AACN CSC Exam – Questions with Answers &
Explanations | Latest 2026 Cardiac Surgery
Certification Prep Guide
SECTION 1: CARDIOTHORACIC SURGERY PROCEDURES & COMPLICATIONS
(Questions 1–50)
1. A 68-year-old male with triple-vessel coronary artery disease is scheduled for
CABG. Which conduit is considered the gold standard for grafting the left anterior
descending artery due to superior long-term patency?
A. Saphenous vein graft
B. Left internal mammary artery (LIMA)
C. Radial artery
D. Right internal mammary artery (RIMA)
Answer: B. The LIMA is the preferred conduit for CABG due to its superior long-term
patency rates of 90-95% at 10 years when anastomosed to the LAD. Saphenous vein grafts
have lower patency rates of 50-60% at 10 years and are used for secondary targets.
2. A patient with symptomatic atrial fibrillation refractory to medical therapy is
scheduled for a surgical procedure. Which procedure creates a "maze" of scar tissue
in the atria to block abnormal electrical pathways?
A. Coronary artery bypass grafting
B. Cox-Maze procedure
,C. Valve replacement
D. Pericardial window
Answer: B. The Cox-Maze procedure creates scar tissue in the atria to redirect electrical
impulses. It is indicated for patients with symptomatic atrial fibrillation refractory to medical
therapy or catheter ablation and is often performed concurrently with other cardiac
surgeries.
3. A 78-year-old female with severe aortic stenosis is deemed high-risk for surgical
valve replacement. She is scheduled for a transcatheter procedure. Which imaging
modality provides the most accurate measurement of annular dimensions for valve
sizing?
A. Transthoracic echocardiography (TTE)
B. Transesophageal echocardiography (TEE)
C. Multidetector computed tomography (MDCT)
D. Cardiac magnetic resonance imaging (CMR)
Answer: C. MDCT offers high-resolution, three-dimensional reconstruction of the aortic
annulus, essential for accurately sizing the transcatheter valve. TEE provides valuable
intraprocedural guidance, but MDCT is superior for pre-procedural annular measurement.
4. A patient is undergoing off-pump coronary artery bypass (OPCAB). What is the
primary advantage of this approach compared with conventional CABG on
cardiopulmonary bypass?
A. Reduced operative time
B. Lower risk of stroke
C. Decreased blood loss
D. Improved graft patency
,Answer: B. OPCAB avoids the use of cardiopulmonary bypass, thereby reducing the risk of
embolic phenomena that can cause postoperative stroke. It also reduces the systemic
inflammatory response associated with CPB.
5. During aortic root replacement, which graft material is most commonly used to
recreate the sinuses of Valsalva?
A. Dacron tube graft
B. Homograft (cryopreserved aortic root)
C. Bovine pericardial patch
D. Polytetrafluoroethylene (PTFE) patch
Answer: B. Homografts preserve native aortic root anatomy, including the sinuses of
Valsalva, making them the preferred choice for root replacement when available. They also
have excellent hemodynamic properties and lower risk of infection.
6. A 68-year-old male with severe aortic stenosis (mean gradient 55 mmHg, valve area
0.7 cm²) and 70% LAD stenosis is scheduled for surgery. Which strategy is most
appropriate?
A. Isolated surgical aortic valve replacement (SAVR)
B. Transcatheter aortic valve replacement (TAVR) with percutaneous coronary intervention
C. SAVR with concomitant coronary artery bypass grafting (CABG)
D. Medical management with optimization of antianginal therapy
Answer: C. Current guidelines recommend surgical aortic valve replacement with
concomitant CABG for patients with severe aortic stenosis and significant coronary artery
disease who are surgical candidates. This addresses both the valvular and coronary
pathology simultaneously, reducing the need for future reinterventions.
, 7. A 45-year-old female undergoes mitral valve repair for severe mitral regurgitation.
Post-bypass TEE reveals residual mild central mitral regurgitation with a stable mean
gradient of 4 mmHg. What is the appropriate next step in management?
A. Return to cardiopulmonary bypass for immediate re-repair
B. Accept the result and close the chest
C. Perform a mitral valve replacement
D. Administer intravenous nitroglycerin to reduce afterload
Answer: B. A residual mild (1+) central mitral regurgitation after mitral valve repair with an
acceptable mean gradient is generally considered an acceptable result. The goal of mitral
valve repair is to achieve a competent valve without significant stenosis. Mild residual
regurgitation is often well-tolerated and may improve with postoperative left ventricular
remodeling.
8. A 72-year-old male with severe aortic stenosis undergoes TAVR via transfemoral
approach. During balloon valvuloplasty, the patient develops acute hypotension and
bradycardia. TEE shows a new moderate pericardial effusion with right ventricular
collapse. What is the most likely diagnosis?
A. Myocardial infarction
B. Aortic dissection
C. Pericardial tamponade due to ventricular perforation
D. Anaphylactic reaction to contrast media
Answer: C. Acute pericardial tamponade is a known complication of TAVR, particularly
during balloon valvuloplasty or valve deployment. The wire or balloon can perforate the right
ventricle, leading to pericardial effusion and subsequent tamponade. The clinical
presentation of hypotension, bradycardia, and right ventricular collapse on TEE is classic for
tamponade.
Explanations | Latest 2026 Cardiac Surgery
Certification Prep Guide
SECTION 1: CARDIOTHORACIC SURGERY PROCEDURES & COMPLICATIONS
(Questions 1–50)
1. A 68-year-old male with triple-vessel coronary artery disease is scheduled for
CABG. Which conduit is considered the gold standard for grafting the left anterior
descending artery due to superior long-term patency?
A. Saphenous vein graft
B. Left internal mammary artery (LIMA)
C. Radial artery
D. Right internal mammary artery (RIMA)
Answer: B. The LIMA is the preferred conduit for CABG due to its superior long-term
patency rates of 90-95% at 10 years when anastomosed to the LAD. Saphenous vein grafts
have lower patency rates of 50-60% at 10 years and are used for secondary targets.
2. A patient with symptomatic atrial fibrillation refractory to medical therapy is
scheduled for a surgical procedure. Which procedure creates a "maze" of scar tissue
in the atria to block abnormal electrical pathways?
A. Coronary artery bypass grafting
B. Cox-Maze procedure
,C. Valve replacement
D. Pericardial window
Answer: B. The Cox-Maze procedure creates scar tissue in the atria to redirect electrical
impulses. It is indicated for patients with symptomatic atrial fibrillation refractory to medical
therapy or catheter ablation and is often performed concurrently with other cardiac
surgeries.
3. A 78-year-old female with severe aortic stenosis is deemed high-risk for surgical
valve replacement. She is scheduled for a transcatheter procedure. Which imaging
modality provides the most accurate measurement of annular dimensions for valve
sizing?
A. Transthoracic echocardiography (TTE)
B. Transesophageal echocardiography (TEE)
C. Multidetector computed tomography (MDCT)
D. Cardiac magnetic resonance imaging (CMR)
Answer: C. MDCT offers high-resolution, three-dimensional reconstruction of the aortic
annulus, essential for accurately sizing the transcatheter valve. TEE provides valuable
intraprocedural guidance, but MDCT is superior for pre-procedural annular measurement.
4. A patient is undergoing off-pump coronary artery bypass (OPCAB). What is the
primary advantage of this approach compared with conventional CABG on
cardiopulmonary bypass?
A. Reduced operative time
B. Lower risk of stroke
C. Decreased blood loss
D. Improved graft patency
,Answer: B. OPCAB avoids the use of cardiopulmonary bypass, thereby reducing the risk of
embolic phenomena that can cause postoperative stroke. It also reduces the systemic
inflammatory response associated with CPB.
5. During aortic root replacement, which graft material is most commonly used to
recreate the sinuses of Valsalva?
A. Dacron tube graft
B. Homograft (cryopreserved aortic root)
C. Bovine pericardial patch
D. Polytetrafluoroethylene (PTFE) patch
Answer: B. Homografts preserve native aortic root anatomy, including the sinuses of
Valsalva, making them the preferred choice for root replacement when available. They also
have excellent hemodynamic properties and lower risk of infection.
6. A 68-year-old male with severe aortic stenosis (mean gradient 55 mmHg, valve area
0.7 cm²) and 70% LAD stenosis is scheduled for surgery. Which strategy is most
appropriate?
A. Isolated surgical aortic valve replacement (SAVR)
B. Transcatheter aortic valve replacement (TAVR) with percutaneous coronary intervention
C. SAVR with concomitant coronary artery bypass grafting (CABG)
D. Medical management with optimization of antianginal therapy
Answer: C. Current guidelines recommend surgical aortic valve replacement with
concomitant CABG for patients with severe aortic stenosis and significant coronary artery
disease who are surgical candidates. This addresses both the valvular and coronary
pathology simultaneously, reducing the need for future reinterventions.
, 7. A 45-year-old female undergoes mitral valve repair for severe mitral regurgitation.
Post-bypass TEE reveals residual mild central mitral regurgitation with a stable mean
gradient of 4 mmHg. What is the appropriate next step in management?
A. Return to cardiopulmonary bypass for immediate re-repair
B. Accept the result and close the chest
C. Perform a mitral valve replacement
D. Administer intravenous nitroglycerin to reduce afterload
Answer: B. A residual mild (1+) central mitral regurgitation after mitral valve repair with an
acceptable mean gradient is generally considered an acceptable result. The goal of mitral
valve repair is to achieve a competent valve without significant stenosis. Mild residual
regurgitation is often well-tolerated and may improve with postoperative left ventricular
remodeling.
8. A 72-year-old male with severe aortic stenosis undergoes TAVR via transfemoral
approach. During balloon valvuloplasty, the patient develops acute hypotension and
bradycardia. TEE shows a new moderate pericardial effusion with right ventricular
collapse. What is the most likely diagnosis?
A. Myocardial infarction
B. Aortic dissection
C. Pericardial tamponade due to ventricular perforation
D. Anaphylactic reaction to contrast media
Answer: C. Acute pericardial tamponade is a known complication of TAVR, particularly
during balloon valvuloplasty or valve deployment. The wire or balloon can perforate the right
ventricle, leading to pericardial effusion and subsequent tamponade. The clinical
presentation of hypotension, bradycardia, and right ventricular collapse on TEE is classic for
tamponade.
