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Principles III > CABG & Valve repair/replacement sx PPt (test #2) josh's take > Flashcards

CABG & Valve repair/replacement sx PPt (test #2) josh's take Flashcards

1
Q

what 2 items make up the cardiac skeleton

A
  1. tough fibrous rings surrounding Av valves
  2. 2 additional fibrous annuli develop in relation to the base of the aorta and the pulmonary trunk
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2
Q

the tough fibrous rings surrounding the AV valves are what?

A

the points of attachment

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3
Q

what is the fixation point for cardiac musculature?

A

annulus fibrosis

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4
Q

picture of the skeleton of the heart we just went over

A
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5
Q

2 chambers of the heart

A

ventricles

atria

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6
Q

which chamber is smaller and thinner

A

atria

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7
Q

the ventricles muscles are thicker than the atria which venticle is thicker? for extra credit what are their “nomal thickness?”

A

left

left is usually 1 cm thicker than right

right 0.5 cm

left 1.5 cm thick

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8
Q

RIGHT ATRIUM:

muscle wall thickness of what?

A

2mm

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9
Q

RIGHT ATRIUM:

recieves blood from where?

A

SVC

IVC

Coronary sinus (dont forget this one)

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10
Q

RIGHT ATRIUM:

consist of what 2 parts?

A

anterior

posterior

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11
Q

RIGHT ATRIUM:

which part is thin walled TRABECULATED portion?

which part is smooth walled portion?

A
  1. Anterior
  2. Posterior
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12
Q

RIGHT ATRIUM:

what 2 things are contained in it?

A
  1. intraatrial septum
  2. fossa ovalis cordis t(he fossa ovalis is a depression in the right atrium of the heart, the remnant of a thin fibrous sheet that covered the foramen ovale during fetal development.)
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13
Q

RIGHT VENTRICLE:

the RV ejects blood throught the_______ into the ________ for gas exchange in the lungs

A

pulmonary valve

pulmonary arteries

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14
Q

RIGHT VENTRICLE:

what is the muscle wall thickness?

A

4-5 mm (note mm not cm)

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15
Q

RIGHT VENTRICLE:

the papillary muscles attach to the ______ ______ and _____ _______

A

ventricular walls

chordae tendineae

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17
Q

RIGHT VENTRICLE:

the chordae tendineae and papillary muscles help prevent what?

A

the eversion of the tricuspid valve.

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18
Q

RIGHT VENTRICLE:

recap all of that shit!! include papillar muscles, what they do, and all other structures!!

A

papillary muscles attach to the VENTRICULAR WALLS and CHORDAE TENDINEAE

the CHORDAE TENDINEAE attach to the cusp of the TRICUSPID VALVE

The CHORDAE TENDINEAE and PAPILLARY MUSCLES help prevent the eversion if the tricuspid valve!!!

got it get it good

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19
Q

LEFT ATRIUM:

is a reservoir for what?

A

oxygenated blood from the pulmonary veins

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20
Q

LEFT ATRIUM:

provides a ___-___% increase in LVEDV called the “____ ____”

A

20-30%

“atrial kick”

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21
Q

LEFT ATRIUM:

diastolic dysfunction + loss of “atrial kick” = what?

A

impaired CO

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22
Q

LEFT ATRIUM:

is located posterior to what?

A

Left pulm artery

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23
Q

LEFT ATRIUM:

has a muscle wall thickness of what?

A

3 mm

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24
Q

LEFT ATRIUM:

is the LA wall rough or smooth

A

smooth motha fucker

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25
Q

LEFT VENTRICLE:

ejects blood into what?

A

the aorta

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26
Q

LEFT VENTRICLE:

what is the wall thickness

A

8-15mm

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27
Q

LEFT VENTRICLE:

what separates the RV from the LV?

A

ventricular septum

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28
Q

LEFT VENTRICLE:

the upper 1/3 of the ventricular septum is what?

the remaining 2/3rds of the septum and the rest of the ventricular wall is covered with what?

A
  1. smooth endocardium
  2. trabeculae carneae ( rounded or irregular muscular columns which project from the inner surface of the right and left ventricles of the heart.[1] They should not be confused with the pectinate muscles, which are present in the right atrium[1] and right and left auricle only.)
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29
Q

LEFT VENTRICLE:

present in the LV are 2 large _____ muscles?

A

papillary muscles

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30
Q

LEFT VENTRICLE:

Chordae tendineae of each of the 2 large papillary muscles are attached to the cusps of what?

A

mitral valve

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31
Q

CARDIAC VALVES:

ideally cardiac valves flow in what direction?

A

one way

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32
Q

CARDIAC VALVES:

open and close in response to what?

A

pressure gradients

and

action of papillary muscles

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33
Q

CARDIAC VALVES:

what are the 2 valves

A

AV

semilunar

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34
Q

TRICUSPID VALVE:

LOCATED WHERE?

A

right AV orfice

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35
Q

TRICUSPID VALVE:

are the 3 leaflets equal or unequal in size?

A

unequal

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36
Q

TRICUSPID VALVE:

what are the names of the 3 leaflets?

A

anterior

septal

posterior

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37
Q

TRICUSPID VALVE:

what is the normal area?

A

7 cm2

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38
Q

what valve has the largest area?

A

TRICUSPID VALVE:

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39
Q

MITRAL VALVE:

IS LOCATED WHERE?

A

left AV orfice

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40
Q

MITRAL VALVE:

how many leaflets does it have

A

2 all others 3

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41
Q

MITRAL VALVE:

the 2 major leaflets are connected by what?

A

commissural tissue

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42
Q

MITRAL VALVE:

what are the 2 leaflets named

A

anteromedial

posteriolateral

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43
Q

MITRAL VALVE:

of the 2 leaflets which one is easier to diagnose and repair? and why?

A

posteriolateral

b/c feild of view is better

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44
Q

MITRAL VALVE:

what is normal surface area

A

4-6 cm2

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45
Q

SEMILUNAR VALVES:

what are the 2 valves?

A

aortic and pulmonary

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46
Q

SEMILUNAR VALVES:

are their valve configeration similar?

A

yepper!!!

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47
Q

SEMILUNAR VALVES:

which valve is slightly thicker?

why?

A

Aortic

due to higher pressures

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48
Q

SEMILUNAR VALVES:

are located where?

A

within the outflow tracts of their corrosponding ventricles

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49
Q

SEMILUNAR VALVES:

each valve has how many cusp ( i think cusp and and leaflets are interchangable)

A

3

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50
Q

SEMILUNAR VALVES:

normal aortic valve area in what?

A

1-3 cm2

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51
Q

self reminder!!

A

go back and do cards on NYHF scale

METs

canadian heart scale

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52
Q

PREOPERATIVE EVALUATION:

regardless of pathology preoperative evaluation should be primarily concerned with determining what?

A
  • severity of disease
  • hemodynamic signifigance
  • residual ventrcular function
  • presence of secondary effects on organ function
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53
Q

PREOPERATIVE EVALUATION:

how do you see if there is presence of secondary effects on organ function?

A

check labs is the heart fucking with their kidneys? check BUN?creatinine etc

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54
Q

PREOPERATIVE EVALUATION:

valvular heart disease history should focus on what? (4 things)

A
  1. functional class
  2. medication review
  3. concominant symptoms
  4. concominant CAD
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55
Q

PREOPERATIVE EVALUATION:

******

what are the 2 most major test to perform

A

ECHO

Left Heart Cath

(stress test not that important)

56
Q

PREOPERATIVE EVALUATION:

what is teh gold standard for eval of valvular disease and ventricular function?

A

ECHOcardiography

57
Q

PREOPERATIVE EVALUATION:

what are the 5 things the ECHO shows

A
  1. systolic/diastolic dysfunction
  2. LV muscular abnormalities
  3. intr-chamber defects
  4. Septal Abnormalities
  5. measures areas and estimates pressures
58
Q

PREOPERATIVE EVALUATION:

what estimates pressures better? a cath or echo?

A

ECHO

59
Q

PREOPERATIVE EVALUATION:

what type of ECHO is bets for mitral valve

A

TEE

60
Q

PREOPERATIVE EVALUATION:

CAD:

what is the gold standard for preop eval?

A

coronary angiography

61
Q

PREOPERATIVE EVALUATION:

CAD:

Why is coronary angiography the gold sandard for pr-op eveak?

A

direct engagement of coronary ostia with radio-opaque dye

62
Q

PREOPERATIVE EVALUATION:

CAD:

what does the Coronary angiography show or do?

A

estimates areas

measures pressures

63
Q

PREOPERATIVE EVALUATION: things to know

ECHO report

A
  1. valvular abnormalities
  2. areas
  3. pressure gradients
  4. pulmHTN
  5. LV function
64
Q

PREOPERATIVE EVALUATION: things to know

LHC

A
  • blockages/vessels
  • LV function
  • pressure gradients
  • pulmHTN (RHC)
65
Q

PREOPERATIVE EVALUATION: things to know

besides ECHO report and LHC report, what other 3 important things do you want to now about??

A

functional capacity

pressence of conduit (make sure they have grafts left)

recent infections

66
Q

VALVE REPLACEMENT:

All valvular lesions can be classified in the same way! what is the phrase to help classify/differentiate them

A

“the_______ vale fails to open/close*** properly during ventricular ***systole/diastole”

67
Q

note to self

A

get old murmur shit from health assessment

68
Q

AVR:

describe of Aortic stenosis (AS)

“the_______ valve fails to open/close properly during ventricular systole/diastole”

A

“the Aortic valve fails to open*** properly during ventricular ***systole”

69
Q

AVR: AS

is caused by what?

A
  • rhumatic, bicuspid calcification origins
70
Q

AVR: AS

complications!

A
  • LVH
  • prone to dysrhymias
  • ****toeratesl tachy poorly****
71
Q

AVR:

Aortic insufficiency (i am guessing regurg)

“the_______ valve fails to open/close properly during ventricular systole/diastole”

A

“the Aortic valve fails to close*** properly during ventricular ***diastole”

72
Q

AVR: AI

caused by what?

A
  • Annuluar dilation
  • chordae rupture
73
Q

AVR: AI

is often present with what other d/o as well?

A

AS (aortic stenosis)

74
Q

AVR:

The surgical procedure is on full ______, and is usually performed through a median sternotomy incision

A

CPB

75
Q

AVR:

Cardioplegia is often acheived how?

A

Antegrade and retrograde

76
Q

AVR:

after the heart is arrested how is the rest of the sx performed?

A
  • the aorta is opened to expose the AV
  • leaflets removed and annulus debreded piecemeal
  • prosthesis lowered into annulus and securely sutured in place
77
Q

MVR:

Mitral Stenosis (MS)

“the_______ valve fails to open/close properly during ventricular systole/diastole”

A

“the Mitral valve fails to open properly during ventricular diastole”

78
Q

AVR: MS

causes

A
  • rheumatic (frequent origin)
79
Q

MVR: MS

can cause what complications?

A

backing up up blood

  • puml HTn
  • Pulm Edema
  • Afib
  • Low CO (with normal EF)
80
Q

MVR: MS

why is there a low CO but a normal EF remains?

A

b/c you are still ejecting 60% of LVEDV, but due to the restristion in filling the LV there is a low amount to actually eject

81
Q

MVR:

Mitral regurgitation (MR)

“the_______ valve fails to open/close properly during ventricular systole/diastole”

A

“the mitral valve fails to close properly during ventricular systole”

82
Q

MVR: MR

Common causes

A
  • single leafelet pathology
  • ruptured chord
83
Q

MVR: MR

effects caused from MR

A
  • Pulm HTN
  • pulm edema
  • A-fib
  • Low CO (with normal EF)
84
Q

“the_______ valve fails to open/close properly during ventricular systole/diastole”

Name them all!!!!

  1. Aortic stenosis (AS)
  2. Aortic insufficiency (AI)
  3. Mitral Stenosis (MS)
  4. Mitral Regurgitation (MR)
A
  1. “the Aortic valve fails to open properly during ventricular systole”
  2. “the Aortic valve fails to close properly during ventricular diastole”
  3. “the Mitral valve fails to open** properly during ventricular **diastole”
  4. “the Mitral valve fails to close properly during ventricular systole”
85
Q

BAM !!!!

I know you awesome

A

Mind fucking you boyd and your wiggly little arms cant stop it!!!

86
Q

MVR: MS

is this usually repaired?

A

NO

87
Q

MVR: repair or replacement

repair is usually reserved for what?

A

mitral regurgitation (partial annular ring)

88
Q

MVR: replacement or repair

what is almost always replaced not repaired

A

MS

89
Q

MVR:

Key aspects to teither replacement or repair sx

A
  • Full CPB
  • antegrade & retrograde cardioplegia
  • BiCaval canulation -surgical approach
90
Q

CABG

graft materials

A
  • mammary artery
  • other arterial conduit
  • Saphenous vein (RSVG)
  • Cryo-vein
  • Synthetic conduit
91
Q

CABG

graft listed from best to worst in remaining natural blood flow

A

pedical > arterial > venous

92
Q

CABG:

what are pedicle grafts flow?

A

native arterial flow

93
Q

CABG:

what type of flow do free grafts have?

A

arterial flow from aorta

94
Q

CABG:

for surgeries the involve CPB

  1. distal anastamoses are under what?
  2. proximal anastamosis are under what?
A
  1. total clamp
  2. surgeons choice
95
Q

CABG:

for surgeries off the Pump (no CPB)

  1. what type of CABG is it?
  2. usually only use whatp of grafts?
A
  1. beating heart
  2. pedicle grafts (if possible)
96
Q

TMR:

what the hell does it stand for?

A

transmyocardial revascularization

97
Q

TMR:

what is used to perform the sx?

A

Cold Beam excimer laser

98
Q

TMR:

the procedure cuts channels to acheive what?

A

improve angiogenesis

99
Q

TMR:

what are its theraputic goals?

A

improved flow

denervation

100
Q

CPB:

Failure to wean is most commonly caused by what?

A

poor left ventricular function

101
Q

CPB:

what can occur with vasodilation and must be closely monitored?

A

Metabolic acidosis

102
Q

CPB:

what type of emboli can occur?

A

particulate

103
Q

CPB:

if weaning is not sucessfull and return to CPB is required what may need to be given? (drug)

A

additional heparin

104
Q

CPB: failure to wean

with failure to wean what 2 things may be needed to be performed to assist the pt?

A

IABP

VAD

105
Q

CPB: failure to wean

IABP does what?

A

diastolic augmentation improves coronary perfusion

106
Q

CPB: failure to wean

with the VAD, what 2 things will be required

A
  1. requires anticoagulation
  2. requires close and vigilant observation by both perfusion and anesthesia
107
Q

CABG & VALVE sx: Putting it all together

Anesthesia and OR set up

A
  1. standard machine, suction, defibrillator check
  2. Airway set up
    • Largest ETT possible
    • NC is preinduction line placement
  3. OG tube following TEE @ end of case
  4. IV poles with @ least 1 triple pump
  5. 2 Y-set IV’s set up and flushed devoid of air in tubing, one on a warmer
108
Q

CABG & VALVE sx: Putting it all together

anesthetic interview

A
  • H&P
  • labs
  • diagnostic test
  • stress test
  • ECHO
  • cardiac cath
  • Blood availability (and products)
  • pt education
  • Confirm pt
  • consent verify
109
Q

CABG & VALVE sx: Putting it all together

premedication

A
  • benzo
  • opiods
110
Q

CABG & VALVE sx: Putting it all together

meds intra-op

A
  • prop or etomidate
  • fent 20 ml (1,000 mcgs)
  • Versed 10 ml (10 mg)
  • sux’s and NDMR
  • Neosynephrine, ephedrine, NTG, epinephrine
  • antifibrolytic
111
Q

CABG & VALVE sx: Putting it all together

tell me the basics of the case (what you will do) once pt is on room throughout case!!

keep it short 5 simple steps

A
  • Induction - opiods, induction agent, muscle relaxant
  • DL and intubate (secure OETT)
  • volatile
  • Lines (in not done in preop)
  • maintain normotension
  • TEE completed
112
Q

CABG & VALVE sx: Pre-CPB

what must you do during the sternotomy

A

put lungs down

113
Q

CABG & VALVE sx: Pre-CPB

what do u want the SBP to be during aortic cannulation?

A

100mmHg

114
Q

CABG & VALVE sx: Pre-CPB

whay may you be asked to “hand bag” the pt pre-CPB

A

decreased lung excersion

115
Q

CABG & VALVE sx: Pre-CPB

what test is important to get pre CPB?

A

TEG

(Thromboelastography)

116
Q

CABG & VALVE sx: Pre-CPB

how much heparin and when do u give it?

A

300 U/kg

on call by surgeon

117
Q

CABG & VALVE sx: Pre-CPB

what is acceptable ACT?

A

>400 sec

118
Q

CABG & VALVE sx: Pre-CPB

what should you expect with direct surgical manipulation?

A

hypotension

119
Q

CABG & VALVE sx: Pre-CPB

what do you want to do with UOP

A

empty and record

120
Q

CABG & VALVE sx: CPB

things to do during CPB!!!

A
  1. D/C all IV fluids,
  2. turn off ventilator and gasses
  3. withdraw PA cath 4-5 cm
  4. cardio plegia willl be administered
  5. continue dosing fent, versed, and NDMR prn
  6. Monitor UOP
  7. Calculate drug dosing for post-bypass infusions (we need all the time we can get)
121
Q

CABG & VALVE sx: WEANING CPB

what do you do during rewarming?

A
  • check TOF
  • redose NDMR, versed, fentanyl prn
122
Q

CABG & VALVE sx: WEANING CPB

what may be present during rewarming

A

sweating!!!

123
Q

CABG & VALVE sx: WEANING CPB

when do you inflate the lungs?

A

when the surgeon says too ( this is the only time a surgeon will ever tell us what to do)

124
Q

CABG & VALVE sx: WEANING CPB

when do you place pt back on ventilator?

A

ok one more time!!

when the surgeon says too

125
Q

CABG & VALVE sx: WEANING CPB

what do you want to do right away when off pump

A
  • obtain CO/CI
  • TEE
  • insert OGT
126
Q

CABG & VALVE sx: WEANING CPB

when requested to give protamine ( a substance deriveted from the sweet nector of salmon sperm) how much do u give!

A

1 mg per mg of heparin

hmm but we gave heparin in Units??? how does that work out!!!! ready… we learned that 100 units = 1 mg last test (((( wow damn that hurt my head)))) bam bitches take that boyd!!!! boom bringing down the house fuck face!!!!

ok I am done!!!! got excited

127
Q

CABG & VALVE sx: WEANING CPB

what may be necessary at times due tto arrythymias

A

defib with internal paddles and AV pacing

128
Q

CABG & VALVE sx: Prepare for transport

what must you bring for transport!!

A

emergency equipment

resuscitation meds

129
Q

CABG & VALVE sx:

The ICU note should include what?

A
  • transported with monitors
  • Ambu w/ 100% O2
  • Record VS, PA, CVP, and CO/CI
  • Vent settings: Rate, volume, FiO2, PEEP, PS
130
Q

what is a new alternative to traditional procedures with valves

A

transcatheter aortic valve replacement

131
Q

transcatheter aortic valve replacement

what is the pt population??

A
  • ones deemed “too sick” for traditional valve replacement
132
Q

transcatheter aortic valve replacement

what does the procedure do?

A

minimally invasive procedure

aortic valvuloplasty with deployment of new stent/valve

133
Q

transcatheter aortic valve replacement

what are the current outcomes like?

A

unk (its too new)

134
Q

your done

A

ahhhhh

135
Q

Freddo

A

Cold

Principles III (24 decks)

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