NEET SS Cardiothoracic and Vascular Surgery (MCh) Syllabus

Compare mechanical versus bioprosthetic heart valves regarding durability and anticoagulation.

Mechanical valves are very durable but require lifelong warfarin anticoagulation; bioprosthetic valves avoid long-term anticoagulation but degenerate over ~10-15 years, favoring older patients.

What is the target INR for a mechanical mitral valve prosthesis?

Typically INR 2.5-3.5 (higher than for an aortic mechanical valve, which targets 2.0-3.0), reflecting higher thrombogenicity in the mitral position.

What is the preferred surgical strategy for degenerative mitral regurgitation when feasible, and why?

Mitral valve repair (e.g., leaflet resection/neochordae plus annuloplasty ring) is preferred over replacement due to better preservation of LV function, lower mortality, and freedom from prosthesis-related complications.

List the modified Duke major criteria categories for diagnosing infective endocarditis.

Major criteria: (1) positive blood cultures with typical organisms or persistent bacteremia, and (2) evidence of endocardial involvement (echo showing vegetation, abscess, new dehiscence, or new valvular regurgitation).

Name three accepted surgical indications in active infective endocarditis.

Heart failure from valve dysfunction, uncontrolled infection (abscess, persistent bacteremia, fungal/resistant organisms), and prevention of embolism (large >10 mm mobile vegetations, especially with prior embolic event).

What is the Bentall procedure?

Composite replacement of the aortic valve and ascending aorta with a valved conduit, with reimplantation of the coronary arteries (buttons) into the graft; used for aortic root aneurysm with valve disease.

What is a valve-sparing aortic root replacement (David vs Yacoub) used for?

Replacement of the aortic root preserving the native aortic valve; David = reimplantation technique (valve inside graft), Yacoub = remodeling technique (graft tailored to sinuses), used in aneurysm with a salvageable valve.

Name three common acyanotic congenital heart lesions with left-to-right shunts.

Atrial septal defect (ASD), ventricular septal defect (VSD), and patent ductus arteriosus (PDA).

What is the most common type of ASD and where is it located?

Ostium secundum ASD, located in the region of the fossa ovalis (mid-atrial septum).

What is Eisenmenger syndrome and its significance for surgery?

A long-standing left-to-right shunt causing pulmonary vascular obstructive disease and pulmonary hypertension, leading to shunt reversal (right-to-left) and cyanosis; it generally contraindicates simple defect closure.

What is the natural-history term for closure of a VSD, and which VSDs commonly close spontaneously?

Spontaneous closure; small muscular and perimembranous VSDs often close on their own during childhood.

List the four components of Tetralogy of Fallot.

(1) VSD, (2) overriding aorta, (3) right ventricular outflow tract obstruction (pulmonary stenosis), and (4) right ventricular hypertrophy.

In Tetralogy of Fallot, what determines the degree of cyanosis?

The severity of right ventricular outflow tract obstruction (pulmonary stenosis) - greater obstruction increases right-to-left shunting across the VSD and worsens cyanosis.

What is the definitive surgical repair of Tetralogy of Fallot?

Intracardiac repair: VSD closure with a patch and relief of RVOT obstruction (infundibular resection +/- transannular/pulmonary patch or RV-PA conduit).

Name the '5 Ts' of cyanotic congenital heart disease.

Tetralogy of Fallot, Transposition of the great arteries, Truncus arteriosus, Tricuspid atresia, and Total anomalous pulmonary venous connection (TAPVC).

What is the surgery of choice for d-transposition of the great arteries (d-TGA)?

The arterial switch operation (Jatene), ideally within the first 2 weeks of life, switching the great arteries and reimplanting the coronaries.

What is a Blalock-Taussig (BT) shunt and its purpose?

A palliative systemic-to-pulmonary artery shunt (classically subclavian-to-pulmonary, now usually a modified Gore-Tex interposition) that increases pulmonary blood flow in cyanotic lesions with decreased flow.

Describe the staged single-ventricle (Fontan) pathway and its physiologic goal.

Typically stage 1 palliation (e.g., Norwood/BT shunt), stage 2 bidirectional Glenn (SVC to PA), and stage 3 Fontan completion (IVC to PA); the goal is to route systemic venous return passively to the lungs, bypassing the single functional ventricle.

What is the bidirectional Glenn procedure?

An end-to-side anastomosis of the superior vena cava to the pulmonary artery, directing SVC (upper body) venous return directly to the lungs as a stage in single-ventricle palliation.

What procedure is the Norwood used for?

First-stage palliation of hypoplastic left heart syndrome (HLHS), creating a neoaorta from the pulmonary artery/aorta and establishing pulmonary blood flow via a shunt.

What is the most common type of TAPVC and a key surgical urgency factor?

Supracardiac type is most common; obstructed TAPVC is a surgical emergency in the neonate because pulmonary venous obstruction causes severe pulmonary edema and hypoxia.

Describe the standard surgical resections for lung cancer based on extent.

Lobectomy is the standard for resectable NSCLC; pneumonectomy for central tumors crossing fissures; segmentectomy/wedge for limited-function patients or small peripheral tumors; with systematic mediastinal lymph node dissection.

In the anterior mediastinum, what are the classic 'terrible Ts' differential masses?

Thymoma, Teratoma (germ cell tumors), Thyroid (retrosternal goiter), and 'Terrible' lymphoma.

What myasthenic association makes thymectomy therapeutic, and what investigation evaluates the thymus?

Myasthenia gravis is associated with thymoma/thymic hyperplasia; CT chest evaluates the thymus, and thymectomy can improve or induce remission of myasthenia gravis.

What is the surgical management of a primary spontaneous pneumothorax that recurs or persists?

VATS bullectomy/apical blebectomy with pleurodesis (mechanical or chemical) to prevent recurrence; persistent air leak or recurrence are key indications.

What is the gold-standard operation for esophageal achalasia and its key adjunct?

Laparoscopic Heller myotomy (division of lower esophageal sphincter muscle) with a partial fundoplication (e.g., Dor or Toupet) to prevent postoperative reflux.

Name two common surgical approaches for esophagectomy and a key difference.

Transhiatal (abdominal + cervical, no thoracotomy, anastomosis in neck) and transthoracic Ivor-Lewis (abdominal + right thoracotomy, intrathoracic anastomosis); transhiatal avoids thoracotomy but allows less mediastinal nodal clearance.

Per the Stanford classification, how are aortic dissections divided and which needs urgent surgery?

Stanford A involves the ascending aorta (and requires urgent surgical repair); Stanford B is confined to the descending aorta distal to the left subclavian and is usually managed medically or with TEVAR.

What is the threshold diameter for elective repair of an asymptomatic infrarenal abdominal aortic aneurysm?

Generally a diameter >=5.5 cm in men (or rapid growth >0.5 cm/6 months or symptoms); repair can be open or endovascular (EVAR).

What is the gold-standard surgical bypass for aortoiliac occlusive disease and an alternative for high-risk patients?

Aortobifemoral bypass is the durable gold standard; for high-risk patients, extra-anatomic bypass (e.g., axillobifemoral or femorofemoral crossover) is an alternative.