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LS CV Oral Review > 101-200 > Flashcards

101-200 Flashcards

1
Q

Repair of descending aneurysm:

after proximal anastomosis, how should flow to the head and heart be re-instituted

A

Arterial flow is re-instituted either through the axillary or a perfusion cannula into the graft.

Flow should be restarted slowly at 500-700cc.hr

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2
Q

Descending aortic dissection

% of patients with visceral malperfusion ?

what is the most common mechanism of malperfusion ?

A

21% of patients have visceral malperfusion

80% of these cases are dynamic branch compromise

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3
Q

Dynamic branch compromise

A

Most common type of malperfusion following repair of Type B dissection (80% of cases)

Due to narrowing or compression with the majority of flow through the false lumen compressing the osteal opening

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4
Q

Static branch malperfusion

A

Dissection flap or intimal tear extends into the branch leading to obstruction of flow from intimal intussusception

Maybe augmented by the presence of a thrombus

This may be treated percutaneously

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5
Q

WHO Pulmonary Hypertension Classification

○ WHO Group I -

A

_○ WHO Group I - Pulmonary *arterial* hypertension (PAH)_

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6
Q

WHO Classification of pulmonary hypertension

○ WHO Group II -

A

○ WHO Group II - Pulmonary hypertension associated with left heart disease

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7
Q

WHO Pulmonary HTN Classification

○ WHO Group III -

A

○ WHO Group III - Pulmonary hypertension associated with lung diseases and/ or hypoxemia

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8
Q

WHO Classification of Pulmonary hypertension

○ WHO Group IV -

A

○ WHO Group IV - Pulmonary hypertension due to chronic thrombotic and/ or embolic disease

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9
Q

WHO Classification of pulmonary hypertension

○ WHO Group V

A

○ WHO Group V - Miscellaneous.

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10
Q

WHO Classification

Pulmonary arterial hypertension (PAH)

A

○ WHO Group I - Pulmonary arterial hypertension (PAH)

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11
Q

WHO Classification

Pulmonary hypertension associated with left heart disease

A

○ WHO Group II - Pulmonary hypertension associated with left heart disease

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12
Q

WHO Classification:

Pulmonary hypertension associated with lung diseases and/ or hypoxemia

A

○ WHO Group III - Pulmonary hypertension associated with lung diseases and/ or hypoxemia

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13
Q

WHO Classification

Pulmonary hypertension due to chronic thrombotic and/ or embolic disease

A

○ WHO Group IV - Pulmonary hypertension due to chronic thrombotic and/ or embolic disease

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14
Q

What is a non-restrictive VSD ?

A

Left and right ventricular pressures equalize

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15
Q

What are the major factors that impact the flow patterns across a VSD ?

A
  1. Chief factor: Pulmonary / Systemic resistance
  2. Size of the Defect
  3. Others
    • HCT (viscosity)
    • CO (velocity)
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16
Q

What determines the Qp/Qs in a non-restrictive VSD

A

Difference in the pulmonary - systemic vascular resistance

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17
Q

What determines the Qp/Qs in a restrictive VSD

A

(PVR + Gradient across the VSD) - SVR

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18
Q

How does VSD size impact the flow across it ?

A

As the size of the VSD –> 50% of the aortic annulus the flow becomes non-restrictive

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19
Q

General categories of VSD

A
  1. Inlet
  2. outlet
  3. Perimembranous
  4. Muscular t
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20
Q

A child with swiss cheese VSD

flow left to right

Qp/Qs > 2.1

approach ?

A
  1. Pulmonary banding
  2. most of the defects will close with time
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21
Q

Describe the conduction system with respect to a conal VSD

A

Conduction system is remote

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22
Q

Conduction system with respect to a d-looped perimembranous VSD

A

posterior and inferior to the defect

  • place sutures on the RV side only
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23
Q

Conduction system with respect to a perimembranous defect with l-looped ventricles

A

anterior and superior to the defect

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24
Q

Conduction system with respect to an inlet VSD

A

apex of the triangle of koch

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25
Q

Infective endocarditis

  • overall 6-month mortality
A

20-25%

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26
Q

Infective endocarditis

  • perioperative mortality
A

10%

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27
Q

Infective endocarditis

The rate of re-infection of a prosthesis?

A

2%

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28
Q

Native valve endocarditis

Class I Indications for Surgery

(ACC/AHA 2006/2014/2017; ESC 2009, 2015)

A

Class I

  1. Heart Failure
  2. Evidence of LV dysfunction or PA HTN
  3. Abscess, Fistula, Pseudo-Aneurysm
  4. Fungal or highly resistant bacterial IE
  5. Persistent bacteremia after 1 week Ab Rx

Mnemonic:

F HEAP (Fungus, heart failure, EF(low), Abscess), Persistent Bacteremia)

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29
Q

Native Valve Endocarditis

Class II Reccomendations

(ACC/AHA 2006/2014/2017; ESC 2009, 2015)

A

Class II Reccomendations

Recurrent emboli and persistent vegetation despite appropriate AB Rx (IIa)

Large ( > 10mm) mobile vegetation, particularly on AMVL (IIb)

Increase in vegetation size on AB Rx (IIb)

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30
Q

Prosthetic valve endocarditis

Class I Indications for surgery

A
  1. Heart Failure (IB)
  2. Severe prosthetic valve dysfunction (IB)
  3. Dehiscence, abscess, fistula, etc. (IB)
  4. Fungal or highly resistant bacterial PVE (IC)
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31
Q

Prosthetic valve endocarditis

Class II Endocarditis

A

CLASS II

  • Persistent bacteremia or recurrent emboli despite appropriate AB Rx (IIa, C)
  • Relapsing infection (IIa, C)
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32
Q

MRI findings for myocardial viability -

A

Lack of Viability of Myocardium

  • Late gadolinium enhancement (LGE) identifies the presence, location, distribution, and transmural extent of nonviable myocardium
  • > 25% transmural distribution of LGE on CMR is bad sign
  • Extracellular volume (T1 mapping)
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33
Q

Echocardiographic signs of irreversible myocardium -

A

Viability of Myocardium:

  1. Extensive thinning
  2. Extensive akinesia or dyskinesia
  3. No Contractile reserve on DSE

Suggestions of Longstanding Disease (hence irreversible)

  1. Severely dilated left ventricle (LVEDD > 70mm)
  2. LVEF < 25%
  3. Moderate or Severe Right ventricular dysfunction
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34
Q

Pivotal Trial for HVAD for Bridge to Transplant Indication

A

ADVANCE (2012)

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35
Q

Pivotal Trial for HVAD for Destination Therapy

A

ENDUANCE

(2017)

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36
Q

Pivotal Trial for HeartMate 3 for Short Term and Long Term Use

A

MOMENTUM 3

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37
Q

Indications for surgical embolectomy

A

Surgical embolectomy Failed thrombolytic therapy
Failed catheter embolectomy
Insufficient time for effective thrombolytic therapy in critical patients

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38
Q

The procedure of choice for:

Older patients (e.g., age >50 years) with aortic root aneurysm and normal aortic annulus

A

Remodeling

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39
Q

Mutation associated with Marfan’s Syndrome

A

Mutation of the FBN 1 Gene encoding for Fibrillin -1

10% will have a TGF-B receptor mutation

40
Q

Marfan’s Syndrome

Histology phenotype

A

Fragmentation of the elastic lamellae

Loss of smooth muscle cells

41
Q

Loeys-Dietz Syndrome

Mutation

A

TGF-B receptor 1 or II mutation

42
Q

Loeys-Dietz Syndrome

Phenotype

A
  1. Aggressive aortic disease
    • 98% develop aortic root aneurysm
    • High incidence of dissection
  2. arterial tortuosity
  3. Hypertelorism
  4. bifid uvula
  5. cleft palate
  6. Prominent facial features in kids correlate with pathology
43
Q

Ehlers-Danlos

mutation

A

COL3A1 Gene mutation

Encoding type III collagen

44
Q

Phenotype of Ehlers-Danlos Syndrome

A

Easy bruisability

Thin Skin

Facial features

Arterial, uterine, and intestinal rupture

45
Q

Fundamental mechanisms of the two major valve preserving surgeries for the aortic root

A

Remodeling - Yacoub

Reimplantation -David

46
Q

DISSECT mnemonic for aortic dissections

A

mnemonic “DISSECT”:

Duration,

Intimal tear (location),

Size (maximum diameter),

Segmental Extent (ascending, descending, etc.),

Complications,

Thrombosis of the false lumen

47
Q

T David II procedure

A

Same as the Yacoub I (remodeling)

Yacoub - remodeling

TDavid II and III are the same

III adds a strip betwen the mitral trigones

48
Q

Differences in the David Procedures

A

I : reimplantation (interupted around the base)

II - is a Yacoub Remodeling ( scalloped sinus)

III- is the same as a II but a synthetic strip between mitral trigones

IV: is the same as a 1, but the graft is 4mm larger and distal plication

V: same as a 1 but 6mm larger and proximal and distal plications

49
Q

Mutation for:

  1. Marfan’s
  2. Loeys-Dietz
  3. Ehler’s Danlos
A

Mutation for:

  1. Marfan’s : FBN 1
  2. Loeys-Dietz : TGF-B
  3. Ehler’s Danlos : Type IV Callogen
50
Q

AHA Class I guidelines for surgery on the ascending aorta

A

Isolated and asymptomatic - 5.5 cm

Marfan 5.0

Growth rate > 0.5cm/year

Conominant valve opration = 4.5 cm

Symptomatic

51
Q

Normal root diameter

male/female

A

Root (female) 3.50 to 3.72

Root (male) 3.63 to 3.91

52
Q

Normal ascending aorta diameter -

53
Q

The procedure of choice:

Younger patients with inherited aortic root aneurysms such as in Marfan syndrome, Loyes-Dietz syndrome, familial aneurysm, and incompetent bicuspid aortic valve frequently have associated annuloaortic ectasia

A

These patients should have reimplantation of the aortic valve to permanently stabilize the aortic annulus.

54
Q

Size indications for surgery on the aortic arch

55
Q

size guidelines for surveillance of aortic arch aneurysm

A
  • < 4cm: yearly
  • > 4cm: q6 months
56
Q

How does a persistent LSVC affect cardioprotection

A

Persistent LSVC:

Blood returns to the LA via the coronary sinus

  1. venous drainage issue
  2. blood enters the CS to the LA and is warmer, so may impact on the cooling of the heart.
  3. Difficult to administer retrograde cardioplegia
57
Q

After unclamping the aorta during a case with retrograde cardioplegia you notice the myocardium is slow to regain electrical activity.

A

Make sure the retrograde balloon is down

58
Q

Recommendations for aortic aneurysm intervention in Marfan’s Syndrome

A

Surgical repair when the aorta reaches 5.0 cm unless

there is a family history of AoD at 5.0 cm,

a rapidly expanding aneurysm or presence or

significant aortic valve regurgitation

59
Q

AHA recommendations for intervention for Loey’s Dietz syndrome

A

Surgical repair recommended at an

aortic diameter of 4.2 cm by TEE

(internal diameter) or 4.4 to 4.6 cm

by CT and/or MR (external diameter)

60
Q

AHA recs for an aneurysm repair with

bicuspid / marfans with concomitant valve disease

61
Q

where is the David IV plicated

A

at the ST Junction

62
Q

When pharmacologic maneuvers fail to rectify SAM- the fundamental issue is typically?

A
  1. the residual anterior and posterior leaflet heights
  2. the _septal-lateral diamete_r of the mitral annulus following ring annuloplasty
63
Q

Physical signs of AI

A

water hammer pulse

wide pulse pressure

low diastolic blood pressure

diastolic decreshendo murmur

64
Q

% of patients with an atherosclerotic ascending aneurysm that also have a AAA?

65
Q

Marfan’s Syndrome

Key phenotypic features

A
  1. Stature: tall, thin
  2. Lax joints
  3. Lentis ectopia
  4. High arched palate
66
Q

Loeys-Dietz syndrome

key phenotypic

A
  1. Blue sclerae
  2. Hypotelorism
  3. Bifid uvula
  4. Malar flattening
  5. Retrognathia
  6. Translucent skin
  7. Arachnodactaly
67
Q

David method

sizing dacron graft for aortic root reimplantation

A

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

Ideal STJ plus 4 to 6 mm

68
Q

El-Khoury technique for determining graft size for aortic root repair

A
  • Height of interleaflet triangle (between LCC and NCC)
69
Q

Gender/body sized approach to determining the size of the graft for an aortic root replacement

A
  • 28 mm women / 30 mm male
  • 30 mm woman / 32 mm male BAV
70
Q

sizing of the graft for a biobental

A

the tube graft is usually 3-5mm larger than the valve chosen

71
Q

how frequently should a root aneurysm be followed up postoperatively

A

CT scans should be performed at 1, 3, 6, 12 months then annually thereafter

72
Q
A

TOF

Tight RVOT

RV trabeculations - BIG RV

Overiding aorta

73
Q
A

TET Cxr - Boot shaped heart

74
Q

Indications for Palliative procedure for TET

A

< 6kg and symptomatic

< 4 months and symptomatic

Small pulmonary arteries

Need for RV-PA conduit

LAD from RCA

Multiple cardiac abnormalities

75
Q

Indication for primary repair of TET

A

> 4-6 Months of age

6-12 months after shunt

76
Q

Size of a BT shunt

A

shunt size =

1-2 x weight

3.5 - 4.0 mm most common

77
Q

On what side should a BT shunt be performed?

A

The side opposite the arch

so most commonly on the left

78
Q

What type of VSD does TOF have?

A

he ventricular septal defect (VSD) in tetralogy of Fallot (TOF) is a perimembranous defect with extension into the subpulmonary region.

79
Q

coronary concerns for TOF

A

LAD may arise from the RCA, thus coursing across or near the infundibulum

80
Q

RV/PA pressure ratio following TOF repair

A

RV/PA ratio > 0.7 correlates with worse outcome

81
Q

Steps to TOF Repair

A
  1. CPB w. moderate hypothermia
  2. Check RV for coronary anomalies which may be of issue
  3. Divide systemic to pulmonary shunts / PDA
  4. Transect RVO obstructing muscles
  5. Close the VSD with a PTFE patch
  6. Close ASD (unless concern for RV dysfunction)
  7. Probe pulmonary valve - annular enlargement if small
82
Q

TOF Repair

What to do if need for RVOT enlargement but coronary artery obstructing

A

RV to PA conduit

RV ventriculotomy below the coronary

83
Q

Operative survival and late survival of TOF

A

Operative: 95%

Late : 0%

84
Q

An adult patient with TET repair in infancy

Indications for pulmonic valve replacement

A
  1. PI
  2. RV enlargement
    • EDVI > 160
    • ESVI > 80
  3. Worsening TR
  4. Decreased exercise tolerance
  5. QRS > 180ms
85
Q

smooth part of the right atrium

A

Sinus venarum

86
Q

European Society of Cardiology/ACCF/AHA/World Heart Federation

Universal Definition of Myocardial Infarction

A
  1. new ST elevation at the J point in at least 2 contiguous leads of :
    1. In Men: 2 mm (0.2 mV) in men
    2. In Women: 1.5 mm (0.15 mV) in women in leads V2–V3 and/or of 1 mm (0.1mV) in other contiguous chest leads or the limb leads (7).
87
Q

In the setting of a STEMI when should reprofusing therapy be administered

A

Reperfusion therapy is reasonable for patients with STEMI and symptom onset within the prior 12 to 24 hours who have clinical and/or ECG evidence of ongoing ischemia. Primary PCI

is the preferred strategy in this population (81,94,95). (Level

of Evidence: B)

88
Q

P2Y12 therapy for adjunct with PCI for NSTEMI

A

A loading dose of a P2Y12 receptor inhibitor should be given as early as possible or at time of primary PCI to patients with STEMI.

a. Clopidogrel 600 mg
b. Prasugrel 60 mg
c. Ticagrelor 180 mg

89
Q

Ticagrelor

A

Brilinta

P2Y12

90
Q

Class II Antiarrhythmic Agents

A

Class II:

  • beta-blockade
  • Block sympathetic activity
  • reduce rate and conduction
91
Q

Class III Antiarrhythmic Rx

A

Class III:

potassium-channel blockade

Delay repolarization (phase 3) and thereby increase action potential duration and effective refractory period.

92
Q

Contraindication to AF ablation by PV isolation

A

Surgical ablation for symptomatic AF by pulmonary vein isolation alone is not recommended in the setting of:

left atrial enlargement (>4.5 cm)

or

more than moderate mitral regurgitation

93
Q

Cox-Maze III

A

Cut and sew

94
Q

Risk factors for pre-operative atrial fibrillation

A

hypertension

obesity

alcohol consumption

diabetes mellitus

structural heart

  • Mitral valve produces the most LA enlargement

Atrial fibrosis (ischemia)

95
Q

Indications for stand-alone Cox-Maze

A

The primary indication for ablation in stand-alone patients is the presence of symptomatic AF refractory to at least one class I or III antiarrhythmic drug. In

96
Q

For stand-alone surgical ablation, what is the rate of?

Mortality?

Morbidity?

Pacemaker?

A

Mortality: 0.74%

Morbidity: 16.43

Pacemaker: 1.03%

97
Q

What sutures should be used to repair an Apical VSD

A

1-0 Tevdek

LS CV Oral Review (6 decks)

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