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Cardiac Flashcards

1
Q

Formula for ppoFEV1?

A

Pre-operative FEV1 x (19-number of segments to be resected)/19

Pre-op FEV1 x (remaining segments/total functioning segments)

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2
Q

Constituents of CARDIOPLEGIA?

A

JCUH uses:

  • Potassium - 20mmol
  • Procaine
  • Magnesium
Potential for:
Calcium
Mannitol
Bicarbonate/Histadine
Aspartate
Glutamate
Adenosine
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3
Q

What dose of KCl in cardioplegia?

How does it work?

A

20mmol
Inactivates fast Na channels which decreases resting membrane potential preventing the upstroke of the cardiac action potential
Myocardium becomes un-excitable and arrests

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4
Q

What does calcium do in cardioplegia?

A

At a low dose - to reduce the amount available for contraction
Maintains cell membrane integrity

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5
Q

What does Magnesium do in cardioplegia?

A

Prevents loss from cells
Maintains role as enzymatic co-factor
Competes with Ca to decrease Ca induced contraction

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6
Q

Role of mannitol in cardioplegia?

A

Raises osmolality which means decreased tissue oedema

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7
Q

Role of Bicarbonate/Histadine in cardioplegia?

A

Offset metabolic acidosis caused by ischaemia

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8
Q

Role of Procaine in cardioplegia?

A

Decreases excitability/conduction/reduction of arrhythmia at reperfusion

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9
Q

Describe the route(s) of administration of cardioplegia solution

A
  1. Antegrade - cannula in aortic root/coronary ostium
  2. Retrograde - cannula in coronary sinus and perfuses backwards; may not reach RV well

Usually a bit of both every 15-20 minutes

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10
Q

Complications of cardioplegia?

A
  1. Direct damage to myocardium from cannulae
  2. Failure to attain widespread cardiac perfusion (e.g. RV)
  3. Myocardial oedema, haemorrhage and injury
  4. Incorrect composition
  5. Arrhythmias
  6. Fluid overload
  7. Reperfusion injury
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11
Q

What are the benefits of using blood cardioplegia vs crystalloid cardioplegia?

A 
Blood has:
O2 carrying capacity [Hb is usually 5]; pO2 on L side of OHDC
H+ buffer
O2 free radical scavenging
Delivery of other nutrients
Reduced myocardial oedema
Improved micro vascular flow
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12
Q

When do you perfuse your coronary arteries?

A

Well, that depends… on L or R or if branch is supplying atrial or ventricular myocardium
Mainly during diastole for Left coronary arteries BUT some is throughout the cardiac cycle (e.g. RCA)

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13
Q

What is normal coronary blood flow?

A

250ml/min

Or 5% of CO

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14
Q

List 3 different types of resp and cardiac function tests for pneumonectomy

A

FEV1/PPOFEV1 >2L (or more than >30% PPO value); if <30%, need CPET
Diffusion capacity - DLCO >30%
CPET >11ml/kg AT
VO2 Max >20 ideally

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15
Q

List 3 lung protective strategies when doing OLV

A 
Vt 6ml/kg of IDEAL body weight
Peak pressure <30cmH2O
FiO2 to keep SpO2 94-98%
Aim for normal PaCO2
Plateau pressure <24cmH2O
PEEP at 5cmH2O
Avoid hYPERoxia
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16
Q

What is the final test that is done (intra-op) to assess patient suitability for pneumonectomy?

A

Clamping of ipsilateral pulmonary artery: resulting in shunting of blood supply into non-operative lung
Done for ALL patients

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17
Q

What are the adverse physiological responses to pulmonary artery clamping that would make the team reassess whether to continue with pneumonectomy?

A

CVS instability or excessive rise in CVP

Hypoxia despite FiO2 1.0

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18
Q

List 4 possible post op complications SPECIFIC to a pneumonectomy

A

Arrhythmias - 40% develop AF
Post pneumonectomy pulmonary oedema
Broncho-pleural fistula
Cardiac herniation

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19
Q

Symptoms of severe AS?

A

Angina
Syncope
Shortness of breath

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20
Q

What specific cardiac investigations may be used to assess AS

A

ECHO - LV contractility
Angiogram - to assess need for grafting at the same time
ECG - for ischaemia or LVH

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21
Q

In SEVERE AS, what are the values for:

  1. Peak aortic flow velocity
  2. Mean pressure gradient
  3. Valve area
A
  1. 4m/s
  2. > 50mmHg
  3. 0.6cm2/m2/BSA

(Normal velocity of any blood flow in the body is 1m.s)

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22
Q

Describe the pathophysiological features of Aortic Stenosis

A
  1. Valve stiffens -> progressive decrease in aortic valve area
  2. Increased LV afterload
  3. Compensatory LV hypertrophy
  4. Early diastolic dysfunction
  5. Decreased compliance with increased LVEDP
  6. Late systolic dysfunction
  7. Decreased systolic contractility and SV
  8. Heart failure and ischaemia
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23
Q

List the haemodynamic goals for intraoperative management of AS

A 
Avoid arrhythmias
Avoid tachycardia (maintain adequate diastolic time)
Maintain afterload (maintain normal to high SVR)
Maintain pre-load/euvolaemia
Maintain SpO2 >94%
Normothermia
Maintain Hb
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24
Q

List the ways in which Dilated Cardiomyopathy may present

A

Sudden death
Increasing shortness of breath/LV failure
Embolism

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25
List the pharmacological treatments for DCM
``` Beta blockers Diuretics ACEi Aldosterone antagonist Anti-coagulants (as stasis in LV increases risk of LV clot) ```
26
List NON-pharmacological treatments for DCM
LVAD ICD L ventriculotomy Heart transplant
27
List predictors of poor outcome in DCM patients undergoing surgery
LVEF <20% Elevated LVEDP LV hypokinesia Non-sustained VT
28
What are the haemodynamic goals when anaesthetising a DCM patient?
``` Avoid arrhythmias Avoid tachycardia Maintain preload Maintain afterload Avoid myocardial depression ```
29
How would you achieve your haemodynamic goals for a DCM patient?
``` Choice of anaesthetic - regional vs GA Control arrhythmias Arterial line Fentanyl heavy GA Low dose peripheral vasoconstrictor infusion ```
30
Define Pulm HTN
PASP >25mmHg at rest >30mmHg on exercise (On R heart catheterisation)
31
List the 5 classifications of Pulmonary HTN
1. Idiopathic PAH 2. LV disease 3. Lung disease 4. VTE 5. Misc - e.g. sarcoidosis
32
How does pulmonary hypertension cause R heart failure
Raised Pulm artery pressure requires increase from RV RV hypertrophy Increased O2 demand RV dilates, decreasing contractility and output L septal shift and decreased LV compliance
33
What drugs would you use to treat CHRONIC pulmonary HTN?
Prostacyclins - Flolan/iloprost Endothelin receptor antagonists - Bosentan Phosphodiesterase V inhibitors - sildenafil Nitric Oxide Calcium channel blockers
34
What factors increase PVR?
``` Hypoxia Acidosis Pain Hypercapnea Hypothermia PEEP ```
35
What surgical options are there for Pulm HTN?
Lung transplant | Pulmonary endarterectomy for VTE
36
What is the normal innervation of the heart?
Vagus nerve - CN X | T1-T4 of spinal cord post-ganglionic cardiac accelerator fibres from cardiac plexus
37
List the alterations in physiology in the transplanted heart
Resting tachycardia due to loss of vagal tone No response to DIRECT autonomic influence or drugs that act via ANS (e.g. atropine) Absent rate response to baroreceptors - no Valsalva response/carotid sinus stimulation/hypovolaemia/light anaesthesia Stimulated only through direct acting agents such as catecholamines Absent sensory innervation - silent MI SV is pre-load dependent, therefore need to maintain filling pressures PPM or pacemaker wires will be present - avoid RIJ No catecholamine stores in the myocardium = decreased response to ephedrine
38
What concerns do you have when anaesthetising a patient with a heart transplant for non-cardiac surgery?
Physiology - denervation of orthoptic heart Defib/PPM presence Problems with rejection Complications of transplant - leaky valve/conduction defects Immunosuppression and its complications Infection Difficult IV access Close monitoring pre-, intra- and post-operative ECG will show double P wave (?) Risk of silent MI
39
What drugs are used for immunosuppression following heart transplant?
Steroids Calcineurin antagonists - cyclosporin and tacrolimus Antiproliferative drugs - MMF
40
What are the implications of immunosuppression for perioperative care of the patient with a heart transplant?
Renal impairment Hepatic impairment Need to ensure immunosuppression still delivered Steroids require supplementation to account for stress response Pre-op blood essential for renal function/LFTs Strict asepsis Abx prophylaxis Dyslipidaemia HTN Diabetes Calcineurin inhibitors enhance the effect of NMBD Skin malignancy
41
List some long term health problems in the patient with a heart transplant
``` Chronic rejection Renal impairment/failure Hepatic impairment/failure Skin malignancy Diabetes Infection Sarcoidosis Amyloidosis ```
42
What are the indications for pneumonectomy?
Trauma with uncontrolled haemorrhage Bronchial carcinoma Chronic infection - TB/fungal Pneumonectomy is incredibly aggressive, so lobectomy is much preferred
43
List the central neurological complications of ON-PUMP cardiac surgery
Stroke Post op cognitive impairment Fatal brain injury Seizures Visual field defects Focal spinal cord injury: paraplegia/spinal stroke Type 1 = actual brain injury (e.g. stroke); Type 2 = delirium
44
List the peripheral neurological complications of ON PUMP cardiac surgery
Brachial plexus injury Saphenous nerve injury Phrenic nerve injury Anterior intercostal nerve injury
45
What are the patient specific risk factors for the central neurological complications after cardiac surgery?
``` Older age >65 Female>male Diabetes LVSD Previous CVA AF PVD - atheromatous aorta Low CO state post op ```
46
What are the procedural factors for central neurological complications after cardiac surgery?
Valve surgery (multivalve>mitral>aortic replacement) +/-CABG Re-do or emergency surgery Cannulation of atheromatous proximal aorta Intra-operative hyperglycaemia Poor temperature control Deep hypothermic circulatory arrest (when required for the surgery)
47
List the monitoring that could be used to reduce the incidence of POCD
Transcranial Doppler NIRS BIS Cerebral oximetry
48
How can hypothermia be neuroprotective?
Reduce CMRO2 (7% decrease for every 1 degree fall) Attenuates neuroinflammatory response Reduce apoptosis Inhibit free radical generation
49
List some methods to reduce the incidence of neurological complications
TOE checking for atheromatous aorta prior to cannulation Use high quality line filters Avoid hyperthermia Avoid multiple cross clamp of aorta Close glycaemic control Maintain cerebral perfusion Use NMDA antagonist (Mg, lidocaine) for pharmacological neuroprotection Use alpha stat (which is default for adults anyway)
50
How do you confirm a (LEFT) double lumen tube is placed correctly?
Insert the DLT to the L side Attach Y connector Sealing caps closed Inflate tracheal cuff - ventilate both lumens and check for CO2 etc Ventilate via endobronchial lumen by occluding tracheal lumen of Y connector; listen for air leak when you have opened cap on tracheal side and deflated tracheal cuff (check CO2, chest movement/auscultation) Ventilate via tracheal lumen by occluding the bronchial lumen of Y connector; listen for air leak (after opening cap of bronchial lumen)/observe chest movement/auscultate
51
What may be different with a right sided DLT?
Need to think about the RUL and having an eye to ventilate the RUL
52
Outline the possible complications associated with the use of double lumen tubes
``` Damage: anything that gets in the way… Teeth/lips/tongue/pharynx/trachea/carina/palate Arytenoid cartilage & cords Eye Mucosal sloughing Hypoglossal and lingual nerves Oesophagus ```
53
What size DLT would you use in a man? A woman?
39 for men | 37 for women
54
Name some complications from using a DLT
``` Failure to ventilate Diffuse fibrosis of glottis Emphysema (subcutaneous) Pneumothorax Endobronchial aspiration Laryngeal obstruction Vocal cord paralysis Submucosal haemorrhage ```
55
What can you use if you cannot get the DLT in place?
Single lumen tube and bronchial blocker | Use fibreoptic scope to check placement of bronchial blocker
56
How would you manage the development of hypoxaemia during OLV?
Increase FiO2 to 1.0 Inform the surgeon Apply PEEP/adjust PEEP to ventilated lung Oxygen insufflation to non-ventilated lung (without using PEEP etc) Ventilate both lungs/intermittent two lung ventilation Optimise cardiac output Optimise Hb
57
What factors can lead to the development of high airway pressures during OLV?
Bronchospasm Obstruction of the ETT by sputum/blood Malposition of DLT (e.g. missing out RUL) - use scope to reposition Malposition of bronchial blocker - use scope to reposition Pneumothorax of ventilated lung
58
How do you treat hypoxaemia due to shunt in pneumonectomy?
Increase FiO2 Optimise ventilator settings Oxygen insufflation to non-ventilated lung CPAP with O2 to non-ventilated lung PEEP to ventilated lung Increase Cardiac Output (improves mixed venous O2 saturation) Intermittent 2 lung ventilation Encourage early clamping of pulmonary artery to non-ventilated lung (during planned resection)
59
What are the ABSOLUTE indications for one lung ventilation?
Prevent contamination of healthy lung - abscess, empyema, haemorrhage Control distribution of ventilation - BP fistula, traumatic bronchial disruption Facilitate single lung lavage - Cystic Fibrosis
60
Compare and contrast DLT, bronchial blocker and single lumen tube
DLT +quick to place; CPAP to operative lung; alternate OLV; suction/bronchoscopy -limited sizes; difficult to place in distorted anatomy; not good for post op ventilation; potential airway trauma BB +easy size selection; easy to use; post op ventilation possible by removal -longer to insert; suction not possible; bronchoscopy of isolated lung impossible; slow and incomplete collapse of lung SLT +easier to place in altered anatomy/emergency -difficult for left OLV; bronchoscopy/suction/CPAP all impossible to isolated lung
61
For pneumonectomy, what FEV do you need?
>2L
62
If pre-op FEV1 <2L, what other test would you do and what result is needed for operation to be considered?
CPET VO2 max >15ml/kg/min
63
What Activated Clotting Time is needed for: 1. On pump CABG 2. Off pump CABG
1. >480s or 4x baseline 2. 250-300s (Normal value is 70-120s)
64
List some theoretical benefits of “off pump” CABG compared to on pump
``` Avoiding the complications of CPB…: Reduced post op cognitive impairment Reduced consumption of clotting factors Reduced renal impairment Reduced ARDS Reduced air emboli ``` Reduced cross clamp/risk of emboli Reduced transfusion Reduced ICU stay duration
65
List some causes of haemodynamic instability during ‘off pump’ CABG
Arrhythmia Ischaemia from vessel anastomoses Haemorrhage Deep anaesthesia/low SVR Surgical compression of great vessels Manipulation of heart distorting annulus - causes MR/TR Surgical equipment causing RWMAs/impaired filling
66
List ways to minimise instability during “off pump” CABG
``` Adequate preload/filling Maintain contractility Inotropic support Monitor/correct electrolyte abnormalities Avoid hypothermia Avoid acidosis Use of shunt to minimise ischaemia Good communication with surgeons and anaesthetic team ```
67
Mitral stenosis: criteria
``` Valve areas: Normal 4-6cm2 Mild 1.6 - 2.0cm2 (patient will be symptomatic) Moderate 1-1.5cm2 Severe <1cm2 ``` Pressure gradients: Mild <5mmHg Moderate 6-10mmHg Severe >10mmHg
68
Why is Mitral Stenosis so bad in pregnancy?
MS means LV underfilled Changes in pregnancy (increased HR, increased CO/blood volume, decreased SVR) exacerbate pulmonary hypertension and congestion. Also reduce LV filling time MS has fixed CO so any decrease in SVR will decrease coronary perfusion AF will make this worse If valve area <1.5cm2 then decompensation likely
69
List the haemodynamic effects of an IABP on: 1. Aorta 2. Heart 3. Coronary blood flow
1. Decreased systolic pressure Increased diastolic pressure 2. Decreased afterload Decreased preload Increased CO 3. Increased coronary blood flow/perfusion
70
What are the principles of IABP?
``` Balloon in descending aorta Counterpulsation Inflates during diastole Deflates at early systole Synchronised with ECG ```
71
List some contraindications to IABP
``` AR Aortic dissection AAA Aortic stents Uncontrolled sepsis End stage LV impairment with no recovery Tachyarrhythmias Severe PVD ```
72
List 6 complications of IABP
``` Limb ischaemia De-synchronisation with cardiac cycle (which will increase work of heart!) VTE Compartment syndrome Aortic dissection Occlusion of renal blood flow due to malposition Cardiac tamponade Balloon rupture ```
73
What is the anaesthetic management of regurgitant murmurs?
Full Fast Forward
74
Pacemakers: | What do the letters mean?
1: Chamber paced (V, A or D-Dual) 2: Chamber sensed (V, A, D) 3: Mode of response (Triggered, Inhibited, Dual) 4: Programmable functions 5: Anti-tachycardia factors
75
Describe what each position of a pacemaker code denotes?
1. Chamber paced (V/A/D) 2. Chamber sensed (V/A/D/O) 3. Response to sensing (I/T/D/O) 4. Programmable functions (P/M/C/R/B/N/O) 5. Anti-arrhythmic function (S/E/D)
76
Describe what each position of an ICD code denotes
1. Shock chamber (A/V/D/O) 2. Anti-tachcardia pacing chamber (A/V/D/O) 3. Tacharrhythmia detection (E/H) 4. Pacemaker capability
77
What features make up Lee’s Revised Cardiac Risk index?
``` Known Coronary Artery Disease Diabetes REQUIRING INSULIN History of CCF History of CVA High risk surgical procedure Creatinine of >170 ```
78
Using Lee’s Revised Cardiac Risk Score, what are the % of complications for any operation? E.g. Score 0 = … Score 1 = …
Score 0 = 0.4% of major intra-operative cardiac event Score 1 = 0.9% risk Score 2 = 6.6% risk Score 3 = 11% risk
79
What factors affect myocardial oxygen supply?
``` Diastolic filling time Coronary perfusion pressure Arterial O2 content Hb Coronary artery diameter ```
80
What factors affect myocardial O2 demand?
HR Contractility Ventricular wall tension Afterload (accept SVR)
81
How does GTN work in ischaemic heart disease? What dose would you start with?
``` Reduces LVEDP (reduced wall tension) 10-200mcg/min ``` By reducing wall tension, GTN reduces myocardial O2 demand and increases sub-endocardial O2 supply through increased coronary blood flow
82
What class of drug is enoximone?
Phosphodiesterase III inhibitor | Prevents degradation of cAMP
83
What ECG features may be present in a patient with AS?
``` LVH L axis deviation Heart block ST depression/TWI in LATERAL leads P wave enlargement ```
84
What are the criteria for Infective Endocarditis?
Duke’s criteria: Major: - Positive blood culture with likely organism - Positive ECHO showing intra cardiac abscess/oscillating mass/dehiscence of prosthetic valve - Dehiscence of new valve Minor: - Fever >38 - IVDU or predisposing heart condition - Vascular phenomena - emboli; Janeway lesions; mycotic aneurysm - Immunological phenomena - GN; Osler; Roth - Microbiological phenomena - BCs not typical - Echo findings not meeting major criteria but suggestive
85
What are the minor criteria for IE?
Fever Predisposition - IVDU Septic emboli/mycoptic aneurysm ICH
86
List 6 patient related factors that are used in the EUROSCORE2
``` Age >60 Female sex COPD Extracardiac arteriopathy Neurological dysfunction/disease Previous cardiac surgery Raised Cr Active endocarditis Critical pre-operative state - history of VF/pulseless VT, IABP, CPR ```
87
Which factors convey the highest risk in the EURO Score II
Ejection fraction <20% Emergency salvage operation Dialysis
88
What is the EURO Score II used for?
In hospital mortality after cardiac surgery | Not so useful after 30 days
89
What are the cardiac/operation related factors involved in EUROScore II?
``` NYHA LV function Recent MI Pulmonary Hypertension Urgency of surgery Weight of the intervention - type of surgery (single CABG vs valves etc) Surgery on thoracic aorta ```
90
What is the greatest risk for CVA in patients undergoing on pump CABG?
Proximal aortic atheroma HTN/prev CVA/IDDM/carotid bruit all increase risk but they are not procedure specific
91
What medical devices/procedures interact with a PPM/ICD?
``` Radiofrequency ablation Radiation therapy ECT TENS Extracorporeal shock-wave lithotripsy ```
92
What are the associations with tracheo-oesophageal fistula?
``` VACTERL Vertebral Anorectal Cardiac Tracheal Esophageal Renal Limb ``` Trisomy 21, Trisomy 18, Pierre Robin, DiGeorge
93
How would you manage a neonate born with trache-oesophageal fistula?
Insertion of orogastric tube- suction Avoid bag mask ventilation Gas induction and spontaneously breathing Use muscle relaxant when cuff beyond defect
94
Define preload
End diastolic ventricular wall tension
95
Define afterload
Tension developed in ventricular wall during systole Tension generated in order to eject blood during systole Determined by SVR, ventricular volume, wall thickness and conditions that obstruct outflow
96
Define MAP
Diastolic BP + 1/3rd pulse pressure Average arterial blood pressure throughout cardiac cycle
97
What is FTc?
Flow time corrected: duration of flow during systole corrected for heart rate Normal = 330-360ms Low = hypovolaemia or increased afterload High = low afterload
98
What is peak velocity in cardiac output monitoring?
Highest blood velocity during systole Used as a surrogate for LV contractility Normal value: 1m/s
99
What are the indications for OFF PUMP cardiac surgery?
``` Atheromatous aortic disease precluding bypass Previous CVA Renal disease Diabetes Ventricular dysfunction Advanced age Chronic lung disease ```
100
What ACT is needed for OFF PUMP surgery?
250 - 300s | Normal is 100s
101
How can the risks associated with lung resection be quantified pre-operatively?
Measure FEV1 and DLCO Calculate ppoFEV1 and DLCO based on anatomical calculation, V/Q scans or CT —If >60% - all good —if <60% but >40% - stair climb/shuttle walk If poor performance - CPET (?or straight to CPET?) CPET etc
102
What factors influence coronary blood flow?
Under autoregulation between 60-160mmHg —O2 demand —Metabolic factors - high CO2, K+, H+, prostaglandins, adenosine or NO) —HR - an increase in HR encroaches on the diastolic filling time —Patency of coronary vessels (atheroma prevents dilation due to O2 demand, causing downstream ischaemia) —Autonomic/neurogenic control (minor) — Factors inherent to the circulation (aortic diastolic pressure — LVEDP; HR; CO; isovolumetric relaxation phase) — Humoral factors (Angiotensin, T3/T4)
103
What is the myocardial O2 extraction ratio?
80% Compared to 25% in the rest of the body O2 extraction of 30mls/minute in the resting heart
104
What is the pathophysiology of pulmonary hypertension?
Pulmonary vasculature hypertrophies/fibroses and narrows vessels causing increased pressures RV hypertrophies against increased afterload LV failure from decreased volume reaching LV andinterventricular septal interdependence Coronary perfusion to RV depends on perfusion pressure at aortic root - dependent on SVR
105
What are the anaesthetic goals when anaesthetising a patient with pulmonary hypertension?
Avoid hypoxia Avoid hypercarbia Avoid acidosis Avoid increasing PVR Avoid large decrease in SVR or venous return Avoid arrhythmias Reduce venous shunt (alveolar recruitment) Avoid hyperinflation of alveoli Avoid hypothermia Avoid volume overload Avoid/decrease stress and sympathetic response
106
What are the treatment options for pulmonary hypertension?
Medical: —Calcium channel blockers —Endothelin receptor antagonist (bosentan) —Phosphodiesterase V inhibitor (sildenafil) —Prostacyclin analogue (epoprostenol) Surgical: —Atrial septostomy —Lung transplant —Endarterectomy (if VTE) Ancillary: —O2 —Diuretics —Digoxin
107
What are the causes of LV hypertrophy?
Hypertension HOCM …
108
What are the anaesthetic goals when anaesthetising a patient with HOCM?
Maintain SVR Avoid tachycardia Avoid arrhythmias Maintain preload Monitor - TOE
109
What are the indications for One-Lung Ventilation?
Absolute: —Ventilation control in surgery to major airways/bronchopulmonary fistula —Isolation from infection/haemorrhage —Whole lung lavage Relative: —Facilitate surgery: VATS, oesophagectomy, lobectomy, pneumonectomy
110
What are the codes for a pacemaker?
- Chamber Paced (0,A,V,D) - Chamber Sensed (0,A,V,D) - Response (0,I,T,D) - Rate Response (0,R) - Anti-tachycardia function (0,P,S,D)
111
What pulmonary vasodilators are there?
Prostacylin (IV/neb) Flolan —mimics endogenous pulmonary arterial prostacylin Endothelin receptor antagonist Bosentan —vasodilatation by antagonising endothelin PDE inhibitors sildenafil —inhibit breakdown of cGMP and sustains action of NO
112
What features on ECHO/ECG for HCM?
Systolic anterior motion mitral leaflet Septal hypertrophy LV hypertrophy Inferolateral Q waves LVH criteria
113
Management of HOCM?
Medical: Beta blockers Pacemakers Surgical: Myectomy Septal ablation Transplant
114
Describe the coronary blood supply
5% of CO; 250ml/min blood R&L circulations RCA from R aortic sinus -> runs in AV groove -> gives off marginal artery before running posteriorly and forming posterior interventricular artery (PIVA determines dominance) LCA from L aortic sinus -> gives off circumflex and anterior inverventricular artery; Cx runs around and anastamoses with RCA; AIVA runs downward and anastamoses with PIVA RCA supplies electronics LCA supplies pump Venous drainage: 70% accompany the arteries; drain into R atrium via coronary sinus Great/middle/small/oblique cardiac vein The rest drains directly into cardiac cavity
115
What are the causes of AF?
``` Cardiogenic: —IHD —Mitral valve disease —Hypertension — Non-cardiogenic: —Sepsis —PE —Hyperthyroid —Electrolyte imblance (K/Mg) ```
116
Indications for OLV?
Absolute: —BPF —Pulmonary haemorrhage —Thorascopic procedures ``` Relative: —Pneumonectomy —Lung volume reduction surgery —Upper lobectomy —VATS —Thoracic aortic aneurysm —Oesophageal surgery ```
117
Describe the physiology of OLV
—After induction, the lungs move down the compliance curve (paralysis of chest wall/diaphragm) —Upper lobe is now better ventilated —Lower lung is better perfused -> VQ mismatch (shunt in lower lung and dead space in upper) —Situation worsens once upper lung is deflated, since there is no ventilation of upper lung but blood flow continues (increased shunt) —HPV slowly improves this —Patients with abnormal upper lungs may already have limited ventilation/blood flow; OLV may produce little disturbance HPV reduced by volatile anaesthetic agent (but only if >1 MAC)
118
What are the components of a pacemaker?
—Pulse generator -Battery -Electronic circuitry - silicon chip, output circuitry —Pacing lead(s)
119
What are the components of an ICD?
``` —Pulse generator -Battery -Electronic circuitry -Capacitor —Lead(s) ```
120
What are the causes of reduced transfer factor/diffusing capacity? What are the causes of increased?
1. Anaemia Fibrosis/interstitial lung disease Alveolar destruction Pulm HTN 2. Pulmonary haemorrhage Polycythaemia
121
Which PH patients benefit from R heart catheterisation?
Group 1 (PAH) Group 4 (chronic CTE) To assess the severity of haemodynamic impairment and assess potential vasoreactivity
122
How do you support the failing Right Ventricle?
1. Optimise RV preload: —appropriate fluid; consider diuretic if significant TR 2. Augment the RV: —milrinone strengthens RV contraction & reduces PVR —can also use dobutamine, adrenaline, levosimendan 3. Reduce RV afterload: —reverse causes of HPV —inhaled NO, milrinone, prostacyclin 4. Maintain systemic BP/coronary perfusion: —vasopressin (may also pulmonary vasodilate and improve PVR/SVR ratio); noradrenaline
123
What effect do the following drugs have on the denervated heart? 1. Adrenaline 2. Noradrenaline 3. Dobutamine 4. Isoprenaline 5. Ephedrine 6. Atropine 7. Glcyopryrrolate 8. Digoxin
1. Augmented 2. Augmented 3. Normal 4. Normal 5. Decreased 6. No effect 7. No effect 8. No effect
124
What are some absolute contraindications for lung transplant?
—BMI >35 —Malignancy within 5 years (except cutaneous or paediatric) —Significant chest wall abnormality —Uncontrolled extra-pulmonary disease —Substance addiction or misuse within 6 months —Smoking within 6 months —Alcohol use - potentially —Non-adherence to therapy etc —Mental health unable to cooperate with transplant —Absence of social support https://nhsbtdbe.blob.core.windows.net/umbraco-assets-corp/29406/pol231.pdf
125
What are some relative contra-indications for lung transplant?
—>60 years —Poor rehab potential —Burkholderia —BMI >30 —Chronic infection with resistant bugs —Osteoporosis - severe/symptomatic —Mechanical ventilation —Coronary artery disease —Renal impairment eGFR<50= —Poorly controlled DM with end organ damage —Any other disease causing end organ damage —Already on loads of steroids —HIV, Hep B & C
126
What types of ECMO are there?
Veno-venous: replaces respiratory function - oxygenation and removal of CO2 Veno-arterial: replaces cardiac and respiratory function - pump generates perfusion pressure Arterio-venous: replaces respiratory function, but heart is the pump; good at removing CO2, less good at oxygenation
127
Why do suspected endocarditis patients need a TOE?
Because TTE only detects vegetations about 50% TOE sensitivity is between 90-100%
128
What is a persistent left-sided superior vena cava and why is it important?
1 in 200 healthy people; more common if other cardiac defects Majority empty into coronary sinus, so more at risk of arrhythmias; may bypass pulmonary system which puts at high risk of air embolism Ideally use R side for lines etc, but usually possible to use L side with appropriate precautions; may be smaller diameter than R SVC so may not tolerate CVVH etc
129
What is the pathological process in prolonged QT syndrome?
Blockade of the rapid K outward current in cardiac myocytes (There are 2 rectifier currents allowing potassium efflux from cardiac myocytes - rapid & slow)
130
What are the indications for VV ECMO? What are the contraindications?
1. Respiratory failure with: -adequate cardiac function -Murray score >3 -pH <7.20 from hypercarbia 2. Absolute: -Severe heart failure/cardiogenic shock -Severe CHRONIC Pulmonary Hypertension & RV Failure -Ongoing cardiac arrest Relative: -Ventilated >7 days with high pressures/FiO2 -Severe immunosuppression (solid organ transplant recipients) -CPR duration >30mins with no neurological recovery -BMI <18
131
What are the indications for VA-ECMO? What are the contraindications?
1. Cardiogenic shock causing: -persistent lactate >3 -persistent cardiac index <2.2 -end organ dysfunction -EF <30% 2. Limited reversibility Peripheral arterial disease Aortic dissection precluding cannulation Aortic regurgitation Massive bleeding CVA within 6 months CPR >30mins
132
What are the absolute contraindications to all forms of ECMO?
Life expectancy <12 months Heart disease not suitable for transplant Lung disease not suitable for transplant Pulmonary HTN Advanced malignancy GvHD BMT recipient within 9 months Cachexia due to underlying progressive disease
133
What are the common causative organisms for IE?
Staph >50% of the time (80% being S. aureus) Strep Enterococcus Gram -ve rods (E coli, P aeruginosa)
134
What are the guidelines for managing a secondary pneumothorax?
BTS guidelines O2; can attempt aspiration if small Small bore chest drain 8-14Fr Refer to Respiratory Refer to Thoracics if lung not expanded at 48 hours —Surgical intervention - pleurectomy preferable —Suction should be high volume/low pressure
135
What is the innervation of the heart?
Extrinsic innervation from parasympathetic (CN X) and sympathetic inputs (T1-T4) —Superficial cardiac plexus - terminates inferior to aortic arch —Deep cardiac plexus - terminates posterior to aortic arch, anterior to carina, into 2 halves which supply RCA and LCA
136
What are some causes of hypotension in the post cardiac surgery patient?
Hypovolaemia: -bleeding - medical vs surgical Ventricular dysfunction: -stunning -reperfusion injury -hypocalcaemia -metabolic Vasoplegia: -rewarming -anaphylaxis Tamponade Graft failure Arrhythmias or inadequate pacing
137
Describe the pacemaker action potential
138
Describe the cardiac myocyte action potential
139
What are the causes of AKI after cardiac surgery?
Combination of: 1. Hypoperfusion: Hypotension Non-pulsation flow Reduced CO Haemodilution Atheroembolism Activation of RAAS 2. Direct nephrotoxicity: Ischaemia-reperfusion Inflammation/oxidative stress - free radicals Free haemoglobin
140
Do you know of any criteria that can help predict hospital survival on initiation of ECMO?
RESP score Respiratory ECMO Survival Prediction Score I - V, with I having good prognosis and V having poor prognosis Takes into account lots of things (patient characteristics, disease characteristics, state prior to ECMO)
141
What is cardiogenic shock?
Tissue hypoperfusion due to primary cardiac failure after correction of preload Hypotension Trachycardia Oliguria +/-Organ congestion
142
What is the pathophysiology of cardiogenic shock?
Impaired LV systolic function: -decreased CO/SV ->decreased BP and systemic perfusion -> decreased coronary perfusion & vasoconstriction and fluid retention Impaired LV diastolic function: -increased LVEDP -> pulmonary congestion -> hypoxaemia Causing ischaemia and progressive dysfunction
143
What are the causes of cardiogenic shock?
—Ischaemia: -Pump failure -Valve rupture -Conduction delay - RCA -Arrhythmia -VSD Other: -Myocarditis -End-stage cardiomyopathy -LVOTO -Toxins - beta blockers & calcium channel blockers -Contusion
144
Main causes of endocarditis?
—Cardiac -valvular disease -non-native valve -previous cardiac surgery —Non cardiac -lines -IV injections -dialysis
145
Which bacteria cause endocarditis?
S aureus S viridancs Enterococcus Coag -ve Staph Other Strep Non-HACEK HACEK

FRCA & FICM (9 decks)

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