22 CARDIOVASCULAR DISEASE

Question 1

1. What percent of adult patients undergoing surgery are estimated to have, or be at
   risk for, coronary artery disease?

Question 2

2. What are some components of a routine preoperative cardiac evaluation? What are
   some more specialized methods of cardiac evaluation? What is the ultimate
   purpose of a preoperative cardiac evaluation?

Question 3

3. What are some important aspects of the preoperative history taken from patients
   with coronary artery disease with respect to their cardiac status?

Question 4

4. What are some coexisting noncardiac diseases that are frequently present in
   patients with coronary artery disease?

Question 5

5. By what percent can a major coronary artery be stenosed in an asymptomatic
   patient?

Question 6

6. What is the best indicator for a patient’s cardiac reserve?

Question 7

7. When is angina pectoris considered “stable”?

Question 8

8. When is angina pectoris considered “unstable”? What is the clinical implication of
   unstable angina?

Question 9

9. What is it likely an indication of when dyspnea follows the onset of angina
   pectoris?

Question 10

10. How does angina pectoris due to spasm of the coronary arteries differ from classic
    angina pectoris?

Question 11

11. What is silent myocardial ischemia?

Question 12

12. What is the most common symptom of angina in men and women?

Question 13

13. Approximately what percent of myocardial ischemic episodes are not associated
    with angina pectoris? Approximately what percent of myocardial infarctions are
    not associated with angina pectoris?

Question 14

14. Is hypertension or tachycardia more likely to result in myocardial ischemia in the
    patient with coronary artery disease? What is the physiologic explanation for this?

Question 15

15. What is the basis for the common recommendation that elective surgery be delayed
    until 6 months or more after a prior myocardial infarction?

Question 16

16. What is the approximate incidence of perioperative myocardial infarction 6
    months after a myocardial infarction? What is the approximate incidence of
    perioperative myocardial infarction in patients who have not had a prior
    myocardial infarction?

Question 17

17. What time period after surgery do most perioperative myocardial infarctions
    occur?

Question 18

18. What are some cardiac medications that patients with coronary artery disease are
    likely to be taking? What is the recommendation regarding the patient’s
    preoperative medicine regimen with regard to their regular cardiac medicines?

Question 19

19. What information can be gained from a preoperative electrocardiogram?

Question 20

20. How might myocardial ischemia appear on the electrocardiogram?

Question 21

21. Complete the following table:

Question 22

22. Name some determinants of myocardial oxygen requirements and delivery.

Question 23

23. What are some intraoperative goals for the anesthesiologist in an attempt to
    decrease the risk of myocardial ischemia in patients at risk?

Question 24

24. What is the difference between risk stratification and risk reduction?

Question 25

25. What are the risks of recent percutaneous coronary angioplasty in surgical patients
    and how do they differ with bare metal versus drug eluting stents?

Question 26

26. What are two potential benefits of administering premedication preoperatively to
    patients with coronary artery disease?

Question 27

27. How should anesthesia be induced in patients at risk for myocardial ischemia?

Question 28

28. Why is there an increased risk of myocardial ischemia during direct laryngoscopy?
    What are some things the anesthesiologist may do during this time to minimize this
    risk?

Question 29

29. What are some methods of maintenance of anesthesia that may be employed by the
    anesthesiologist for the patient with coronary artery disease?

Question 30

30. What is coronary artery steal syndrome? What is its clinical significance?

Question 31

31. What is a concern regarding the administration of a regional anesthetic to patients
    with coronary artery disease?

Question 32

32. What are some considerations an anesthesiologist should take when selecting a
    neuromuscular blocking drug for patients with coronary artery disease? What is
    unique about pancuronium in this situation?

Question 33

33. How should neuromuscular blockade be reversed in patients with coronary artery
    disease?

Question 34

34. What are some factors that influence the intensity of intraoperative monitoring by
    the anesthesiologist?

Question 35

35. When might an intraoperative pulmonary artery catheter be useful? What
    information does it provide?

Question 36

36. What is some information that may be provided by an intraoperative
    transesophageal echocardiogram?

Question 37

37. What are some treatment options when myocardial ischemia is detected
    intraoperatively?

Question 38

38. What is the problem with decreases in body temperature that may occur
    intraoperatively in patients with coronary artery disease?

Question 39

39. Why is it important to monitor heart rate in the patient with coronary artery
    disease?

Question 40

40. What information can be gained from Doppler echocardiography in patients with
    valvular heart disease?

Question 41

41. How should anesthetic drugs and neuromuscular blocking drugs be selected for the
    patient with valvular heart disease?

Question 42

43. What is mitral stenosis? How does it affect left atrial and pulmonary venous
    pressures? At what chronic left atrial pressure is an increase in pulmonary vascular
    resistance likely to be seen?42. When is it important to administer antibiotics to patients with known valvular
    heart disease?

Question 43

43. What is mitral stenosis? How does it affect left atrial and pulmonary venous
    pressures? At what chronic left atrial pressure is an increase in pulmonary vascular
    resistance likely to be seen?

Question 44

44. What is the most common cause of mitral stenosis? How does it present?

Question 45

45. Why are patients with mitral stenosis at an increased risk of atrial fibrillation?

Question 46

46. Why are patients with mitral stenosis at an increased risk of thrombus formation in
    the left atrium?

Question 47

47. What are some anesthetic considerations for patients with mitral stenosis?

Question 48

48. How can the maintenance of anesthesia be achieved in patients with mitral
    stenosis?

Question 49

49. How might the adequacy of intravascular fluid replacement be monitored in
    patients with mitral stenosis? Why is this important?

Question 50

50. Why might the mechanical support of ventilation be required postoperatively in
    patients with mitral stenosis?

Question 51

51. What is mitral regurgitation? How is mitral regurgitation reflected on the
    recording of pulmonary artery occlusion pressure tracings?

Question 52

52. What is the most common cause of mitral regurgitation? What other pathologic
    process is often present under these circumstances? What are some other causes of
    mitral regurgitation?

Question 53

53. What are some anesthetic considerations for patients with mitral regurgitation?

Question 54

54. How can the maintenance of anesthesia be achieved in patients with mitral
    regurgitation?

Question 55

55. What is aortic stenosis? How is the severity of aortic stenosis estimated? What is
    considered to be hemodynamically significant aortic stenosis?

Question 56

56. Name at least two causes of aortic stenosis. What is the natural course of aortic
    stenosis?

Question 57

57. Why might patients with aortic stenosis have angina pectoris despite the absence
    of coronary artery disease?

Question 58

58. How is aortic stenosis diagnosed on cardiac auscultation? Why is it
    important for the anesthesiologist to rule out aortic stenosis by auscultation
    preoperatively?

Question 59

59. What are some anesthetic considerations for the patient with aortic stenosis?

Question 60

60. What would result from tachycardia, bradycardia, or decreases in systemic
    vascular resistance in the patient with aortic stenosis?

Question 61

61. How can the maintenance of anesthesia be achieved in patients with aortic
    stenosis?

Question 62

62. How should the intravascular fluid status be managed intraoperatively in patients
    with aortic stenosis?

Question 63

63. In patients with chronic aortic stenosis, why might the pulmonary artery occlusion
    pressure not be reflective of the left ventricular end-diastolic volume?

Question 64

64. How effective are external cardiac compressions in patients with aortic stenosis
    during cardiopulmonary arrest?

Question 65

65. What is aortic regurgitation? What is the effect of chronic aortic regurgitation on
    the left ventricle?

Question 66

66. What is acute aortic regurgitation most likely due to? What is chronic aortic
    regurgitation most likely due to?

Question 67

67. Why might a patient with aortic regurgitation have angina pectoris despite the
    absence of coronary artery disease?

Question 68

68. What are the goals for the anesthetic management of aortic regurgitation?
    The anesthetic management of aortic regurgitation resembles the anesthetic
    management for which other valvular disease?

Question 69

69. What is mitral valve prolapse? What percent of the adult population is estimated
    to have mitral valve prolapse?

Question 70

70. What are some other conditions associated with mitral valve prolapse?

Question 71

71. What symptoms do most patients with mitral valve prolapse have?

Question 72

72. What are some potential complications of mitral valve prolapse?

Question 73

73. What is the goal of the maintenance of anesthesia in patients with mitral valve
    prolapse? How should the intravascular fluid volume status be managed in patients
    with mitral valve prolapse?

Question 74

74. What is the potential problem with regional anesthesia in patients with mitral
    valve prolapse?

Question 75

75. What are some tools available to the clinician for the diagnosis of disturbances in
    cardiac conduction and rhythm?

Question 76

76. What are some types of conduction defects? Are conduction defects above or
    below the atrioventricular node usually permanent?

Question 77

77. Is the placement of a prophylactic artificial cardiac pacemaker before surgery
    indicated in a patient with a bifascicular block? Why or why not? What is the
    theoretical concern?

Question 78

78. How is third-degree atrioventricular heart block treated? What are the various
    methods by which this can be accomplished? How can third-degree heart
    block be treated pharmacologically?

Question 79

79. What is sick sinus syndrome? How does it present? How is it treated?

Question 80

80. What are ventricular premature beats? What are the hallmark features of a
    ventricular premature beat on an electrocardiogram?

Question 81

81. When do premature ventricular beats warrant treatment? How are they treated
    under these circumstances?

Question 82

82. What may be some causes of ventricular premature beats?

Question 83

83. When is ventricular tachycardia diagnosed? How can it be treated?

Question 84

84. What are preexcitation syndromes?

Question 85

85. What is Wolff-Parkinson-White (WPW) syndrome? What is the incidence of WPW
    syndrome in the general population? How is it characterized on the
    electrocardiogram?

Question 86

86. What is the most common cardiac dysrhythmia associated with WPW syndrome?
    How can it be treated?

Question 87

87. What is the goal of the anesthetic management of a patient with WPW syndrome?

Question 88

88. What are the various methods by which paroxysmal atrial tachycardia or
    fibrillation may be treated in the perioperative period in patients with WPW
    syndrome?

Question 89

89. What is prolonged QT interval syndrome? What adverse events are associated with
    a prolonged QT interval? How can they be treated pharmacologically?

Question 90

90. What is a congenital cause of prolonged QT interval syndrome? How is a stellate
    ganglion block thought to work for this?

Question 91

91. What is the goal of the anesthetic management of a patient with a chronically
    prolonged QT interval?

Question 92

92. What should be included in the preoperative evaluation of the patient with an
    artificial cardiac pacemaker?
93. How should the pacemaker b

Question 93

93. How should the pacemaker be evaluated by the anesthesiologist preoperatively?

Question 94

94. What intraoperative monitoring is important in a patient with an artificial cardiac
    pacemaker?

Question 95

95. What can occur if the ground plate for electrocautery is placed too near the pulse
    generator of the artificial cardiac pacemaker?

Question 96

96. How is the selection of drugs or anesthetic techniques altered by the presence of an
    artificial cardiac pacemaker in a patient?

Question 97

97. Why should a magnet be kept in the operating room intraoperatively for a patient
    with an artificial cardiac pacemaker undergoing anesthesia?

Question 98

98. What are some causes of temporary pacemaker malfunction? When is placement of
    a pulmonary artery catheter in a patient with an artificial cardiac pacemaker a risk?

Question 99

99. What is the definition of essential hypertension? What is the benefit of the
    long-term treatment of patients with essential hypertension?

Question 100

100. What should be included in the preoperative evaluation of a patient with essential
     hypertension?

Question 101

101. How should blood pressure medications be managed in the perioperative period in
     the patient with essential hypertension?

Question 102

102. What other medical problems are frequently seen in patients with essential
     hypertension? Approximately what percent of patients with peripheral vascular
     disease can be assumed to have 50% or greater stenosis of one or more coronary
     arteries even in the absence of symptoms?

Question 103

103. How is the curve for the autoregulation of cerebral blood flow altered in patients
     with essential hypertension?

Question 104

104. What is the value of treating essential hypertension in patients before an elective
     procedure?

Question 105

105. How do patients with essential hypertension frequently respond physiologically to
     the induction of anesthesia with intravenous medications? Why is this thought
     to occur?

Question 106

106. How do patients with essential hypertension frequently respond physiologically to
     direct laryngoscopy? What are these patients at risk of during this time? How
     can this response be attenuated?

Question 107

107. What is the goal for the anesthetic management of patients with essential
     hypertension?

Question 108

108. How can the maintenance of anesthesia in patients with essential hypertension be
     achieved?

Question 109

109. How might intraoperative hypotension be managed by the anesthesiologist in
     patients with essential hypertension?

Question 110

110. What is the potential problem with regional anesthesia in patients with essential
     hypertension?

Question 111

111. How frequently does hypertension occur in the early postoperative period in
     patients with essential hypertension? How can it be managed?

Question 112

112. What is the correlation between congestive heart failure and postoperative
     morbidity? What does this suggest for the patient scheduled for elective surgery
     in the presence of congestive heart failure?

Question 113

113. What is the goal of the anesthetic management of patients with congestive heart
     failure who are undergoing urgent or emergent surgery? What medicines may
     be useful to achieve this?

Question 114

114. How does positive-pressure ventilation of the lungs affect patients in congestive
     heart failure?

Question 115

115. For major surgery in patients with congestive heart failure, what monitoring may
     be necessary?

Question 116

116. For peripheral surgery in patients with congestive heart failure, can regional
     anesthesia be selected as an anesthetic option?

Question 117

117. What is another name for hypertrophic cardiomyopathy? What pathophysiology
     defines hypertrophic cardiomyopathy? What is the stroke volume in patients
     with hypertrophic cardiomyopathy?

Question 118

118. What is the goal of the anesthetic management of patients with hypertrophic
     cardiomyopathy?

Question 119

119. How can intraoperative hypotension be treated in patients with hypertrophic
     cardiomyopathy?

Question 120

120. How can intraoperative hypertension be treated in patients with hypertrophic
     cardiomyopathy?

Question 121

121. What is the problem with using b agonists for the treatment of hypotension or
     using nitrates for the treatment of hypertension in patients with hypertrophic
     cardiomyopathy?

Question 122

122. What is cor pulmonale?

Question 123

123. What are some signs and symptoms associated with cor pulmonale?

Question 124

124. What are some treatment methods for cor pulmonale?

Question 125

125. What is the recommendation for the patient with cor pulmonale who is scheduled
     for an elective surgical procedure?

Question 126

126. What is the goal of the anesthetic management of patients with cor pulmonale?
     How can this be achieved?

Question 127

127. What is the advantage of monitoring pulmonary artery pressure during surgery in
     patients with cor pulmonale?

Question 128

128. What is cardiac tamponade?

Question 129

129. Name some manifestations of cardiac tamponade.

Question 130

130. What is the treatment for cardiac tamponade? What are some temporizing
     measures for patients with cardiac tamponade awaiting definitive treatment?

Question 131

131. What is the goal of the anesthetic management of cardiac tamponade?

Question 132

132. What effect can the induction of anesthesia and positive-pressure ventilation of
     the lungs have on patients with cardiac tamponade?

Question 133

133. What is the recommendation for anesthesia in patients with cardiac tamponade?

Question 134

134. What pharmacologic agents may be useful in patients with cardiac tamponade?

Question 135

135. What is the most frequent cause of aortic aneurysms? Do most aortic aneurysms
     involve the thoracic or abdominal aorta?

Question 136

136. What is a dissecting aneurysm?

Question 137

137. When is elective resection of an abdominal aortic aneurysm recommended?

Question 138

138. What are some medical problems frequently associated with aortic aneurysms?

Question 139

139. What is the goal of the anesthetic management of patients undergoing resection of
     an abdominal aortic aneurysm? What monitoring is warranted in these
     procedures?

Question 140

140. When are patients with coronary artery disease especially at risk of myocardial
     ischemia during surgery for resection of an aortic aneurysm?

Question 141

141. How should intraoperative fluids be managed during surgery for resection of an
     aortic aneurysm?

Question 142

142. Why does hypotension frequently accompany unclamping of the abdominal aorta
     during surgery for the resection of an aortic aneurysm? What are some methods for
     minimizing the hypotension?

Question 143

143. What are some concerns regarding renal function in patients undergoing aortic
     aneurysm repair?

Question 144

144. What are some concerns regarding spinal cord function in patients undergoing
     aortic aneurysm repair?

Question 145

145. How is blood drained from the venae cavae during cardiopulmonary bypass?

Question 146

146. What are two different types of pumps that are used to return blood to the arterial
     system during cardiopulmonary bypass? Which results in less trauma to blood?

Question 147

147. How is blood kept from entering the heart from the superior and inferior venae
     cavae during cardiopulmonary bypass for mitral valve or intracardiac surgery?

Question 148

148. Under what conditions does the aorta need to be cross-clamped distal to the aortic
     valve and proximal to the inflow cannula during cardiopulmonary bypass?

Question 149

150. What is the required cardiac index delivered by the roller pump on the
     cardiopulmonary bypass machine dependent upon? What approximate cardiac
     index is usually sufficient?

Question 150

150. What is the required cardiac index delivered by the roller pump on the
     cardiopulmonary bypass machine dependent upon? What approximate cardiac
     index is usually sufficient?

Question 151

151. What is the advantage of low flows during cardiopulmonary bypass?

Question 152

152. What are two different types of oxygenators that are used to oxygenate blood that
     is returning to the arterial system during cardiopulmonary bypass?

Question 153

153. What is the advantage of a bubble oxygenator? What is the disadvantage of a
     bubble oxygenator?

Question 154

154. What is the advantage of a membrane oxygenator? What is the disadvantage of
     a membrane oxygenator?

Question 155

155. How can the patient’s body be heated or cooled by the cardiopulmonary bypass
     machine?

Question 156

156. How is blood loss from the field recirculated to the patient during cardiopulmonary
     bypass?

Question 157

157. What is a problem with the cardiotomy suction used during cardiopulmonary
     bypass?

Question 158

158. Why might the left ventricle need a vent during cardiopulmonary bypass?
     How might this be achieved?

Question 159

159. How are systemic emboli from cellular debris prevented from occurring during
     cardiopulmonary bypass?

Question 160

160. What does priming of the cardiopulmonary bypass system refer to? What is the
     cardiopulmonary bypass system primed with?

Question 161

161. What is the patient’s hematocrit maintained at during cardiopulmonary bypass?
     Why is it important to hemodilute the patient’s blood during cardiopulmonary
     bypass?

Question 162

162. Why is it important to remove all air from the cardiopulmonary bypass system
     during cardiopulmonary bypass?

Question 163

163. Why is heparin-induced anticoagulation of the patient’s blood necessary during
     cardiopulmonary bypass? What dose of heparin is usually administered? How is
     the adequacy of anticoagulation confirmed?

Question 164

164. What are some explanations for the low mean arterial pressure often seen after the
     institution of cardiopulmonary bypass? What blood pressure is typically
     considered acceptable?

Question 165

165. Why does blood pressure slowly rise spontaneously after some time on
     cardiopulmonary bypass?

Question 166

166. What are the dangers of hypertension while on cardiopulmonary bypass? How can
     hypertension under these circumstances be treated?

Question 167

167. What are some methods by which the adequacy of tissue perfusion during
     cardiopulmonary bypass can be evaluated?

Question 168

168. Why is diuresis induced during cardiopulmonary bypass?

Question 169

169. What may be the cause of an increasing central venous pressure with or without
     facial edema while on cardiopulmonary bypass? How can this be confirmed?

Question 170

170. What may be the cause of increasing abdominal distention while on
     cardiopulmonary bypass?

Question 171

171. What are some complications of extracorporeal circulatory support or
     cardiopulmonary bypass?

Question 172

172. How should ventilation of the lungs be managed during cardiopulmonary
     bypass?

Question 173

173. What is the goal of myocardial preservation during cardiopulmonary bypass?
     What are some methods by which this can be achieved?

Question 174

174. What is the oxygen consumption of a normally contracting heart at 30 C? What is
     the oxygen consumption of a fibrillating heart at 22 C? What is the oxygen
     consumption of an electromechanically quiet heart at 22 C?

Question 175

175. How is the effectiveness of cold cardioplegia of the heart measured?

Question 176

176. What are two potential negative effects of intramyocardial hyperkalemia due to
     cold cardioplegia after cardiopulmonary bypass? How can they be treated?

Question 177

177. What are two potential sources for systemic hyperkalemia during
     cardiopulmonary bypass? How can the hyperkalemia be treated if it were to persist
     at the conclusion of cardiopulmonary bypass?

Question 178

178. Why might supplemental intravenous anesthetics be administered during
     cardiopulmonary bypass?

Question 179

179. Why might supplemental neuromuscular blocking drugs be administered during
     cardiopulmonary bypass?

Question 180

180. Is supplemental anesthesia routinely required during rewarming after the
     conclusion of cardiopulmonary bypass?

Question 181

181. What conditions in the patient must be present for cardiopulmonary bypass to be
     discontinued?

Question 182

182. When are the aortic and vena cava cannulae removed after cardiopulmonary bypass?

Question 183

183. What are some potential problems associated with persistent hypothermia after
     cardiopulmonary bypass?

Question 184

184. What special precautions must be taken before discontinuing cardiopulmonary
     bypass in patients who have had the left side of the heart opened, as during valve
     replacement surgery? What is the potential risk?

Question 185

185. For each of the following situations, please complete the diagnosis and appropriate
     therapy

Question 186

186. Why might a patient have posterior papillary muscle dysfunction after
     cardiopulmonary bypass? How would this be manifest on the pulmonary artery
     occlusion pressure tracing?

Question 187

187. What is a mechanical addition to the pharmacologic support of cardiac output in
     patients with a poor cardiac output after cardiopulmonary bypass? How does it
     work? What physiologic alterations may interfere with its efficacy?

Question 188

188. When is protamine administered after cardiopulmonary bypass? Why?

Question 189

189. What are some possible side effects of protamine administration?

Question 190

190. What does the perfusionist do with blood and fluid that remains in the
     cardiopulmonary bypass circuit after cardiopulmonary bypass?

Question 191

191. Why might there be a gradient between central aortic and radial artery blood
     pressures in the early period after cardiopulmonary bypass? How long can this
     effect persist?