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2025 CCTC Review Course > 10 Heart > Flashcards

10 Heart Flashcards

1
Q

Heart patients are classified according to how sick they are as determined by the following systems:

A
  • New York Heart Association (NYHA) Heart Failure Classification
  • System AHA/ACC stages
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2
Q

Per the NYHA, a Class I patient…

A

has cardiac disease but without limitations of physical activity

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3
Q

Per the NYHA, a Class II patient…

A

has slight limitations of physical activity that will resolve with rest

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4
Q

Per the NYHA, a Class III patient…

A

has marked limitations of physical activity but is usually comfortable at rest

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5
Q

Per the NYHA, a Class IV patient…

A

has an inability to carry on any physical activity without symptoms, even at rest

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6
Q

Per the AHA/ACC, a Stage A patient…

A

is at risk for Heart failure but has not developed structural heart changes

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7
Q

Per the AHA/ACC, a Stage B patient…

A

has structural heart disease without symptoms

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8
Q

Per the AHA/ACC, a Stage C patient…

A

has structural abnormalities with symptoms of heart failure

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9
Q

Per the AHA/ACC, a Stage D patient…

A

has end-stage, refractory heart failure

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10
Q

Indications for heart transplant include…

A
  • End stage heart disease unresponsive to conventional therapy
  • Ventricular arrhythmias despite medications or ablation
  • Re-transplantation or graft failure
  • Declining functional status – (NYHA Class 3 or 4, or CHF with poor prognosis < 2- year survival)
  • All other medical and surgical options exhausted
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11
Q

Common diagnoses that could lead to heart transplant include…

A
  • Cardiomyopathy
  • Valvular Heart Disease
  • Myocarditis
  • Cardiac Tumors
  • Congenital heart disease
  • Metabolic disorders
  • Toxins
  • Systemic Diseases
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12
Q

Absolute contraindications to heart transplant include…

A
  • Significant peripheral vascular disease
  • Cerebrovascular disease
  • Active infection (except for LVAD patients)
  • Irreversible pulmonary hypertension (4-6 wood units or TPG >12)
  • Significant primary lung disease
  • Recent pulmonary embolus (within 6 wks of transplant)
  • Irreversible end organ function or failure (renal/hepatic)
  • Recent cancer (within 5 years)
  • Life threatening illness- survival < 5 years
  • Severe neurologic injury or impairment
  • Active AIDS
  • Active alcohol, smoking or drugs
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13
Q

Heart failure generally begins with the…

A

left side, specifically the left ventricle

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14
Q

With left sided heart failure, the patient may experience the following symptoms:

A
  • Cough
  • crackles
  • wheezing
  • confusion
  • cyanosis
  • blood tinged sputum
  • shortness of breath
  • exertional dyspnea
  • orthopnea
  • tachycardia
  • elevated pulmonary capillary wedge pressure
  • paroxysmal nocturnal dyspnea
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15
Q

With right sided heart failure, the patient may experience the following symptoms:

A
  • Fatigue
  • Ascites
  • Anorexia/GI symptoms
  • swelling in hands/fingers
  • Edema
  • Increased peripheral venous pressure
  • Enlarged liver and spleen
  • Distended jugular veins
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16
Q

With right sided heart failure, patients can also develop…

A

pulmonary hypertension (PHTN)

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17
Q

Cardiac diagnostic tests include…

A
  • ECG
  • Right and left heart cath (check PVRi)
  • Echocardiogram (Low EF indicating poor function)
  • Cardiopulmonary Stress Test - Vo2 max < 14ml/kg/min (50% predicted, major limitation of activity)
  • Thallium stress test-nuclear imaging method that shows how well blood flows into the heart muscle, both at rest and during activity.
  • Pacemaker/defibrillator analysis (EF < 35%)
  • Holter monitor
  • Cardiac MRI
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18
Q

The normal range for cardiac output is…

A

4-8L/min

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19
Q

The normal range for cardiac index is…

A

2.5-4L/min/m2

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20
Q

The normal range for pulmonary artery pressure is…

A

12-16mmHg

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21
Q

Normal BNP is…

A

<100pg/ml

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22
Q

Normal NT-Pro BNP is…

A

<125 pg/ml

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23
Q

Normal Troponin is…

A

0-0.4

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24
Q

Per OPTN listing criteria, a Status 1 patient includes someone…

A
  • VA ECMO
  • Non-dischargeable, surgically implanted, non-endovascular biventricular support device
  • MCSD with life-threatening ventricular arrhythmia
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25
Q

Per OPTN listing criteria, a Status 2 patient includes someone…

A
  • Non-dischargeable, surgically implanted, non-endovascular LVAD
  • IABP
  • V-tach / V-fib, mechanical support not required
  • MCSD with device malfunction/mechanical failure
  • TAH, BiVAD, RVAD, or VAD for single ventricle patients
  • Percutaneous endovascular MCSD
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26
Q

Per OPTN listing criteria, a Status 3 patient includes someone…

A
  • Dischargeable LVAD for discretionary 30 days
  • Multiple inotropes or single high-dose inotrope with continuous hemodynamic monitoring
  • VA ECMO after 7 days; percutaneous endovascular circulatory support device or IABP after 14 days
  • Non-dischargeable, surgically implanted, non-endovascular LVAD after 14 days
  • MCSD with one of the following:
    • device infection
    • hemolysis
    • pump thrombosis
    • right heart failure
    • mucosal bleeding
    • aortic insufficiency
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27
Q

Per OPTN listing criteria, a Status 4 patient includes someone…

A
  • Dischargeable LVAD without discretionary 30 days
  • Inotropes without hemodynamic monitoring
  • Re-transplant
  • Diagnosis of one of the following:
    • congenital heart disease (CHD)
    • ischemic heart disease with intractable angina
    • hypertrophic cardiomyopathy
    • restrictive cardiomyopathy
    • amyloidosis
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28
Q

Per OPTN listing criteria, a Status 5 patient includes someone…

A

On the waitlist for at least one other organ at the same hospital

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29
Q

Per OPTN listing criteria, a Status 6 patient includes someone…

A

All remaining active candidates

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30
Q

An adolescent donor is defined as…

A

11 years of age or older, but less than 18 years of age

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31
Q

Per OPTN listing criteria for pediatric patients, a Status 1A is someone on a …

A
  • ventilator
  • mechanical assistance
  • ductal dependent pulmonary or systemic circulation maintained by stent or prostaglandins
  • CHD on inotropes in the hospital
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32
Q

Per OPTN listing criteria for pediatric patients, a Status 1B is someone on …

A
  • high dose inotropes
  • restrictive or hypertrophic cardiomyopathy < 1 yr at time of listing
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33
Q

Per OPTN listing criteria for pediatric patients, a Status 2 is someone on …

A

Active listing, not meeting above criteria

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34
Q

Per OPTN listing criteria for pediatric patients, a Status 7 is someone …

A

temporarily unsuitable for transplant

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35
Q

ABO incompatible blood products can be used in pediatric patients that are…

A

typically, but not exclusively, Infants less than 12months of age to up to 2nd birthday

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36
Q

The geographic area for allocation of hearts includes circles of …

A

nautical miles from donor hospital up to 2500 based on level of matching

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37
Q

While waiting of the list, patients may be medically managed to maintain optimal hemodynamics through the following:

A
  • Diuretics
  • ACE inhibitors/ARB
  • Beta-blockade
  • Hydral/Nitrates
  • Aldosterone blockers
  • Digoxin
  • Angiotensin Receptor Neprilysin Inhibitors (ARNI)
  • Inotropic support Anti-coagulation
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38
Q

An AICD (automatic implantable cardiovascular defibrillator) is used…

A

to prevent sudden cardiac death

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39
Q

Indications for an AICD include…

A
  • cardiac arrest
  • recurrent VT
  • prior MI with LVEF <35% WITH documented VT
  • prior MI with LVEF <30%
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40
Q

CRT (cardiac resynchronization therapy) is used to…

A

synchronize ventricular contractions

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41
Q

The indications for CRT include…

A
  • Moderate to severe HF: (NYHA class III or IV) EF < 35%
  • Wide QRS (duration > 120 ms)
  • Remains symptomatic despite stable, optimal heart failure drug therapy
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42
Q

An Intra Aortic Balloon Pump (IABP) increases…

A
  • myocardial oxygen perfusion while increasing cardiac output
  • oxygen supply increases/coronary blood flow increases
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43
Q

The first steps in choosing mechanical support for heart failure patient takes into consideration…

A
  • Size of patient
  • Anatomy of patient
  • Urgency
  • Goal of Support/Device
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44
Q

A VAD (ventricular assist device) is a…

A
  • mechanical blood pump used to support a failing ventricle
  • it is implanted and contained completely within the pericardial space
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45
Q

Bridge to Recovery is the use of a device to…

A

provide time for native heart function to return

46
Q

Bridge to Transplant is the use of a device to…

A

provide normal hemodynamics until a donor heart becomes available

47
Q

Bridge to Bridge/Candidacy is the use of a device until…

A

adequate assessment of the patient can be made

48
Q

Destination therapy is the use of a device to…

A

provide normal hemodynamics in a patient who is not a candidate for transplant

49
Q

The universal comorbidities associated with cardiac assist devices include…

A
  • Stroke
  • Bleeding
  • Infection
  • device malfunction
50
Q

ECMO (Extracorporeal Membrane Oxygenation) is support for patients whose…

A
  • heart and lungs are severely diseased or damaged
  • blood is oxygenated outside the body
  • very invasive
  • not long-term
51
Q

A device used in an infant/small child/small adult to maintain blood flow through a pump is called a…

A

Berlin Heart

52
Q

A native heart is removed except for the atria when using this type of cardiac assist device:

A

Total Artificial Heart (TAH)

53
Q

For a heart transplant, specific donor criteria includes…

A
  • Age < 70 years old
  • Size - height and weight
  • Blood group
  • EF > 50 (prefer > 60)
  • EKG – no Q waves (s/s of MI)
  • No pressors (epi, vasopressin)
  • No trauma to heart
54
Q

For a heart transplant, specific donor exclusion criteria includes…

A
  • Cardiac abnormalities (lab, EKG, echo, and usually left heart catheterization if >40 years old)
  • Increased pressor support
  • Chest trauma (cardiac contusion)
  • Increased risk patient (drugs, multiple sexual partners, prison) – although can accept a high-risk donor if center is willing and recipient consents
  • Pre-existing disease (HIV, hepatitis)
  • Cancer
55
Q

If a patient presents for heart transplant, with IV inotropes when they arrive to ICU…

A

continue until surgery. They will be removed in OR.

56
Q

The most common surgical technique used with heart transplantation is…

A

Bi-Caval technique

57
Q

The 5 anastomoses for Bi-Caval surgery include…

A
  • 2 venous (SVC and IVC)
  • Aorta
  • Pulmonary Artery
  • Left arterial cuff (pulm veins)
58
Q

The advantages of Bi-Caval technique includes…

A
  • less dysrhythmias
  • tricuspid valve more competent
59
Q

The disadvantages of Bi-Caval technique includes…

A
  • increased ischemic time
  • caval stenosis
60
Q

The surgical technique that sews the donor and recipient’s atrial cuffs together is called…

A

Bi-Atrial technique

61
Q

With a Bi-Atrial technique the EKG findings might show…

62
Q

The preferred ischemic time for heart transplantation is…

A

less than 5 hours

63
Q

Atropine will not work for bradycardia after heart transplant due to…

A

denervation during transplant

64
Q

Denervation means…

A

no autonomic nervous system control

65
Q

The leading cause of early post heart transplant morbidity is due to…

A

Right Ventricle Dysfunction

66
Q

Signs and symptoms of right ventricle dysfunction include…

A
  • Hypotension
  • Tachycardia
  • Elevated CVP
  • Decreased CO
67
Q

Interventions for right ventricle dysfunction include…

A
  • Optimize preload, decrease RV afterload and PVR
  • Inhaled Nitric Oxide, sildenafil
  • Decease PA pressure
  • IV medications such as nitro, nipride, dobutamine, milrinone, nitric oxide
  • Mechanical support LVAD, IABP
  • With proper interventions, CVP should decrease, CO increase, PVR decrease, hypotension resolved
68
Q

Left ventricular failure can be caused by…

A
  • Ischemic injury
  • Reperfusion Injury
  • Damage to graft
  • Poor reserve
69
Q

Signs and symptoms of left ventricular failure include…

A
  • Decreased in CO, CI, SV
  • Decreased EF ≤ to 30% or < 25% less than baseline
  • Decreased tissue perfusion
  • Increased creatinine and LFT’s
  • HF symptoms
70
Q

Interventions for left ventricular failure include…

A
  • Agents to increase CO and SVR
  • Milrinone, epi, norepi, dobutamine
  • Pacing - atrial
  • Prepare for: IABP ECMO LVAD
71
Q

The most common telemetry rhythm after heart transplant is…

A

Junctional rhythm

72
Q

Many patients come out of surgery with a temporary pacemaker. An ideal HR immediate post surgery is…

73
Q

Bleeding can be caused by…

A
  • Liver dysfunction
  • Hypothermia
  • Heparin product
  • Bypass – destruction of cells
  • Trauma
74
Q

Signs and symptoms of bleeding after heart transplant include…

A
  • Increased chest tube drainage
  • Decreased Hgb and Hct
  • Increased heart rate and O2 need
  • Decreased Cardiac Output/Cardiac Index
  • SVO2 <65
  • Hypotension
75
Q

Interventions for bleeding can include…

A
  • Administration of blood
  • Protamine (reverse effects of heparin)
  • Return to the OR
76
Q

Cardiac tamponade is caused by…

A
  • Blood accumulating in the pericardium resulting in slow or rapid compression of the heart.
  • Chest trauma, surgery, aortic dissection
77
Q

Signs and symptoms of cardiac tamponade include…

A
  • Increased SOB, anxiety
  • Arm/chest pain
  • Decreased CT drainage
  • Increased CVP, wedge pressure
  • Decreased CO/CI,
  • decreased urine
  • Hypotension, narrow pulse pressure
  • Distant heart sounds
78
Q

Infections seen early post transplant can include:

A
  • Pneumonia – gram negative
  • Wounds – gram negative and staph
  • Skin –HSV
  • Foley catheter – UTI’s
  • Line care/discontinue lines & catheters ASAP
79
Q

Infections that can present early or late in heart transplant recipients include…

A
  • Bacterial
  • Viral
  • Fungal
  • Parasitic
80
Q

Bacterial infections common to heart transplant recipients include…

A
  • Staph
  • C. Diff
  • Salmonella
  • Pseudomonas
  • Listeria
  • Legionella
  • mycobacterium
81
Q

Viral infections common to heart transplant recipients include…

A
  • influenza
  • herpes
  • EBV
  • Varicella
  • CMV
82
Q

Fungal infections common to heart transplant recipients include…

A
  • candida
  • aspergillus
  • PCP
  • histoplasma
83
Q

Parasitic infections common to heart transplant recipient include…

A
  • toxoplasma
  • cryptosporidium
84
Q

Prophylaxis prevention for viral infections may include…

A
  • ganciclovir IV or oral valganciclovir
85
Q

Prophylaxis prevention for bacterial infections may include…

86
Q

Prophylaxis prevention for fungal infections may include…

A

Fluconazole/Nystatin

87
Q

The type of antibody mediated rejection that occurs immediately post heart transplant is…

A

Hyperacute

88
Q

The main cause of hyperacute rejection post heart transplant is due to..

A

Cytotoxic antibodies from recipient

89
Q

The risk factors for hyperacute rejection post heart transplant include…

A
  • Blood group mismatch
  • Pre-existing antibody to donor cells
  • Pre-sensitization (high PRA’s) (not looking at specificities)
90
Q

Signs and symptoms of hyperacute rejection include…

A
  • Similar to cardiogenic shock:
    • Decreased BP
    • Decreased CO/CI
    • Increased CVP, wedge, SVR
    • Pulmonary congestion
    • Peripheral edema
    • S3/S4 heard
91
Q

Interventions for hyperacute rejection include…

A
  • Mechanical circulatory support (ECMO/LVAD)
  • Relist
92
Q

Rejection is common and is treatable if…

A

caught early

93
Q

Acute cellular rejection can be associated with..

A

severe hemodynamic compromise

94
Q

Acute cellular rejection post heart transplant can be caused by…

A
  • the infiltrates of T lymphocytes and macrophages in heart
    • Severe cases cause cell accumulation and necrosis
    • Medication used to prevent T cell response on target (organ)
    • Suppress cytotoxin production through steroids and calcineurin inhibitors
    • Prevent expansion of lymphocytes (cellcept and azathioprine)
95
Q

Signs and symptoms of acute cellular rejection post heart transplant include…

A
  • Flu like symptoms (fever, malaise, fatigue, nausea, vomiting, diarrhea)
  • JVD
  • Edema, increased weight
  • SOB, crackles/wheezes
  • Third heart sound, pericardial effusion
96
Q

The most common approach for an endomyocardial biopsy is via the…

A

internal jugular vein

97
Q

Treatment for Cellular Rejection: Grade 0R & 1R includes…

A
  • No treatment, adjust medication to therapeutic levels and re-biopsy according to schedule and/or patient condition
98
Q

Treatment for Cellular Rejection: Grade 2R includes…

A
  • IV or oral steroids
  • Hospitalization based on patient condition
99
Q

Treatment for Cellular Rejection: Grade 3R includes…

A
  • IV steroids
  • Possible use of Cytotoxic Agents (Thymoglobulin)
  • Plasmapheresis (DSA involvement)
  • Mechanical support as indicated
100
Q

According to the ISHLT 2004 biopsy grading scale, grade 0 will indicate…

A

No acute cellular rejection

101
Q

According to the ISHLT 2004 biopsy grading scale, grade 1R will indicate…

A

Mild, low grade acute cellular rejection. Interstitial and/or perivascular infiltrate w/up to one focus of myocyte damage

102
Q

According to the ISHLT 2004 biopsy grading scale, grade 2R will indicate…

A

Moderate, intermediate grade acute cellular rejection – two or more foci of infiltrate w/associated myocyte damage

103
Q

According to the ISHLT 2004 biopsy grading scale, grade 3R will indicate…

A

Severe, high grade, acute cellular rejection – diffuse infiltrate with multifocal myocyte damage ± edema, ± hemorrhage, ± vasculitis

104
Q

Antibody-mediated rejection is caused by…

A

B cell antibodies that cause vascular inflammation and damage

105
Q

Ongoing treatment for AMR may take…

A
  • weeks to months
  • require ongoing ECHO and DSA surveillance
  • include assessment for CAV
106
Q

Treatment for AMR may include…

A
  • Pheresis
  • Rituximab
  • IVIG
  • Thymoglobulin
  • Cytoxan
  • Bortezomib
  • Eculizumab
107
Q

Chronic rejection manifests as…

A

Coronary Artery Vasculopathy: CAV

108
Q

Signs and Symptoms of CAV include…

A
  • Angina/Chest pain RARE due to denervated allograft
  • Increased fatigue
  • Dyspnea on exertion or at rest
  • Increased LV filling pressures
109
Q

Diagnosis of Chronic Rejection includes…

A
  • Noninvasive testing is not always reliable:
    • Nuclear stress test
    • Exercise EKG
  • Left heart catheterization
  • IVUS (intravascular ultrasound)
    • assess the diameter
    • Wall morphology
    • Quantifies stenosis
110
Q

Treatment for chronic rejection may include…

A
  • Percutaneous transluminal coronary angioplasty (PTCA) or bypass may be limited due to nature of the disease (post stenting there is 50-60% restenosis)
  • Progression may be slowed by adjusting immunosuppression (adding sirolimus), treating DM and hypertension
  • Only real treatment is re-transplant
111
Q

Long-term complications common to heart transplant include…

A
  • Diabetes
  • Hypertension
  • Hyperlipidemia
  • Kidney Disease
  • GI problems
  • Osteoporosis
  • Infection
  • Neoplasms – skin cancers, lymphomas

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