Cardiac Adult Flashcards
1
Q
Debakey Type II Dissection
A
A DeBakey type II
dissection is limited to the ascending aorta and all involvement is proximal to the innominate artery.
10-15% of all dissectons
NB: Debakey - type 1 is the whole thing, type II is proximal, type III is distal
2
Q
Comparison of the of size of the tricuspid and mitral valves
A
-
Annular size
- 28-32mm for the mitral valve
- 28-34mm for the tricuspid valve.
3
Q
Long term prognosis following tricuspid valve excision for endocarditis
A
(1) approximately one-half of the patients report ankle edema and mild exercise intolerance.
(2) Early death occurs in 12% of drug addicts after excision without replacement of the tricuspid valve.
(3) Hemodynamic and functional statuses begin to progressively deteriorate after 5 years.
(4) Late survival in such patients is 63% at 15 years, with death due to return to drug addiction and not to recurrent right-sided endocarditis.
4
Q
Quantification of Tricuspid Regurgitation on Transesophageal Echocardiogram
A
- mild is confined to the inferior half of the right atrium (1+ to 2+)
- moderate spans the entire depth of the right atrium (3+)
- severe spans the entire atrial depth with r_etrograde systolic flow into the hepatic veins_ (4+)
5
Q
Treatment and diagnosis of a suspected pericardial effusion?
A
-
Treatment and diagnosis
- Pericardiocentesis is an appropriate first therapeutic maneuver and cytology samples may confirm malignancy.
- Approximately 40% of malignant effusion taps, however, are non-diagnostic and the effusion recurrence rate is high.
- Pericardial biopsy doubles the diagnostic accuracy and improves drainage.
6
Q
ECG in Tricuspid Stenosis vs Regurgitaion
A
tricuspid regurgitation: the electrocardiogram displays a reversed QRS complex and T wave, consistent with right ventricular hypertrophy.
tricuspid stenosis: the QRS complex is normal, but the P waves are prominent in leads II and V1.
7
Q
Symptom criteria for catheter intervention for mitral stenosis (valvotomy or valvuloplasty) ?
A
Criteria for catheter intervention for mitral stenosis (valvotomy or valvuloplasty) :
· symptoms: NYHA Class II or worse
8
Q
AFFIRM TRIAL
- Anticoagulation used ?
A
AFFIRM
A/C Used?
The INR goal for all patients was 2.0-3.0, but warfarin was stopped in selected patients in the rhythm control group (under 15%) who were in stable NSR.
9
Q
Classification?
% of dissection
A
Debakey 1 :
- originates in the ascending aorta and involves both the ascending and descending aorta at least distal to the innominate artery.
- 60% of dissections
10
Q
Does the type of mitral annuloplasty affect the devellopment of SAM
A
No. The type of ring annuloplasty does not influence the risk of SAM, and this condition has been reported with essentially all types of annuloplasty rings (flexible, rigid, semi-rigid rings and partial or complete designs).
11
Q
Mitral Valve - coaptation depth ?
A
Coaptation Depth:
- the distance between the annular plane and the plane of leaflet coaptation,
- measure of the degree of leaflet tethering and correlates with the severity of ischemic mitral regurgitation.
12
Q
Criteria for ischemic mitral regurgitation ?
A
Ischemic mitral regurgitation may; therefore, best be defined by the presence of all of the following:
- Prior history of myocardial infarction
- Tethering of predominantly P2 and P3
- Type IIIb Carpentier dysfunction
13
Q
Echo criteria for mild mitral stenosis
A
MVA > 1.5cm2
14
Q
Valve characteristic criteria for catheter intervention for mitral stenosis (valvotomy or valvuloplasty) :
A
Valve characteristic criteria for catheter intervention for mitral stenosis (valvotomy or valvuloplasty) :
Moderate to severe mitral stenosis (MVA < 1.5cm2)
Favoral valve morphology:
- Non calcified,
- Pliable,
- Wilkins score <8
15
Q
Indications for Surgery for Tricuspid valve endocarditis:
A
Fever and leucocytosis alone are not sufficient indications for surgical intervention in patients with tricuspid valve infections.
Deteriorating hemodynamics or persistent positive blood cultures beyond 2 to 3 weeks should be present before operation is undertaken.
While recurrent cerebral or peripheral embolization is an indication for valve replacement for left-sided endocarditis, the same is not true for right-sided infections.
Recurrent pulmonary emboli are frequent, but do not mandate surgical intervention; if systemic sepsis is controlled, significant respiratory compromise rarely occurs.
16
Q
Tricuspid regurgiation - associated cxr
A
- Cardiomegaly
- increased size of the RA and RV
- a prominent azygos vein,
possible pleural effusion and upward diaphragmatic displacement owing to ascites
17
Q
Classification ?
% of all Dissections
A
Debakey type III
25-30%
18
Q
Thromboembolic risks associated with tricuspid valve replacement
A
- Thrombosis of prosthetic tricuspid valves occurs at a _rate of 1% per patient-yea_r.
- More common with past mechanical prostheses (Smeloff-Cutter, Bjork-Shiley) than with current bileaflet valves.
- Bioprosthetic valve thrombosis is rare.
- If a tricuspid prosthesis does clot, however, thrombolytic therapy has a reported success rate of over 80%.
- Pulmonary embolization rates following tricuspid replacement has been reported to be less than 1%.
19
Q
what is this
A
“square-root sign” and is caused by rapid early diastolic filling followed by limited ventricular filling due to maximal ventricular wall distension allowed by the pericardium.
Limited ventricular filling is seen in both cardiac tamponade and constrictive pericarditis.
right ventricular end-diastolic pressure is one third or more of the right ventricular systolic pressure
the left ventricular systolic function is normal
20
Q
AFFIRM TRIAL
Study Design ?
A
AFFIRM
Study Design: 213 study sites randomized 4060 patients over age 65 or with risk factors for stroke or death.
Study Groups:
- Cardioversion and antiarrhythmic drugs (all classes) were used in the rhythm control group to achieve and maintain sinus rhythm.
- Rate Control Group beta-blockers, calcium channel blockers, and digoxin were used to achieve a heart rate less than 80.
21
Q
JVP in patients with Tricuspid Regurgiation
A
- CVP wave form
- Impressive jugular venous distention with an s-wave or fused c- and v- waves, followed by a prominent y- descent, is present.
- During inspiration, this finding is accentuated because of the physiologic increase in venous return.
22
Q
Does the size of an annuloplasty righ affect the devellopment of SAM
A
Yes.
Bigger tends to be better from SAM prerspective
Example scenerio demonstrates a 40mm band, which is the largest available
23
Q
Immunohistocytology for pheochromocytoma
A
-
Neuroendocrine tumor markers are positive:
- chromogranin
- synaptophysin
- gamma-enolase,
- nuclear S100,
- CD56.
- Cytokeratin stain is negative.
24
Q
Role of revascularization with post MI mitral regurgitation
A
Concurrent revascularization lowers perioperative mortality and all critical abnormalities should be addressed at the time of operation.
25
Histologic appearance of pheo
1. appearance is rather bland,
2. with nests of pale cells with round nuclei
3. prominent pale pink cytoplasm
4. Nuclei are pleomorphic but there is essentially no mitotic activity.
26
Posterior bleeding durring **mitral surgery** - *Posterior disruption*
who is the population at risk?
* more common in _women_ and _elderly_ patients, but can also occur in young patients following _decalcification_ for mitral repair.
27
Effusive - constrictive pericarditis
1. presentation
2. treatment
1. _Effusive-constrictive pericarditis should be considered in patients who present with a pericardial effusion and thickened pericardium._
2. *Clinical presentation* of EFFUSIVE-CONSTRICTIVE PERICARDITIS.
1. These patients typically present 1-4 years after radiation therapy with tamponade-like symptoms.
2. Drainage fails to relieve symptoms because residual constrictive physiology persists.
3. Treatment of EFFUSIVE CONSTRICTIVE PERICARDITIS:
1. Conservative or expectant care will provide no improvement.
2. When effusive-constrictive disease is identified **pericardiectomy** should be performed promptly.
28
CVP wave form
when does atrial systole go
**atrial systole** is from the trough of the **Y** descent to the **a** peak
29
**Carney Complex**
General definition
**CARNEY COMPLEX**
* Multiple endocrine neoplasia
* Typified by multiple nevi
* Nearly complete penetrance
* Myxomas are common - in any chamber
30
**ECG of tricuspid stenosis:**
**ECG of tricuspid stenosis:** the QRS complex is normal, but the P waves are prominent in leads II and V1.
31
AFFIRM TRIAL
1. what does it stand for?
2. Study Design ?
3. what were the study groups ?
4. Anticoagulation used ?
5. End points ?
6. Cross over rates?
7. QOL
8. Overall Prognosis and conclusion
AFFIRM
1. Atrial Fibrillation Follow-up Investigation of Rhythm Management
_2. Study Design:_ 213 study sites randomized 4060 patients over age 65 or with risk factors for stroke or death.
3. Study Groups:
* Cardioversion and antiarrhythmic drugs (all classes) were used in the rhythm control group to achieve and maintain sinus rhythm.
* Rate Control Group beta-blockers, calcium channel blockers, and digoxin were used to achieve a heart rate less than 80.
A/C Used?
The INR goal for all patients was 2.0-3.0, but warfarin was stopped in selected patients in the rhythm control group (under 15%) who were in stable NSR.
5. End point? Study endpoints were death, disabling stroke, disabling anoxic encephalopathy, major bleeding, and cardiac arrest.
viii. The actuarial crossover rates?
· from rhythm control to rate control were 17%, 27% and 37% after one, three, and five years, respectively.
_What was the stroke rate?_ The stroke rate was about 1%/year in each group and most events happened when warfarin had been stopped or when the INR was subtherapeutic.
7. _Quality of life assessments_ were similar between groups. The adjusted hazard ratio for death was higher in the rhythm control group for older patients, those without CHF and those with CAD.
8. The outlook for the rhythm control group appeared to worsen later in the study (average follow-up was 3.5 years).
xii. Cause of death analysis was not completed in this study.
xiii. Investigators concluded that the strategy of restoring and maintaining sinus rhythm had no clear advantage over controlling the ventricular rate and allowing atrial fibrillation to persist.
* However, on multivariate analysis, the presence of sinus rhythm was an independent predictor of improved survival.*
Newer studies confirm conclusions of the AFFIRM (Atrial
32
Posterior bleeding durring **mitral surgery** - *Circumflex coronary artery injury* -
How is it _corrected_?
1. The correct response is a graft to a distal circumflex marginal branch, but great care must be taken.
33
Posterior bleeding durring **mitral surgery** - *Circumflex coronary artery injury* -
How is it identified?
1. Associated findings:
* Bleeding can occur from the atrioventricular groove
* generally modest
* ensues following removal of the cross-clamp.
* Low cardiac output and posterolateral or inferior wall dysfunction after weaning from bypass should raise suspicion of circumflex injury or occlusion.
34
CVP wave form - when is the atrial sysotle and diastole when is the ventricular systole and diastole
see pic
35
Most common cancers causing malignant pericardial effusions?
1. The most common malignancies that involve the pericardium are:
1. lung cancer
2. breast cancer
3. malignant melanoma
4. lymphoma
36
Reasons to suspect familial myxoma
tumors are multiple
recurrent
atypically located
37
Crawford classification of TAAA
38
Incidence of **pericardial effusions** in _HIV_ patients?
Incidence – 5%
39
Indications for *concomitant repair* of *moderate* tricuspid regurgitation with mitral valve repair are:
1. _significant pulmonary hypertension_,
1. *especially* if it is long-standing or minimally reversible;
2. _long-standing right ventricular dilation_,
1. *especially* with tricuspid annular enlargement;
3. _tricuspid regurgitation that has been clinically significant and constant with persistent evidence of right heart failure._
40
What type of CVP tracing is this
CVP Tracing of TR
CVP wave form: Impressive jugular venous distention with an s-wave or fused c- and v- waves, followed by a prominent y- descent, is present.
During inspiration, this finding is accentuated because of the physiologic increase in venous return.
41
Apelin
Apelin is the endogenous ligand for the G-protein-coupled APJ receptor that is expressed at the surface of some cell types including cardiac cells
## Footnote
the cardiomyocytes of the adult where apelin behaves as one of the most potent stimulator of cardiac contractility
42
how arethe ventricular pressures in constriction?
**Limited ventricular filling** is seen in both cardiac tamponade and constrictive pericarditis.
_right ventricular end-diastolic pressure_ is one third or more of the right ventricular systolic pressure
the _left ventricular systolic function_ is normal
43
Techniques of shortening the anterior leaflet
1. transverse incision toward the base of the anterior leaflet and re-suturing
* will shorten the leaflet by 5 to 7 mm
2. resect a 2 to 3 mm transverse ellipse of the leaflet before re-suturing
* shorten the leaflet by 7 to 10 mm
3. A triangular resection of A2 is another option to shorten its length
44
Most common cause of sudden cardiac death in the young
HOCM
45
AFFIRM TRIAL
1. what does it stand for?
AFFIRM
1. Atrial Fibrillation Follow-up Investigation of Rhythm Management
46
Criteria for isolated mitral valve repair
1. Presence of symptoms
1. Note NYHA class correlates with post operative outcomes
2. left ventricular ejection fraction (≤ 60%)
3. the left ventricular end-systolic dimension is greater than 45mm
4. Atrial fibrillation
5. Pulmonary Hypertension
1. PAs \> 50mmHg at rest
2. PAs\> 60mmHg with exercise
6. While there is a consensus that patients in whom mitral repair is feasible should undergo surgery before left ventricular decompensation is documented, the poorer outcomes associated with mitral replacement mean that _asymptomatic patients with severe mitral regurgitation but preserved left ventricular function should not undergo surgery unless a greater than 90% successful repair rate is likely._
47
Posterior bleeding durring **mitral surgery** - *Circumflex coronary artery injury* -
How does it happen?
1. can occur during mitral valve replacement or repair if sutures are placed too far behind the posterior annulus.
48
How can **mitral surgery** be performed *without* cardiac arrest?
When mitral valve repair is performed via right anterior thoracotomy in patients with a relative contraindication to median sternotomy, the left side of the heart can be opened while the heart beats, *as long as aortic pressure is maintained and the ventricle is kept empty to avoid systemic air embolization.*
49
Incidence of severe TR at the time of Mitral valave repair
* **TR** is s severe in _10-20% of patients_ who undergo **mitral valve procedures.**
50
Tricuspid stenosis - most frequent aetiology
(a) most commonly rheumatic à rare to have isolated tricuspid stenosis, as some degree of TR is always present and coexisting mitral and aortic disease are occasionally seen.
51
ECG of tricuspid regurgitation:
tricuspid regurgitation: the electrocardiogram displays a reversed QRS complex and T wave, consistent with right ventricular hypertrophy.
52
AFFIRM TRIAL
1. End points ?
. End point? Study endpoints were death, disabling stroke, disabling anoxic encephalopathy, major bleeding, and cardiac arrest.
53
CVP tracing with a steep Y descent
*y descent occurs with the opening of the tricuspid valve* - and *corelates with atrial emptying*
a **steep** descent correlates with _rapid atrial emptying_
consistent with **constrictive pericarditis** or **tampnnade**
in **tamponnnade** the _y-descent is **attenuated**._
54
criteria for percutaneous mitral valvotomy or valvuloplasty
Criteria for catheter intervention for mitral stenosis (valvotomy or valvuloplasty) :
**· symptoms:** NYHA Class II or worse
· **valve characteristics:**
1. Favoral valve morphology: Non calcified, Pliable, Wilkins score \<8
2. Moderate to severe mitral stenosis
· **pulmonary artery pressures.**
\>50mmHg at Rest
\> 60 mmHg during Exercise .
55
CVP Tracing
what do large A-waves indicate ?
Large a waves indicate that the right atrium is contacting against increased resistance
*Example*:
* tricuspid stenosis
* pulmonary stenosis
* pulmonary hypertension
56
Definitive imaging useful to confirm or rule out a pheochromocytoma
131MIBG scan
111indium octreotide scan
is a more specific confirmatory imaging study for this tumor.
57
HOCM Surgical Ressection vs ETOH injection
A 2005 Canadian study compared outcomes of 48 patients who had myomectomy with 60 that underwent alcohol injection.
The surgical group had superior outcomes in virtually every measure including:
i. functional class
ii. survival
iii. freedom from pacemakers
iv. pressure gradient
v. mitral systolic anterior motion.
vi. The measured septal thickness and the incidence of mitral regurgitation were similar at an average follow-up interval of 2.2 years
J Thorac Cardiovasc Surg. 2005 Feb;129(2):351-8.
Hypertrophic obstructive cardiomyopathy: comparison of outcomes after myectomy or alcohol ablation adjusted by propensity score.
Ralph-Edwards A, Woo A, McCrindle BW, Shapero JL, Schwartz L, Rakowski H, Wigle ED, Williams WG.
58
Debakey Classification ?
% of all ?
**DeBakey type II**
dissection is limited to the ascending aorta and all involvement is proximal to the innominate artery.
10-15% of all dissectons
NB: Type 1 is the whole arota; II is proximal, and III is distal
59
what type of CVP tracing is this
Tricuspid stenosis
## Footnote
In sinus rhythm, the right atrial tracing and jugular venous pulse have prominent a-waves that accentuate with inspiration
60
Selection criteria for CRT ?
1. cardiomyopathy (ischemic or nonischemic)
2. NYHA functional class III or IV despite maximal medical therapy (but not on continuous IV therapy),
3. left ventricular ejection fraction ≤ 35%
4. QRS duration ≥ 120 msec (bundle branch block)
5. sinus rhythm.
61
Transplant
Claimed advantages of the bi-caval vs the biatrial anastomosis
1. decreased diuretic requirements
not a huge RA as in the bi-atrial
2. lower incidences of atrial arrhythmias
3. less conduction disturbance
4. decreased A-V valve regurgitation
5. efficient atrial transport
6. less right ventricular failure
7. reduced length of stay.
62
**Atrial Fibrillation**
## Footnote
Epicardial autonomic lowering of the atrial fibrillation threshold is mediated through:
A. Acetylcholine,
B.Apelin
c. Epinepherine
d. Histamine
e. Vasopressin
In the laboratory "_cholinergic atrial fibrillation_" can be maintained or induced by exogenous a**cetylcholine, carbachol, methacholine or bethanechol.**
Vasopressin, dopamine and epinephrine all lower the threshold for atrial fibrillation but they are neither neurotransmitters nor selective receptor simulators.
63
*Most common bacteria* causing **native tricuspid valve endocardidis**
* Most common bacteria* causing **native tricuspid valve endocardidis:**
* Staphylococcus aureus*, which is often methicillin resistant
64
Most common causes of chylous pericardial effusion?
Chylous pericardial effusions are rare, but they may be seen with:
extensive mediastinal disease from lymphoma
leukemia
small cell carcinoma
65
Compare/ Contrast the **Mitral** and **Tricuspid** _leaflet_ phenotype
1. _Mitral valve_ leaflets can be separated into two (anterior leaflet) or three (posterior leaflet) distinct zones:
* (1) Distal rough zone, which represents the zone of coaptation and receives the insertion of the chordae tendineae on its ventricular surface
* (2) Proximal clear zone, which has no chordal attachments,
* (3) Basal zone (only posterior leaflet) which receives tertiary chordae tendineae directly from the ventricular surface.
_Tricuspid valve_ leaflets also can be separated into three distinct zones, but all zones receive chordal attachments
66
Incidence of heart block following a tricuspid replacement
The early postoperative incidence of complete heart block following tricuspid valve replacement is approximately 5-15%, but 25-45% of patients will develop heart block later on, presumably due to scarring and fibrosis around the prosthesis.
67
Heart Transplant
**Late tricuspid regurgitation** with the bi-caval *vs* the bi-atrial technique:
1. Is seen after both techniques
2. most commonly caused by chordal and leaflet disruption from frequent right ventricular endomyocardial biopsies.
68
AFFIRM TRIAL
1. what does it stand for?
2. Study Design ?
3. what were the study groups ?
4. Anticoagulation used ?
5. End points ?
6. Cross over rates?
7. QOL
8. Overall Prognosis and conclusion
AFFIRM
1. Atrial Fibrillation Follow-up Investigation of Rhythm Management
_2. Study Design:_ 213 study sites randomized 4060 patients over age 65 or with risk factors for stroke or death.
3. Study Groups:
* Cardioversion and antiarrhythmic drugs (all classes) were used in the rhythm control group to achieve and maintain sinus rhythm.
* Rate Control Group beta-blockers, calcium channel blockers, and digoxin were used to achieve a heart rate less than 80.
A/C Used?
The INR goal for all patients was 2.0-3.0, but warfarin was stopped in selected patients in the rhythm control group (under 15%) who were in stable NSR.
5. End point? Study endpoints were death, disabling stroke, disabling anoxic encephalopathy, major bleeding, and cardiac arrest.
viii. The actuarial crossover rates?
· from rhythm control to rate control were 17%, 27% and 37% after one, three, and five years, respectively.
_What was the stroke rate?_ The stroke rate was about 1%/year in each group and most events happened when warfarin had been stopped or when the INR was subtherapeutic.
7. _Quality of life assessments_ were similar between groups. The adjusted hazard ratio for death was higher in the rhythm control group for older patients, those without CHF and those with CAD.
8. The outlook for the rhythm control group appeared to worsen later in the study (average follow-up was 3.5 years).
xii. Cause of death analysis was not completed in this study.
xiii. Investigators concluded that the strategy of restoring and maintaining sinus rhythm had no clear advantage over controlling the ventricular rate and allowing atrial fibrillation to persist.
* However, on multivariate analysis, the presence of sinus rhythm was an independent predictor of improved survival.*
Newer studies confirm conclusions of the AFFIRM (Atrial
69
An impressive jugular venous distention with:
an s-wave or fused c- and v- waves, followed by a prominent y- descent
Tricuspid regurgitation
70
Fundamental rule in treating *posterior blood* following **Mitral valve Surgery**
*However, under no circumstance should the heart be elevated following mitral valve replacement to inspect the area nor should repair be attempted without cardiopulmonary bypass. Otherwise, atrioventricular groove disruption may occur.*
71
Proporiton of HOCM patients that are susceptible to SCD
a minority of all HCM patients is susceptible to this risk (10%-15%).
72
**Retrograde Cardioplegia**
Delivery in the presence of a persistent LSVC
**Retrograde Cardioplegia** & **Presence of a left superior vena cava**
1. _if an innominate vein is present_: it can be occluded **during cardiopulmonary bypass** to allow retrograde coronary perfusion.
2. _if the innominate vein is absent:_ assessment of its size and the presence of a **right SVC** is important.
1. _Options are:_
* Retrograde cardioplegia may be given with intermittent LSVC occlusion if LSVC pressure monitoring indicates safety,
or
* if the occluded LSVC is decompressed with a cannula into the venous circuit
73
Asymptomatic Mitral Regurgitation
Asymptomatic patients with chronic mitral regurgitation should be treated medically unless there is left ventricular enlargement (based on echo, x-ray and physical examination).
**_ACC/AHA Procedure Guidelines for patients with valvular heart disease favor surgical intervention when:_**
1. the ejection fraction is under 60% or
2. the left ventricular end-systolic dimension is greater than 45mm
74
Chamber size in TS and TR
TS: the RA enlarges while the RV becomes small
TR: Ra and RV booth enlarge
75
Perioperative pmedical management of a patient with pheochromocytoma
1. _Volume_ loading
2. _alpha_ blockade prior to beta-blockade
* _beta_ blockade is rarely required
3. strict _glucose_ monitoring
4. Occasionally _alpha-methylparatyrosine_ (an inhibitor of tyrosine 3-mono-oxygenase, and consequently of catecholamine synthesis) is useful as well.
76
**CVP Tracing**
v-wave in tricuspid regurgitation
The v wave, which results from increasing blood in the right atrium during ventricular systole, is prominent with tricuspid regurgitation
77
AFFIRM TRIAL
1. Overall Prognosis and conclusion
AFFIRM
Cause of death analysis was not completed in this study.
Investigators concluded that the strategy of restoring and maintaining sinus rhythm had no clear advantage over controlling the ventricular rate and allowing atrial fibrillation to persist.
*However, on multivariate analysis, the presence of sinus rhythm was an independent predictor of improved survival.*
Newer studies confirm conclusions of the AFFIRM (Atrial
78
Differential diagnosis of effusions after radiation therapy.
1.
1. Effusive-constrictive pericarditis
1. 2. _DDx:_
1. _Acute phase:_ Asymptomatic pericardial effusion with pericarditis is a common finding during the acute phase of radiation-induced pericardial disease.
2. _Delayed pericarditis_ with or without effusion may present months to years following radiation therapy.
3. _Effusive-constrictive pericarditis_: should be considered in patients who present with a pericardial effusion and thickened pericardium.
1. These patients typically present 1-4 years after radiation therapy with tamponade-like symptoms.
2. Drainage fails to relieve symptoms because residual constrictive physiology persists.
79
**Anatomy** of _*functional* Tricuspid Regurgitation_
1. involves the anterior two-thirds of the annulus,
2. both the anterior and posterior leaflets.
* septal leaflet is attached to the fibrous skeleton of the heart and does not dilate.
* Dilation occurs with a 2:1 ratio in the posterior versus anterior leaflet,
3. necessitating inclusion of the posterior leaflet during tricuspid annuloplasty.
80
what type of CVP tracing is this ?
Constrictive pericarditis
81
**Kussmaul sign**
_Kussmaul sign_ is a :
paradoxical rise in jugular venous pressure (JVP) on inspiration,
or
a failure in the appropriate fall of the JVP with inspiration.
It can be seen in some forms of heart disease and is usually indicative of limited right ventricular filling due to right heart dysfunction.
82
**Carney complex**
Other systems to be concerned about
Myxomas can appear anywhere in any chamber
May often recur
can be seen on the eyeline, ear, breast, nipple
May be part of MEN; therefore, need to think with respect to:
Thyroid, adrenal, pituitary, testicle and breast
83
_% pericardial centesis_ of **malignant pericardial effusion** with *negative cytology*
Approximately **40% of malignant effusion taps, however, are non-diagnostic** and the effusion recurrence rate is high.
84
Components of normal cvp tracing
The normal central venous pressure tracing consists of three positive waves (a, c, v) and two negative troughs (x, y)
85
**Pulmonary artery pressure** criteria for _catheter intervention for mitral stenosis_ (valvotomy or valvuloplasty) ?
Criteria for catheter intervention for mitral stenosis (valvotomy or valvuloplasty) :
**Pulmonary artery pressures.**
1. \>50mmHg at Rest
2. \> 60 mmHg during Exercise .
86
Stanford / Debakey Proximal aortic classification system?
87
What type of CVP tracing is this?
Normal CVP tracing
88
Effectiveness of ETOH injection for HOCM
i. Current follow-up studies in multiple centers report an effectiveness of 75%-80%.
89
Causes of *posterior blood* following **Mitral valve Surgery**
1. _Injury to the *circumflex coronary artery*_:
1. can occur during mitral valve replacement or repair if sutures are placed too far behind the posterior annulus.
* Associated findings
* Bleeding can occur from the atrioventricular groove
* generally modest
* ensues following removal of the cross-clamp.
* Low cardiac output and posterolateral or inferior wall dysfunction after weaning from bypass should raise suspicion of circumflex injury or occlusion.
2. The correct response is a graft to a distal circumflex marginal branch, but great care must be taken.
3. The heart must not be lifted or aggressively rolled to the right, which will promote atrioventricular disruption or penetration of the posterior left ventricular wall by the struts of the bioprosthetic mitral valve.
2. _Perforation of the posterior left ventricular wall can occur secondary to vent placement._
1. generally be repaired with 2-0 or 3-0 pledgeted mattress sutures in an empty, beating heart.
2. *However, under no circumstance should the heart be elevated following mitral valve replacement to inspect the area nor should repair be attempted without cardiopulmonary bypass. Otherwise, atrioventricular groove disruption may occur.*
3. _Coronary sinus injury:_
1. generally the result of either :
* forceful cannula placement
* continued infusion when the coronary sinus pressure exceeds 50-60mmHg.
2. **Identification**:
* Perforation presents most often during infusion of cardioplegia while the cross-clamp is on.
* The perfusionists notes high pressure, then low pressure, or the surgeon sees arterial blood posteriorly during infusion.
* Even if perforation is not noticed until the procedure is complete, a significant bleed would generally present shortly after removal of the catheter rather than after discontinuation of cardiopulmonary bypass.
3. **Repair**:
* direct suture repair with a pledgeted pursestring 4-0 or 5-0 polypropylene suture around the perforated cannula is ideal
* a pericardial patch can be secured to the cardiac surface externally around the ruptured vein to seal the area.
* A hematoma in the atrioventricular groove from coronary sinus disruption can sometimes be left alone since low venous pressure permits self-containment after protamine administration.
4. Once injury is identified and repaired, the catheter should not be reinserted and an alternate mode of myocardial protection should be employed.
Another infrequent complication is placement of a valve suture through the coronary sinus balloon. Extraction of the catheter requires force, but coronary sinus injury is usually minimal.
1. _Atrioventricular groove disruption is one of the most dreaded complications in cardiac surgery._
1. This occurs most often with elevation of the left ventricle following mitral valve replacement.
2. It is more common when the mitral annulus is calcified.
3. *also* been reported with off-pump coronary artery bypass grafting during exposure of the _circumflex coronary artery._
4. Disruption in this area occurs due to separation between the left atrium and ventricle in the back of the heart.
5. Population at risk:
* more common in women and elderly patients, but can also occur in young patients following decalcification for mitral repair.
2. Classic descriptions for repair include reinstitution of cardiopulmonary bypass, cardioplegic arrest, and repeat left atriotomy with pledgeted suture repair from both within and outside the heart after removing the prosthesis. However, primary suture repair can injure both the circumflex artery and coronary sinus in the atrioventricular groove and has met with limited success in most reports. Pericardial patch reconstruction of the posterior annulus after removing the prosthesis currently offers the best chance at successful repair. For pericardial patch reconstruction of the posterior annulus, a circumferential bovine pericardial patch is sutured into left ventricular endocardium far from the groove, then across the annulus at the anterolateral and posteromedial commissures, with completion to the left atrial endocardium above the annulus. Deep bites with a running 4-0 polypropylene suture will generally hold the patch in place since the tendency is for left ventricular pressure to push the patch against the endocardium. Pledgeted valve sutures can then be secured into the patch in the region of the posterior annulus leaving the atrioventricular groove untouched. The risk of this complication can probably be minimized if trouble is anticipated and addressed with techniques similar to pericardial patch reconstruction of the posterior mitral annulus in patients with extensive calcification.
Encouraging results were also reported with multiple applications of _an epicardial tissue sealant composed of a biodegradable collagen/fibrinogen system._ This may be a favorable option for a minor atrioventricular groove disruption with a small leak
90
Best predicotor of survival for patients with asymptomatic MR
NYHA class is strongly predictive of late survival.
91
**_Sliding valvuloplasty_**
use?
Hints to determine measurements?
sliding valvuloplasty
1) to deal with myxomatous valves with excess, prolapsing tissue.
2) decrease the height of the remaining posterior leaflet tissue if :
* it exceeds 1.5 cm.
4) In the illustration the hooks used for valve analysis are 1 mm in diameter and the angled portion is 5 mm long.
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AFFIRM TRIAL
1. QOL ?
_Quality of life assessments_ were similar between groups. The adjusted hazard ratio for death was higher in the rhythm control group for older patients, those without CHF and those with CAD.
93
**Left venticular indicines** for prediction of the benefit of surgery for _ischemic MR_ with _severe heart failrue ?_
A recent review of outcomes in patients undergoing combined CABG and mitral valve annuloplasty for ischemic MR suggests:
1. **left ventricular end-diastolic diameter (LVEDD) \> 6.5 cm** is associated with:
1. reduced reverse remodeling
2. elevated early and late postoperative mortality.
2. **left ventricular end-systolic volume index (LVESVI) \> 150 mL/m2** predicts the same bad outcomes.
94
Current ACC/AHA **Class I** indications for surgery in _native valve endocarditis_ include:
1) *any* *acute* valve lesion resulting in **heart failure**
2) **aortic or mitral regurgitation** with **hemodynamic evidence** of elevated _left ventricular end-diastolic or left atrial pressures_ or _moderate pulmonary hypertension_
3) structural complications such as annular or aortic abscess, or other _destructive penetrating lesions_ including fistulae and _"kissing lesions"_
4) _fungal_ or other _highly resistant organisms_
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AFFIRM TRIAL
1. Stroke rate
_What was the stroke rate?_ The stroke rate was about 1%/year in each group and most events happened when warfarin had been stopped or when the INR was subtherapeutic.
96
When these maneuvers fail to reverse SAM the cause is usually a discrepancy between:
When these maneuvers fail to _reverse_ **SAM** the cause is usually a discrepancy between:
1. the residual anterior and posterior leaflet heights
2. the septal-lateral diameter of the mitral annulus following ring annuloplasty.
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**Retrograde cardioplegia**
Optimal retrograde cardioplegia perfusion pressure ?
Optimal pressure is around 40mmHg
## Footnote
*Higher than **50-60mmHg is Dangerous***
98
**Retrograde Cardioplegia**
Minimum Coronary Sinus pressure to ensure appropriate position?
\< 20mmHg
99
How to differentiate _organic_ from _functional_ **tricuspid regurgiation**?
(1) Generally, if the patient with severe tricuspid regurgitation has a right ventricular systolic pressure above 60 mmHg, then the tricuspid regurgitation is functional and the result of left-sided heart failure.
(2) However, if the right ventricular systolic pressure is 40 mmHg, there is a substantial organic component.
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Tricuspid regurgitaion
Most common etiology
Left sided heart failure
