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1-100 Flashcards

1
Q

what makes an aortic dissection “Complicated”

A

Complicated dissection is those with:

  • persistent pain
  • thoracoabdominal mal perfusion
  • impending rupture
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2
Q

sizing of the graft for a valve-sparing root

  1. Estimated annulus
  2. Dacron graft size
A

Aortic annulus ~ 2/3 cusps height x 2
Dacron graft ~ 2/3 cusps height x 2 + LVOT thickness

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3
Q

DeBakey type 1 aneurysm

A

Ascending and descending aorta

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4
Q

Signs of mitral stenosis

A
  1. Low volume pulse pressure
  2. Irregular pulse
  3. Tapping non-displaced apex beat
  4. Loud S1 heart sound
  5. Opening snap Mid diastolic rumbling heart loudest at the apex
  6. Pulmonary HTN
    1. Mitral facies : Rosy cheeks while the rest of the face is cyanotic
    2. Central cyanosis
    3. Loud P2 heart sound
    4. TR – pan systolic murmur at right sternal edge
    5. Pulmonary Regurgitation: Grahm Steel early systolic murmur on inspiration
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5
Q

Social history questions for aortic dissection

physical exam

A

Query the use of amphetamines or coccaine

Physical:

Skeletal to diagnose CT disease

Vascular exam should be documented

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6
Q

Medical treatment of a type B dissection

A

a. Beta - blocker ( esmolol or labetolol)
b. vasodilator (nipride)

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7
Q

what territory does ECG lead I represent

A

anterolateral

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8
Q

Severe mitral regurgitation in an asymptomatic patient direction

of treatment

A
  1. if LVEF > 60, LVESD < 40 and liklihood of repair > 95% with expected mortality < 1% –> Repair
  2. if new onset afib or PASP > 50 and liklihood of repair > 95% and expected mortality < 1% –> Repair
  3. if LVEF 30-60% or LVESD > 40 –>“mitral surgery”

Per Boling:

LVEF < 60%, PAP > 50, LVESD > 40, AF

If > 95% repair, <1%, mortality

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9
Q

MVA for Moderate MS

A

MS (mitral valve area 1.6 cm2 to 2.0 cm2)

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10
Q

the direction of the jet with a restricted leaflet

A

jet will be toward the restricted leaflet

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11
Q

Ghent criteria

Minor Skeletal Criteria

A
  1. Pectus excavatum of moderate severity
  2. Joint hypermobility
  3. Highly arched palate with crowding of teeth
  4. Facial appearance:
    • dolichocephaly
    • malar hypoplasia
    • enophthalmos
    • retrognathia
    • down-slating palpebral fissures
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12
Q

Low Risk Pulmonary Embolism

A

Embolism without the presence of :

  1. shock
  2. hypotension
  3. RV dysfunction
  4. Myocardial injury
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13
Q

Diagnostic criteria for STEMI

A

Angina sx for > 20 min

with

ST elevation > 1mm in 2 contigous leads

or

LBBB

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14
Q

Method of selecting a tricuspid ring size

A
  1. Using a sizer:

septal leaflet and the surface area of leaflet tissue from the anterior pap muscle

  1. Approximately

30-32 for a female

32-34 for a male

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15
Q

Reccomendation

Mitral stenosis patient

symptomatic

MVA < 1.5cm2

Wilkins < 8

No LA thrombus

No MR

A

Class 1: PMBC

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16
Q

Anteroseptal ECG leads

A

V1 and V2

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17
Q

IIb/IIIa inhibitors

when should they be discontinued

A
  1. Eptifibatide (integrillin) - IIb/IIIa Inhibitor - 2-4 hr
  2. Tirofiban ( Aggrastat) - IIb/IIIa inhibitor -2 -4 hours
  3. Abciximab (Repro) - IIb/IIIa inhibitor -12 hours

EAT !

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18
Q

Crawford Type IV aneurysm

A

Extends from the diaphragm to below the renal arteries

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19
Q

what territory does V6 represent?

A

anterolateral

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20
Q

Ghent Criteria

Pulmonary minor criteria

A

Spontaneous PTx

Apical Blebs

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21
Q

Type B aortic dissection -

Medical vs Surgical management

what is the rate of surgical reintervention

A

Equivalent

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22
Q

Fondaparinux trade name

A

Arixtra

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23
Q

Ghent criteria

minor skin criteria

A
  1. Strech marks not associated with weight changes
  2. Recurrent incisional hernia
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24
Q

Ghent Criteria:

Major family history Criteria

A
  1. Having a first-degree relative (parent, child, or sibling) who meets these diagnostic criteria independently
  2. Presence of a mutation in FBN1 known to cause the Marfan syndrome
  3. Presence of a haplotype around FBN1, inherited by descent, known to be associated with unequivocally diagnosed Marfan syndrome in the family
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25
Q

Posterior medial papillary muscle

blood supply

A

PM pap muscle is more vulnerable because of its single blood supply:

RCA for right dominant

cx for left dominant

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26
Q

DeBakey IIIa aneurysm

A

Confined to the thoracic descending aorta alone

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27
Q

“theme” of fibroelastic defficiency mitral repair

A

No resection or limited resection

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28
Q

which ECG lead is the ground?

A

Right Leg

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29
Q

Ghent Criteria

Minor CV Criteria

A
  1. Mitral valve prolapse with or without mitral valve regurgitation
  2. Dilatation of the main pulmonary artery, in the absence of valvular or peripheral pulmonic stenosis or any other obvious cause in patients age < 40 years
  3. Calcification of the mitral annulus in patients age < 40 years
  4. Dilatation of dissection of the descending thoracic or abdominal aorta in patients age < 50 years
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30
Q

“theme” to Barlow’s repair

A

Barlow’s - remove tissue

Tissue dissection and leaflet displacement

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31
Q

General criteria for Marfan’s Diagnosis by Ghent

A

Positive family history

  • at least 2 systems (skeletal, cardiovascular, ocular)
  • and the presence of at least 1 major criterion (eg, ascending aortic aneurysm, ectopia lentis)

negative family history / unknown__,

major criteria in 2 systems and have involvement of at least 1 other system (skeletal, cardiovascular, ocular).

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32
Q

Ghent Criteria

Major Skeletal Diagnostic Criteria

A

Presence of at least 4 :

  1. Pectus carinatum
  2. Pectus excavatum requiring surgery
  3. Reduced upper-to-lower segment ratio or arm span-to-height ratio greater than 1.05
  4. Wrist and thumb signs
  5. Scoliosis > 20 degrees or spondylolisthesis
  6. reduced extensions at the elbows (< 170 degrees) Medial displacement of the medial malleolus causing pes planus
  7. Protrusio acetabulare of any degree (ascertained on radiographs) (femoral head is medial to the ileoischeal line)
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33
Q

The goal of a medical therapy for a type B dissection

A

Reduction of the Systolic bp

Reduction of the mean bp

Reduction of the dp/pt

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34
Q

how long should a BMS be on plavix

A

30 days

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35
Q

What is the Crawford Extent:

Descending aorta from near the left subclavian to the abdominal vessels but not the renal arteries

A

Type I

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36
Q

Anterio apical ECG leads

A

V3 - V4

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37
Q

In repairing a descending aneurysm

what should be done with intercostal arteries above T7?

Why?

A

Oversew

Eliminate steal of blood from the spinal cord

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38
Q

ECG of PE

Lead 3 findings

A
  1. q-wave
  2. inverted t-wave
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39
Q

Factors which make a patient more susceptible to recurrent MR

A
  1. larger MV annular diameter (>3.7cm)
  2. High tethering area
  3. greater MR severity (3.5+)
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40
Q

anterolateral ECG leads

A

V5-V6, I, avL

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41
Q

duration of symptoms for STEMI

A

20 minutes

42
Q

Evaluation of IMR

  • features to note on the evaluation of the angiogram
A
  1. look for an occluded vessel with an inferior wall motion abnormality
  2. Clarify right vs left dominance
  3. Viability may be of help
43
Q

The phenotype of fMR with normal mitral leaflets

A
  1. Pronounced global LV dilation

(typically have < 30% EF)

2.Ischemic MR - frm caused by asymmetric LV remodeling

disruption of the subvalvular apparatus (of the posterior medial papillary muscle leading to leaflet tethering)

44
Q

what territory does ECG lead V4 represent?

A

anteroapical

45
Q

what territory does ECG lead V3 represent

A

anteropical

46
Q

Wilkins Score

A

Wilkins Score:

  1. Components:
    1. Leaflet mobility
    2. Thickenening
    3. leaflet calcification
    4. subvalvular thickening
  2. Each scores between 0-4 - (score between 0-16)
    1. > 9 – unlikely to be amenable to PMBV
47
Q

Crawford type II aneurysm

A

Descending aneurysm that

Begins: near the subclavian

Extends: below the renal arteries

48
Q

how long should a DES be on plavix

49
Q

Diastolic pressure half time for mitral stenosis

A

> 150ms (severe)

> 220 ms (very severe)

50
Q

The primary goals of repairing a type B dissection

A

To replace only a short segment of aorta

To redirect flow into the true lumen

To stay above T7 and avoid reimplant of intercostal arteries

51
Q

what territory does ECG lead III represent

52
Q

what territory does ECG lead aVL represent

A

anterolateral

53
Q

Defect associated with Ehlers-Danlos syndrome

A

Defective type III Callogen

the hallmark of this disease is Aortic Dissection, not an aneurysm

54
Q

What leads suggest right ischemia

A

II, III, aVF

+/-

reciprical changein V1 V2

55
Q

DeBakey Type 2 aneurysm

A

Ascending alone

56
Q

Intermediate risk pulmonary embolism

A

Embolus in the RV +/- evidence of myocardial injury shock or hypotension

57
Q

DeBakey IIIb aneurysm

A

Thoracic aorta

and

abdominal aorta

58
Q

Rx for low risk PE

A

LMWH or Fondaparinux

59
Q

Fondaparinux dosing

A

weight based

50-100Kg –> 7.5,

>100kg: 10mg

give sc x 5-9 days –> overlap with coumadin

Dc with INR 2-3

hold if plt < 100,000

60
Q

Rx for intermediate risk pe

A

Heparin / Fondaparinux and long-term A/C

61
Q

ECG leads indicative of inferior wall damage

A

II, III, aVf

62
Q

what territory does V5 represent

A

anterolateral

63
Q

Class IIa reccomendations for percutaneous balloon mitral commisurotomy

A

Class IIa

  1. asymptomatic patients
  2. very severe MS (mitral valve area ≤1.0 cm2, stage C)
  3. favorable valve morphology
  4. the absence of left atrial thrombus or moderate-to-severe MR
64
Q

Mitral Regurgitation

Recommendation directly for repair

A

IIa:

  • Severe MR on echo
  • Asymptomatic with either:
  • LVEF >60% and LVESD < 40mm
  • or
  • new AF or PASP > 50 mmHg
  • with the likelihood of:
  • successful repair > 95%
  • and
  • expected mortality < 1%
65
Q

what territory does lead aVf represent

66
Q

ECG of PE

lead 1 findings

67
Q

ECG changes indicative of posterior wall infarct

A

reciprocal changes in V1 and V2

68
Q

what separates a chronic and acute dissection

69
Q

Ghent Criteria

major ocular criteria

A

Ectopia lentis

70
Q

Type B Dissection

30 day mortality for

Medical vs Surgical management

A

Type B 30 day mortality:

Medical management: 9- 16%

Surgical managment: 27-32%

71
Q

Anticoagulation reccomended for mitral stenosis

A

Class I Evidence:

1) MS and AF (paroxysmal, persistent, or permanent)
2) MS and a prior embolic event
3) MS and a left atrial thrombus

72
Q

gastrointestinal bleeding from angiodysplasia in the presence of aortic stenosis.

A

Heyde’s syndrome is a syndrome of gastrointestinal bleeding from angiodysplasia in the presence of aortic stenosis.

73
Q

what territory does ECG lead II represent

74
Q

Crawford Type III aneurysm

A

Begins at T6, and extends to the abdominal aorta

75
Q

what are the class 1 recomendations to perform MVR for MS as concominant surgery

A

Concominant mitral valve surgery with severe MS (MVA < 1.5cm2) and underoing surgery for other indications.

76
Q

Ghent Criteria

Minor Occular Criteria

A

Abnormally flat cornea (as measured by keratometry) Increased axial length of globe (as measured by ultrasound)

77
Q

Ghent Criteria for Marfan’s

Major cardiovascular criteria

A

Dilatation of the ascending aorta with or without aortic regurgitation and involving at least the sinuses of Valsalva or dissection of the ascending aorta

78
Q

Ghent Criteria for Marfan’s Major

Dural Criteria

A

Lumbarsacral dural ectasia as demonstrated by CT or MRI

79
Q

Diagnosis with nSTEMI

A

Chest pain at least 10 minutes

elevated biomarkers

or

ST of 0.5 or 1mm

or

ST depression > 0.5

or

TWI greater than 1mm

80
Q

Crawford Extent

Begins near the origin of the left subclavian

Extends to below the renal arteries

81
Q

MVA for severe Mitral stenosis

A

< 1.5 cm2 (severe)

<1.0cm2 (very severe)

82
Q

Ghent Criteria

what systems have major criteria

A
  1. Genetics
  2. Skeletal
  3. Occular
  4. CV
  5. Dura
83
Q

DeBakey Type III aneurysm

A

Descending alone

84
Q

Imaging studies pre CPB

A
  1. if the history of a stroke: head CT
  2. Carotid duplex: if a stroke or bruit or LM
  3. ABI
  4. PFT
  5. Chest CT for any patient with calcification on CT
85
Q

what territory does V2 represent

A

Either:

Antero septal

or

reciprocal changes represent posterior

86
Q

pH Stat or alpha-stat for DHCA

A

dependent upon the age of the patient:

pH-stat in the paediatric (P in the P)

alpha-stat in the adult patient. (a for the a)

87
Q

Class 1 Reccomendations for Percutaneous mitral balloon commissurotomy

A

Class 1 Recommendation:

  1. symptomatic
  2. severe MS (mitral valve area ≤1.5 cm2, stage D)
  3. favorable valve morphology
  4. the absence of left atrial thrombus
  5. absence moderate-to-severe MRs )
88
Q

Class IIb Reccomendations for percutaneous balloon mitral commisurotomy

A

Class IIb

  1. asymptomatic patients
    1. severe MS (mitral valve area ≤1.5 cm2, stage C)
    2. favorable valve morphology
    3. absence of left atrial thrombus or moderate-to-severe MR
  2. asymptomatic patients
    1. who have new onset of AF.
  3. Symptomatic
    1. mitral valve area greater than 1.5 cm2
    2. evidence of hemodynamically significant MS
      1. pulmonary artery wedge pressure greater than 25 mm Hg or
      2. mean mitral valve gradient greater than 15 mm Hg during exercise
  4. Severely symptomatic (NYHA class III to IV)
    1. severe MS (mitral valve area ≤1.5 cm2, stage D)
    2. have a suboptimal valve anatomy and who are not candidates for surgery or at high risk for surgery.
89
Q

Pre CPB Review of systems (6)

A
  1. Stroke
  2. Renal disease
  3. Respiratory problems
  4. Bleeding Disorders
  5. Peripheral vascular Disease
  6. Intestinal angina
90
Q

5-year survival after repair of:

  1. Ascending
  2. Arch
  3. Descending
  4. Thoracoabdominal
  5. Marfans
A

5-year survival after repair of:

  1. Ascending: 70%
  2. Arch: 80%
  3. Descending: 60%
  4. Thoracoabdominal: 60%
  5. Marfans: 85%
91
Q

Reccomendation for

Mitral Stenosis patient

severely symptomatic (NYHA III to IV)

MVA < 1.5cm2

prior failed PMBC

A

Class 1 Recomendations are to perform surgery

92
Q

DeBakey classifications including the ascending aorta

A

Type I and Type II

93
Q

Labs to order pre CPB

A
  1. CBC
  2. BMP
  3. Coags
  4. LFT’s
94
Q

EKG of Pulmonary Embolism

95
Q

Type B Aortic Dissection:

Factors which would advocate for endovascular treatment

A

Endovascular -

  • Older
  • Poor operative risk
    1. Renal failure
    2. COPD
    3. Poor cardiac function
    4. Acidotic from mal perfusion
  • Favorable anatomy
96
Q

what territory does V1 represent

A

Either:

Antero septal

or

reciprocal changes represent posterior

97
Q

MOA of Fondaparinux

A

chemically related to LMW heparin

98
Q

Crawford extent I aneurysm

A

Descending aorta from near the left subclavian to the abdominal vessels but the renal arteries are excluded.

99
Q

Crawford Extent

Does Type III include the renal arteries

A

Type III :

From T6 to below the renal arteries.

100
Q

how do differentiate on physical exam an acute VSD from an MR

A

MR is best heard at the apex

VSD a the left sternal border and has a thrill

101
Q

Ghent Score consistent with Marfans

LS CV Oral Review (6 decks)

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