Approach to Patients withHemodynamic Compromise

Question 1

What are serious complications associated with right ventricular endomyocardial biopsy?

Answer 1

• Chamber perforation
• Pericardial tamponade
• Supraventricular and ventricular arrhythmias
• Complete atrioventricular (AV) block
• Pulmonary embolism

The risk of major complications is reported at <1%.

Question 2

What factors may increase the risk of complications during right ventricular endomyocardial biopsy?

Answer 2

• Right ventricular chamber enlargement
• Elevated right ventricular filling pressure
• Thrombocytopenia
• Anticoagulation

Prior cardiac surgery that involved excision of the pericardium may have a lower risk of tamponade in the event a perforation occurs.

Question 3

What is the Brockenbrough-Braunwald sign?

Answer 3

Augmentation of left ventricular contractility and outflow tract obstruction following a premature ventricular beat.

Question 4

How should acute left ventricular outflow obstruction be managed initially?

Answer 4

• Bed rest
• Administration of IV fluids to augment preload

Refractory hypotension should be managed with IV phenylephrine.

Question 5

What are common clinical manifestations of reactions to iodinated contrast media?

Answer 5

• Pruritus
• Urticaria
• Bronchospasm
• Angioedema
• Shock

These manifestations are due to histamine release and are anaphylactoid reactions.

Question 6

What is the management for anaphylactoid contrast reactions in the catheterization laboratory?

Answer 6

• Administration of IV antihistamines (anti-H1 and anti-H2)
• Corticosteroids
• Epinephrine for severe reactions

Corticosteroids do not work immediately.

Question 7

What hemodynamic changes are consistent with cardiogenic shock?

Answer 7

• Elevated pulmonary capillary wedge pressure (PCWP)
• Relatively low cardiac output
• Elevated systemic vascular resistance (SVR)

This contrasts with shock secondary to predominant right ventricular involvement, where the PCWP is only mildly elevated.

Question 8

What is the Bezold-Jarisch reflex?

Answer 8

A reflex leading to bradycardia and peripheral vasodilation, often occurring in response to inferior wall myocardial infarction.

Question 9

What are the three types of coronary artery perforations classified by investigators?

Answer 9

• Type 1: Extraluminal crater without extravasation
• Type 2: Pericardial or myocardial blush without contrast extravasation
• Type 3: Extravasation through frank perforation

Type 1 and 2 perforations can usually be managed with prolonged balloon inflations.

Question 10

What is the usual dose of protamine sulfate for neutralizing heparin?

Answer 10

1 mg of protamine sulfate for each 100 units of heparin (UFH).

Question 11

What is the no-reflow phenomenon?

Answer 11

Impairment in the coronary microcirculation following restoration of epicardial coronary blood flow.

Question 12

What are side effects related to IV contrast agents?

Answer 12

• Bradycardia
• Hypotension
• Nausea
• Vomiting

These effects are related to the tonicity of the agent used and occur more frequently with high-osmolar contrast agents.

Question 13

What are characteristic ECG findings in acute pericarditis?

Answer 13

• Diffuse, concave ST-segment elevation
• PR-segment depression

Question 14

What are the three commercially available platforms for providing temporary circulatory support?

Answer 14

• Left atrium-to-femoral artery bypass (TandemHeart)
• Impella catheter-mounted intraluminal axial pump
• Venoarterial extracorporeal membrane oxygenation (VA-ECMO)

Question 15

What is the management for acute retroperitoneal bleeding following transfemoral catheterization?

Answer 15

• Femoral angiography to identify arterial puncture site
• Balloon occlusion followed by insertion of a covered stent

Vascular surgery can also be performed to repair the site of bleeding.

Question 16

What is the role of isoproterenol in treating bradyarrhythmias?

Answer 16

It is a nonselective beta adrenergic receptor agonist that accelerates the heart rate.

Question 17

What are the signs of pericardial tamponade on hemodynamic tracing?

Answer 17

• Transient right atrial inversion
• Blunted respirophasic variation in IVC
• Elevated mean PCWP

IV fluids are initially given to optimize intracardiac filling.

Question 18

What condition is indicated by a hemodynamic tracing consistent with pericardial tamponade?

Answer 18

Pericardial tamponade

Pericardial tamponade occurs when pericardial pressure exceeds mean right atrial pressure.

Question 19

What happens to the right atrium during pericardial tamponade?

Answer 19

Transient right atrial inversion on echocardiography

This inversion occurs due to increased pericardial pressure.

Question 20

What is the initial treatment for pericardial tamponade?

Answer 20

IV fluids to optimize intracardiac filling

This helps in managing the hemodynamic instability.

Question 21

What is typically observed in the inferior vena cava (IVC) in pericardial tamponade?

Answer 21

Dilated with blunted respirophasic variation

This indicates impaired cardiac filling dynamics.

Question 22

What is the mean pulmonary capillary wedge pressure (PCPW) in the context described?

Answer 22

24 mm Hg

This level suggests significant hemodynamic compromise.

Question 23

What is a common finding associated with cardiac tamponade?

Answer 23

Pulsus paradoxus >10 mm Hg

This reflects the drop in blood pressure during inspiration.

Question 24

What should be suspected in a patient with a history of mechanical valve replacement and abrupt onset of symptoms?

Answer 24

Prosthetic valve thrombosis (PVT)

Especially in the setting of inadequate anticoagulation.

Question 25

What do the 2014 AHA and ACC guidelines recommend for evaluating valve dysfunction?

Answer 25

Echocardiography (transthoracic and transesophageal)

This is for assessing hemodynamic severity, valve leaflet motion, and thrombus size.

Question 26

What imaging technique does fluoroscopy improve upon for mechanical valve assessment?

Answer 26

Ultrasound

Fluoroscopy allows for accurate assessment of leaflet opening and closing.

Question 27

What class of recommendation is assigned for emergency surgery in patients with thrombosed left-sided prosthetic valve and NYHA Class III or IV symptoms?

Answer 27

Class I recommendation

Indicates that surgery is essential in these cases.

Question 28

What is the recommendation for recent onset of NYHA Class I or II symptoms with a small thrombus?

Answer 28

Class IIa recommendation

This applies if the thrombus is less than 0.8 cm².

Question 29

What is associated with larger thrombi in the context of prosthetic valve thrombosis?

Answer 29

Greater thrombolysis-related embolic complications

This highlights the risks of thrombolysis in larger thrombi.