201-300 Flashcards
Surgical treatment of aneurysm of the ascending aorta with aortic insufficiency and marked displacement of the coronary ostia with a saphenous vein graft.
Zubiate- Kay procedure
JTCVS 1976
Tachy-brady syndrome
PAT/flutter/ fibrillation followed by symptomatic pauses
Carotid sinus syndrome
Hyperactive carotid sinus reflex
a. carotid sinus stimulation - cardiac asystole > 3 seconds
b. carotid sinus syndrome - hyperactive reflex _ production of symptoms with carotid sinus stimulation
Treatment of Carotid sinus syndrome
Pacemaker therapy - for patients with a cardioinhibitory response (syncope)
PPM may not resolve the vasodepressor response
Electrode testing
Pacing threshold (atrial / ventricle)
Sensing threshold (atria / ventricle)
pacing threshold = lowest voltage to produced depolarization
- Atrial - 1.0V or less
- Ventricular - 0.3V or less
Sensing threshold - Ability to identify depolarization
- Atrial p wave - 2mv or more
- Ventricular QRS: 5 mv or more
CHADS2 score
C - Congestive heart failure (1)
H - Hypertension (1)
A - Age 65-74 (1), >75 (2)
D - Diabetes - 1
S - Prior Stroke or TIA (2)
V - Vascular (1)
S - sex (female -1)
Max sore 9
Atrial fibrillation - criteria for:
Isolated vs recurrent vs paroxysmal vs persistent vs permanent
- Isolated - a single episode
- recurrent > 2 episodes
- Paroxysmal - lasts < 7 days and reverts spontaneously
- persistent - does not terminate spontenously - requires Rx or DC cardioversion
- Permanent - does not revert
Common causes of atrial fibrillation
- idiopathic
- Mitral valve and subsequent LA dilation
- Ischemic heart disease
- HTN
- Post-cardiac surgery
- Alcohol
- Thyrotoxicosis
what are the AHA guidelines for afib and anticoagulation
All patients with recurrent afib
Paroxysmal
Persistent
Permanent
INR Goal for afib with a mechanical valve
2.5-3.5
In considering INR, what are high risk factors for thromboembolism
- Stroke
- TIA
- Systemic embolism
- Rheumatic heart disease
For what a fib patients should the INR goal be between 2.0 and 3.0
Afib + either
1 high-risk factor
> 1 Moderate risk factor
What are the risk factors for atrial fibrillation following cardiac surgery
- Age
- beta-blocker withdraw
- Electrolyte imbalance
- Hypoxia
- Ischemia
- Pericardial effusion
- infection
In general, in what patients is a Maze procedure less successful
Atria > 5 cm
Afib > 5 years
Ligament of Marshall
The ligament of Marshall (LOM)
located on the epicardium between the left atrial appendage and the left pulmonary veins.
The corresponding endocardial structure is the left lateral ridge.
LOM is a source of paroxysmal AF, and may activate at fast rates during persistent AF.
Heart Rate identification of atrial fibrillation
Typically a variable block
2:1, 3:1, 4:1
Atrial rate of 300 bpm, with a V response of 150, 100, 75
Class I Antiarrhythmic
Class I:
1a: Quinidine, procainamide disopyramide
1b: Lidocaine, phenytoin
1c: Flecainide, propafenone
Class IV Antiarrhythmic
Slow calcium channel
Verapamil, diltiasem, adenosine
Coronary artery concerns with surgical ablation
Left dominant patients are at increased risk of injury when ablating close to the coronary sinus
Tetralogy of Fallot
key elements to ask about the ECHO
- what is the status of the RVOT + Pulmonary valve
- Pulm atresia/stenosis
- are the PA’s confluent or MAPCA
causes of shock in a patient s/p bullectomy
and how to work up
Tension ptx
- check ct not clamped
- intubate
- large bore IV
MI
PE
septic shock
Initial treatment of massive PE
70 u/kg bolus
heparin infusion 20u/kg/hr
Goal PTT 50-70
Options if a patient with massive PE if they do not stabilize after starting anticoagulation
- Thrombolytics
- Percutaneous mechanical removal
- Pulmonary thrombectomy
- VA ECMO
Survival of PE patients in shock vs not shock
Mortality
Shock: 52%
Not schock: 15%
Indications for surgical embolectomy
- Hemodynamic collapse with unlikely patient survival
- unequivocal PE in the main or lobar PA resulting in significant impairment of gas exchange
- unstable patient with absolute contraindication for thrombolytic or anticoagulation
- risk of potential pulmonary embolism by large RA or RV clot
Prognosis of post MI VSD
Poor
- 25% in 24 hours
- 50% in one week
- 80% in one month
- 97% in one year
preoperative management of post MI VSD
Reduce afterload to reduce left to right shunt
Maintain adequate output with inotropes and or IABP
Most common levels of the Artery of Adamkiewicz
T8-T12
Major complications associated with aortic aneurysm disease
Stroke: 2-11%
paraplegia 2-20%
Renal failure: 3-15%
Pulmonary failure: 20-30%
2010 AHA/STS Guidelines for stenting of the thoacic aorta
Class 1: acute, traumatic, ischemic type B
Class IIa; symptomatic PAU/IMH chronic traumatic dege
Aorta
Endovascular zone
0 - ascending to innominate
1 - inominate to the the subclavin
2 - left cartoid to the left subclavian
3- Left sc to proimal descending
4 - descending
Types of endograft leak
5 types
Type 1 - leak at the ends of the graft
Type 2: sac filling via branch vessel
Type 3: defect in the graft fabric
Type IV: porous graft (intentional leak)
Type V - endotension
Type 1 Endovascular leak
Type 1: leak at the graft ends
1a proximal
1b distal
1c iliac occluder
Type II endovascular leak
Type II: sac filling via vascular branch
IIa: single vessel
IIb: two vessels
Type III Endovascular leak
leak through a defect in the graft fabric
IIIa - junctional separation of the modular components
IIIb fracture or hole involving the endograft
Type Iv endovascular leak
generally due to a porous graft (design of the graft)
Type V endoleak
due to endotension
Endovascular zone?
Ascending to innominate
Zone 0
Ascending to innominae
Endovascular zone
Innominate to left carotid
zone 1
Endovascular zone
Left carotid to left subclavian
zone 2
Endovascular zone
left subclavian to descending aorta
zone 3
Endovascular zone
Descending aorta
zone 4
what type of endoleak requires intervention
Type I and III
will need intervention
what type of endovascular leas is the most common
type II back bleeding from branch vessels
how to decompress the heart during descending left heart bypass
Left superior pulmonary vein
or
LV Apex
Post descending repair
ICP /MAP goals
Keep the ICP < 10
Do not drain more CSF than 20ml/hr
MAP > 80-90
Components of Del Nido Cardioplegia
Components of the crystalloid solution include:
- Plasmalyte A
- sodium bicarbonate
- mannitol (decreases myocardial edema and acts as a free radical scavenger),
- potassium (depolarization),
- lidocaine (maintains arrest in a hyperpolarized state)
- magnesium
MUF
modified ultrafiltration
Used to minimize total body oedema
Root cardioplegia needle size
kids / adults
Kids > 5kg- 18g angiocath
Bigger: 12-16g
Retograde cardioplegia catheter size
Adult
Pediatric
neonate
Adult : 15
Kid : 9 - 13
Neonate: 6
Fench to mm conversion
1F = 0.33 mm
8F - 2.64 mm
Correlation between Edwards
24-, 22-, 19-, and 18-F sheaths and mm size
24-, 22-, 19-, and 18-F sheaths
9.2, 8.4, 7.5, and 7.2 mm, respectively.
notice 19–> 18 is 0.3
Incidence of HIT in patients who undergocardiac surgery
1The overall incidence of HIT in patients who undergo cardiac surgery ranges from 0.1% to 3% .
Factors Strongly associaed with HIT
- Female sex
- atrial fibrillation
- congestive heart failure
- chronic kidney disease
- chronic liver disease
Effect of HIT on mortality after Cardiac surgery
No HIT: 4.5%
+ HIT: 11%
Any thrombocytopenia: 4%
HIT in post cardiac patients can thus result in more than 50% increase in mortality
What type of thrombosis is most common in patients with HIT?
Arterial thrombosis is more common than venous thrombosis in cardiac patients with HIT
Timing of CABG Post MI
EF > 30% - proceed any point after MI completed
EF < 30% stabalize recover for 7 days after MI
How to differentiatte the cause of TR based on RV pressures
If RVs is > 60 mmHg then tricuspid regurigation in functional and due to left sided heart pressure
if the RVs > 40 then there is a substantial organic component
If there is no gradient between the RA to PA diastolic …
the the RV likely has severe dysfunction
tricuspid valve replacement will likely not help
RVESA and tricuspid regurgitation
if RVESA is < 20 cm2 then RV function is preserved
or if change in area < 35% then reduced function
criteria for prompting imaging of the chest in trauma
Nexus Criteria (similar to spine)
>= 1 should have imaging
- Age > 60
- Rapid decelleration
- fall > 20 feet
- MVC > 40 mph
- Chest pain
- Intoxication
- Altered Mendtal Status
- Distracting Injury
- TTP
Clamp and sew surgical repair of traumatic aortic injury
- time limit for clamp and sew
Cross clamp time >30 minutes is associated with a paraplegia rate of 15-30%
Significant mediastinal injury - what should you not forget to do?
EGD.
particularly gun shot wounds, may be associated with multiple other injuries.
need to be suspicious for an esophageal injury. EGD should be done prior to closing the chest.
Definition of FFR
pressure in the post stenotic area of a coronary artery to
pressure in the ascending aorta
-at Maximal coronary vascular pharmacologic dilation
What FFR indiciates significat coronary artery stenosis
An FFR less than 0.8 is significant for coronary artery stenosis
What was the FAME study?
What did it show ?
Functional Flow Reserve vs Angiography for Multivessel Evaluation
(FAME)
FFR was negative :
- in 90% stenosis - in 4% of cases
- in 71-90% stenosis - 20% of cases
- in 51 - 70% stenosis - 65% of cases
David-Feindel formula
To determine the size of a graft for a David procedure
diameter = [2x (Hcusp x 2/3)] + 6-8mm
nodule of Arantius.
Nodule at the free edge of the aortic leaflet.
