Approach to Patients withHemodynamic Compromise Flashcards
What are serious complications associated with right ventricular endomyocardial biopsy?
- Chamber perforation
- Pericardial tamponade
- Supraventricular and ventricular arrhythmias
- Complete atrioventricular (AV) block
- Pulmonary embolism
The risk of major complications is reported at <1%.
What factors may increase the risk of complications during right ventricular endomyocardial biopsy?
- 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.
What is the Brockenbrough-Braunwald sign?
Augmentation of left ventricular contractility and outflow tract obstruction following a premature ventricular beat.
How should acute left ventricular outflow obstruction be managed initially?
- Bed rest
- Administration of IV fluids to augment preload
Refractory hypotension should be managed with IV phenylephrine.
What are common clinical manifestations of reactions to iodinated contrast media?
- Pruritus
- Urticaria
- Bronchospasm
- Angioedema
- Shock
These manifestations are due to histamine release and are anaphylactoid reactions.
What is the management for anaphylactoid contrast reactions in the catheterization laboratory?
- Administration of IV antihistamines (anti-H1 and anti-H2)
- Corticosteroids
- Epinephrine for severe reactions
Corticosteroids do not work immediately.
What hemodynamic changes are consistent with cardiogenic shock?
- 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.
What is the Bezold-Jarisch reflex?
A reflex leading to bradycardia and peripheral vasodilation, often occurring in response to inferior wall myocardial infarction.
What are the three types of coronary artery perforations classified by investigators?
- 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.
What is the usual dose of protamine sulfate for neutralizing heparin?
1 mg of protamine sulfate for each 100 units of heparin (UFH).
What is the no-reflow phenomenon?
Impairment in the coronary microcirculation following restoration of epicardial coronary blood flow.
What are side effects related to IV contrast agents?
- Bradycardia
- Hypotension
- Nausea
- Vomiting
These effects are related to the tonicity of the agent used and occur more frequently with high-osmolar contrast agents.
What are characteristic ECG findings in acute pericarditis?
- Diffuse, concave ST-segment elevation
- PR-segment depression
What are the three commercially available platforms for providing temporary circulatory support?
- Left atrium-to-femoral artery bypass (TandemHeart)
- Impella catheter-mounted intraluminal axial pump
- Venoarterial extracorporeal membrane oxygenation (VA-ECMO)
What is the management for acute retroperitoneal bleeding following transfemoral catheterization?
- 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.
What is the role of isoproterenol in treating bradyarrhythmias?
It is a nonselective beta adrenergic receptor agonist that accelerates the heart rate.
What are the signs of pericardial tamponade on hemodynamic tracing?
- Transient right atrial inversion
- Blunted respirophasic variation in IVC
- Elevated mean PCWP
IV fluids are initially given to optimize intracardiac filling.
What condition is indicated by a hemodynamic tracing consistent with pericardial tamponade?
Pericardial tamponade
Pericardial tamponade occurs when pericardial pressure exceeds mean right atrial pressure.
What happens to the right atrium during pericardial tamponade?
Transient right atrial inversion on echocardiography
This inversion occurs due to increased pericardial pressure.
What is the initial treatment for pericardial tamponade?
IV fluids to optimize intracardiac filling
This helps in managing the hemodynamic instability.
What is typically observed in the inferior vena cava (IVC) in pericardial tamponade?
Dilated with blunted respirophasic variation
This indicates impaired cardiac filling dynamics.
What is the mean pulmonary capillary wedge pressure (PCPW) in the context described?
24 mm Hg
This level suggests significant hemodynamic compromise.
What is a common finding associated with cardiac tamponade?
Pulsus paradoxus >10 mm Hg
This reflects the drop in blood pressure during inspiration.
What should be suspected in a patient with a history of mechanical valve replacement and abrupt onset of symptoms?
Prosthetic valve thrombosis (PVT)
Especially in the setting of inadequate anticoagulation.
What do the 2014 AHA and ACC guidelines recommend for evaluating valve dysfunction?
Echocardiography (transthoracic and transesophageal)
This is for assessing hemodynamic severity, valve leaflet motion, and thrombus size.
What imaging technique does fluoroscopy improve upon for mechanical valve assessment?
Ultrasound
Fluoroscopy allows for accurate assessment of leaflet opening and closing.
What class of recommendation is assigned for emergency surgery in patients with thrombosed left-sided prosthetic valve and NYHA Class III or IV symptoms?
Class I recommendation
Indicates that surgery is essential in these cases.
What is the recommendation for recent onset of NYHA Class I or II symptoms with a small thrombus?
Class IIa recommendation
This applies if the thrombus is less than 0.8 cm².
What is associated with larger thrombi in the context of prosthetic valve thrombosis?
Greater thrombolysis-related embolic complications
This highlights the risks of thrombolysis in larger thrombi.
