Cardiac Flashcards
This represents?
A normal JVP
CVP waveforms:
a-wave: atrial contraction, “Atrial”
c-wave: ventricular contraction, “triCuspid”
v-wave: atrial filling, “Villing”
x-descent: ventricle emptying, atrial relaxation, “relaXation”
y-descent: atrium emptying, “emptYing”
This represents?
Constrictive pericarditis (will see similar pattern in RV ischemia)
CVP waveforms:
a-wave: atrial contraction, “Atrial”
c-wave: ventricular contraction, “triCuspid”
v-wave: atrial filling, “Villing”
x-descent: ventricle emptying, atrial relaxation, “relaXation”
y-descent: atrium emptying, “emptYing”
This represents?
Complete AV block
CVP waveforms:
a-wave: atrial contraction, “Atrial”
c-wave: ventricular contraction, “triCuspid”
v-wave: atrial filling, “Villing”
x-descent: ventricle emptying, atrial relaxation, “relaXation”
y-descent: atrium emptying, “emptYing”
This represents?
Cardiac tamponade
CVP waveforms:
a-wave: atrial contraction, “Atrial”
c-wave: ventricular contraction, “triCuspid”
v-wave: atrial filling, “Villing”
x-descent: ventricle emptying, atrial relaxation, “relaXation”
y-descent: atrium emptying, “emptYing”
This represents?
Tricuspid stenosis
CVP waveforms:
a-wave: atrial contraction, “Atrial”
c-wave: ventricular contraction, “triCuspid”
v-wave: atrial filling, “Villing”
x-descent: ventricle emptying, atrial relaxation, “relaXation”
y-descent: atrium emptying, “emptYing”
This represents?
Atrial fibrillation (notice loss of A-wave)
CVP waveforms:
a-wave: atrial contraction, “Atrial”
c-wave: ventricular contraction, “triCuspid”
v-wave: atrial filling, “Villing”
x-descent: ventricle emptying, atrial relaxation, “relaXation”
y-descent: atrium emptying, “emptYing”
ECG change that suggests hypOcalcemia?
prolonged corrected QT interval (QTc) in any lead
Well-described complications of radiofrequency catheter ablation for atrial fibrillation?
phrenic nerve injury and thermal injury to esophagus causing atrioesophageal fistula (due to close proximity to posterior left atrium of both structures)
avoid muscle relaxants so phrenic nerve stimulation may be more easily identified and continuous monitoring of esophageal temperature!
Where is an intra-aortic balloon pump positioned? when does it inflate? when does it deflate?
Positioned in the descending aorta.
Inflates during mid-diastole.
Deflates during systole.
ACT goal for cardiopulmonary bypass?
400-480 seconds (classically 480 seconds)
If ACT value is not appropriate for cardiopulmonary bypass after 2 appropriate heparin doses, what is the problem?
heparin resistance due to antithrombin III deficiency (likely iatrogenic):
give 2-3 units FFP or antithrombin III deficiency
cardiac parameter that is similar between the young and the elderly?
RESTING stroke volume is similar but elderly patients are unable to augment CO with EXERCISE due to diastolic dysfunction and decreased beta receptor sensitivity
goals of anesthetic management in cardiac tamponade?
Fast, full, tight
fast HR
full preload
maintain SVR
alpha stat pH at 18 degrees versus 37 degrees?
18 degrees: hypothermic alkalosis so PaCO2 diffuses into the blood and pH increases (pH~7.6 with PaCO2~16)
37 degrees: pH normalizes to 7.4
acid base status with pH stat at 18 degrees versus 37 degrees?
18 degrees: pH stat adds CO2 to the CPB sweep gas so that pH remains normal at 7.4
37 degrees: because CO2 is added, pH is acidotic when warmed to body temperature
Current literature favors pH stat over alpha stat because acidotic pH leads to cerbral vasodilation, higher cerebral blood flow and more efficient/uniform brain cooling
Type of hypertension that is a better predictor of CAD and mortality in YOUNGER patients?
Diastolic hypertension aka essential hypertension (DBP > 90)
Type of hypertension associated with increased risk of stroke, CAD and mortality in patients > age 60?
systolic and pulse pressure hypertension
systolic HTN = SBP > 140
pulse pressure HTN = pulse pressure > 65
**reflects arterial stiffening during the pulsatile component of the blood pressure
Diagnosis of PHTN requires what value determined by right heart catheterization? What is the NORMAL value?
MEAN pulmonary artery pressure > 25 mmHg at rest
Normal mean pulmonary artery pressures ~14 with an upper limit of 20
Which type of MI is most commonly associated with complete (3rd degree) heart block? Why?
inferior wall MI because the RCA also supplies the AV node
Common type of MI intraoperatively?
Type II - demand ischemia (versus type I from acute thrombosis)
3 main determinants of myocardial oxygen demand?
HR
contractility
wall tension (Laplace law T=PR/h)
formula for cardiac perfusion pressure?
CPP = AoDP - LVEDP
Anesthetic management goals for cardiac tamponade?
“Full fast and tight”
Maintain HR bc cardiac output becomes mostly HR dependent
Maintain SVR
Maintain spontaneous breathing (PPV can cause CV collapse)
When is the left ventricle perfused?
only diastole
When is the right ventricle perfused?
peak/late systole and early diastole bc pressures needed to overcome gradient on right side is lower (than in left side which only perfuses during diastole)
Main determinants of myocardial supply?
arterial oxygen content: CaO2 = (Hgb * 1.34 * SaO2) + (0.003 * PaO2)
cardiac perfusion pressure = AoDP - LVEDP
Drug of choice for bradycardia in transplanted heart?
isoproterenol or epinephrine because directly act on cardiac receptors; anticholinergics and ephedrine ineffective
Management of bradycardia during carotid stent deployment (common occurrence) that can lead to life-threatening hypotension?
glycopyrrolate prophylactically (better than atropine)
also transcutaneous/transvenous pacing
Beck’s triad?
In cardiac tamponade:
(1) pulsus paradoxus: BP decreases >10mmHg with INSPIRATION due to poor LV filling
(2) muffled heart sounds
(3) increased venous pressure evidenced by jugular venous distention
**also electrical alternans
How to prevent windsock effect during endovascular aortic aneurysm repair?
(1) induce hypotension (SBP <70)
(2) transient systole with adenosine
(3) rapid ventricular pacing (>180 bpm) which will stop LV ejection
All maneuvers that decrease the shear force exerted on the stent-graft during deployment
What type of receptor mutations seen in congenital long QT syndrome (LQTS)?
sodium and potassium channels
QTc in LQTS?
QTc > 440 msec
pacemaker indications?
(1) symptomatic sinus node disease like symptomatic bradycardia or sick sinus syndrome
(2) High grade AV block such as 2nd degree Type II mobitz or 3rd degree complete block
(3) supraventricular tachycardias refractory or bad side effects to ablation drugs like LQTS especially if QTc>550
(4) HOCM or dilated cardiomyopathy
NOT Afib
Difference between type I mobitz and type II mobitz?
Both are second degree AV blocks
Mobitz type I: progressive PR prolongation followed by dropped beat
Mobitz type II: PR interval unchanged but atria suddenly fails to conduct to ventricle
type II: pacemaker indicated!
What type of shock fails to generate adequate cardiac output to provide end-organ perfusion?
cardiogenic shock and obstructive shock: both have decreased CO but other parameters are increased (particularly PaOP and wedge pressure in cardiogenic shock)
Which type of shock is a failure of vasculature to generate adequate SVR?
distributive shock: SVR and CVP decreased but everything else fairly normal to high (CO generally high in sepsis for example)
Which type of shock is due to intravascular volume depletion?
hypovolemic shock: HR and stroke volume increased to compensate for decreased CO
How is transcutaneous pacing similar to VOO pacing?
Activates right ventricle (because closest to anterior chest); RA often not activated therefore NO atrial kick
nitroglycerine versus nicardipine versus nitroprusside
nitroglycerine = venous vasodilator nicArdipine = arteriolar vasodilator nitroprusside = balanced vasodilator
how long to wait for time sensitive surgery in setting of bare metal stent? versus drug eluting stent?
BMS: wait 14 days
DES: wait 180 days
how long to wait for ELECTIVE surgery in setting of bare metal stent? versus drug eluting stent?
BMS: wait 30 days
DES: wait 1 year
infective endocarditis prophylaxis indicated when which 2 combination of factors are at play?
high risk factors:
(1) prosthetic valves
(2) prior hx of IE
(3) congenital heart dz: unrepaired, recently repaired (<6 mos), or repaired with residual defect
(4) valvular pathology in transplanted heart
-PLUS-
high risk surgery:
(1) dental work (not routine cleaning)
(2) respiratory tract including T&As and bronchoscopy with biopsy
(3) skin/musculoskeletal procedures
NOT considered high risk procedures for infective endocarditis?
GU/GI
vaginal/cesarean delivery
infective endocarditis antibiotic of choice? If allergic?
amoxicillin or ampicillin 2g one hour prior to incision
allergy: give clinda 600 mg, azithro 500 mg or ceftriaxone 1g
drug contraindicated in ACUTE heart failure?
beta blockers due to NEGATIVE INOTROPIC effects
pressures and ETCO2 if ACLS chest compressions are adequate?
pressures = 20-25
ETCO2 > 20
Patient should be on preoperative beta blocker with how many risk factors?
> 3
CHF, CAD, CKD, CVA or DM
Drug 90% effective in converting new onset atrial flutter?
ibutilide
Factors that improve defibrillation?
quick defibrillation
use of electrode gel - decreases transthoracic resistance
biphasic LOW energy defibrillation (better than monophasic)
larger electrodes 8-12 cm
Right coronary artery supplies:
SA/AV nodes
Posterior descending artery
Posteromedial papillary muscle
Right (acute) marginal artery (supplies lateral right ventricle - only lateral territory supplied by RCA)
(INFERIOR territories plus posterior and lateral right ventricle)
Left coronary artery supplies:
LAD and LCX
Anterior and lateral territories plus most of septum
QT interval with hyperphosphatemia?
Prolonged
The pacemaker rate should always be ________ than the patient’s intrinsic heart rate to prevent R on T phenomena in an asynchronous mode.
faster
Most useful TEE measurement for the assessment of left ventricular DIASTOLIC function?
mitral inflow velocities
via transmitral pulsed wave Doppler
Best TEE view to detect lateral wall motion abnormalities?
mid-esophageal 4 chamber view: shows anterolateral wall (LAD and LCX) and inferoseptal wall
Best view TEE to evaluate right coronary distribution?
mid-esophageal 2 chamber view
Red arrow pointing to?
Where are the inferior vs anterior walls on the transgastric mid papillary short axis view?
What is the coronary distribution of the walls in the transgastric midpapillary short axis view?
Name the different segments on this view
Coronary distribution?
Main walls on mid esophageal 2-chamber view?
Mid Esophageal Commissural View Between 45-60 degrees?
Advantages of the Mid Esophageal Long Axis View at around 130 degrees?
LVOT is clearly seen and the aortic valve can be assessed for the presence of aortic insufficiency in this view. The A2 leaflet is closest to the LVOT and the P2 leaflet of the mitral valve is seen on the left of the image
Mainstay treatment in LQTS?
Beta blockade! Cardiac pacemakers or AICDs if beta blockade not efficacious or too many side effects.
Mid-systolic heart murmur heard with which lesions?
aortic stenosis
pulmonic stenosis
HOCM
diastolic murmurs?
PR ARMS
pulm regurg
aortic regurg
mitral stenosis
**all others are systolic murmurs
greatest advantage of mechanical heart valves? disadvantage?
greatest advantage is durability; prosthetic valves need replacement in 10-20- years; mechanical valves last longer than 20 years
greatest disadvantage: more thrombogenic and require systemic anticoagulation so avoided in childbearing age women and those at high risk of bleeding/falling
infective endocarditis has a high in-hospital mortality rate that further increases with any of of the following:
prosthetic valve heart failure septic shock neuro abnormalities advanced age
**interestingly acute renal failure does not increase mortality risk
A = positive inotropy B = normal C = negative inotropy D = cardiogenic failure
A = diuretics B = vasodilators (ace-i or ntg) C = inotropy plus vasodilation (milrinone) D = inotropy (epi/NE/exercise)
How to measure bivalirudin anti-coagulation activity?
Ecarin clotting time if for CPB
