E) a "high-d ose narcotic" techniqu e
cholesterolem ia is to u nd ergo right carotid
end arterectom y for sym p tom atic, high-grad e 118. An 84-year-old fem ale w ith know n severe
stenosis. Which one of the follow ing state- m itral stenosis is to u nd ergo u rgent left hip
m ents regard ing the anesthetic care for carotid hem iarthrop lasty after su ffering a fem u r frac-
artery surgery in this p atient is tru e? tu re after a fall. The patient had a failed sp inal
(A) Blood p ressu re d u ring carotid occlu sion anesthetic in the p ast and is refu sing neu raxial
shou ld be m aintained at, or above the anesthesia. The hemod ynamic goal after ind uc-
p atient's baseline. tion of anesthesia should includ e
(B) The u se of a BIS m onitor w ill reliably (A) increased heart rate
d etect intraop erative cerebral ischem ia. (B) increased contractility
(C) increased p reload
 Que s tions : 112–124 219

(D) d ecreased contractility (C) ind u ction, p aralysis, intu bation, and
(E) increased afterload laryngoscop y
(D) p aralysis, intu bation, ind u ction, and
119. In com p aring p atients u nd ergoing esop hagec- laryngoscop y
tom y against those u nd ergoing p u lm onary (E) to establish an airw ay before p aralysis
resection, it is generally TRUE that esop hagec- or instrum entation
tom y patients
(A) have better nu tritional statu s 123. A p atient w ith esop hageal obstru ction is to
have a general anesthetic for esop hagoscopy.
(B) have less risk of asp iration
H e has had a bariu m sw allow on the p reviou s
(C) have better p u lm onary fu nction d ay. One of the greatest d angers of the planned
(D) are less likely to be hyp oxic d u ring sin- p roced u re is
gle lu ng ventilation
(A) bleed ing
(E) are less likely to need p ostop erative
ventilation (B) hyp otension
(C) d ifficu lt intu bation
120. The hu m an larynx (D) asp iration
(A) lies at the level of the 1st throu gh 4th (E) arrhythm ia
cervical vertebrae
DIRECTION S: Use the follow ing figu re to answ er
(B) in the ad u lt is narrow est at the level of
Qu estions 124-127:
the cricoid cartilage
(C) is innervated solely by the recu rrent
laryngeal nerve
(D) is p rotected anteriorly by the w id e
exp anse of the cricoid cartilage
(E) lies w ithin the thyroid cartilage

121. A p atient is u nd ergoing a m ed iastinoscop y

w hen there is a su d d en loss of p u lse and p res-
sure w ave being m onitored at the right w rist.
Th e m ed iastin oscop e is w ith d raw n , w ith
resu m p tion of norm al vital signs. The m ost
likely cau se of the p roblem is
(A) card iac arrest 124. The figu re show s a view of a p atient w ith a
(B) su p erior vena cava obstru ction d ou ble-lu m en tu be view ed from the head of
the bed . To ventilate the right lu ng and d eflate
(C) air in the m ed iastinu m
the left lung, one shou ld
(D) com p ression of the innom inate artery
(E) anesthetic overd ose (A) clam p at 1 and u ncap at 3
(B) clam p at 6 and u ncap at 3
122. A 71-year-old m an is ad m itted w ith a com - (C) clam p at 5 and u ncap at 3
plaint of hoarseness and sore throat. On ind i- (D) clam p at 5 and u ncap at 4
rect laryngoscop y, a su p raglottic m ass is noted (E) clam p at 1 and 6 and u ncap at 3
w ith ed em a of the cord s. H e is sched u led for a
d irect laryngoscop y u nd er general anesthesia.
The ap p roach to this p roced u re shou ld be
(A) kept sim ple, since it is a short proced u re
(B) ind u ction, paralysis, and laryngoscopy
220 13: Ane s the s ia for Ca rdiothora cic a nd Va s cula r S urge ry

125. After the tube has been correctly p ositioned , a (D) inflate the bronchial cu ff
bronchoscop e is u sed . By op ening at 4 and (E) inflate the tracheal cu ff
looking d ow n the lum en of 2, one shou ld see
(A) the left u p p er lobe w ith a right-sid ed 127. All of the follow ing are tru e abou t the d ou ble-
tube lu m en tu be in the figu re EXCEPT
(B) the carina w ith a right-sid ed tu be (A) lu m en 1 is the bronchial lum en in a left-
(C) the trachea w ith a right-sid ed tu be sid ed tu be
(D) the carina w ith a left-sid ed tu be (B) the p ressu res are equ al at 1 and 2 w hen
(E) the left u p p er lobe w ith a left-sid ed tu be no clam ps are ap plied
(C) CPAP to the right lu ng is ap p lied at 4
126. To lavage the right lu ng w hile ventilating the (D) clam p ing at 6 isolates the left lu ng from
left lu ng, one w ou ld p erform all the follow ing the anesthesia circu it
EXCEPT (E) clam p ing at 5 and u ncapp ing at 3 w ill
(A) clam p at 6 allow the left lu ng to collap se
(B) clam p at 2
DIRECTION S: Use the follow ing figu re to answ er
(C) p ou r flu id into 4 Qu estions 128-129:

128. The d evice d ep icted in the figu re is (A) It is u sefu l to obtain one-lu ng ventila-
tion in p atients w ho are alread y intu -
(A) a Univent bronchial blocker tu be
bated or have a d ifficu lt airw ay.
(B) a Fogarty catheter
(B) Positive p ressu re ventilation has to be
(C) a Sengstaken-Blakem ore tu be interru p ted for p rop er p lacem ent.
(D) an ind ep end ent (Arnd t) end obronchial (C) There is no need for fiberop tic bronchos-
blocker copy to verify correct positioning of the
(E) an airw ay exchange catheter d evice.
(D) It can only be u sed in p atients u nd ergo-
129. Which one of the follow ing statem ents abou t ing right sid ed su rgery.
the d evice d epicted is tru e?
(E) With this device, the endotracheal tube
has to be exchanged at the end of surgery
if the patient is to remain intubated.
 Que s tions : 125–136 221

130. Du ring ap neic oxygenation
(A) the tim e elap sed before d esatu ration
occu rs is ind epend ent of the patient's
pu lm onary statu s
(B) all arrhythm ias are d u e to hyp oxem ia
(C) the carbon d ioxid e tension is not
im p ortant
(D) the carbon d ioxid e level rises abou t 3-6
m m H g/ m in
(E) p u lse oxim etry is not help fu l
134. Which one of the follow ing interventions is
m ost likely to resu lt in p reservation of renal
fu nction d uring aortic aneurysm su rgery?
(A) Ad m inistration of fu rosem id e
(B) Keeping aortic cross clam p tim e less
than 120 m in
(C) Ad m inistration of d opam ine
(D) End ovascular app roach to aortic aneu-
rysm rep air
(E) Ad m inistration of m annitol

131. The bronchial venous systems d rains into all of DIRECTION S: Use the follow ing scenario to answ er
the follow ing vascu lar bed s EXCEPT Qu estions 135-136: A 75-kg p atient is u nd ergoing
elective rep air of an aortic aneu rysm . Tw enty m in-
(A) Thebesian veins
u tes after incision the p atient d evelops tachycard ia,
(B) hem iazygos veins hyp otension, and su bsequ ent ST elevations in lead
(C) azygos veins V, as w ell as a rise in the p u lm onary artery (PA)
(D) p u lm onary veins p ressu res. An infusion of vasop ressor is started to
(E) m ed iastinal veins correct hyp otension.

132. A 58-year-old m ale w ith p ast m ed ical history 135. In ad d ition to correcting the hyp otension, the
significant for m od erate to severe aortic regu r- m ost effective intervention for the treatm ent of
gitation is u nd ergoing lap aroscop ic ventral elevated PA p ressu res in this scenario is
h ern ia rep air u n d er gen eral an esth esia. (A) infu sion of m ilrinone
Assu m ing that the p atient's blood p ressu re is
(B) ad d ition of inhaled nitric oxid e
norm al an d at baselin e, ad m inistration of
w hich one of the follow ing d ru gs is likely to (C) infu sion of nitroglycerin
resu lt in im p roved forw ard flow ? (D) start hyp erventilation
(E) increase in FIO 2 to 1.0
(A) N orep inep hrine
(B) Glycop yrrolate 136. With respect to the patient's tachycard ia, the
(C) Esm olol next best step in m anagem ent is
(D) Phenylep hrine
(A) observation only
(E) Vasop ressin
(B) ad m inistration of m etop rolol
133. The ad m inistration of fentanyl in large d oses (C) ad m inistration of nicard ip ine
(0.1 m g/ kg) generally resu lts in (D) ad m inistration of neostigm ine
(E) ad m inistration of glycop yrrolate
(A) increased p u lm onary vascu lar resistance
(B) d ecreased heart rate
(C) histam ine release
(D) m ore p rofou nd hyp otension than is seen
w ith m orp hine (1 m g/ kg)
222 13: Ane s the s ia for Ca rdiothora cic a nd Va s cula r S urge ry
137. A 72-year-old patient u nd erw ent an u ncomp li-
cated CABG for severe three-vessel coronary
artery d isease fou r h ou rs ago an d is now
requ iring increasing levels of hem od ynam ic
su p p ort. The p atient w as started on an ep i-
nephrine infusion, currently at 2 mcg/ kg/ min.
Vital signs are blood pressure (BP) 80/ 50, heart
rate 130, p u lm onary artery p ressu re 50/ 25,
central venous pressu re 24, card iac ind ex 1.6,
and the ECG show s variations in am p litu d e. A
bed sid e transthoracic echocard iogram show s
right atrial collap se and abnorm al ventricu lar
septal m otion. Based on the patient's presenta-
tion, the next best step in m anagem ent is to
(A) ad d norep inep hrine
(B) stop ep inep hrine and start m ilrinone
(C) retu rn im m ed iately to the op erating
room for reexp loration of the chest
(D) ad d nitroglycerin
(E) stat CT of the chest w ith p u lm onary
em bolism p rotocol
138. An anesthetic consid eration for Marfan syn-
d rom e is
(A) atlanto-axial instability
(B) aortic stenosis
(C) p ossible d ifficu lt intu bation
(D) m itral regu rgitation
(E) ventricu lar sep tal d efect (VSD)
139. A 29-year-old male su ffered a motorcycle crash
and is u nd ergoing intram ed u llary nailing of
the left fem u r. The accid ent occu rred 24 h ago.
Shortly after intram ed u llary ream ing, the
patient d evelops tachycard ia, hypotension and
hyp oxem ia. There are no ST-segm ent changes
on the five-lead EKG. What is the m ost likely
find ing on the p atient's transesop hageal echo-
card iogram ?
(A) Flu id collection arou nd the heart w ith-
ou t any d iastolic collapse
(B) Regional w all m otion abnorm alities in
the anterolateral w all of the left ventricle
(C) Large color flow via the intra-atrial
sep tu m
(D) Distend ed right atriu m and ventricle,
collapsed left atriu m and ventricle
(E) Large color flow via the intraventricu lar
septum
140. When Pa CO 2 and p H are m anaged by the
alpha-stat method d u ring hypothermic card io-
p u lm onary byp ass,
(A) the corrected p H is 7.4
(B) ABG resu lts w ill be corrected to cu rrent
p atient tem p eratu re
(C) the u ncorrected Pa CO 2 is 40 m m H g
(D) the corrected Pa CO 2 is 40 m m H g
141. A 77-year-old w om an w ith coronary artery
d isease and significant aortic stenosis d evelops
m yocard ial ischem ia shortly after ind uction of
anesth esia. Sh e is being treated w ith beta
blockers and nitroglycerin, and her blood pres-
su re is being su p p orted w ith an infu sion of
norep inep hrine. Throu ghou t this event the
p atient's oxygen satu ration is 100%. Th e
p atient continu es to be ischem ic. What state-
m ent abou t the u se of an intraaortic balloon
p u m p (IABP) in this p atient is tru e?
(A) An IABP is not ind icated and the p atient
shou ld be p ut on card iop ulm onary
byp ass.
(B) An IABP is contraind icated becau se the
p atient has aortic stenosis.
(C) An IABP shou ld be p laced im m ed iately.
(D) The tip of the IABP balloon has to be
placed just distal to the coronary arteries.
(E) An IABP is contraind icated d u e to the
risk of leg ischem ia.
142. A 65-year-old fem ale w ith a history of severe
aortic stenosis requ ires u rgent lap aroscop ic
cholecystectom y. An im portant hem od ynam ic
goal d u ring anesthetic care is
(A) d ecreased afterload
(B) slow heart rate
(C) d ecreased p reload
(D) high heart rate
(E) d ecreased contractility

143. Cannon w aves in the central venou s p ressu re
tracing
(A) are cau sed by atrial fibrillation
(B) can be seen w ith atrioventricu lar nod al
rhythm s
(C) resu lt from left atrial contraction against
the closed m itral valve
(D) w ill resolve w ith ventricu lar p acing
(E) rep resent an artifact cau sed by air in the
pressu re transd u cer system
144. The right lu ng, in the u p right p osition
(A) is the sm aller of the tw o
(B) has a single fissu re
(C) has three lobes
(D) receives 45% of total lu ng blood flow
(E) is less frequ ently involved in asp iration
com p ared to the left
145. A 74-year-old p atient is to u nd ergo for right-
sid ed thoracotom y for resection of lu ng cancer.
The patient's past med ical history is significant
for m yocard ial infarction fou r m onths ago at
w hich tim e the p atient u nd erw ent the p lace-
m en t of tw o d ru g-elu ting stents and w as
started on antip latelet therapy w ith clopid o-
grel. Accord ing to the p atient's card iologist,
the patient is to continue clop id ogrel throu gh-
ou t the periop erative p eriod . The su rgeon is
requ esting an analgesic strategy that w ou ld
provid e the p atient w ith abou t 36 h of p ostop -
erative p ain control to facilitate extu bation and
early m obilization. Which one of the follow ing
is the m ost effective and safest m ethod of anal-
gesia for this p atient?
(A) p ostop erative right intercostal block
(B) lu m bar ep id u ral catheter
(C) p atient controlled analgesia w ith IV
op ioid
(D) thoracic ep id u ral catheter
(E) right p aravertebral block via continu ou s
catheter
Que s tions : 137–147 223
146. A patient w ith severe COPD and severe pu l-
m onary hyp ertension is to u nd ergo bilateral
lu n g tran sp lan t. Th e en -bloc d ou ble-lu n g
transp lant, as com p ared to bilateral sequ ential
single-lung transp lantation
(A) has a d ecreased need for blood
transfu sions
(B) has a low er incid ence of ischem ia at the
site of tracheal anastom osis
(C) resu lts in a higher need for card iop u l-
m onary byp ass
(D) is technically easier
(E) d oes not requ ire card iac arrest
147. A 68-year-old p atient is to u nd ergo a Whipp le
p roced u re for resection of a tu m or of the head
of the p ancreas. The patient's past m ed ical his-
tory is significant for m yocard ial infarction
and the placem ent of a bare metal stent, hyp er-
tension, hypercholesterolem ia, and COPD sec-
ond ary to tobacco abu se. The p reop erative
ECG is significant for a right bu nd le branch
block, and the p reop erative TTE is significant
for d iastolic d ysfu nction w ith an ejection frac-
tion of 45% as w ell as mod erate to severe aortic
regu rgitation. In ad d ition to arterial blood
p ressu re, a d ecision is m ad e for intraop erative
m onitoring w ith a pu lm onary artery catheter
for estimation of left ventricular preload . Based
on this patient's presentation, left ventricu lar
p reload as assessed by p u lm onary artery cath-
eter m easu rem ents w ill likely be
(A) u nd erestim ated becau se of aortic regu r-
gitation
(B) overestim ated d ue to the right bund le
branch block
(C) u nd erestim ated d u e to d ecreased left
ventricular com p liance
(D) u nd erestim ated becau se the patient w ill
be on p ositive p ressu re ventilation
(E) accu rately reflected by LAP, LVEDP, and
PAOP
224 13: Ane s the s ia for Ca rdiothora cic a nd Va s cula r S urge ry
DIRECTION S: Use the follow ing figu re to answ er
Qu estions 148-149:
148. A 58-year-old m ale com es to the em ergency
d epartment w ith d iffuse chest pain that is rad i-
ating into his back. H is past m ed ical history is
significant for tobacco and alcohol abu se,
hyp ertension, and hyp ercholesterolem ia, as
w ell as p erip heral vascu lar d isease. A w orku p
for acu te coronary synd rom e is negative, and
the patient und ergoes CT imaging of chest and
abd om en w ith IV contrast that reveals a thora-
coabd om inal aneurysm that is d eem ed sym p -
tomatic and the patient is sched uled to und ergo
u rgent su rgical repair. Based on the d raw ing,
w hich one of the follow ing classifications of
this patient's aneurysm is accu rate?
(A) Stanford A
(B) DeBakey II
(C) Stanford B
(D) Craw ford I
(E) Craw ford II
149. The risk of sp inal cord ischem ia w ith su rgical
rep air of this typ e of lesion is ap p roxim ately
(A) 2%
(B) 10%
(C) 20%
(D) 30%
(E) 40%
150. An 82-year-old p atien t w ith an terior tw o-
vessel coronary artery d isease and u nstable
an gin a is referred by the card iologist for
CABG. H er p ast m ed ical history is otherw ise
significant for typ e I d iabetes, chronic renal
in su fficien cy, p erip h eral vascu lar d isease,
COPD, and atherosclerotic ascend ing aortic
d isease. The card iac su rgeon d ecid es to p er-
form off-p u m p CABG to the LAD and the
RCA. Consid ering this patient's com orbid ities
and the p rop osed p roced u re, it is tru e that
(A) m inim ally invasive coronary artery
byp ass grafting w ou ld be a su itable
alternative
(B) the su rgeon w ill requ ire a stabilization
d evice for the d istal anastom oses
(C) cooling of the p atient is requ ired as p art
of the proced u re
(D) hem od ynam ic goals are easier to
achieve as com p ared to CABG w ith car-
d iopu lm onary byp ass
(E) the u se of p rop ofol for m aintenance of
anesthesia w ill resu lt in equ ivalent m yo-
card ial p rotection as com pared to vola-
tile anesthetics
151. The p atient p op u lation m ost likely to benefit
from transcatheter aortic valve im p lantation is
(A) child ren and you ng ad u lts w ith congen-
ital, noncalcific aortic stenosis
(B) ad u lt p atients w ith severe aortic
regu rgitation
 Que s tions : 148–157 225

(C) asymptomatic adult patients with calcific noted in the su rgical field . A throm boelasto-
aortic stenosis and severe obstruction gram show s d ecreased m axim u m am p litu d e.
(D) ad u lt p atients w ith sym p tom atic severe The ap p rop riate treatm ent inclu d es ad m inis-
aortic stenosis d eem ed too high risk for tration of w hich one of the follow ing?
su rgery (A) Protam ine
(E) ad u lt p atients w ith sym p tom atic severe (B) Cryop recip itate
aortic stenosis w ithou t other associated
(C) Fresh frozen p lasm a
com orbid ities
(D) Am inocap roic acid
152. A 60-year-old fem ale w as ad m itted w ith a (E) Platelets
large goiter and a history of hoarseness. An
incid ental find ing on the chest x-ray w as tra- 155. Structu res that pass anteriorly to the trachea
cheal d eviation w ith questionable narrow ing inclu d e all of the follow ing EXCEPT
of the tracheal lu m en. After ind u ction w as (A) p u lm onary artery
com plicated by a d ifficult intubation requiring
(B) thyroid isthm u s
m u ltip le attem p ts, the thyroid w as rem oved
w ith som e d ifficu lty and at the end of the p ro- (C) innom inate artery
ced u re the p atient w as breathing sp ontane- (D) aortic arch
ously. Im m ed iately after extubation, breathing (E) left brachiocep halic vein
w as labored and retraction w as noted . Cau ses
of this may includ e all of the follow ing EXCEPT 156. Ind ications for one-lu ng ventilation inclu d e all
of the follow ing EXCEPT
(A) bilateral recu rrent laryngeal nerve
inju ry (A) infection w ith p u ru lent secretions
(B) laryngosp asm (B) m assive p u lm onary hem orrhage
(C) tracheal collap se (C) bronchop leu ral fistu la
(D) bronchosp asm (D) u nilateral bronchop u lm onary lavage for
(E) thyrotoxicosis alveolar p roteinosis
(E) Ivor-Lew is esop hagectom y
153. H yp oxic p u lm onary vasoconstriction
157. Du ring aw ake, closed chest ventilation in the
(A) occu rs w hen regional atelectasis
lateral d ecu bitu s p osition,
m echanically obstru cts blood flow
(B) is p rim arily triggered by alveolar carbon (A) the lu ng relationship s are the sam e as in
d ioxid e tension the sem irecu m bent p osition, i.e., the
(C) lead s to d iversion of blood aw ay from ap ex is in zone 1 and the bases are in
poorly ventilated areas of the lu ng zone 3
(D) is p otentiated by ad m inistration of (B) ventilation is highest at the ap ex
nitrou s oxid e (C) p erfu sion is greater in the nond ep en-
(E) is au gm ented by an increase in p u lm o- d ent lu ng
nary artery p ressu re (D) com p liance is u nequ al in the tw o lu ngs
(E) the nond ep end ent lu ng receives m ost of
154. At the conclu sion of an aortic aneu rysm rep air the tid al ventilation
associated w ith significant blood loss, d iffu se
bleed ing and the absence of clot form ation is
226 13: Ane s the s ia for Ca rdiothora cic a nd Va s cula r S urge ry
158. A 35-year-old m an is ad m itted to the em er-
gency d ep artm ent follow ing an au tom obile
accid ent. It is noted that there is a contu sion
over the anterior thorax, he is tachypneic, and
h e has a scap h oid abd om en. Au scu ltation
reveals p oor breath sou nd s on the left sid e.
Chest x-ray show s a large air cavity in the left
sid e of the thorax. Blood p ressu re is 80/ 60, and
heart rate is 120 p er m inu te. Diagnoses that
m ust be consid ered includ e all of the follow ing
EXCEPT
(A) ru p tu red sp leen
(B) p neu m othorax
(C) d iap hragm atic hernia
(D) card iac contu sion
(E) fat em bolism synd rom e
159. A 69-year-old w om an is sched u led for rou tine
CABG. Since her preoperative card iac catheter-
ization, her p latelet cou nt has d rop p ed from
312 to 252 × 103/ m m 3. A hep arin-ind u ced
throm bocytop enia (H IT) im m u noassay has
been ord ered and it resulted in a p ositive H IT
antibod y. She has a large bru ise at the site of
her catheterization. There are no signs of d eep
ven ou s th rom bu s or any other th rom botic
events. You shou ld
(A) d elay surgery for 2 m onths
(B) p roceed w ith su rgery and u se a d irect
throm bin inhibitor instead of heparin
(C) p roceed w ith su rgery and u se
heparin
(D) u se only 50% of the regu lar hep arin
d ose and proceed w ith su rgery
(E) u se a com bination of w arfarin and low -
d ose heparin to achieve ad equ ate anti-
coagulation
160. A 73-year-old p atient is und ergoing em ergent
three-vessel CABG for sym ptom atic left m ain
coronary artery d isease. Upon com pletion of
the su rgical p roced u re, the p atient d evelop s
the need for high d ose inotropic su pport, and
the d ecision is m ad e to im plant a left ventricu -
lar assist d evice (LVAD) to facilitate w eaning
from card iop u lm onary byp ass (CPB). After
d iscontinu ation of CPB, the p atient is noted to
be hyp otensive w ith low p u m p flow rates
ap p arent on the LVAD d evice. Im m ed iate TEE
exam ination d oes not show any evid ence of
inflow cannu la obstru ction, bu t is significant
for systolic collap se of the right atriu m and
d iastolic collap se of the right ventricle. The
ECG show s low QRS voltage. The m ost likely
cau se for this patient's hypotension is
(A) graft failu re
(B) acu te hyp ovolem ia
(C) right ventricu lar failu re
(D) p u lm onary em bolu s
(E) p ericard ial tam p onad e
161. The ad vantages of u ltrasou nd -gu id ed central
venous catheter placem ent, as com pared to the
land m ark techniqu e, inclu d e all of the follow -
ing EXCEPT
(A) p revention of arterial inju ry
(B) d irect visu alization of the target
vessel
(C) d ecreased tim e requ ired for internal ju g-
u lar vein catheterization
(D) d ecreased nu m ber of attem p ts
requ ired
(E) d ecreased overall com p lication rate
DIRECTION S (Qu estions 162-164): Each grou p of
item s below consists of lettered head ings follow ed
by a list of nu m bered p hrases or statem ents. For
each nu m bered p hrase or statem ent, select the ON E
lettered head ing or com p onent that is m ost closely
associated w ith it and fill in the circle containing the
correspond ing letter on the answ er sheet. Each let-
tered head ing or com p onent m ay be selected once,
m ore than once, or not at all.
 Que s tions : 158–165 227

lettered head ing or com p onent that is m ost closely

associated w ith it. Each lettered head ing or com po-
nen t m ay be selected on ce, m ore th an on ce, or n ot
at all.
(A) Mid -esop hageal fou r cham ber
(B) Mid -esop hageal tw o cham ber
(C) Mid -esop hageal long axis
(D) Transgastric tw o cham ber
(E) Transgastric m id -p ap illary short axis
(F) Mid -esop hageal aortic valve short axis
(G) Mid -esop hageal aortic valve long axis
(H ) Mid -esop hageal bicaval
(I) Mid -esop hageal right ventricu lar
inflow -ou tflow
(J) Deep transgastric long axis
(K) Up p er esop hageal aortic valve short axis
(L) Up p er esop hageal aortic valve long axis
(M) Transgastric long axis
(N ) Mid -esop hageal ascend ing aortic short
axis
(O) Mid -esop hageal ascend ing aortic long
For each p atient, select the ap p rop riate d iagram of axis
the heart sou nd s.
For each p hotograp h of a transesop hageal echocar-
162. A 64-year-old p atient w ith a history of rheu - d iogram , select the stand ard , tw o-d im ensional
m atic fever presenting for elective aortic valve tom ographic view.
rep lacem ent.
165.
163. A 21-year-old fem ale w ith Dow n synd rom e
and echocard iograp hic evid ence of right ven-
tricu lar overload .

164. A 70-year-old m ale w ith a 60 p ack-year history

of sm oking and a history of pneum onectom y
for lu ng cancer w ith m ild resp iratory insu ffi-
ciency and evid ence of right ventricu lar strain
on echocard iography.

DIRECTION S (Qu estions 165-174): Each grou p of

item s below consists of lettered head ings follow ed
by a list of nu m bered p hrases or statem ents. For
each num bered p hrase or statem ent, select the ON E
228 13: Ane s the s ia for Ca rdiothora cic a nd Va s cula r S urge ry

166. 169.

167. 170.

171.
168.
 Que s tions : 166–174 229

172. 174.

173.
 Answe rs a nd Expla na tions
94. (A) The best next step in m anagem ent is to ini-
tiate artificial card iac p acing, either via pacer
cables still in situ, or via transcutaneou s pad s.
Ind ications for artificial pacing includ e, bu t are
n ot lim ited to: SA nod e d ysfu n ction w ith
sym p tom atic brad ycard ia as d escribed in this
case, junctional rhythm that can som etim es be
corrected by means of overd rive pacing, symp-
tom atic chronotropic incom p etence, and atrial
fibrillation w ith brad ycard ia an d p au ses
greater than 5 sec. In settings ou tsid e the car-
d iac ICU, ad m in istration of ch ron otrop ic
agents su ch as ep inep hrine m ight be ind icated
on a tem porary basis as a brid ge to pacer ther-
ap y. (6:1876)
95. (E) N o pharm acological alternative m eets both
goals. (6:2235)
96. (B) The inferior w all of the left ventricle is su p -
p lied by the right coronary artery and is m ost
ap p arent in lead s II, III, and AVF. (6:1836)
97. (C) An incom p etent tricu sp id valve p erm its
right ventricu lar p ressu re to be transm itted to
the right atriu m , cau sing increased am plitu d e
of the v w ave. Increased a w aves occu r in heart
block and ju nctional rhythm , w hile a w aves
are absent in atrial fibrillation. (5:409; 6:1905)
98. (D ) At 17°C, cerebral oxygen consum ption is
reduced to about 8% of the normothermic value
and , w hile metabolic activity is d ecreased , cel-
lular integrity is maintained . This accounts for
the brain's tolerance to mod est periods of car-
d iac arrest during hypothermia. Both cerebral
blood flow and electrical activity d ecrease
d uring hypothermia. (6:166)
230
99. (C) The external noninvasive u nits are ven -
tricu lar p acing d evices. (1:896; 4:817; 5:1084;
6:72)
100. (D ) The patient d escribed in this vignette likely
has m ed iastinitis from esop hageal ru p tu re,
acu te lu ng injury, and very little, if any, toler-
ance for apnea d uring airw ay instru mentation.
The safest choice am ong the op tions listed to
secure the airw ay and be able to p rovid e single
lu ng ventilation is rap id -sequ ence ind u ction,
follow ed by p lacem ent of a Univent tu be. The
Univent is a single lu m en tu be w ith bu ilt in
bronchial blocker that p asses throu gh a sm all
channel w ithin the w all of the end otracheal
tube. Other choices w ould inclu d e the Arnd t,
or Cohen, end obronchial blockers, that are
gu id ed w ith fiberop tic bron ch oscop y, or a
w ire-gu id ed m echanism resp ectively. If a d ou -
ble-lu m en tu be is chosen, a left-sid ed d ou ble-
lu m en tu be is the tu be of choice, how ever
u nlikely to be tolerated by this p atient d u e to
baseline hyp oxem ia. Placem ent of a stand ard
single-lu m en tu be is unlikely to resu lt in ad e-
qu ate lu ng sep aration, thu s m aking su rgical
exp osu re far m ore d ifficu lt. (5:967, 985)
101. (E) Of the anticholinergic agents, glycop yrro-
late and scopolamine are better antisialagogues
than atropine. The other m ed ications listed are
cholinesterase inhibitors that have increased
salivation as a m ajor sid e effect. (5:973)
102. (A) CPAP w ith oxygen to the collap sed lu ng
w ill d ecrease shu nt and im p rove the hyp ox-
em ia. The rem aining choices B, C, and D are
listed in the ord er the clinician shou ld p roceed
if ap p lication of CPAP to the non-d ep end ent

lu ng d oes not resolve the hyp oxem ia. Op tion
E w ou ld likely be less effective, and m ight lead
to overd istention of the op erative lu ng. (5:972)
103. (B) Shivering is blocked w ith m uscle relaxants
d u ring w arm ing and cooling bu t d oes not
occur in very cold m u scle. (5:908)
104. (E) N itroglycerin is metabolized to nitric oxid e,
an activator of gu anylate cyclase in vascular
smooth muscle. The enzyme prod uces intracel-
lu lar cyclic-GMP. The cyclic-GMP is d egrad ed
by a sp ecific phosphod iesterase (PDE-5) that is
inhibited by sild enafil. Profou nd hyp otension
can occur w hen a sublingual d ose of nitroglyc-
erin is given w ithin several hou rs of an oral
d ose of sild enafil. Intravenou s nitroglycerin
m ust be slow ly titrated in that setting. (1:752;
6:2025)
105. (E) Magnets cau se m ost p acem akers to p ace
asynchronou sly at a preset rate, how ever som e
d evices m ay be d eactivated p erm anently and
have to be rep rogram m ed . Magnets d o not
affect the p acing rate of ICD's. Since new er
d evices are very com p lex, the u se of m agnets
shou ld be reserved for em ergency situations,
and the d evices have to be interrogated after
com p letion of su rgery. The ind ifferent p late
shou ld be placed aw ay from the p acem aker or
ICD. If the p acer is in d em and m od e, it m ay
sense the cautery current as d epolarization and
shut off. (5:63, 1281)
106. (B) This patient has sym p tom s consistent w ith
su perior vena cava (SVC) synd rom e. In ad d i-
tion to the sym ptom s d escribed in (B), these
p atients m ay have m u ltiorgan involvem ent
inclu d ing neu rologic, resp iratory, card iac, gas-
trointestinal, and renal sym ptom s. The other
find ings d escribed here m ight be fou nd in a
p atient w ith thoracic ou tlet synd rom e in (A),
congestive heart failure in (C), acute asthm a or
a COPD exacerbation in (D), and hyp erventila-
tion synd rom e in (E). (5:993-4; 6:2185)
107. (D ) Patients w ith SVC synd rom e shou ld be
kept u p right to facilitate venou s d rainage of
the u p p er vessels, and if a general an esthetic
is requ ired be ind u ced w hile m aintaining
Answe rs : 94–112 231
sp ontaneou s respirations d u e to the high risk
of airw ay com pression and card iovascular col-
lap se resu lting from the loss of m u scle tone
associated w ith ad m inistration of m u scle
relaxants and the su p ine p osition. In m any
cases these patients requ ire fiberoptic intuba-
tion. Du e to the im p aired venou s d rainage
from the SVC to the heart, intravenou s lines
shou ld be p laced in the low er extrem ities.
(5:993-4)
108. (B) With m od ern pacem aker u nits, the energy
ou tpu t is so low that there is little d anger of
fibrillation. H ow ever, ventricu lar fibrillation is
m ore com m on in the patient w ith a high cate-
cholam ine concentration, m yocard ial infarc-
tion, or hypoxem ia. (6:1899)
109. (D ) The intraaortic balloon pu m p is d eflated
d u ring systole. It is rap id ly inflated d u ring
d iastole, thereby increasing coronary blood
flow. It d ecreases im p ed ance to left ventricle
ejection. It is contraind icated in the p atient
w ith aortic insu fficiency. (6:2235-6)
110. (B) Clam p ing of the thoracic aorta lead s to an
im m ed iate in crease in blood p ressu re.
Assu m ing the heart can w ithstand the m ark-
ed ly increased afterload , there shou ld not be
stand still or hypotension. Blood pressure read -
ings m ay be lost in the left arm , bu t the p u lse
in the right arm shou ld be p resent, d ep end ing
on the placem ent of the clam p relative to the
take-off of the vessels to the arm s. (5:1025-7)
111. (D ) A com p lication of aortic su rgery is sp inal
cord ischem ia d ue to com p rom ise of the rad ic-
u lar arteries. These arteries are not constant,
and the large artery to the sp ine, the artery of
Ad amkiew itz, may be compromised lead ing to
ischem ia. Pressu re on the cord can also lead to
ischem ia. H yp otherm ia m ay be p rotective.
Loss of cerebrosp inal flu id is not a factor. Long
p eriod s of hypotension m ay lead to ischem ia.
(5:1025-8)
112. (E) The exp ansion of the vascu lar bed that
occu rs follow s the release of the clam ps. It is
d u e to a reactive vasod ilatation. Other factors,
such as blood loss, inadequate fluid replacement,
232 13: Ane s the s ia for Ca rdiothora cic a nd Va s cula r S urge ry
vasoactive d ru gs, and extravasation of flu id ,
are all im p ortant. (5:1028-9)
113. (C) The flow rate on total byp ass can be varied
to achieve the p erfu sion p ressu re that is
d esired . This m u st be varied w ith the state of
resistance. (5:899)
114. (A) When the patient is on bypass, the pressure
is usu ally kep t above 50 m m H g. Low er p res-
su res can be tolerated , bu t there is no agree-
m ent on an y sp ecific p erfu sion p ressu re.
(5:899)
115. (A) The overrid ing goals of anesthetic care for
carotid end arterectom y (CEA) su rgery are
hemod ynamic stability and prompt emergence
from anesthesia at the conclu sion of the p roce-
d u re to facilitate n eu rologic exam in ation .
There is u niversal agreem ent that the p atient's
blood p ressu re shou ld be m aintained at, or
20% higher, than the highest record ed aw ake
blood p ressu re to m aintain ad equ ate collateral
cerebral p erfu sion d u ring carotid clam p ing.
Exp erience w ith processed EEG m onitors su ch
as the BIS is still lacking, and the raw EEG pro-
vid es higher sensitivity for the d etection of
intraop erative cerebral ischem ia. There is no
conclusive evid ence in the literatu re su ggest-
ing an ad vantage of volatile anesthetics over
p rop ofol w ith regard to brain p rotection
d u ring CEA. Preop erative clam p tests are not
ind icated , and general anesthesia com p ared to
regional anesthesia ap p ears to resu lt in id enti-
cal ou tcom es, w ith the p ossible excep tion of
p atients w ith contralateral carotid occlu sion
w ho m ight benefit from regional anesthesia.
(5:1018-21)
116. (C) Wall motion abnormalities d etected by TEE
gen erally p reced e isch em ic ST-ch an ges
d etected on ECG. N one of the other op tions is
su itable for the d etection of intraop erative
ischem ia. (5:1867)
117. (A) Strategies to mitigate the risk of spinal cord
isch em ia in th is h igh -risk p atien t in clu d e
p lacem ent of a lu m bar d rain, as w ell as neuro-
p hysiologic m onitoring su ch as SSEP's or
MEP's. Intraoperative EEG monitoring w ill not
p rovid e inform ation abou t sp inal cord isch-
em ia, and is consid ered the gold stand ard for
monitoring the brain d uring CEA. Hypotension
is to be avoid ed since it w ould increase the risk
of ischem ia. DH CA is a techniqu e em ployed
d u ring op en rep air or rep lacem ent of the tho-
racic aorta. Patients u nd ergoin g su ccessfu l
stent graft repair of the thoracic aorta are rou-
tinely extubated at the end of the p roced ure,
and a high-d ose op ioid techniqu e d oes not
p rovid e sp inal cord p rotection. (5:915, 940,
1019)
118. (C) The hem od ynam ic goals for this p atient
shou ld includ e a slow heart rate and augm en-
tation of preload to ensure preservation of for-
w ard flow th rou gh th e sten osed valve.
Tachycard ia and increase in afterload and con-
tractility cou ld d ecrease card iac ou tp u t and
increase m yocard ial oxygen d em and resp ec-
tively. (5:910)
119. (C) Esop hagectom y patients are generally mal-
nourished . They are at risk for aspiration, since
esop h ageal fu n ction is frequ en tly com p ro-
m ised . Th eir p u lm on ary fu n ction is equ al
betw een their lu ngs, and thu s they are m ore
likely to have a significant shu nt d u ring one-
lung ventilation. The surgery is more extensive
than m ost thoracotom ies, and the p atients
m ore frail, so p ostop erative ven tilation is
com m on. (5:983)
120. (E) The larynx lies at the level of the 3rd --6th
cervical vertebrae, and in the ad u lt, the nar-
row est p ortion is at the level of the vocal cord s.
The larynx is innervated by the recu rrent
laryngeal nerve and the su p erior laryngeal
nerve. It lies w ithin the thyroid cartilage. The
w id e m argin of the cricoid cartilage is p oste-
rior. (5:548)
121. (D ) The innom inate artery passes anterior to
the trachea and can be com p ressed by the
m ed iastinoscope. The right su bclavian artery
is a branch of the innom inate artery, w hile the
left su bclavian artery com es off the aorta
d irectly and d oes not cross in front of the tra-
chea. Com pression of flow in the innom inate
w ill also obstru ct flow to the right carotid

artery, and m ay com p rom ise cerebral p erfu -
sion in patients w ith cerebrovascu lar d isease
or an incom p lete circle of Willis. Air in the
m ed iastinum shou ld have little hem od ynam ic
effect. Card iac arrest, su p erior ven a cava
obstru ction, and anesthetic overd ose can all
cause p ulselessness, bu t rarely as sud d enly or
reversibly. H aving a m onitor of p erfu sion on
the other arm , such as an oxim eter probe, can
help d ifferen tiate inn om in ate com p ression
from other cau ses of circu latory com p rom ise.
(5:988)
122. (E) In any p atient w ith hoarseness and a d ocu -
m ented su praglottic m ass, it is m and atory to
establish the airw ay before p roceed ing w ith
the anesthesia. Aw ake fiberop tic intu bation,
aw ake tracheostom y (all w ith topical anesthe-
sia), or sp on tan eou s ven tilation w ith an
inhaled anesthetic are the only safe m ethod s.
(5:1234-5)
123. (D ) Asp iration is possible, since the esop hagu s
m ay contain barium from the exam ination as
w ell as oth er oral in take. Th e esop h agu s
should be suctioned before ind uction, although
the thick bariu m suspension m ay not be com -
p letely rem oved . (5:983)
124. (C) By clam ping at 5, gas cannot flow into the
left lumen, and thus to the left lung. Uncapping
at 3 allow s the gas in the left lu ng to escap e.
Clam p ing at 1 w ou ld p revent flow to the left
sid e, bu t uncapping w ou ld cause a leak in the
anesthetic circu it. Assu m ing good tu be posi-
tion and isolation, the hand ed ness of the tube
d oesn't m atter. (5:963-5)
125. (D ) Throu gh p osition 4, one is looking d ow n
the right lum en. From the right lu m en, no left
lu ng segm ental bronchi can be seen w ith any
typ e of p rop erly p ositioned d ou ble-lu m en
tu be. The right lu m en w ill be the tracheal
lu m en on a left-sid ed tu be, in w hich case the
carina can be seen. (5:965)
126. (B) All the step s are correct for ventilating via
the left lu m en w hile p ou ring flu id into the
right lu m en excep t that clam p ing at 2 w ill
Answe rs : 113–131 233
block the flu id flow. The cu ffs shou ld be u p to
ensu re lu ng isolation. (5:978)
127. (D ) Clam p ing at 6 isolates the right lu ng.
(5:963-5)
128. (D ) The Arnd t bronchial blocker can be used in
p atients w ho are alread y intubated , so there is
no need to change the end otracheal to a d ou-
ble-lu m en tu be shou ld one-lu ng ventilation be
required . It can also be u sed for patients w ith
a d ifficu lt airw ay and p atients w ith trau m a
w ho require one-lu ng ventilation. The Univent
tu be is a single lu m en end otracheal tu be w ith
an integrated , m ovable bronchial blocker. The
Sengstaken-Blakem ore tu be is an esop hageal
d evice u sed for tem p orary control of intracta-
ble variceal bleed ing. (5:967)
129. (A) Positive p ressu re ventilation d oes not have
to be interru p ted d u ring p lacem ent of the
bronchial blocker becau se of the m u ltip ort
ad ap ter that w ill accom m od ate the breathing
circu it, a fiberop tic bronchoscop e and the
end obronchial blocker. The d evice has to be
p laced u nd er fiberop tic bronchoscop ic gu id -
ance and its u se is not lim ited to only the left
or right lu ng. If the p atient continu es on
m echanical ventilation u pon conclu sion of sur-
gery, the end obronchial balloon is d eflated and
the d evice rem oved w hile the end otracheal
tu be rem ains in place. (5:967)
130. (D ) Th e carbon d ioxid e ten sion rises abou t
6 m m H g d u ring the first m inu te of ap neic
oxygenation and abou t 3-6 m m H g p er m inu te
thereafter. It w ill rise more quickly in ind ivid u-
als w ith a low FRC. All arrhythm ias are not
d ue to hypoxem ia but m ay be d ue to increased
catecholamines. These in turn may be increased
d u e to increased carbon d ioxid e. Pu lse oxim -
etry has been of d efinite benefit in these proce-
d u res. (5:551)
131. (A) The Thebesian veins are the sm allest veins
in the heart and d rain d irectly into the ventri-
cles, w hereas the rem aind er of the coronary
arterial blood is d rained via the venou s system
into the coronary sinu s and eventu ally into the
234 13: Ane s the s ia for Ca rdiothora cic a nd Va s cula r S urge ry
right atriu m . All other op tions are correct.
(5:902, 951)
132. (B) The hem od ynam ic goal of anesthetic care
is the red u ction of the regu rgitant fraction that
can be achieved by augm entation of preload ,
mild ly increased heart rate (i.e., ad ministration
of low -d ose glycopyrrolate), and avoid ance of
increased afterload . (5:910)
133. (B) Ad m inistration of high-d ose fentanyl w ill
resu lt in brad ycard ia, bu t blood p ressu re w ill
rem ain relatively stable. Fentanyl, as op p osed
to m orphine, d oes not release histam ine. The
card iac ou tpu t w ill d ecrease to a m ild d egree.
Morp hine-ind u ced changes are m ore p ro-
nou nced . (5:711-2)
134. (D ) While som e of the p harm acological strate-
gies m entioned have been show n to p reserve
renal fu nction in anim al m od els, this has not
been conclu sively show n in hu m ans. Am ong
the strongest pred ictors of postoperative renal
d ysfunction is aortic cross clam p tim e, particu-
larly if the aorta is clam p ed for m ore than 50
min. Of note, even the infrarenal location of the
aortic cross clam p can cau se changes in renal
blood flow that in tu rn can contribu te to p ost-
operative renal d ysfu nction. The m ost signifi-
cant p rogress in p revention of acu te kid ney
inju ry d uring aortic surgery has com e from the
w id esp read ad op tion of end ovascu lar tech-
niqu es. (5:1027-8)
135. (C) The rise in PA p ressu re is d u e to left ven-
tricu lar d ysfu nction resu lting in a rise in left
ventricu lar end d iastolic p ressu re (LVEDP).
The goal in this situ ation is to d ecrease LVEDP,
w hich w ill translate into low er PA p ressu res,
in ord er to im p rove m yocard ial p erfu sion.
N itroglycerin in d u ces ven od ilation , th u s
d ecreasing ventricular filling, transmural pres-
su re, and m yocard ial w ork. A sid e effect of
nitroglycerin is hyp otension that is cou nter-
p rod u ctive and often treated sim u ltaneou sly
w ith phenylephrine. While milrinone decreases
PA p ressu re it lead s to an increase in m yocar-
d ial oxygen con su m p tion . N itric oxid e
d ecreases the PA p ressu re as w ell, bu t it m ight
not have a significant effect on LVEDP. Since the
p atient in this vignette is neither hypoxic nor
hypercarbic, increased ventilation and oxygen-
ation are u nlikely to d ecrease PA p ressu re.
(1:747-55)
136. (B) Tachycard ia in p atients w ith coron ary
artery d isease is controlled w ith beta blockers.
They d ecrease heart rate and m yocard ial con-
tractility, resulting in better coronary perfusion
and less oxygen d em and . Observation only is
not ind icated . N icard ipine may low er the heart
rate, bu t d oes not red u ce contractility. (1:326)
137. (C) This patient has the sym ptom s of im m ed i-
ate p ostop erative card iac tam p onad e: hyp o-
ten sion , tach ycard ia, equ alization an d
elevation of PA d iastolic p ressu re and CVP,
and low card iac ind ex. While norep inephrine
m ight help to su p p ort the blood p ressu re, it
d elays d efinitive care. Milrinone w ould ad d to
the hypotension, and so w ou ld nitroglycerin.
Chest CT is not ind icated based on the hem o-
d ynamic abnormalities and w ould delay defin-
itive therap y. (5:458, 913; 6:1975)
138. (C) Marfan synd rom e is associated w ith aortic
changes m aking d issection m ore com m on.
H yp ertension shou ld be avoid ed . The high-
arched p alate m ay m ake intu bation m ore d if-
ficu lt. Aortic stenosis is not seen, bu t aortic
insu fficiency is com m on. Atlanto-axial insta-
bility and / or ventricu lar sep tal d efect are seen
w ith congenital synd rom es su ch as Dow n and
achond rop lasia. (5:271-2)
139. (D ) The m ost likely d iagnosis is fat em bolism
synd rom e. The typ ical TEE p ictu re for any
large (p u lm onary) em bolu s is an overfilled
right sid e of the heart, and significantly u nd er-
filled left sid e. Flu id arou nd the heart is ind i-
cating a p ericard ial effu sion or tam p onad e;
this p atient is alread y 24 h p ost-trau m a and
there is no collapse of the patient's heart cham -
bers that rend ers the d iagnosis of tam p onad e
u nlikely. Regional w all m otion abnorm alities
in d icate a p ossible ischem ic even t that is
u nlikely d u e to this patient's age and the lack
of ST-changes on a 5 lead EKG. Large color
flow s across the sep ta on echocard iograp hy

ind icate an ASD or a VSD that are u nlikely to
ap pear acu tely in this situ ation. (5:1203)
140. (C) The other resp onses p ertain to the p H -stat
m ethod . (5:532)
141. (C) Becau se p harm acologic attem p ts at revers-
in g isch em ia h ave failed , in sertion of an
intraaortic balloon is ind icated . The treatm ent
of m yocard ial ischem ia inclu d es correcting the
hem od ynam ics (slow -norm al heart rate, high-
norm al blood pressure, and low ering of the PA
p ressu re) and treatm ent of severe anem ia and
hypoxem ia. Since the event occu rred shortly
after ind u ction, large blood loss and severe
anem ia are u nlikely. Im m ed iate initiation of
card iopu lm onary bypass in this situation is an
option, bu t is im practical since the su rgery is
ju st beginning. Absolu te contraind ications for
p lacem ent of an IABP are aortic regu rgitation
and aortic d issection. The pu m p can be placed
w ith the help of TEE, x-ray or even by ap p rox-
im ation, if TEE and x-ray are not available. The
tip of the balloon has to be placed in the p roxi-
m al thoracic aorta just d istal to the left subcla-
vian artery. IABP therap y m ay cau se leg
ischem ia, how ever in this situation the benefits
of IABP (increased coronary blood flow ) out-
w eigh the p otential for leg ischem ia, for w hich
the p atient need s careful p ostop erative obser-
vation. (6:2234-5; Kar B, et al., Circulation 2012;
125:1809-17).
142. (B) Slow heart rate and m aintenance of after-
load are the hemod ynamic goals for the patient
w ith severe aortic stenosis, w hile d ecreased
afterload and higher heart rate are p referred in
p atients w ith aortic and m itral regu rgitation.
Decreased contractility is d esired in hyp ertro-
p hic obstructive card iom yop athy (H OCM) to
avoid left ventricu lar ou tflow obstru ction .
(5:910)
143. (B) Can non w aves ap p ear w hen the right
atriu m contracts after closu re of the tricu sp id
valve, and is not d u e to artifact. The a-w ave is
not p resent w ith atrial fibrillation and can be
cau sed by ventricu lar p acing and resu lting
AV-d issociation . Effectiv e restoration of
AV-synchrony w ith atrial or AV-p acing w ill
Answe rs : 132–148 235
restore the norm al CVP trace. Loss of the atrial
com ponent of ventricu lar filling d uring ju nc-
tional rhythm m ay be poorly tolerated . (5:409;
6:1823)
144. (C) The right lu ng is the larger of the tw o. It
has three lobes (u p p er, m id d le, and low er) and
tw o fissures (horizontal and oblique). Since it
is the larger of the tw o, it receives 55% of total
blood flow. Since the axis of the right mainstem
bronchu s is m ore in line w ith the trachea, the
right lu ng is m ore frequ ently involved in cases
of asp iration as com p ared to the left. (5:951,
959, 1002)
145. (E) Becau se the p atient is on antip latelet ther-
ap y w ith clop id ogrel, neuraxial techniques are
contraind icated . An intercostal block w ill only
last from 4–8 h; an intrap leural catheter w ould
be m ore su itable bu t is not listed as an op tion
in the qu estion. IV PCA is u nlikely to p rovid e
the sam e level of analgesia and is associated
w ith greater sid e effects as comp ared to a p ara-
vertebral catheter that is consid ered safe in
p atients on antiplatelet therap y. (5:1007-8)
146. (C) With the excep tion of op tion C, all of the
op tions listed are ad vantages of bilateral
sequ ential single-lung transplantation that has
the ad d itional ad vantage of not requiring full
anticoagu lation. (5:1091)
147. (A) Left ventricu lar p reload in this p atient w ill
likely be u nd erestim ated d u e to aortic regu rgi-
tation, w hich lead s to a d iscrepancy betw een
LAP and LVEDP, d u e to continu ed ventricu lar
filling after mitral valve closure. A right bundle
branch block and d ecreased pu lm onary vascu -
lar bed su ch as in COPD w ill also m ake u nd er-
estim ation of left ventricu lar p reload m ore
likely, w hile p ositive p ressu re ventilation and
d ecreased left ventricular compliance w ill lead
to overestim ation of left ventricu lar p reload .
(5:414-5)
148. (E) The figu re show s a thoracoabd om inal
aneu rysm classified as Craw ford typ e II that
involves the entire d escend ing thoracic aorta
w ith extension across the d iap hragm throu gh
the abd om inal aorta to the aortic bifu rcation.
236 13: Ane s the s ia for Ca rdiothora cic a nd Va s cula r S urge ry
Stanford A and B as w ell as BeBakey I through
III are classifications of aortic d issections.
(5:918; 6:2063)
149. (C) The risk of spinal cord ischemia w ith either
open or end ovascu lar rep air is approxim ately
20% for this typ e of lesion. (5:917)
150. (B) While off-p u m p CABG is a su itable
ap p roach for anterior, inferior, and lateral ves-
sels, m inim ally-invasive CABG, u tilizing the
internal thoracic (m am m ary) artery, is su itable
for one- or tw o-vessel d isease on the left sid e
of the heart. While the hem od ynam ic goals for
patients und ergoing CABG w ith card iopu lmo-
nary byp ass, and those und ergoing off-p u m p
CABG are the sam e, they are hard er to attain
w ith the latter ap p roach d u e to the m obiliza-
tion of the heart that m ay cau se arrhythm ia
an d h em od yn am ic instability, p articu larly
w hen the d istal anastom oses are p erform ed .
Myocard ial p rotection ap p ears to be better
w ith the u se of volatile anesthetics as com -
p ared to p rop ofol, reflected in less m yocard ial
inju ry in the first 24 h p ostop eratively. Patients
u nd ergoing off-p u m p CABG p roced u res are
kep t norm otherm ic. (5:907-8)
151. (D ) Cu rrent ind ications for transcatheter aortic
valve im plantation inclu d e ad ult patients w ith
severe aortic stenosis d eem ed too high risk for
surgery. The proced ure is currently being eval-
u ated as an alternative to reop eration in
p atients w ith p rosthetic valve failure not d u e
to paravalvular regurgitation. The patient pop-
u lation d escribed in op tion A is u su ally
referred for percu taneou s balloon aortic valvu -
lop lasty, w hile asym p tom atic p atients w ith
severe obstruction are u sually follow ed care-
fu lly w ith serial echocard iogram s u ntil they
m eet op erative criteria. (6:1941)
152. (E) N erve inju ry is com m on w ith d ifficu lt d is-
sections. Laryngospasm m ay be present d ue to
secretions or injury to the vocal cord s d uring
d ifficu lt intu bation. Tracheal collap se m ay be
p resent d u e to tracheom alacia. Bronchosp asm
m ay be a reason for the d ysp nea d u e to airw ay
sensitivity. While thyrotoxicosis can cau se
resp iratory failu re secon d ary to in creased
p rod u ction of carbon d ioxid e and increased
w ork of breathing, its onset w ou ld be m ore
grad u al. (5:151, 575-6)
153. (C) H yp oxic p u lm on ary vasocon striction
(H PV) is a constriction of p u lm onary arteries
in resp onse to alveolar hyp oxia. Atelectatic
lu ngs have id entical d egrees of H PV to those
ventilated w ith nitrogen, exclu d ing m echani-
cal factors. H PV can occur in d enervated lungs
(e.g., after tran sp lan tation ). H yp ocap n ia
d ecreases H PV, bu t hyp ercap nia has no effect.
H yp oxia is th e p rim ary trigger of H PV.
Alkalosis and acid osis both d ecrease H PV, as
d oes ad m inistration of nitrou s oxid e. The p u l-
m onary vasoconstrictor resp onse to hypoxia is
d ecreased w ith increases in p u lm onary artery
p ressure, card iac ou tp u t, left atrial p ressure, or
central blood volu m e. (5:612-3, 967-70)
154. (E) A throm boelastogram (TEG) m easures the
clot strength over tim e. The am plitud e of the
grap h refers to the clot strength at a given tim e
d u ring the clot form ation. The m axim u m
strength (or amp litu d e) correlates w ith platelet
fu nction. Protam ine w ou ld be given to reverse
the effects of heparin. To d ifferentiate betw een
the effects of heparin ad m inistered intraopera-
tively and other causes of coagulopathy, tw o
TEG sam p les need to be analyzed : one w ith,
and one w ithout, heparinase. Plasma and cryo-
p recip itate w ou ld be ind icated for slow onset
and slow form ation of clotting on the TEG,
resp ectively (p rolonged R-valu e and d im in-
ished angle A). Am inocap roic acid is ad m inis-
tered for states of hyperfibrinolysis. (5:194)
155. (A) The p u lm onary artery is cau d al to the
carina. (5:988)
156. (E) The other options are indications for one-lung
ventilation. In the setting of infection with puru-
lent secretions, the goal is to avoid spillage and
contamination of the contralateral lung. During
surgery for bronchopleural fistula, the goal is to
control the distribution of ventilation to the unaf-
fected lu ng. Other p roced u res w ith high p rior-
ity for one-lung ventilation includ e thoracic
aortic aneurysm repair, pneumonectomy, upper
lobectom y and vid eo-assisted thoracoscop ic

su rgery (VATS), however the indication is not
absolute. (5:963, 1038)
157. (D ) In the lateral position, lu ng relationships
change. While there are three d istinct zones as
in the u p right p atient, these are d istribu ted
along a vertical grad ient in the lateral p osition.
Perfusion is therefore greater in the d epend ent
lung that also receives most of the tid al ventila-
tion. Com p liance d iffers betw een the lu ngs
becau se the d ep end ent lu ng is at a low er FRC
d u e to the w eight of the abd om inal contents
and m ed iastin u m . The d ep end en t alveoli
therefore are on the steep portion of the trans-
p u lm onary p ressu re-alveolar volu m e cu rve
that exp lains their greater share of the tid al
ventilation (5:961-2)
158. (E) In the p atient w ith blu nt anterior chest
inju ry, resp iratory d istress, and hyp otension,
all of the d iagnoses listed w ith the exception of
op tion E m u st be consid ered . Fat em bolism
synd rom e is m ore likely to affect p atients w ith
m ajor low er extrem ity or p elvic fractu res.
(5:1351, 1362)
159. (C) Su rgery shou ld proceed w ith u sing hepa-
rin. It rem ains the first-line anticoagu lant for
p atients und ergoing card iac su rgery and can
be read ily reversed w ith p rotam ine at the con-
clusion of su rgery. The patient d escribed in this
vignette d oes not fit the d iagnosis for H IT. The
large hem atom a d escribed m ight exp lain the
d rop in p latelets that is less than 50% from
baselin e. An tibod y serocon version in th e
absence of clinical signs d oes not confirm the
d iagnosis of H IT. The p atient's su rgery shou ld
not be d elayed nor should alternative m ethod s
of anticoagu lation be pu rsu ed . Direct throm -
bin inhibitors su ch as argatroban and bivaliru -
d in cannot be reversed. Low er doses of heparin
are not ind icated , and w ou ld increase the risk
of clotting w ithin the card iopulm onary bypass
m achine. (5:900)
160. (E) The m ost com m on causes for hypotension
in the setting of low LVAD p u m p flow rates in
ad d ition to inflow cannu la obstru ction are
options B through E. The latter is m ost likely in
this scenario given the TEE find ings as w ell as
Answe rs : 149–166 237
the low voltage ECG. Ad d itional find ings on
TEE evalu ation m ay inclu d e p ericard ial effu -
sion as w ell as equ alization of cham ber pres-
sures on pulmonary artery catheter monitoring.
Graft failure is less likely based on the scenario
given. (5:925)
161. (A) The u se of u ltrasou nd technology, w hile
p rovid ing several ad vantages, d oes not com -
p letely p revent arterial inju ry. A thorou gh
u nd erstand ing of anatom y as w ell as form al
training in u ltrasou nd techniqu e is param ou nt
in avoid in g th ese typ es of com p lication s.
(5:411)
162. (D ) Dep icted here is reversed or parad oxical
sp litting of the second heart sound that can be
fou nd in aortic stenosis, as w ell as LBBB.
Exam ination find ings consistent w ith severe
AS w ou ld inclu d e p arvu st et tard u s carotid
u p strokes, a late-p eaking grad e 3 or greater
m id systolic m u rm u r, as soft A 2, a su stained LV
ap ical im p u lse, and an S4. (6:1827-8)
163. (B) The p atient has a congenital atrial sep tal
d efect that is com m on in Dow n synd rom e,
often first encou ntered in the ad u lt life, and
m ore com m on in fem ale patients. The associ-
ated murmur is mid-systolic in nature. (6:1827-8,
1921)
164. (E) The p atient has p u lm onary hyp ertension
after p neu m onectom y that w ill m anifest as
narrow splitting of S2. Pre-existing im pairment
of pu lm onary vascular com p liance associated
w ith CH F, and cor p ulm onale m ay be exacer-
bated after extensive lu ng resection, lead ing to
seriou s p u lm onary hyp ertension and right-
sid ed heart failu re. (5:954; 6:1827-8)
165. (I) (Lauer R, M athew JP. Transesophageal tomo-
graphic views. In: M athew JP, et al., eds., Clinical
M anual and Review of Transesophageal
Echocardiography, 2nd ed., N ew York: M cGraw-
Hill, 2010, Figure 5-27)
166. (G) (Lauer R, M athew JP. Transesophageal tomo-
graphic views. In: M athew JP, et al., eds., Clinical
M anual and Review of Transesophageal
238 13: Ane s the s ia for Ca rdiothora cic a nd Va s cula r S urge ry
Echocardiography, 2nd ed., N ew York: M cGraw-
Hill, 2010, Figure 5-20)
167. (D ) (Lauer R, M athew JP. Transesophageal tomo-
graphic views. In: M athew JP, et al., eds., Clinical
M anual and Review of Transesophageal
Echocardiography, 2nd ed., N ew York: M cGraw-
Hill, 2010, Figure 5-14)
168. (E) (Lauer R, M athew JP. Transesophageal tomo-
graphic views. In: M athew JP, et al., eds., Clinical
M anual and Review of Transesophageal
Echocardiography, 2nd ed., New York: McGraw-Hill,
2010, Figure 5-11)
169. (C) (Lauer R, M athew JP. Transesophageal tomo-
graphic views. In: M athew JP, et al., eds., Clinical
M anual and Review of Transesophageal
Echocardiography, 2nd ed., New York: McGraw-Hill,
2010, Figure 5-9)
170. (A) (Lauer R, M athew JP. Transesophageal tomo-
graphic views. In: M athew JP, et al., eds., Clinical
M anual and Review of Transesophageal
Echocardiography, 2nd ed., New York: McGraw-Hill,
2010, Figure 5-7)
171. (H) (Lauer R, M athew JP. Transesophageal tomo-
graphic views. In: M athew JP, et al., eds., Clinical
M anual and Review of Transesophageal
Echocardiography, 2nd ed., N ew York: M cGraw-
Hill, 2010, Figure 5-25)
172. (B) (Lauer R, M athew JP. Transesophageal tomo-
graphic views. In: M athew JP, et al., eds., Clinical
M anual and Review of Transesophageal
Echocardiography, 2nd ed., N ew York: M cGraw-
Hill, 2010, Figure 5-8)
173. (L) (Lauer R, M athew JP. Transesophageal tomo-
graphic views. In: M athew JP, et al., eds., Clinical
M anual and Review of Transesophageal
Echocardiography, 2nd ed., N ew York: M cGraw-
Hill, 2010, Figure 5-34)
174. (F) (Lauer R, M athew JP. Transesophageal tomo-
graphic views. In: M athew JP, et al., eds., Clinical
M anual and Review of Transesophageal
Echocardiography, 2nd ed., New York: McGraw-Hill,
2010, Figure 5-19)