Sample MEBCTS Questions

Disciplines
General
Principles of surgery and critical care

You evaluate in the ICU a 57-year-old male after uneventful open thoracoabdominal aorta repair for chronic type B aortic dissection. Surgery finished 24h ago. He has a spinal fluid drain functioning, cerebrospinal fluid pressure is 12 mmHg and he moves all limbs.

His CVP is 10 mmHg. Mean systemic arterial pressure of 92 mmHg on noradrenaline 0.03 mcg/kg/min. Cardiac index is 3 l/min/m2.

Labs: Haemoglobin 11 g/dL, INR 1.4, platelet count is 90.000 /mm3, creatinine 1.1 mg/dL.

Which of the following is the most appropriate management plan for this patient?

  1. Transfuse platelets to remove the spinal drain and discontinue noradrenaline
  2. Increase further the mean arterial pressure preventively
  3. Continue to titrate vasoconstrictors for mean arterial systemic pressure above 85 mmHg
  4. Initiate diuretics to increase spinal cord perfusion pressure
  5. Discontinue noradrenalin and maintain the spinal drain

Syllabus maps
Section: 2.5.14 – Adult Cardiac – Thoracic Vascular Disease (and pulmonary embolism)
Learning outcome: Ability to recognise and plan the management (including adjunct treatments) for a patient with thoracic vascular disease (i.e. neuroprotection, spinal cord protection)

Section: 2.5.15 – Adult Cardiac – Thoracic Vascular Disease (and pulmonary embolism)
Learning outcome: Identification of appropriate treatment options including surgical approaches for patients with thoracic vascular disease (including peri-operative monitoring, perfusion and neuroprotective strategies)

Section: 2.5.18 – Adult Cardiac – Thoracic Vascular Disease (and pulmonary embolism)
Learning outcome: Ability to recognise and plan the management of common post-operative complications following thoracic vascular surgery

Section: 2.1.7 – Adult Cardiac – Principles of surgery and critical care
Learning outcome: Knowledge of the ICU treatment options (including advantages and disadvantages) for critically-ill patients with cardiovascular and thoracic diseases pre-and post-operatively (e.g. pharmacology of inotropic agents)

Section: 2.1.16 – Adult Cardiac – Principles of surgery and critical care
Learning outcome: Prioritisation and interpretation of diagnostic and physiological assessment tests for critically-ill patients with cardiovascular and thoracic diseases (e.g. pre- and post-operative)

Section: 2.1.19 – Adult Cardiac – Principles of surgery and critical care
Learning outcome: Adaptation of treatment options based on the understanding of pathophysiology (e.g. selection of inotropic drugs)

Section: 2.1.20 – Adult Cardiac – Principles of surgery and critical care
Learning outcome: Identification of appropriate treatments with preventative care for critically-ill patients with cardiovascular and thoracic diseases (e.g. arrhythmias, nutrition, prophylactic antibiotics)

Disciplines
Thoracic Disease
Chest Wall/Pleura/Mediastinum/Diaphragm

An otherwise healthy 58-year-old male smoker presents with a Superior Vena Cava Syndrome.

His CT-scan demonstrates a large mediastinal tumor that extents into the right chest, and the angiography reveals almost complete occlusion of the SVC. A CT-guided biopsy shows: lymphoma.

What is the most appropriate next step in the management of this patient?

  1. Schedule the patient for an immediate PET-scan
  2. Call an interventional radiologist and plan immediate stenting of the SVC – then refer to medical oncologic treatment
  3. Perform median sternotomy and extraanatomic bypass
  4. Plan a right upper lobectomy with SVC reconstruction under cardiopulmonary bypass
  5. Refer the patient for haematological treatment

Syllabus maps
Section: 4.2.2 – Thoracic – Chest Wall/Pleura/Mediastinum/Diaphragm
Learning outcome: Knowledge of the physiology of the chest wall, pleura, mediastinum and diaphragm including changes accompanying benign, malignant and traumatic disorders and the effects of treatment

Section: 4.2.3 – Thoracic – Chest Wall/Pleura/Mediastinum/Diaphragm
Learning outcome: Knowledge of clinical presentations and common variations of benign, malignant, and traumatic disorders of the chest wall, pleura, mediastinum and diaphragm (including mediastinal tumours)

Section: 4.2.4 – Thoracic – Chest Wall/Pleura/Mediastinum/Diaphragm
Learning outcome: Knowledge of diagnostic and staging tests including advantages and disadvantages for the evaluation of disorders of the chest wall, pleura, mediastinum and diaphragm (including tumour markers)

Section: 4.2.5 – Thoracic – Chest Wall/Pleura/Mediastinum/Diaphragm
Learning outcome: Knowledge of treatment options (medical and surgical) including advantages and disadvantages for benign, malignant and traumatic disorders of the chest wall, pleura, mediastinum and diaphragm

Section: 4.2.19 – Thoracic – Chest Wall/Pleura/Mediastinum/Diaphragm
Learning outcome: Prioritisation and Interpretation of subsequent diagnostic/assessment tests for routine benign, malignant, and traumatic disorders of the chest wall, pleura, mediastinum and diaphragm

Section: 4.2.20 – Thoracic – Chest Wall/Pleura/Mediastinum/Diaphragm
Learning outcome: Identification of appropriate treatment options for a patient with benign, malignant, and traumatic disorders of the chest wall, pleura, mediastinum and diaphragm

Disciplines
Congenital Heart Disease
Congenital

You repair a superior sinus venosus atrial septal defect with partial anomalous pulmonary venous return (upper and middle right veins) in a 3-year-old child, using a two patch technique. After weaning from cardiopulmonary bypass, your central venous pressure is 20 mmHg. The patient is otherwise hemodynamically stable without inotropes or vasopressors. On transoesophageal echocardiography, there is no residual atrial septal defect, the pulmonary veins drain to the left atrium, biventricular systolic function is normal.

You take a direct (with needle) pressure measurement of the superior vena cava and right atrium, which shows a gradient of 8 mmHg.

What is the most appropriate next step?

  1. Re-institute cardiopulmonary bypass and enlarge the atrial septal patch.
  2. Re-institute cardiopulmonary bypass and enlarge the SVC-RA patch √ correct answer
  3. Introduce inotropes and reassess CVP
  4. Transfer to the catheterization lab for further assessment
  5. Increase PEEP, decannulate from cardiopulmonary bypass and give protamine

Syllabus maps
Section: 3.2.5 – Congenital – Congenital
Learning outcome: Knowledge of the diagnostic tests (including advantages and disadvantages) available for evaluating congenital heart disease

Section: 3.2.10 – Congenital – Congenital
Learning outcome: Knowledge of the risks, benefits and complications of common treatment options

Section: 3.2.30 – Congenital – Congenital
Learning outcome: Interpretation of common abnormalities associated with congenital heart disease, with echocardiography

Section: 3.2.31 – Congenital – Congenital
Learning outcome: Ability to generate a differential diagnosis of common congenital heart conditions with similar presentations

Section: 3.2.34 – Congenital – Congenital
Learning outcome: Ability to identify the appropriate treatment for common conditions of congenital heart disease (e.g., selection of palliative vs. definitive)

Disciplines
Acquired Cardiac Disease
Valvular Heart Disease

You operated on a 69-year-old female 3 years ago performing mitral and aortic tissue valve replacement, left atrial amputation and LIMA-LAD grafting. She has done well with normal echocardiograms at annual serial follow up.

She has presented in your hospital with pulmonary edema and mild self-controlled haemoptysis and is found to have a large aorta-to-left atrium fistula. There is no periprosthetic leak detected by echo. She is intermittently febrile but blood cultures are negative.

What is the most appropriate course of action?

  1. Advise a percutaneous plug (Amplatzer) occlusion of the fistula
  2. Implant an IABP and stabilize her from a pulmonary point of view before surgery
  3. Obtain a Positron Emission Tomography/CT and if perivalvular uptake advise redo surgery
  4. Proceed with patch closure alone of the fistula
  5. Perform aortic valve-in-valve with a larger aortic prosthesis

Syllabus maps
Section: 2.4.3 – Adult Cardiac – Valvular Heart Disease
Learning outcome: Knowledge of the clinical presentations, differential diagnoses and common variations of valvular heart disease including infective endocarditis

Section: 2.4.4 – Adult Cardiac – Valvular Heart Disease
Learning outcome: Knowledge of the diagnostic tests (including advantages and disadvantages) available for evaluation of valvular heart disease (i.e. Echocardiography)

Section: 2.4.5 – Adult Cardiac – Valvular Heart Disease
Learning outcome: Knowledge of the interventional treatment options (including advantages and disadvantages) for valvular heart disease (e.g. Repair vs replacement; open vs minimally invasive or percutaneous)

Section: 2.4.7 – Adult Cardiac – Valvular Heart Disease
Learning outcome: Knowledge of ESC/EACTS guidelines for valvular heart disease

Section: 2.4.11 – Adult Cardiac – Valvular Heart Disease
Learning outcome: Prioritisation and interpretation of the diagnostic and physiologic assessment tests for patients with valvular heart disease (e.g. echocardiogram, cardiac catheterisation)

Section: 2.4.12 – Adult Cardiac – Valvular Heart Disease
Learning outcome: Identification of the appropriate treatment options for a patient with valvular heart disease including infective endocarditis

Section: 2.4.13 – Adult Cardiac – Valvular Heart Disease
Learning outcome: Adaptation of a management plan based on the understanding of complex cardiac physiology (e.g. multi-valve pathology)