Specialist & Consultant Cardiothoracic Surgery oral assessment prep

Knowledge: This is acute type A aortic dissection, DeBakey type I. Untreated early mortality is classically quoted at 1 to 2 percent per hour, mainly from rupture into the pericardium, coronary malperfusion, acute aortic regurgitation and stroke. The effusion and arm pressure difference signal tamponade risk and arch branch involvement. Emergency surgery is recommended by both the 2024 EACTS/STS and 2022 ACC/AHA guidelines. Antithrombotic therapy given for presumed coronary syndrome increases bleeding but does not contraindicate surgery. Malperfusion of brain, gut, kidneys or limbs must be assessed because it changes risk and sometimes the sequence of treatment.

Management: I accept him for emergency surgery and alert theatre, perfusion and anaesthesia at once. Meanwhile I give opioid analgesia and intravenous beta-blockade to keep systolic pressure around 100 to 120 mmHg and heart rate near 60, provided there is no tamponade physiology. I stop enoxaparin and prepare platelets, cryoprecipitate and plasma for the clopidogrel effect. I avoid pericardiocentesis unless he is in extremis, when only controlled small-volume drainage is used. In theatre I use axillary or central cannulation, hypothermic circulatory arrest with antegrade cerebral perfusion, resect the primary entry tear and replace the ascending aorta with an open distal anastomosis. I resuspend or replace the aortic valve depending on root pathology, extending to the arch only when indicated. Afterwards I watch for bleeding, stroke, malperfusion and kidney injury. Follow-up includes lifelong imaging of the residual aorta and strict blood pressure control.

Ethics and communication: If he has capacity, consent is urgent but honest about substantial operative mortality, stroke and paraplegia, and that death is likely without surgery. If he wishes, I involve family by phone without delaying surgery. The missed diagnosis and antithrombotic treatment are reported through the incident system in a learning spirit, not a blaming one.

Reference: 2024 EACTS/STS Guidelines for Diagnosing and Treating Acute and Chronic Syndromes of the Aortic Organ; 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease

Knowledge: This is cardiac tamponade after cardiac surgery. It typically arises from clot after bleeding, with the drains themselves blocked by clot. Post-operative tamponade is often localised, so classic signs and transthoracic echo can mislead, and a high index of suspicion is needed when drainage stops abruptly with rising filling pressures and falling output. Differentials include ventricular failure, graft occlusion, vasoplegia and tension pneumothorax, which are excluded quickly at the bedside. The STS expert consensus on resuscitation after cardiac surgery supports emergency re-sternotomy within about 5 minutes of arrest from tamponade or bleeding, performed in the ICU.

Management: Immediately I call the senior team, anaesthetist and perfusionist and open the emergency re-sternotomy set. Meanwhile I give fluid and blood and correct coagulopathy with targeted products, guided by viscoelastic testing if available, rather than chasing pressure with vasopressors. If she deteriorates further or arrests, I re-open the chest in the ICU under sterile conditions without waiting for theatre, following the STS protocol. If she stabilises, I take her to theatre immediately for re-exploration, evacuate clot, control the bleeding source and check graft flow. I would not rely on stripping drains or wait for a formal echo while she declines. Afterwards I monitor drain output, haemodynamics, lactate and renal function, and review antiplatelet timing. Every return to theatre is recorded and audited.

Ethics and communication: She is sedated and cannot consent, so emergency re-exploration proceeds in her interests under the emergency provisions of UAE law. Her family are told promptly and honestly that bleeding has compressed the heart and that she has returned to theatre. I document timings and decisions clearly. Unit re-exploration rates are monitored as quality indicators, not hidden.

Reference: The Society of Thoracic Surgeons Expert Consensus for the Resuscitation of Patients Who Arrest After Cardiac Surgery, 2017; Sellke, del Nido and Swanson, Sabiston and Spencer Surgery of the Chest

Knowledge: This is native mitral endocarditis due to Staphylococcus aureus, complicated by heart failure from severe regurgitation, a large mobile vegetation and an embolic ischaemic stroke. The 2023 ESC guidelines recommend surgery for heart failure caused by severe regurgitation, emergently or urgently according to severity, and urgent surgery for vegetations of 10 mm or more with embolism. After an ischaemic stroke without haemorrhage, surgery that is indicated should not be delayed provided coma is absent, whereas intracranial haemorrhage usually warrants postponement. Mycotic aneurysm should be sought. The risk of further embolism is highest early in treatment.

Management: Immediately I continue full-dose flucloxacillin or cefazolin, optimise heart failure therapy and present him to the endocarditis team with cardiology, infectious diseases, neurology and neuroradiology. I request brain MRI or CT angiography to exclude haemorrhage and mycotic aneurysm. If these are clear, I plan surgery within days, aiming for mitral repair where tissue allows, which is preferable in a young patient at risk of reinfection, or replacement after radical debridement. Post-operatively the antibiotic course is counted from surgery if valve cultures are positive, with dental review and a search for other emboli. I would not delay surgery four weeks because of a small ischaemic infarct. Follow-up includes echocardiography, addiction services and education about relapse and reinfection.

Ethics and communication: Drug use must not influence the decision to offer surgery, which rests on clinical criteria. I discuss honestly the higher risk of reinfection if injecting continues and offer support rather than judgement. Drug use is confidential health information shared only on a need-to-know basis. I refer him to addiction services with his consent, and any legal reporting follows UAE law and facility policy.

Reference: 2023 ESC Guidelines for the Management of Endocarditis

Knowledge: This is non-small cell lung cancer, provisionally T2a with possible N2 disease. PET-avid mediastinal nodes have a meaningful false-positive rate, so tissue confirmation by EBUS-TBNA, followed by mediastinoscopy if negative and suspicion remains, is required before treatment is decided. Molecular testing for EGFR, ALK and PD-L1 is now needed even in resectable disease because perioperative immunotherapy and adjuvant targeted therapy change outcomes. With FEV1 and DLCO below 80 percent, the ERS/ESTS algorithm calls for cardiopulmonary exercise testing. A peak oxygen uptake above 20 mL/kg/min indicates lobectomy is safe, while below 10 mL/kg/min indicates high risk.

Management: First I explain that operating next week without staging could mean the wrong treatment. Within two weeks he has EBUS-TBNA of the paratracheal and subcarinal stations, molecular profiling, brain MRI and cardiac risk assessment. I arrange cardiopulmonary exercise testing and smoking cessation support, and present him at the thoracic multidisciplinary meeting. If he is N0 or N1 and fit, I offer VATS or robotic lobectomy with systematic nodal dissection, with stereotactic radiotherapy if he proves unfit. If N2 is confirmed, he is considered for neoadjuvant chemo-immunotherapy and resection, or definitive chemoradiotherapy followed by durvalumab. Post-operatively I use enhanced recovery, early mobilisation and physiotherapy. Follow-up includes surveillance CT and adjuvant therapy decisions.

Ethics and communication: I respect his anxiety but explain that correct staging protects him from an operation that may not help. Prognosis is discussed truthfully at the pace he chooses, and family involvement follows his wishes. Surgery is not withheld because he still smokes, but I explain how stopping reduces complications. Costs of molecular tests and immunotherapy are discussed transparently with him and his insurer.

Reference: ERS/ESTS Clinical Guidelines on Fitness for Radical Therapy in Lung Cancer Patients, 2009; NICE Guideline NG122, Lung Cancer: Diagnosis and Management

Knowledge: Post-cardiotomy ECMO is a bridge to recovery, durable support or transplant, never a destination. The 2020 EACTS/ELSO/STS/AATS consensus emphasises defining the goal before and during support and recognising when no exit strategy exists. Here there is no recovery, no candidacy for transplant or a ventricular assist device, multiorgan failure and a large stroke, so continuing support prolongs dying while exposing him to bleeding, infection and limb complications. Futility is a clinical judgement made by the team, ideally with a second consultant opinion, not a unilateral decision. Many families in the region see withdrawal as hastening death, so the distinction between not escalating and withdrawing, and the applicable UAE rules, matter.

Management: First I confirm the picture through a multidisciplinary review with intensive care, cardiology, neurology and a second cardiac surgeon, documenting that there is no exit strategy. I then meet the family in a quiet room with an intensivist, a nurse and a professional interpreter if needed, offering religious support such as an imam or chaplain. I explain the facts simply, listen to their beliefs and do not present the decision as theirs to carry. I agree a plan that excludes escalation such as further surgery, ensures comfort and dignity, and sets a review point. Any decision on withdrawal or do-not-resuscitate orders follows UAE law and facility policy, which may require several physicians to agree and document. If agreement cannot be reached, I seek ethics committee review and offer a second opinion rather than acting unilaterally.

Ethics and communication: Respect for the family's faith is compatible with not offering treatments that cannot help. A consistent message and careful documentation protect patient, family and team. I would not mislead them about prognosis or apply pressure. Staff distress after prolonged futile support is acknowledged and debriefed.

Reference: 2020 EACTS/ELSO/STS/AATS Expert Consensus on Post-Cardiotomy Extracorporeal Life Support in Adult Patients

Knowledge: This is penetrating cardiac injury with tamponade, the right ventricle being most often injured by a parasternal wound. Tamponade may limit exsanguination at first but rapidly causes obstructive shock, and loss of pulse with organised electrical activity is traumatic cardiac arrest from a reversible cause. The EAST guideline strongly recommends emergency department thoracotomy for pulseless patients with penetrating thoracic injury who arrive with signs of life, the group with the best survival. Pericardiocentesis is at best temporising and must not delay surgery. Associated lung, internal mammary or great vessel injury and haemothorax should be anticipated.

Management: Before arrest, the right move is immediate transfer to theatre for sternotomy, with blood products through the massive transfusion protocol and permissive hypotension. Once he loses output, I perform a resuscitative left anterolateral thoracotomy in the department, extended into a clamshell if needed. I open the pericardium longitudinally anterior to the phrenic nerve, evacuate clot and control the wound with a finger. I close it with pledgeted sutures, using horizontal mattress sutures beneath any adjacent coronary artery. Internal cardiac massage and descending aortic cross-clamping are used if needed. Once output returns, he goes to theatre for formal repair, washout and assessment of other injuries. Afterwards echo checks for septal or valve injury, and I monitor for post-pericardiotomy syndrome and infection. I would not continue prolonged closed chest compressions instead of releasing the tamponade.

Ethics and communication: He cannot consent, so the emergency exception applies. Police will be involved because of the assault, so I preserve evidence and share information only through the facility's formal process. The family is updated honestly. Thoracotomy carries sharp injury risk to staff, so experienced operators, protective equipment and post-exposure follow-up are essential.

Reference: EAST Practice Management Guideline on Patient Selection for Emergency Department Thoracotomy, 2015; American College of Surgeons, Advanced Trauma Life Support (ATLS) Student Course Manual, 10th ed, 2018