cardiac misc (incl misc AHA e.g. gen valve, arrhythmia, anticoag, endocarditis incl ppx, HOCM)

Question 1

only class 1 recommendation for infxn ppx

Answer 1

Secondary Prevention of Rheumatic Fever
“In patients with rheumatic heart disease, secondary prevention of rheumatic fever is indicated.”

2° ppx = PCN G IM Q4W or PCN V PO BID
for whichever is longer of:
- rheumatic fever (RF) + carditis + residual valvular dz = 10y OR >40yo
- RF + carditis + NO valvular dz = 10y OR >21yo
- RF + NO carditis = 5y OR >21yo

“In pts with documented valvular heart disease, the duration of rheumatic fever prophylaxis should be ≥10 y or until the patient is 40 y of age (whichever is longer).
Lifelong prophylaxis may be recommended if the patient is at high risk of group A streptococcus exposure. Secondary rheumatic heart disease prophylaxis is required even after valve replacement.”

Question 2

Which types of dental procedures may require abx ppx for endocarditis?

Answer 2

“dental procedures that involve:
- manipulation of gingival tissue,
- manipulation of the periapical region of teeth, or
- perforation of the oral mucosa”

Question 3

Which valvular dz entities require endocarditis abx ppx for dental procedures?

involving manipulation of gingival tissue, manipulation of periapical region of teeth, or perforation of the oral mucosa

Answer 3

• h/o previous IE
• prosthetic valves incl TAVI & homografts Prosthetic cardiac valves, including transcatheter-implanted prostheses and homografts.
• non-valve prostheses Prosthetic material used for cardiac valve repair, such as annuloplasty rings, chords, or clips.
• un-rx cyanotic congenital dz OR rx with residual shunts or regurg at/near prothetic material Unrepaired cyanotic congenital heart disease or repaired congenital heart disease, with residual shunts or valvular regurgitation at the site of or adjacent to the site of a prosthetic patch or prosthetic device.
• structural regurg in transplanted heart Cardiac transplant with valve regurgitation attributable to a structurally abnormal valve.

Question 4

endocarditis abx ppx PO regimens

Answer 4

amoxicillin 2g x1
PCN/ampicillin allergy: Keflex 2g OR azithro 500mg OR clarithro 500mg OR doxy 100mg x1

30-60min before procedure

Question 5

endocarditis abx ppx non-PO regimens

Answer 5

• ampicillin
• Ancef/ceftrx if PCN allergy

ampicillin 2g IM/IV x1
PCN/ampicillin allergy:
Ancef OR ceftrx 1g IM/IV x1

30-60min before procedure

Question 6

preferred/default endocarditis abx ppx PO regimen

Answer 6

amoxicillin 2g x1

30-60min before procedure

Question 7

endocarditis abx ppx PO regimens with PCN/ampicillin allergy

Answer 7

one of:
- Keflex 2g
- azithro OR clarithro 500mg
- doxy 100mg
x1

30-60min before procedure

Question 8

Do high-IE-risk pts need endocarditis abx ppx for non-dental procedures (e.g. TEE, EGD, C-scope) in the absence of active infection?

Answer 8

NO
(3: no benefit)

Question 9

Does a dental procedure that involves manipulation of gingival tissue require endocarditis abx ppx?

Answer 9

YES
(2a)

Question 10

Does a dental procedure that involves manipulation of the periapical region of teeth require endocarditis abx ppx?

Answer 10

YES
(2a)

Question 11

Does a dental procedure that involves perforation of the oral mucosa require endocarditis abx ppx?

Answer 11

YES
(2a)

Question 12

Do patients with prosthetic valves incl TAVI & homografts require endocarditis abx ppx for high-risk dental procedures?

involving manipulation of gingival tissue, manipulation of periapical region of teeth, or perforation of the oral mucosa

Answer 12

YES
(2a)

Prosthetic cardiac valves, including transcatheter-implanted prostheses and homografts.

Question 13

Do patients with non-valve prostheses require endocarditis abx ppx for high-risk dental procedures?

involving manipulation of gingival tissue, manipulation of periapical region of teeth, or perforation of the oral mucosa

Answer 13

YES
(2a)

Prosthetic material used for cardiac valve repair, such as annuloplasty rings, chords, or clips.

Question 14

Do patients with previous IE require endocarditis abx ppx for high-risk dental procedures?

involving manipulation of gingival tissue, manipulation of periapical region of teeth, or perforation of the oral mucosa

Answer 14

YES
(2a)

Question 15

Do patients with un-rx cyanotic congenital dz require endocarditis abx ppx for high-risk dental procedures?

involving manipulation of gingival tissue, manipulation of periapical region of teeth, or perforation of the oral mucosa

Answer 15

YES
(2a)

OR rx with residual shunts or regurg at/near prothetic material

Unrepaired cyanotic congenital heart disease or repaired congenital heart disease, with residual shunts or valvular regurgitation at the site of or adjacent to the site of a prosthetic patch or prosthetic device.

Question 16

Do patients with rxed congenital heart dz with residual shunts or regurg at/near prothetic material require endocarditis abx ppx for high-risk dental procedures?

involving manipulation of gingival tissue, manipulation of periapical region of teeth, or perforation of the oral mucosa

Answer 16

YES
(2a)

OR un-rx cyanotic congenital dz

Unrepaired cyanotic congenital heart disease or repaired congenital heart disease, with residual shunts or valvular regurgitation at the site of or adjacent to the site of a prosthetic patch or prosthetic device.

Question 17

Do patients with structural regurg in a transplanted heart require endocarditis abx ppx for high-risk dental procedures?

involving manipulation of gingival tissue, manipulation of periapical region of teeth, or perforation of the oral mucosa

Answer 17

YES
(2a)

Cardiac transplant with valve regurgitation attributable to a structurally abnormal valve.

Question 18

post-valve-intervention periodic imaging

Answer 18

baseline post-proc TTE + periodic interval monitoring (1)
“In asymptomatic patients with any type of valve intervention, a baseline postprocedural TTE followed by periodic monitoring with TTE is recommended, depending on type of intervention, length of time after intervention, ventricular function, and concurrent cardiac conditions.”

Question 19

initial evaluation/imaging study for suspected HCM

Answer 19

TTE
(1)

Question 20

initial evaluation for suspected HCM

Answer 20

EKG (1)
TTE (1)
24-48h Holter (1)
SCD risk assessment (1)
± exercise stress test (2a)
FH (1) + cascade genetic testing (1)

“exercise stress testing is reasonable to determine functional capacity and to provide prognostic information as part of initial evaluation.”

Question 21

initial evaluation/non-imaging study(ies) for suspected HCM

Answer 21

EKG (1)
24-48h Holter (1)
± exercise stress test (2a)

“exercise stress testing is reasonable to determine functional capacity and to provide prognostic information as part of initial evaluation.”

Question 22

ongoing/subsequent imaging monitoring in HCM pts

(assuming no change in clinical status)

Answer 22

TTE Q1-2Y
(1)

to assess myocardial hypertrophy, dynamic LVOTO, MR, & myocardial fxn

Question 23

ongoing/subsequent non-imaging monitoring in HCM pts

(assuming no change in clinical status)

Answer 23

EKG Q1-2Y (1)
24-48h Holter (1)

Question 24

ongoing/subsequent monitoring in HCM pts

(assuming no change in clinical status)

Answer 24

EKG Q1-2Y (1)
24-48h Holter Q1-2Y (1)
TTE Q1-2Y (1)
SCD risk assessment Q1-2Y (1)

to assess myocardial hypertrophy, dynamic LVOTO, MR, & myocardial fxn

Question 25

evaluation of clinical change or new event in HCM pt

Answer 25

TTE (1)

Question 26

further evaluation of HCM pts with resting LVOT gradient \<50mmHg

Answer 26

TTE with provocative maneuvers (1)

Question 27

initial screening imaging for 1° relatives of HCM pts

Answer 27

TTE (1)

Question 28

initial screening for 1° relatives of HCM pts

Answer 28

EKG (1) TTE (1) cascade genetic testing (1)

Question 29

further evaluation of *sx* HCM pts with resting *& provoked* LVOT gradient \<50mmHg

Answer 29

exercise TTE (1) | for detection & quantification of dynamic LVOTO

Question 30

further evaluation of *asx* HCM pts with resting *& provoked* LVOT gradient \<50mmHg

Answer 30

exercise TTE (2a)

Question 31

imaging during surgical septal myectomy

Answer 31

intraop TEE (1) | to assess MV anatomy & fxn + myectomy adequacy

Question 32

f/u imaging after septal redux tx | EtOH septal ablation OR septal myectomy

Answer 32

TTE within 3-6mo (1) | to evaluate procedural results

Question 33

ongoing/subsequent monitoring for 1° relatives of HCM pts who are genotype-positive, phenotype-negative

Answer 33

serial exam, EKG, TTE: Q1-2Y \<18yo Q3-5Y adults \+ PRN clinical change (1)

Question 34

additional/further imaging evaluation of HCM pts if TTE is inconclusive OR pre-proc planning

Answer 34

TEE (2a) ## Footnote "TEE can be useful if TTE is inconclusive in clinical decision-making regarding medical therapy, and in situations such as planning for myectomy, exclusion of subaortic membrane or MR 2/2 structural abnormalities of the valve apparatus, or in the assessment of feasibility of EtOH septal ablation."

Question 35

additional/further imaging evaluation of HCM pts if ECHO is inconclusive

Answer 35

cardiac MRI (1) ## Footnote "For patients suspected to have HCM in whom echocardiography is inconclusive, CMR imaging is indicated for diagnostic clarification."

Question 36

additional/further imaging evaluation of HCM pts if alternative dxs are suspected

Answer 36

cardiac MRI (1) ## Footnote "For patients with LVH in whome there is a suspicion of alternative diagnoses, including infiltrative or storage disease as well as athlete's heart, CMR imaging is useful."

Question 37

additional/further imaging evaluation of HCM pts not otherwise high-risk or decision still uncertain for ICD

Answer 37

cardiac MRI (1) | to assess for LV wall thickness, EF, LV apical aneurysm, & LGE extent ## Footnote LGE = fibrosis, ≥15% of LV mass = high-risk

Question 38

additional/further imaging evaluation of HCM pts if anatomic mechanism of obstruction is inconclusive on ECHO

Answer 38

cardiac MRI (1) | to inform selection & planning of septal redux tx

Question 39

ongoing/subsequent imaging of HCM pts for SCD risk stratification

Answer 39

cardiac MRI Q3-5Y (2b) | to eval Δs in LGE, EF, morphology incl apical aneurysm or LV thickness ## Footnote "for the purpose of SCD risk stratification"

Question 40

additional/further imaging evaluation of HCM pts if ECHO is inconclusive & cardiac MRI is not available

Answer 40

cardiac CT (2b)

Question 41

evaluation of new palpitations or lightheadedness in HCM pts

Answer 41

\>24h Holter (1) ## Footnote "extended (>24h) EKG monitoring or event recording is recommended, which should not be considered diagnostic unless pts have had symptoms while being monitored."

Question 42

evaluation of HCM pts who may be candidates for SRT but with uncertainty re: presence or severity of LVOTO on non-invasive imaging studies

Answer 42

cardiac cath (1) | for invasive hemodynamic assessment

Question 43

evaluation of HOCM pts who are being considered for SRT but with uncertainty re: fxnal capacity or sx status

Answer 43

exercise stress test (2b) | may be reasonable

Question 44

ongoing/subsequent evaluation of HCM pts in whom fxnal capacity or sx status is uncertain

Answer 44

exercise stress test Q2-3Y (2b) | may be reasonable

Question 45

ICD indications in HCM pts

Answer 45

h/o cardiac arrest, VF, sustained VT (1) OR at least 1 of: (2a) - h/o unexplained syncope - FH SCD - massive LVH (≥3cm) - apical aneurysm - EF\<50% OR NSVT in children (2a) / in adults (2b) OR extensive LGE (≥15% of LV mass) on cardiac MRI (2b)

Question 46

class 1 ICD indication(s) in HCM pts

Answer 46

h/o cardiac arrest, VF, sustained VT (1)

Question 47

class 1 ICD indication(s) in HCM pts | (1)

Answer 47

h/o cardiac arrest, VF, sustained VT (1)

Question 48

class 2a ICD indication(s) in HCM pts

Answer 48

at least 1 of: (2a) - h/o unexplained syncope - FH SCD - massive LVH (≥3cm) - apical aneurysm - EF\<50% - NSVT in children (2a)

Question 49

class 2a ICD indication(s) in HCM pts | (6)

Answer 49

at least 1 of: (2a) - h/o unexplained syncope - FH SCD - massive LVH (≥3cm) - apical aneurysm - EF\<50% - NSVT in children (2a)

Question 50

class 2b ICD indication(s) in HCM pts

Answer 50

NSVT in adults (2b) OR extensive LGE (≥15% of LV mass) on cardiac MRI (2b)

Question 51

class 2b ICD indication(s) in HCM pts | (2)

Answer 51

NSVT in adults (2b) OR extensive LGE (≥15% of LV mass) on cardiac MRI (2b)

Question 52

class 3 ICD recommendation(s) in HCM pts | (2)

Answer 52

without risk factors [and/]OR for sole purpose of competitive sports participation (3: HARM)

Question 53

class 3 ICD recommendation(s) in HCM pts

Answer 53

without risk factors [and/]OR for sole purpose of competitive sports participation (3: HARM)

Question 54

SCD risk factors in HCM pts

Answer 54

- h/o cardiac arrest, VF, sustained VT - h/o unexplained syncope - FH SCD - massive LVH - apical aneurysm - EF\<50% - NSVT in children (2a) / in adults - extensive LGE on cardiac MRI

Question 55

SCD risk factors in HCM pts | (8)

Answer 55

- h/o cardiac arrest, VF, sustained VT - h/o unexplained syncope - FH SCD - massive LVH - apical aneurysm - EF\<50% - NSVT in children (2a) / in adults - extensive LGE on cardiac MRI

Question 56

ICD type in HCM

Answer 56

SDM for transvenous single-chamber OR subQ (1) with single-coil leads (1) | based on preferences, lifestyle, expected need for brady or VT pacing ## Footnote versus dual-coil leads

Question 57

HOCM medical mgmt | in order of preference

Answer 57

1. β-blockers 2. non-dihydropyridine Ca channel blockers (e.g. verapamil, diltiazem) 3. + disopyramide (in combo with #1 or #2) ## Footnote "1. [In patients with HOCM and symptom attributable to LVOTO], nonvasodilating beta-blockers, titrated to effectiveness or maximally tolerated doses, are recommended. (1)" "2. [...], for whom beta-blockers are ineffective or not tolerated, substitution with non-dihydropyridine calcium channel blockers (e.g., verapamil, diltiazem) is recommended. (1) "3. [...*persistent severe symptoms*...] despite beta-blockers or non-dhydropyridine calcium channel blockers, either adding disopyramide in combination with 1 of the other drugs, or SRT performed at experienced centers, is recommended. (1)" "6. For patients with HOCM and severe dyspnea at rest, hypotension, very high resting gradients (e.g., >100mmHg), as well as all children \<6w old, verapamil is potentially harmful. (3: HARM)"

Question 58

pressor of choice in HOCM

Answer 58

Neo (phenylephrine) (1) | **after failure to respond to fluids**; alone or with β-blocker

Question 59

cardiac drugs to avoid in HOCM

Answer 59

vasodilators & digoxin (2b) | vasodil e.g. ACE-Is, ARBs, dihydropyridine calcium channel blockers ## Footnote can worsen sxs 2/2 dynamic LVOTO

Question 60

indications for surgical SRT in HOCM

Answer 60

- severe sxs despite GDMT† (1) - sx + concomitant cardiac surgery† (1) - NYHA II + severe & progressive pHTN OR LA enlargement with ≥1 episode sx afib OR poor fxnal capacity on treadmill exercise testing OR young with very high resting gradients (>100mmHg)‡ (2b) - severe sxs as an alternative to escalation of medical tx† (2b) †at experienced (primary HCM) centers ‡at comprehensive HCM centers

Question 61

# expected/goal SRT in primary/comprehensive HCM centers: 30d mortality | with surgery & with EtOH

Answer 61

≤1% & ≤1%

Question 62

# expected/goal SRT in primary/comprehensive HCM centers: 30d morbidity | with surgery & with EtOH ## Footnote "adverse complications (tamponade, LAD dissection, infection, major bleeding)"

Answer 62

≤10% & ≤10%

Question 63

# expected/goal SRT in primary/comprehensive HCM centers: 30d PPM | with surgery & with EtOH

Answer 63

≤5% myectomy & ≤10% ablation

Question 64

# expected/goal SRT in primary/comprehensive HCM centers: MVR ≤1y | with surgery & with ablation

Answer 64

≤5% & N/A | not specified for ablation

Question 65

# expected/goal SRT in primary/comprehensive HCM centers: ≥mod residual MR | with surgery & with ablation

Answer 65

≤5% & ≤5%

Question 66

# expected/goal SRT in primary/comprehensive HCM centers: repeat proc rate | with surgery & with ablation

Answer 66

≤3% & ≤10%

Question 67

# expected/goal SRT in primary/comprehensive HCM centers: improvement ≥1 NYHA class | with surgery & with ablation

Answer 67

\>90% & \>90%

Question 68

# expected/goal SRT in primary/comprehensive HCM centers: rest & provoked LVOT gradient \<50mmHg | with surgery & with ablation

Answer 68

\>90% & \>90%

Question 69

2 main outcomes differences in EtOH septal ablation v surgical myectomy

Answer 69

in EtOH ablation compared to myectomy: 1. PPM rate ≥2x 2. repeat proc rate ≥3x | PPM: ≤5% v ≤10% / repeat proc: ≤3% v ≤10%

Question 70

highest risk factor for complete heart block / PPM after septal myectomy for HOCM

Answer 70

RBBB (which can be caused by EtOH septal ablation) ⇒10-33% risk (SESATS) because LBB can be resected in myectomy

Question 71

post-septal myectomy LVOT gradient threshold to re-resect

Answer 71

>25mmHg (provoked)

Question 72

recommendation re: mild- to moderate-intensity *recreational* exercise in HCM

Answer 72

YES beneficial to improve cardioresp fitness, physical fxn, QoL, & overall health (1)

Question 73

recommendation re: moderate- to high-intensity competitive sports OR high-intensity recreational exercise in HCM

Answer 73

may be considered after comprehensive eval & SDM (2b) | initial + repeated annually with an expert provider ## Footnote who conveys that the risk of sudden death and ICD shocks may be increased

Question 74

recommendation re: low-intensity *competitive* sports in HCM

Answer 74

is reasonable (2a)

Question 75

recommendation re: any intensity *competitive* sports in genotype-positive, phenotype-negative HCM

Answer 75

is reasonable (2a)

Question 76

class 1 recommendation(s) re: planned valve surgery in pts with afib

Answer 76

potential benefits & added procedural risk of concomitant arrhythmia surgery *should be discussed* (1)

Question 77

class 2a recommendation(s) re: planned valve surgery in pts with sx paroxysmal or persistent afib

Answer 77

concomitant PVI or maze can be beneficial (2a) | **to reduce sxs & prevent recurrent arrhythmia**

Question 78

class 2a recommendation(s) re: planned valve surgery in pts with afib or aflutter

Answer 78

LAA lig/exc is reasonable (2a) | **to reduce risk of thromboembolic events**

Question 79

recommendation re: postop anticoag after LA arrhythmia surgery and/or LAAL/LAAE | "LA surgical ablation of atrial arrhythmias and/or LAA lig/excision"

Answer 79

anticoag ≥3mo is reasonable (2a) | "anticoagulation therapy" NOS

Question 80

Do indications for valve intervention in severe valvular dz differ before planned pregnancy?

Answer 80

NO (1) ## Footnote "In symptomatic women with severe VHD who are considering pregnancy, intervention before pregnancy is recommended on the basis of standard indications." HOWEVER, there are 3 class \<1 recs that conflict with this guideline.

Question 81

indication(s) for valve intervention in asx women considering pregnancy

Answer 81

- severe rheumatic MS with favorable morphology: PMBC @ CVC (2a) - severe AS: "intervention" (2a) - severe MR suitable for rx: MVRx @ CVC (2b)

Question 82

indication(s) for valve intervention in asx women considering pregnancy | (3)

Answer 82

- severe rheumatic MS with favorable morphology: PMBC @ CVC (2a) - severe AS: "intervention" (2a) - severe MR suitable for rx: MVRx @ CVC (2b)

Question 83

recommendation re: valve choice in women of childbearing age

Answer 83

bp > mech d/t increased maternal & fetal risks a/w mech during preg (2a) | can still choose mechanical (SDM valve choice=class 1)

Question 84

How is PPM (patient-prosthesis mismatch) measured/assessed?

Answer 84

iEOA = indexed effective orifice area ≈ AVA:BSA - mild \>0.85 - mod 0.65-0.85 - sev \<0.65

Question 85

iEOA (~AVA:BSA) \<0.65

Answer 85

severe PPM

Question 86

iEOA (~AVA:BSA) = 0.65-0.85

Answer 86

moderate PPM

Question 87

iEOA (~AVA:BSA) >0.85

Answer 87

mild PPM / "at risk"

Question 88

location of Manouguian root enlargement

Answer 88

L-non (LCC-NCC) commissure into the inter-leaflet triangle & AMC ## Footnote https://drive.google.com/file/d/10U7clNgAMS3P8ZZUWH4j--aytUB02oQ1/view https://drive.google.com/file/d/10dvR70BSSF7sNMwU1PtJQ_bkkV9KBrFI/view

Question 89

location of **M**anouguian root enlargement

Answer 89

L-non (LCC-NCC) co**mm**issure into the inter-leaflet triangle, aorto-**m**itral curtain, and anterior **m**itral valve leaflet | 1-1.5cm into the leaflet; do not enter LA roof (sweep away from root) ## Footnote https://drive.google.com/file/d/10U7clNgAMS3P8ZZUWH4j--aytUB02oQ1/view https://drive.google.com/file/d/10dvR70BSSF7sNMwU1PtJQ_bkkV9KBrFI/view

Question 90

farthest proximal (deepest) extent of Manouguian root enlargement

Answer 90

onto the anterior mitral valve leaflet | 1-1.5cm into the leaflet; do not enter LA roof (sweep away from root) ## Footnote https://drive.google.com/file/d/10U7clNgAMS3P8ZZUWH4j--aytUB02oQ1/view https://drive.google.com/file/d/10dvR70BSSF7sNMwU1PtJQ_bkkV9KBrFI/view

Question 91

farthest proximal (deepest) extent of **M**anouguian root enlargement

Answer 91

onto the anterior **m**itral valve leaflet | 1-1.5cm into the leaflet; do not enter LA roof (sweep away from root) ## Footnote https://drive.google.com/file/d/10U7clNgAMS3P8ZZUWH4j--aytUB02oQ1/view https://drive.google.com/file/d/10dvR70BSSF7sNMwU1PtJQ_bkkV9KBrFI/view

Question 92

maximum increase in annular size achievable with Manouguian root enlargement

Answer 92

4mm

Question 93

maximum increase in valve size achievable with Manouguian root enlargement

Answer 93

\+2 valve sizes

Question 94

location of Nicks root enlargement

Answer 94

through the midpoint of non (NCC) sinus ## Footnote https://drive.google.com/file/d/10rQzLHVuQDElGEBX91M-yoY-k2DrAAHq/view

Question 95

location of **N**icks root enlargement

Answer 95

through the midpoint of **n**on (**N**CC) sinus into the fibrous subaortic curtain ## Footnote https://drive.google.com/file/d/10rQzLHVuQDElGEBX91M-yoY-k2DrAAHq/view

Question 96

farthest proximal (deepest) extent of Nicks root enlargement

Answer 96

up to but not into mitral valve | "as far as the origin of the mitral valve" ## Footnote https://drive.google.com/file/d/10gKWb9g-ToZNXP3VNAQ5KcvluEPe8uO-/view

Question 97

maximum increase in annular size achievable with Nicks root enlargement

Answer 97

2mm

Question 98

maximum increase in valve size achievable with Nicks root enlargement

Answer 98

\+1 valve size

Question 99

location of Konno root enlargement

Answer 99

through R (RCC) sinus (4-5mm lateral to/leftward of RCA) into interventricular septum + 2nd incision in anterior wall of RVOT

Question 100

What structure do you have to worry about under the L-non (LCC-NCC) AV commissure?

Answer 100

anterior mitral valve leaflet / aorto-mitral curtain

Question 101

What structure do you have to worry about under the R-non (RCC-NCC) AV commissure?

Answer 101

membranous septum, which contains LBB/bundle of His

Question 102

What structure do you have to worry about behind the non sinus / non-R (NCC-LCC) commissure?

Answer 102

AV node

Question 103

AVR sutures (normal)

Answer 103

pledgeted horizontal mattress from ventricular->aortic

Question 104

AVR sutures at a root enlargement patch

Answer 104

pledgeted horizontal mattress from outside->in

Question 105

standard quantity of Del Nido cardioplegia (total)

Answer 105

1200mL

Question 106

interval to re-dose Del Nido cardioplegia

Answer 106

Q1H

Question 107

quantity of Del Nido cardioplegia for retrograde

Answer 107

500mL

Question 108

quantity of Del Nido cardioplegia for antegrade

Answer 108

700mL

Question 109

quantity of Del Nido cardioplegia for ostial

Answer 109

RCA: 300mL LCA: 400mL total: 700mL

Question 110

ONLY valve(s) for which intervention on *moderate* regurg is indicated

Answer 110

**_AR_** - concomitant \<3 surg (2a) **_TR_** - progressive + concomitant \<3 L valve surg + annulus EDD\>40mm OR prior RH fail sxs (2a)

Question 111

ONLY valve(s) for which intervention on *moderate* dysfxn is indicated

Answer 111

**_AS_** - concomitant \<3 surg (2b) **_AR_** - concomitant \<3 surg (2a) **_TR_** - concomitant \<3 L valve surg + annulus EDD\>40mm (2a) - concomitant \<3 (L valve) surg + prior RH fail sxs (2a) **_MS_** - NYHA ≥II + MVA\>1.5 + PAWP\>25 OR mean grad \>15 with exercise ⇒ PBMC (2b)

Question 112

ONLY valve(s) for which intervention on *moderate* stenosis is indicated

Answer 112

**_AS_** - concomitant \<3 surg (2b) **_MS_** - NYHA ≥II + MVA\>1.5 + PAWP\>25 OR mean grad \>15 with exercise ⇒ PBMC (2b)

Question 113

ONLY valve(s) for which intervention *outside of concomitant \<3 surg* on *moderate* dysfxn is indicated

Answer 113

**_MS_** - NYHA ≥II + MVA\>1.5 + PAWP\>25 OR mean grad \>15 with exercise ⇒ PBMC (2b)

Question 114

only AHA recommendation for warfarin over DOAC for anticoag for afib

Answer 114

afib + rheumatic MS (1)

Question 115

AHA recommendation for anticoag for afib with rheumatic MS

Answer 115

warfarin (1)

Question 116

AHA recommendation for anticoag for afib with any valvular dz except rheumatic MS

Answer 116

DOAC (1) (per CHADS-VASc score)

Question 117

STS risk score (%): low-risk

Answer 117

\<4%

Question 118

STS risk score (%): intermediate-risk

Answer 118

4-8%

Question 119

STS risk score (%): high-risk

Answer 119

\>8%

Question 120

STS risk score = risk of what outcome/endpoint (for risk-stratification)

Answer 120

death

Question 121

Modified Duke criteria for *definite* endocarditis dx

Answer 121

definite IE criteria: - **2 major** - 1 major + 3 minor - 5 minor

Question 122

Modified Duke criteria for *possible* endocarditis dx

Answer 122

poss IE criteria: - **1 major + 1 minor** - 3 minor

Question 123

Modified Duke *major* criteria for endocarditis dx

Answer 123

- **⊕blood cxs** x2 with common bx - **ECHO** (updated: or cardiac CT) signs (veg, leaflet perf, valve aneurysm, abscess, pseudoaneurysm, intracard fistula, NEW regurg, new partial dehisc of prosthetic valve)

Question 124

Modified Duke *minor* criteria for endocarditis dx

Answer 124

- _predisposition:_ incl heart condition, IVDU, h/o endocarditis, prosthetic valve, h/o valve rx, CHD, HOCM - _fever_ >100.4°F (38°C) - _vascular phenomena:_ **septic emboli** (incl Janeway lesions), mycotic aneurysm - _immunologic phenomena:_ glomerulonephritis, Osler's nodes, Roth's spots, rheumatoid factor - _micro:_ ⊕blood cx not meeting major criterion OR ⊕serology for organism c/w IE

Question 125

AHA indication(s) for "early surgery" in endocarditis | early = during initial hospitalization & before abx course completed

Answer 125

- valve dysxfn ⇒ HF sxs (1) - L-sided highly-resistant organism (S. aureus, fungus) (1) - heart block / annular or Ao abscess / destructive penetrating lesions (1) - persistent bacteremia or fevers \>5d after abx (1) - recurrent emboli/persistent veg (2a) - L-sided native valve with mobile veg \>1cm *length* (2b) ## Footnote AHA "early surgery (during initial hospitalization and before completion of a full therapeutic course of antibiotics)"

Question 126

AHA mgmt of permanent/implanted cardiac devices in definite endocarditis

Answer 126

complete removal (incl all leads & generator) | (1)

Question 127

mgmt of relapsing prosthetic valve endocarditis (i.e. recurrent bacteremia after abx course & blood cx clearance)

Answer 127

"surgery" | (1)

Question 128

recommendation re: consideration of redo surgery in endocarditis with ongoing IVDU

Answer 128

addiction med c/s re: long-term prognosis | (1)

Question 129

AHA recommendation for timing of endocarditis surgery in setting of stroke

Answer 129

- non-major & no ICH: no delay (2b) - major stroke and/or ICH: if HDS, delay ≥4w (2b) ## Footnote "11. In patients with IE and an indication for surgery who have suffered a stroke but have no evidence of intracranial hemorrhage or extensive neurological damage, operation without delay may be considered. (2b) \12. For patients with IE and major ischemic stroke with extensive neurological damage or intracranial hemorrhage, if the patient is hemodynamically stable, delaying valve surgery for at least 4 weeks may be considered. (2b)"

Question 130

AATS recommendation for timing of endocarditis surgery in setting of stroke (with neuro deficits)

Answer 130

- non-hemorrhagic/no ICH: delay 1-2w (2a) - hemorrhagic/ICH: delay 3-4w (2a) (surgery 1-7d after ischemic stroke NOT a/w ￪ in-hosp mort) ## Footnote "In patients with stroke and neurologic deficits, timing is decided by weighing the need for cardiac surgery against the risk of expanding the stroke or provoking intracranial bleeding during the operation."

Question 131

AHA definition of "early surgery" in endocarditis

Answer 131

during initial hospitalization and before completion of a full therapeutic course of antibiotics

Question 132

AATS recommendation for timing of surgery in endocarditis

Answer 132

"within days" (1) earlier surgery i.e. emergent or ≤48h for high embolism risk (2a) ## Footnote "Once an indication for surgery is established, the patient should be operated on within days. (1) Earlier surgery (emergency or within 48 hours) is reasonable for patients with large mobile vegetations at imminent risk of embolism. (2a)" "Once an indication for surgery has been established and effective antimicrobial therapy initiated, there is little reason to delay operation. Surgery to prevent embolism mainly is relevant early, during the first few days after antimicrobial therapy is initiated, when the risk of embolism is greatest."

Question 133

AATS indication(s) for surgery in endocarditis

Answer 133

- valve dysxfn ⇒ HF sxs† (1) - highly-resistant organism (S. aureus, fungus)† (1) - heart block / annular or Ao abscess / destructive penetrating lesions† (1) - persistent bacteremia or fevers \>5-7d after abx† (1) - recurrent systemic emboli/persistent veg‡ (2a) - mobile veg \>1cm *length* with e/o embolic phenomena‡ (2b) - R-sided + severe valve dysfxn + HF sxs + veg \>2cm length + persistent bacteremia or fevers \>5-7d OR septic PE (2b) - relapsing prosthetic valve infxn (2a) † during initial hospitalization ‡ urgent or emergent ## Footnote AHA "early surgery (during initial hospitalization and before completion of a full therapeutic course of antibiotics)"

Question 134

AATS recommendation for coronary imaging before endocarditis surgery

Answer 134

guided by normal criteria *with lg AV veg, coronary CTA is an alternative* (1) ## Footnote "The need for preoperative coronary angiography should be guided by normal criteria. This is particularly important if the patient has had coronary artery bypass grafting. In patients with large aortic valve vegetations, CT angiography is an alternative to assess the coronary arteries. (1)"

Question 135

AATS mgmt of permanent/implanted cardiac devices in endocarditis

Answer 135

- infected: complete removal (1) - resistent organisms: complete removal reasonable (2a) - any organisms: complete removal reasonable (2b) - R-sided + affected TV: complete removal (?) - L-sided without convincing device infxn: optional/reasonable (?) - epicardial lead implantation can be considered (2b) ## Footnote - "Complete removal of pacemaker or defibrillator systems, including all leads and the generator, is indicated as part of the early management plan in patients with IE and likely infection of the device or leads. (1) - Complete removal of pacemaker or defibrillator systems, including all leads and the generator, is reasonable in patients with right- or left-sided valvular IE caused by S. aureus or fungi, even without evidence of device or lead infection. (2a) - Complete removal of pacemaker or defibrillator systems, including all leads and the generator, is reasonable in patients undergoing surgery for valvular IE caused by any organism. (2b)" - "At the time of surgery for IE, implantation of a new pacemaker system with epicardial leads may be considered when the patient is pacer dependent and has effective antimicrobial coverage. (2b)" "If infected, and in right-sided IE affecting the tricuspid valve, leads and pacemaker should be removed. In the case of left-sided IE with no convincing evidence of pacemaker and lead involvement, removal is still reasonable but adds to complexity postoperatively and the question of if, when, and how the system should be replaced."

Question 136

endocarditis R-sided veg size indication for surgery

Answer 136

\>2cm

Question 137

endocarditis L-sided veg size indication for surgery

Answer 137

\>1cm

Question 138

INR goal for standard [modern] mech AVR ## Footnote modern = bileaflet or current-generation single-tilting disk

Answer 138

2.5 (2.0-3.0) | (1) ## Footnote "For patients with a mechanical bileaflet or current-generation single-tilting disk AVR and no risk factors for thromboembolism, anticoagulation with a VKA to achieve an INR of 2.5 is recommended. (1)"

Question 139

INR goal for On-X mech AVR

Answer 139

≥3mo postop: 1.5-2.0 **+ ASA81** (early postop: still 2.5 / 2.0-3.0 **+ ASA81** x3mo) | (2b) ## Footnote "For patients with a mechanical bileaflet or current-generation single-tilting disk AVR and no risk factors for thromboembolism, anticoagulation with a VKA to achieve an INR of 2.5 is recommended. (1)" "In patients without risk factors who receive a mechanical On-X aortic heart valve, targeting the INR to a lower goal (1.5–2.0) in conjunction with aspirin 81 mg daily may be a strategy for long-term management. Warfarin dosing is targeted to an INR of 2.5 (range, 2.0–3.0) for the first 3 months after surgery, during which low-dose aspirin is also used. This recommendation is based on a single RCT of lower- versus standard-intensity VKA therapy (with low-dose aspirin) in patients undergoing On-X AVR. The lower-intensity INR group experienced significantly less major and minor bleeding, whereas the rates of stroke, transient ischemic attack, total neurological events, and all-cause mortality were similar between the 2 groups."

Question 140

INR goal for older-gen mech AVR with add'l TE risk factors | e.g. afib, previous thromboembolism, LV dysfxn, hypercoag state ## Footnote older-generation = ball-in-cage [modern = bileaflet or current-generation single-tilting disk]

Answer 140

3.0 (2.5-3.5) | (1) ## Footnote "For patients with a mechanical AVR and additional risk factors for thromboembolism (eg, AF, previous thromboembolism, LV dysfunction, hypercoagulable state) or an older-generation prosthesis (eg, ball-in-cage), anticoagulation with a VKA is indicated to achieve an INR of 3.0. (1)"

Question 141

INR goal for mech MVR

Answer 141

3.0 (2.5-3.5) | (1)

Question 142

anticoag for bp TAVI

Answer 142

ASA81 (2a)

Question 143

anticoag for bp SAVR

Answer 143

ASA81 (2a)

Question 144

anticoag for bp MVR

Answer 144

ASA81 (2a)

Question 145

optional early postop anticoag for bp TAVI at low bleeding risk (2 options)

Answer 145

1. DAPT (ASA81 + Plavix) x3-6mo (2b) 2. warfarin with INR goal 2.5 (2.00-3.0) x3+mo ## Footnote - "For patients with a bioprosthetic TAVI who are at low risk of bleeding, dualantiplatelet therapy with aspirin 75 to 100 mg and clopidogrel 75 mg may be reasonable *for 3 to 6 months* after valve implantation. (2b) - For patients with a bioprosthetic TAVI who are at low risk of bleeding, anticoagulation with a VKA to achieve an INR of 2.5 may be reasonable *for at least 3 months* after valve implantation. (2b)"

Question 146

optional early postop anticoag for bp SAVR at low bleeding risk

Answer 146

warfarin with INR goal 2.5 (2.0-3.0) x3-6mo (2a)

Question 147

optional early postop anticoag for bp MVR at low bleeding risk

Answer 147

warfarin with INR goal 2.5 (2.0-3.0) x3-6mo (2a)

Question 148

anticoag *contraindicated* in bp TAVI

Answer 148

low-dose rivaroxaban (10mg QD) + ASA81 3: HARM

Question 149

indication(s) for bridging mech valve anticoag when holding for non-cardiac procedure

Answer 149

- mech AVR + risk factors (2a) - mech MVR (2a) | RFs=older-gen valve, afib, previous TE, hypercoag state, LV dysfxn

Question 150

anticoag when warfarin is already indicated for a mech valve (either AVR or MVR) & there are concurrent indications for ASA, at low bleeding risk

Answer 150

warfarin with same INR goal + ASA81 (2b)

Question 151

procedures in which holding mech valve anticoag is indicated

Answer 151

major procedures and/or in which bleeding may not easily be controlled ## Footnote "For patients with a bileaflet mechanical AVR and no other risk factors for thromboembolism who are undergoing invasive procedures, temporary interruption of VKA anticoagulation, without bridging agents while the INR is subtherapeutic, is recommended. (1)" RFs=older-gen valve, afib, previous TE, hypercoag state, LV dysfxn

Question 152

procedures in which holding mech valve anticoag is NOT indicated

Answer 152

minor procedures in which bleeding is easily controlled (e.g. dental extractions, cataracts) ## Footnote "For patients with mechanical heart valves who are undergoing minor procedures (eg, dental extractions or cataract removal) where bleeding is easily controlled, continuation of VKA anticoagulation with a therapeutic INR is recommended. (1)"

Question 153

reversal of mech valve anticoag (warfarin)

Answer 153

4-factor PCC | prothrombin complex concentrate ## Footnote "For patients with a mechanical valve prosthesis receiving VKA therapy who require immediate/emergency noncardiac surgery or an invasive procedure, administration of 4-factor prothrombin complex concentrate (or its activated form) is reasonable. (2a)"

Question 154

mech valve anticoag recommendation for major procedures and/or in which bleeding may not easily be controlled

Answer 154

HOLD & NO bridge (1) *unless RFs*: hold & BRIDGE (2a) | RFs=older-gen valve, afib, previous TE, hypercoag state, LV dysfxn, MVR ## Footnote "For patients with a bileaflet mechanical AVR and no other risk factors for thromboembolism who are undergoing invasive procedures, temporary interruption of VKA anticoagulation, without bridging agents while the INR is subtherapeutic, is recommended. (1)" "For patients who are undergoing invasive procedures and have **1) a mechanical AVR and any thromboembolic risk factor, 2) an older-generation mechanical AVR, or 3) a mechanical mitral valve replacement**, bridging anticoagulation therapy during the preoperative time interval when the INR is subtherapeutic is reasonable on an individualized basis, with the risks of bleeding weighed against the benefits of thromboembolism prevention. (2a)"

Question 155

mech valve (with no addl' RFs) anticoag recommendation for major procedures and/or in which bleeding may not easily be controlled

Answer 155

HOLD & NO bridge (1) | RFs=older-gen valve, afib, previous TE, hypercoag state, LV dysfxn, MVR ## Footnote "For patients with a bileaflet mechanical AVR and no other risk factors for thromboembolism who are undergoing invasive procedures, temporary interruption of VKA anticoagulation, without bridging agents while the INR is subtherapeutic, is recommended. (1)"

Question 156

mech valve (with add'l RFs) anticoag recommendation for major procedures and/or in which bleeding may not easily be controlled | RFs=older-gen valve, afib, previous TE, hypercoag state, LV dysfxn, MVR

Answer 156

hold & BRIDGE (2a) | RFs=older-gen valve, afib, previous TE, hypercoag state, LV dysfxn, MVR ## Footnote "For patients who are undergoing invasive procedures and have **1) a mechanical AVR and any thromboembolic risk factor, 2) an older-generation mechanical AVR, or 3) a mechanical mitral valve replacement**, bridging anticoagulation therapy during the preoperative time interval when the INR is subtherapeutic is reasonable on an individualized basis, with the risks of bleeding weighed against the benefits of thromboembolism prevention. (2a)"

Question 157

mech valve anticoag recommendation for minor procedures in which bleeding is easily controlled | (e.g. dental extractions, cataracts)

Answer 157

CONTINUE (1) ## Footnote "For patients with mechanical heart valves who are undergoing minor procedures (eg, dental extractions or cataract removal) where bleeding is easily controlled, continuation of VKA anticoagulation with a therapeutic INR is recommended. (1)"

Question 158

INR goal for mech AVR *with systemic embolic event (incl stroke) while therapeutic*

Answer 158

increase by 0.5: 2.5 (2.0-3.0) OR add ASA81 ## Footnote "In patients with a mechanical AVR who experience a stroke or systemic embolic event while in therapeutic range on VKA anticoagulation, it is reasonable to increase the INR goal from 2.5 (range, 2.0–3.0) to 3.0 (range, 2.5–3.5) or to add daily low-dose aspirin (75–100 mg), with assessment of bleeding risk. (2a)"

Question 159

INR goal for mech AVR *with systemic embolic event (incl stroke) while therapeutic*

Answer 159

increase by 0.5: 3.0 (2.5-3.5) OR add ASA81 ## Footnote "In patients with a mechanical mitral valve replacement who experience a stroke or systemic embolic event while in therapeutic range on VKA anticoagulation, it is reasonable to increase the INR goal from 3.0 (range, 2.53.5) to 4.0 (range, 3.5–4.0) or to add daily low-dose aspirin (75–100 mg), with assessment of bleeding risk. (2a)"

Question 160

anticoag for bp AVR (either TAVI or SAVR) *with systemic embolic event (incl stroke) while on α-PLT tx*

Answer 160

warfarin (usu INR goals) (2b) ## Footnote "In patients with a bioprosthetic surgical or transcatheter aortic valve or bioprosthetic mitral valve who experience a stroke or systemic embolic event while on antiplatelet therapy, VKA anticoagulation, instead of antiplatelet therapy may be considered after assessment of bleeding risk. (2b)"

Question 161

mgmt of thrombosed L-sided mech valves with sxs of valve obstruction

Answer 161

urgent slow-infusion low-dose thrombolysis OR emergency surgery (1)

Question 162

mgmt of thrombosed bp valves that are HDS

Answer 162

warfarin (2a)

Question 163

recommendation for risk-stratification before valve intervention

Answer 163

risk calculator i.e. STS risk score (1)

Question 164

typical adequate/minimum AVR size for men/women

Answer 164

♀21mm ♂23mm

Question 165

AVR size range available

Answer 165

19-29mm (technically 17 avail but is TINY) 21mm still pretty small, but 21 may be OK for most ♀, 23 for most ♂

Question 166

typical adequate/minimum MVR size for men/women

Answer 166

♀/♂ 27mm 25mm still pretty small, 27+ prob OK for most, both ♀/♂ (range: 23?-33mm)

Question 167

typical adequate/minimum MVRx band size for men/women

Answer 167

♀30-32mm ♂32-34mm

Question 168

How do you size an AVR?

Answer 168

using the manufacturer's sizers, to the annulus

Question 169

How do you size a MVR?

Answer 169

using the manufacturer's sizers, to the annulus

Question 170

How do you size a MVRx?

Answer 170

using the manufacturer's sizers, to the anterior leaflet

Question 171

MVR size range available

Answer 171

23?-33mm 25mm still pretty small, 27+ prob OK for most, both ♀/♂

Question 172

STS risk score low/intermediate/high cutoffs

Answer 172

\<4% = low-risk 4-8% = intermediate risk \>8% = high-risk (by risk of death)

Question 173

standard/default ECMO (VA) cannula sizes

Answer 173

17Fr arterial 21-25Fr venous (multi-stage) 7Fr DPC

Question 174

standard/default bicaval venous cannula sizes

Answer 174

28Fr x2 OR 28Fr SVC + 32Fr IVC

Question 175

Are peripheral cannula sizes odd or even?

Answer 175

**odd**

Question 176

Are central cannula sizes odd or even?

Answer 176

**even**

Question 177

standard/default central CPB cannula sizes

Answer 177

20Fr aortic 32/40-36/42Fr venous (dual-stage) BTK: 21Fr arterial 28Fr venous (dual-stage)

Question 178

standard/default LH bypass cannula sizes

Answer 178

20Fr LAA/LSPV 17Fr distal aortic (periph cannula)

Question 179

standard/default axillary artery cannulation graft size

Answer 179

8-10mm

Question 180

Qp:Qs | (formula/how to calculate)

Answer 180

Qp/Qs = *systemic* extremes / *pulmonary* extremes: arterial sat - mixed venous sat \------------------------------------------- PV sat - PA sat (OR arterial sat - Swan PA sat) ## Footnote quotient over quotient so instead of P/S, it's: 1/P / 1/S = S/P = extremes systemic / extremes Pulmonary (e.g. 100-60 / 100-80 for 60 SVC sat & 80 PA sat = 40/20 = 2:1)

Question 181

initial heparin dose for wires/sheaths/cannulas

Answer 181

10,000u to ACT≥250

Question 182

heparin dose before going on bypass

Answer 182

300u/kg

Question 183

adequate retrograde cardioplegia pressure/flow

Answer 183

coronary sinus pressure = 40mmHg (for both continuous & intermittent) 50-100mL/min (BTK) v 150-200 mL/min??? (Julie) - Delivered through the coronary sinus, should not exceed the pressure of 50mmHg

Question 184

appropriate RCP pressure/flow

Answer 184

CVP = 25-35 (BTK: \<25) 300mL/min (BTK: 500mL-1.5L/min) OR ~5-10mL/kg/min

Question 185

appropriate ACP pressure/flow

Answer 185

R radial a-line MAP = 50-70 (~60) (CTS 2e: 40-50) 500mL/min OR ~10-15mL/kg/min *check contralateral carotid for backbleeding*

Question 186

adequate/appropriate antegrade cardioplegia pressure/flow

Answer 186

minimum = enough to close AV line pressure \< 300 200-300mL/min

Question 187

adequate/appropriate ostial cardioplegia pressure/flow

Answer 187

??? 100-150mL/min per coronary ostium

Question 188

standard MAP goal on CPB

Answer 188

65-70

Question 189

MAP goal on CPB with special concerns e.g. carotid stenosis

Answer 189

75-80

Question 190

Where can you find the L SVC?

Answer 190

base of LA appendage, often draining into coronary sinus (involuted L SVC = ligament of Marshall = fibrous connxn bet/ LA & L PVs)

Question 191

mgmt of patent LIMA (or SVG) during redo sternotomy

Answer 191

dissect out & clamp (with risk of inj) OR **cool to 28°C (moderate hypothermia) +**: frequent (at least Q20min Del Nido) cardioplegia OR **continuous retrograde cardioplegia** ± systemic KCl ## Footnote outcomes may be better without dissecting it out, likely d/t risk of injury during dissxn or clamping

Question 192

redo sternotomy precxns

Answer 192

- redo pads (external defibrillator pads) - blood X-matched & *in the room* - groin access (at least sheaths)

Question 193

type of saw for redo sternotomy (i.e. entering anterior then posterior table separately)

Answer 193

oscillating saw

Question 194

type of saw for usual sternotomy (i.e. opening in one cut)

Answer 194

reciprocating saw

Question 195

OS (all-comers) after emergency (VA-???)ECMO

Answer 195

~50% (per Davis lecture)

Question 196

Which is more common: systolic or diastolic murmurs?

Answer 196

systolic (almost everything)

Question 197

Are systolic murmurs always pathological, or sometimes benign?

Answer 197

NO sometimes benign

Question 198

Are diastolic murmurs always pathological, or sometimes benign?

Answer 198

ALWAYS pathological

Question 199

only cause of a continuous murmur

Answer 199

PDA (systemic to pulmonary or systemic to RH shunts)

Question 200

only causes of diastolic murmur (specific)

Answer 200

- **AR** - PR - **MS** - TS

Question 201

only causes of diastolic murmur (general/big-picture)

Answer 201

valvular dz causing abnormal flow into the ventricles during diastole: - ventric outflow valve regurg (**AR**,PR) - ventric inflow valve stenosis (**MS**,TS)

Question 202

VSD murmur

Answer 202

loud/harsh holosystolic @ precordium/L lower sternal border (TV ausc window)

Question 203

PDA murmur

Answer 203

machine-like continuous @ precordium/L lower sternal border (TV ausc window)

Question 204

MR murmur (non-prolapse)

Answer 204

high-pitched, "blowing" holosystolic @ apex radiating to axilla

Question 205

AS murmur

Answer 205

harsh, crescendo-decrescendo systolic ejection, following ejection/opening click @ R upper sternal border radiating to carotids & apex

Question 206

ASD murmur

Answer 206

mid-systolic pulmonary ejection @ with **wide, fixed split S2**

Question 207

MR murmur (r/t prolapse)

Answer 207

high-pitched, "blowing" late/mid-systolic @ apex radiating to axilla

Question 208

fixed split S2

Answer 208

ASD

Question 209

murmur(s) ￪ with valsalva (￬venous return/preload)

Answer 209

HOCM

Question 210

murmur(s) ￪ with hand grip/fist clench (￪SVR/afterload)

Answer 210

MR,AR VSD

Question 211

AR murmur

Answer 211

high-pitched, "blowing," decrescendo immediate/early diastolic @ L sternal border/Erb's point

Question 212

HOCM murmur

Answer 212

high-pitched, crescendo-decrescendo mid-systolic @ L sternal border/Erb's point NOT radiating to carotids (v AS) **￪ with valsalva (￬venous return/preload)**

Question 213

MS murmur

Answer 213

low-pitched, rumbling late diastolic after opening snap @ apex

Question 214

effect of inspiration on murmurs

Answer 214

⇒ ￬intrathoracic pressure ⇒ ￪venous return ⇒ ￪RH preload & ￬LH preload ⇒ ￪RH sounds (& ￪HOCM)

Question 215

effect of expiration on murmurs

Answer 215

⇒ ￪intrathoracic pressure ⇒ ￬venous return ⇒ ￬RH preload & ￪LH preload (from inspiration? incr pulm venous return?) ⇒ ￪LH sounds (& ￬HOCM)

Question 216

effect of hand grip/fist clench on murmurs

Answer 216

⇒ ￪SVR ⇒ ￪afterload ⇒ ￪LV pressure (& ￪MR,VSD)

Question 217

effect of valsalva on murmurs

Answer 217

⇒ ￬venous return ⇒ ￬most murmurs (except ￪HOCM)

Question 218

Are there any indications for valvular *stenosis* based on ventricular morphology (e.g. LVESD, LVEDD)?

Answer 218

NO

Question 219

For which valve pathologies is consideration of LVESD or LVEDD part of the indications for intervention?

Answer 219

**_AR_** (severe) - LVESD>50mm (2a) - progressive on 3 studies ￪LVEDD to \>65mm (2b) **_1° MR_** (severe) - LVESD≥40 (1) - progressive on 3 studies: ￪LVESD (2b)

Question 220

LVESD threshold for severe AR

Answer 220

\>50mm (2a)

Question 221

LVEDD threshold for severe AR

Answer 221

*progressive on 3 studies to* \>65mm (2b)

Question 222

LVESD threshold for severe MR

Answer 222

≥40 (1) OR progressive ￪ on 3 studies (2b)

Question 223

For which valve(s) pathology is LVEDD considered in the indications for intervention?

Answer 223

**_AR_** - progressive on 3 studies ￪LVEDD to \>65mm (2b)

Question 224

For which valve(s) pathology is LVESD considered in the indications for intervention?

Answer 224

**_AR_** - LVESD>50mm (2a) **_1° MR_** - LVESD≥40 (1) - progressive on 3 studies: ￪LVESD (2b)

Question 225

which of LVEDD & LVESD is considered in AR & MR

Answer 225

LVE**D**D = **A**R LVE**S**D = **M**R + AR *(A & D closer in alphabet; M & S closer in alphabet)* but want more excuses to operate on AV

Question 226

indication(s) for intervention in [isolated] secundum ASD (adult)

Answer 226

* ￬fxnal capacity AND * RA and/or RV enlargement AND * L🠆R shunt ⇒ physio sequelae / Qp:Qs≥1.5 *if*: NO cyanosis AND PASP \< 50% SBP AND PVR \< 1/3 SVR rx (transcath OR surgical) ⇒ ￬RV vol & ￪exercise tolerance (1) same if asx (2a) same if asx & no RA/RV dil with concomitant \<3 surg (2a) *can consider with ￪PASP/PVR if \< 2/3 SBP/SVR (2b)*

Question 227

indication(s) for intervention in VSD (adult)

Answer 227

* LV overload AND * L🠆R shunt ⇒ physio sequelae / Qp:Qs≥1.5 *if*: PASP \< 50% SBP AND PVR \< 1/3 SVR rx (transcath OR surgical) (1) same if no LV overload (2b) surgical rx if perimembranous or supracristal causing worse AR (2a) surgical rx if h/o IE attributable to VSD (2b)

Question 228

contraindication(s) intervention in of ASD (adult)

Answer 228

_relative:_ PASP \> 50% SBP PVR \> 1/3 SVR _absolute:_ **PASP \> 2/3 SBP** **PVR \> 2/3 SVR** **R🠆L shunt** (3: HARM)

Question 229

contraindication(s) intervention in of VSD (adult)

Answer 229

_relative:_ PASP \> 50% SBP PVR \> 1/3 SVR _absolute:_ **PASP \> 2/3 SBP** **PVR \> 2/3 SVR** **R🠆L shunt** (3: HARM)

Question 230

contraindication(s) for intervention in AVSD (adult)

Answer 230

_relative:_ PASP \> 50% SBP PVR \> 1/3 SVR _absolute:_ **PASP \> 2/3 SBP** **PVR \> 2/3 SVR** **R🠆L shunt** (3: HARM)

Question 231

contraindication(s) for intervention in ASD (relative), VSD (relative), AVSD (relative), PAPVR, sinus venosus, coronary sinus defect (adult)

Answer 231

- PASP \> 50% SBP - PVR \> 1/3 SVR

Question 232

relative contraindication(s) for intervention in ASD/VSD/AVSD (adult)

Answer 232

- PASP \> 50% SBP - PVR \> 1/3 SVR

Question 233

absolute contraindication(s) for intervention in ASD/VSD/AVSD (adult)

Answer 233

- PASP \> 2/3 SBP - PVR \> 2/3 SVR - R🠆L shunt (3: HARM)

Question 234

indication(s) for intervention in primum ASD/sinus venosus/coronary sinus defect (adult)

Answer 234

* ￬fxnal capacity AND * RA and/or RV enlargement AND * L🠆R shunt ⇒ physio sequelae / Qp:Qs≥1.5 *if*: NO cyanosis AND PASP \< 50% SBP AND PVR \< 1/3 SVR surgical rx (1) *primum ASD only*: can consider with ￪PASP/PVR if \< 2/3 SBP/SVR (2b)

Question 235

indication(s) for intervention in PAPVR incl scimitar vein (adult)

Answer 235

* ￬fxnal capacity AND * RV enlargement/overload AND * L🠆R shunt ⇒ physio sequelae / Qp:Qs≥1.5 *if*: PASP \< 50% SBP AND PVR \< 1/3 SVR surgical rx (1) or PAPVR with concomitant ASD/sinus venosus rx (1) or if asx (2a)

Question 236

indication(s) for intervention in severe L AV valve regurg in AVSD (adult)

Answer 236

same as for regular MR (1)

Question 237

indication(s) for intervention in AVSD (adult)

Answer 237

surgical rx of primary AVSD/residual shunts (1) if: * L🠆R shunt with Qp:Qs≥1.5 AND * PASP \< 50% SBP AND * PVR \< 1/3 SVR can consider with ￪PASP/PVR if \< 2/3 SBP/SVR (2b) surgical rx of LVOTO if max gradient ≥50mmHg OR \<50 with HF sxs or mod+ MR or AR (2a)

Question 238

indication(s) for intervention in PDA (adult)

Answer 238

* LA or LV enlargement (attributable to PDA) AND * L🠆R shunt ⇒ physio sequelae / Qp:Qs≥1.5 *if*: PASP \< 50% SBP AND PVR \< 1/3 SVR rx (1) can consider with ￪PASP/PVR if \< 2/3 SBP/SVR (2b) ## Footnote "Pulmonary blood flow and thus Qp:Qs can be difficult to calculate accurately because of differences in right/left PA blood flow caused by the flow from the PDA. [...] Surgical closure can be performed but is potentially hazardous in adults because of calcification and tissue fragility."

Question 239

indication(s) for intervention in subaortic stenosis (subAS) (adult)

Answer 239

- attributable sxs + LVOT max gradient ≥50mmHg (1) - HF or ischemic sxs OR attributable LV systolic dysfxn + \<50mmHg (1) - asx \<50mmHg + mild+ AR ⫤ AR progression (2b) ## Footnote "Pulmonary blood flow and thus Qp:Qs can be difficult to calculate accurately because of differences in right/left PA blood flow caused by the flow from the PDA. [...] Surgical closure can be performed but is potentially hazardous in adults because of calcification and tissue fragility."

Question 240

indication(s) for intervention on PR s/p rx of PS (adult)

Answer 240

PVR for: * sxs + ≥mod PR + RV enlargement/dysfxn (1) * asx + ≥mod PR + progressive RV enlargement/dysfxn OR progressive ￬exercise capacity (2b) serial f/u for any PR not meeting above criteria ## Footnote AHA ACHD guideline Figure 3. Isolated PR after repair of PS https://drive.google.com/file/d/12YEO9s5RsgP5NWqfCRqR-V4VhDFJKXrJ/view \*Significant PR causes RV dilation. If a patient has moderate or greater PR and normal RV size, most likely the estimation of PR severity is inaccurate or there may be restrictive RV physiology, which would warrant further investigation. †Symptoms may include dyspnea, chest pain, and/or exercise intolerance referable to PR or otherwise unexplained.

Question 241

mgmt of PR s/p rx of PS (adult)

Answer 241

1. ECHO for PR severity & RV size/fxn: - mild PR & RV enlargement ⇒ surveil (1) - ≥mod PR & RV enlargement: 2. sxs (incl exercise test): - +sxs ⇒ PVR (1) - asx ⇒ more w/u 3. cMRI + CPET: - progressive RV dil/dysfxn and/or progressive ￬exercise capacity ⇒ PVR (2b) - stable ⇒ surveil PVR for: * sxs + ≥mod PR + RV enlargement/dysfxn (1) * asx + ≥mod PR + progressive RV enlargement/dysfxn OR progressive ￬exercise capacity (2b) serial f/u for any PR not meeting above criteria ## Footnote AHA ACHD guideline Figure 3. Isolated PR after repair of PS https://drive.google.com/file/d/12YEO9s5RsgP5NWqfCRqR-V4VhDFJKXrJ/view \*Significant PR causes RV dilation. If a patient has moderate or greater PR and normal RV size, most likely the estimation of PR severity is inaccurate or there may be restrictive RV physiology, which would warrant further investigation. †Symptoms may include dyspnea, chest pain, and/or exercise intolerance referable to PR or otherwise unexplained.

Question 242

What determines R/L heart dominance?

Answer 242

PDA origin off RCA v LCx > LAD = R v L dominant = 90% v 9% v 1% co-dominant

Question 243

What is the most common heart dominance (coronary circulation)?

Answer 243

**R**-dominant = 90% L = 9% co- = 1%

Question 244

imaging recommendation for evaluating post-rx ToF

Answer 244

cMRI to quantify ventric size/fxn, PV fxn, PA anatomy, LH abnormalities (1)

Question 245

mandatory pre-intervention testing before RV-PA conduit stenting or transcatheter PVR

Answer 245

coronary artery compression testing (1)

Question 246

indication(s) for intervention on PR in ToF (adult/post-rx)

Answer 246

PVR (surgical or transcatheter) for **≥mod PR** AND: ➢ **\+CV sxs** (1) ⇒ ￬sxs ➢ _asx + ≥2 of:_ (2a) - ≥mild RV/LV dysfxn - RV dil (RVEDVI≥160mL/m² / RVESVI≥80mL/m² / RVEDV ≥2x LVEDV) - RVSP 2/2 RVOTO ≥2/3 SBP - progressive ￬exercise tolerance *⇒ preserve RV size/fxn* ➢ sustained [ventricular] tachyarrhythmias (2b) ➢ surg PVR for concomitant \<3 surg (other residual lesions requiring surgical rx) (2b) ## Footnote AHA ACHD guideline Figure 4. Pulmonary valve replacement in patients with TOF repair and PR https://drive.google.com/file/d/12bncSXwY_LVaRkXGWUbrYB0nL2J7lqgv/view

Question 247

indication(s) for ICD in ToF (adult/post-rx)

Answer 247

multiple RFs: ICD ⇒ 1° ppx of SCD (2a) ## Footnote RFs: - LV systolic or diastolic dysfxn - non-sustained VT - QRS≥180 - extensive RV scarring/fibrosis (on CMR) - inducible sustained VT on EP

Question 248

indications for RV-PA conduit intervention (adult)

Answer 248

* ≥mod PR/PS + ￬fxnal capacity OR arrhythmia (2a) * asx + severe PR/PS + ￬RV RF or RV dil (2b)

Question 249

"classic"/old definition of PAH/pHTN

Answer 249

**mPAP≥25 & PVR≥3.0 Wu** mean PA pressure (mPAP) ≥ 25 mmHg + pulmonary vascular resistance (PVR) ≥ 3.0 Woods units (WU)

Question 250

new/current definition of PAH/pHTN

Answer 250

**mPAP>20 & PVR>2.0 Wu** mean PA pressure (mPAP) > 20 mmHg + pulmonary vascular resistance (PVR) > 2.0 Woods units (WU)

Question 251

indication(s) to operate on anomalous aortic origin of coronary artery (AAOCA)

Answer 251

_LCA from R sinus:_ **YES** - \+sx/exercise test/ischemia (1) - asx (2a) _RCA from L sinus:_ **PROB** - \+sx/exercise test/ischemia (1) - \+ventric arrhythmias (2a) - asx (2b) OR obs (2b) ## Footnote AHA ACHD guideline Figure 5. Anomalous aortic origin of the coronary artery https://drive.google.com/file/d/137Gl6zTGTsGJNG_poFug5pePohBSIlMh/view

Question 252

indication(s) to operate on anomalous aortic origin of R coronary artery (R AAOCA)

Answer 252

_RCA from L sinus:_ **PROB** - \+sx/exercise test/ischemia (1) - \+ventric arrhythmias (2a) - asx (2b) OR obs (2b) ## Footnote AHA ACHD guideline Figure 5. Anomalous aortic origin of the coronary artery https://drive.google.com/file/d/137Gl6zTGTsGJNG_poFug5pePohBSIlMh/view

Question 253

indication(s) to operate on anomalous aortic origin of L coronary artery (L AAOCA)

Answer 253

_LCA from R sinus:_ **YES** - \+sx/exercise test/ischemia (1) - asx (2a) ## Footnote AHA ACHD guideline Figure 5. Anomalous aortic origin of the coronary artery https://drive.google.com/file/d/137Gl6zTGTsGJNG_poFug5pePohBSIlMh/view

Question 254

w/u for anomalous aortic origin of coronary artery (AAOCA)

Answer 254

- any or all of: CTA > LH cath (coronary angio) > cMRI (1) - "anatomic & physiologic" eval for LCA from R sinus OR RCA from L sinus (1)

Question 255

clinical considerations for risk of sudden cardiac death (SCD) in anomalous aortic origin of coronary artery (AAOCA)

Answer 255

* \<35yo (relative) * slit-like/fish-mouth-shaped orifice (more common with RCA from L sinus) * acute * acute angle take-off * intramural course * interarterial course * hypoplasia of prox coronary artery * LCA from R sinus (less common than RCA from L but ? ∝ higher risk of SCD; LCA from R also ∝ myocardial fibrosis) * SCD ∝ exercise ## Footnote * **age**: "AAOCA is more commonly invoked as the cause of SCD in patients \<35 y of age than in patients \>35 y of age, in whom atherosclerotic coronary disease becomes a more prevalent cause. However, death has been attributed to AAOCA in patients of all ages; there does not seem to be an age beyond which the AAOCA may not be relevant, even in the setting of atherosclerotic coronary disease and other concomitant conditions." * **anatomy**: "Slit-like/fish-mouth-shaped orifice, acute angle takeoff, intramural course, interarterial course and hypoplasia of the proximal coronary artery have all been proposed as reasons for symptoms, ischemia and SCD in patients with AAOCA. The slitlike orifice is more commonly seen in anomalous right coronary artery arising from the left sinus. Each of these anatomic findings offers a pathophysiological mechanism for intermittent ischemia, particularly at times of high cardiac output and/or increased aortic wall tension, such as during exercise." * **anomalous origin**: "Left coronary artery arising from the right cusp is less common than the right coronary artery arising from the left cusp but is more often found in autopsy series of SCD. This suggests that anomalous origin of the left coronary artery from the right cusp is more likely to cause SCD than anomalous origin of the right coronary artery from the left cusp. This may be due either to anatomic features that make anomalous aortic origin of the left coronary artery prone to coronary compromise or because a larger proportion of myocardium is supplied by the left coronary artery, or both." / "Anomalous left coronary from the right sinus is less common than anomalous right coronary from the left sinus, but anomalous left coronary artery from the right is more commonly found in autopsy series of athletes and military recruits who had nontraumatic death than right coronary from the left sinus. The overrepresentation of the anomalous left coronary from the right sinus suggests a higher risk of SCD, particular at extremes of exertion and in patients \<35 years of age." * **exercise**: "Autopsy series suggest a most patients die during, or in close temporal association with, exercise." * **ischemia**: "Autopsy series demonstrate myocardial fibrosis in a significant number of patients whose deaths were attributed to AAOCA, particularly in patients with anomalous left coronary artery arising from the right cusp. Surgical series describe patients with ischemia or MI before surgical repair in the absence of other CAD, suggesting a relation of the coronary anomaly to the ischemia. This suggests that had perfusion imaging been obtained before SCD, ischemia would have been found in such patients. However, other data indicate that a normal stress test does not preclude a SCD event, with the proviso that most of those studies used only stress ECG, rather than the more sensitive and specific modalities of nuclear perfusion imaging or stress echocardiography. In addition, postoperative studies have shown that ischemia may be found after surgical repair in the distribution not supplied by the abnormal coronary artery and may not persist on repeat testing." / "However, there are patients in whom a SCD event occurred despite normal stress ECG, and consequently absence of ischemia is not reassuring. Autopsy series show that many patients whose death is attributed to anomalous coronary arteries are young, thus management of patients should take age into account, with heightened concern about the risk of sudden death in younger patients." * **symptoms**: "In autopsy and surgical series, a significant number of patients reported cardiovascular symptoms, including before SCD events. Symptoms are more commonly reported in patients in whom the left coronary artery arises from the right sinus. Surgical series have described improvement in symptoms after surgical repair." Table 34. Factors That May Relate to the Clinical Importance of AAOCA and Risk of SCD https://drive.google.com/file/d/1312p1L2P2nXBnWRC0DiHgfFpr8FMswI-/view

Question 256

approach(es)/intervention(s) for anomalous aortic origin of coronary artery (AAOCA)

Answer 256

AHA: unroofing OR coronary revascularization (bypass) for concomitant fixed obstruction OR re-implantation???

Question 257

indication(s) to operate on anomalous origin of L coronary artery from PA (ALCAPA)

Answer 257

YES (1)

Question 258

indication(s) to operate on anomalous origin of R coronary artery from PA (ARCAPA)

Answer 258

\+sx (1) asx + ventric dysfxn or attributable myocardial ischemia (2a)

Question 259

approach(es)/intervention(s) for anomalous origin of L/R coronary artery from PA (ALCAPA/ARCAPA)

Answer 259

AHA: aortic reimplantation ± interposition graft OR ligation/closure @ level of PA + bypass (CABG: LIMA-LAD or RIMA-RCA/PDA)

Question 260

annual rate of stroke in CHA₂DS₂-VASc score = 2 ♂ / 3 ♀

Answer 260

\>2% (considered high, v 1-2% intermediate & \<1% low)

Question 261

indication(s) for percutaneous LAAO (LA appendage occlusion)

Answer 261

afib + mod-high stroke risk (CHA₂DS₂-VASc≥2): - \+ contraindication to long-term anticoag (2a) - \+ high risk of major bleeding (2b) (as alternative to anticoag)

Question 262

indication(s) for surgical LAAE (LA appendage exclusion/excision)

Answer 262

afib + concomitant \<3 surg + CHA₂DS₂-VASc score≥2 or equivalent stroke risk: - *in add'n to anticoag* ⇒ ￬stroke,syst embo (1) - *without ongoing anticoag* (2b: uncertain) [LAAE surgical technique should ⇒ ∅flow & stump \<1cm by intraop TEE (1)]

Question 263

indication(s) for surgical ablation (Cox maze) for afib

Answer 263

- afib + concomitant \<3 surg (2a) ⇒ ￬recurrent afib - sx, persistent, Rx-refrx afib: hypbrid epicardial + endocardial ablation ⇒ ￬recurrent atrial arrhythmia (2b) ## Footnote "Among patients with AF or AFL, concomitant surgical ablation at the time of cardiac surgery has been shown to reduce the risk of recurrent atrial arrhythmia. However, it is associated with an increased risk of renal dysfunction and pacemaker placement."

Question 264

minimum ACT to go on bypass

Answer 264

480

Question 265

minimum ACT to cannulate

Answer 265

200-250 OR empiric hep dose of 5000-10000u OR 100u/kg OR 300 (CTS 2e) ## Footnote 200 = Salim ("to manipulate the arch/prox Ao") 250 = ??? 5k empiric = BTK??? + JT or Julie 10k empiric = Kim 100u/kg = ~7k typical 70kg pt = Salim

Question 266

STICH

Answer 266

??? aneurysm rx no benefit reduced EF benefit

Question 267

STICH-ES

Answer 267

???

Question 268

BARI

Answer 268

??? multivessel diabetic

Question 269

SYNTAX

Answer 269

??? CABG v PCI

Question 270

steps if ACT inadequate after heparin

Answer 270

1. give more heparin 2. check for a "bad batch"/new vial 3. ATIII \> FFP

Question 271

mgmt of air embolus on CPB

Answer 271

1. STOP BYPASS (clamp lines) 2. head down (reverse T) + 100% FiO2 + steroids ± barbiturate ± mannitol 3. de-air circuit & resume CPB + cool to 18° 4. RCP with aortic root vent on 5. hyperbaric O2 if within 5h of OR

Question 272

minimum stenosis to use a radial artery bypass graft

Answer 272

90% R 80% L

Question 273

minimum stenosis to use a radial artery bypass graft on a R-sided lesion

Answer 273

90%

Question 274

minimum stenosis to use a radial artery bypass graft on a L-sided lesion

Answer 274

80%

Question 275

location/course of persistent L SVC

Answer 275

origin: L IJ & L subclv jxn course: to L of desc Ao, crosses behind LA drainage: coronary sinus

Question 276

incidence of persistent L SVC

Answer 276

~3%

Question 277

protamine dose

Answer 277

1mg/100u hep

Question 278

endovascular interventional wire sizing

Answer 278

diameter (*in*) x length (*cm*)

Question 279

most common cause of/etiology underlying spontaneous bloody/hemorrhagic pericardial effusion

Answer 279

CA (~1/3) ## Footnote SESATS: "The presence of a hemorrhagic effusion is most likely due to malignancy. In a series of large symptomatic pericardial effusion, this was the cause in 1/3 of cases. **Chronic-idiopathic (14%), acute pericarditis (12%), trauma (12%), and uremia (6%)** were other causes of this type of effusion."

Question 280

idiopathic(/viral) pericarditis mgmt

Answer 280

1. NSAIDS (ASA650/ibu800 TID) + colchicine (0.6 QD/BID) ￫ taper NSAIDS once improved, complete 3mo colchicine 2. steroids only if NSAIDS contraindicated or fails ## Footnote UpToDate: The daily maintenance dose of colchicine is weight-based: ●≥70 kg = 0.5 to 0.6 mg BID ●\<70 kg = 0.5 to 0.6 mg QD "Duration of treatment is based upon the resolution of symptoms, which usually occurs in two weeks or less, with tapering once the patient is symptom-free for at least 24 hours." "Failure to respond to aspirin or NSAID therapy within one week (defined as persistence of fever, pleuritic chest pain, a new pericardial effusion, or worsening of general illness) suggests that a cause other than idiopathic or viral pericarditis is present." "Recurrent pericarditis is manifested by recurrence of the symptoms and signs of acute pericarditis after a symptom-free interval of at least four to six weeks." "Symptoms of recurrent pericarditis occur at a variable time after the initial attack, but usually within 18 months."

Question 281

recurrent idiopathic(/viral) pericarditis mgmt

Answer 281

same as 1st episode: 1. NSAIDS (ASA650/ibu800 TID) + colchicine (0.6 QD/BID) ￫ taper NSAIDS once improved, complete 3mo colchicine 2. steroids only if NSAIDS contraindicated or fails ## Footnote SESATS: "Recurrent pericarditis is a challenging problem for clinicians and is a disabling issue for patients. The most common presenting symptoms of recurrent pericarditis are generally the same as those which are seen during the initial episode. Recurrence after initially successful treatment typically occurs within 18 months and often adversely affects the patient's quality of life. While no specific clinical feature of an initial episode of acute pericarditis consistently predicts recurrence, an **initial successful treatment with aspirin or NSAIDs is associated with a reduced risk of recurrence**. In contradistinction, **initial therapy with glucocorticoids is associated with a greater risk of recurrence**. Most patients with recurrent pericarditis can be managed effectively with medical therapy on an outpatient basis. Combination therapy with colchicine and NSAIDs for recurrent pericarditis has been evaluated in 3 randomized, placebo-controlled trials as well as 2 systematic reviews and shown to significantly benefit patients. Furthermore, it has been shown to lower the risk of further recurrent episodes. Intrapericardial steroids achieve high local steroid concentrations while limiting systemic toxicity, however, this treatment is viewed as a last resort, especially in patients who experienced severe side effects of systemic therapy. **In the small amount of patients who do not respond to conventional therapy or who do not tolerate first- and second-line medications, the addition of immune therapy can be considered in the form of azathioprine, anakinra, or human IVIg.**"

Question 282

differentiating features of constrictive pericarditis & restrictive cardiomyopathy

Answer 282

constrictive pericarditis v restrictive CM, respectively: - ￪resp var in ventric filling v minimal - rapid early diastolic filling v slow - "square root" sign of rapid filling then rapid stop v gradual - **equalization of ventricular pressures** v L\>R - **ventricular interdependence** v not ## Footnote https://drive.google.com/file/d/19PZ8DYC_G3iDUAqdiGt6er67itYLA_Li/view

Question 283

diagnosis of CTEPH

Answer 283

- PAP\>25 - PCWP\<15 - mult chronic/organized occlusive thrombi/emboli in PAs after ≥3mo anticoag - V/Q scan showing ≥1 segmental+ perfusion defect(s)

Question 284

predictors of afib recurrence after Cox maze

Answer 284

- age - duration of preop afib - LA dil

Question 285

freedom from recurrent afib after concomitant Cox maze with MVRx

Answer 285

\>80% (SESATS: 3/6/12mo = 85%/81%/84%)

Question 286

risk of PPM with Cox maze (standalone/no concomitant procedures)

Answer 286

~5% (￪ with add'l proc)

Question 287

risk of PPM with biatrial v L atrial Cox maze

Answer 287

14% v 6% ## Footnote SESATS: "The need for permanent pacemaker (PPM) insertion after lone Cox Maze IV (CMIV) has been reported as 5% and increases when the CMIV is performed as a concomitant procedure, most commonly after valvular heart surgery. While many centers only offer surgical ablation as a biatrial procedure in order to address atrial fibrillation (AF) originating from the right atria, many centers offer a left atrial CMIV lesion set only. This reserves biatrial procedures to patients with prolonged AF history or with rightsided heart disease and right atrial enlargement. The biatrial lesion set is associated with an increased need for PPM (13.6% compared with 6.3%, P= 0.028). Left atrial diameter and duration of atrial fibrillation are predictors of recurrent atrial fibrillation but are not predictors of the pacemaker requirement. **The primary indication for PPM after a biatrial lesion set after a CMIV was sinoatrial node dysfunction (40%–68%).** Atrioventricular (AV) block, when present after concomitant surgical ablation, is typically reflective of AV nodal injury, which is most commonly attributed to the valvular procedure that is performed. Concomitant coronary artery bypass grafting does not increase the risk of pacemaker requirement."

Question 288

ppx abx before cardiac surgery

Answer 288

- 1st-gen ceph - +vanc if implanting prosthetic OR pt high-risk for Staph

Question 289

amount of aortic root you can repair before having to replace (e.g. in endocarditis)

Answer 289

up to 1/3 (BTK)

Question 290

max re-warming rate coming off DHCA

Answer 290

**1°C/2min** / 0.5°C/1min max arterial outflow : venous inflow ∆ = 10°C (BTK: max core : periph temp ∆ ≤5°C) ## Footnote SESATS: "When cooling and rewarming, the temperature gradient from the arterial outlet to the venous blood temperature should not exceed 10° C to prevent the formation of gaseous emboli. The maximum arterial temperature should be 37° C to prevent cerebral hyperthermia. The maximum rewarming rate should be less than 0.5° C per minute."

Question 291

mgmt of acute L-sided mech valve thrombosis +sx

Answer 291

urgent slow-infusion, low-dose fibronlysis (tPA) OR emergency surgery

Question 292

mgmt of bp valve thrombosis, hemodynamically stable

Answer 292

hep drip ￫ warfarin

Question 293

ECHO criteria in order of increasing #s for regurgitant valve criteria (in general/all 3)

Answer 293

*alphabetical*: 1. EROA (0.1-0.3/0.2-0.4x2) 2. jet (25-65/20-40/\>50) 3. RF (30-50/30-50/X) 4. RVol (30-60/30-60/30-45) 5. vena contracta (0.3-0.6/0.3-0.7x2)

Question 295

peak gradient in mild RVOTO

Answer 295

\<36

Question 296

peak gradient in moderate RVOTO

Answer 296

36-64

Question 297

peak gradient in severe RVOTO

Answer 297

\>64

Question 298

peak gradient in severe RVOTO

Answer 298

\>64

Question 299

v_max in mild RVOTO

Answer 299

\<3

Question 300

v_max in moderate RVOTO

Answer 300

3-4

Question 301

v_max in severe RVOTO

Answer 301

\>4

Question 302

secondary lesion a/w PA sling

Answer 302

tracheal stenosis/complete tracheal rings

Question 303

Cox maze IV lesions

Answer 303

Pulmonary vein box LAA Crossing mitral valve SVC IVC RAA Crossing tricuspid valve Corinary sinus?

Question 304

configuration of PA sling

Answer 304

*ring around trachea only* - L PA anomalously arises from R PA instead of main PA & courses *between* trachea & esophagus (=R&posterior) - normal R PA (=anterior) - ligamentum arteriosum (=L) *only ring/sling that courses **between** trachea & esophagus* *only ring/sling that creates **anterior** compression of esophagus* ## Footnote - https://drive.google.com/file/d/1DD4xt3c3yaYBj3GN0K6AlgDw24xsOKP7/view - https://drive.google.com/file/d/1DEm-GXr3rW1JYlc-FG-TVGGXpOiGv_Wy/view - https://drive.google.com/file/d/1DFXtxr8JzewSV7q9mxk-duvDX-mKWltF/view

Question 305

indication(s) for rx of recurrent CoA (coarcation) in adult

Answer 305

- peak to peak gradient \>20 - HTN

Question 306

mgmt of recurrent CoA (coarctation) in adult

Answer 306

stent \> balloon stent \> surgery ## Footnote SESATS: "The incidence of recoarctation is between 5% – 14%. It is most common when the repair is done in neonates (\<30 days) and to a lesser extent infants (\<1yo). The presence of hypoplasia in the transverse arch also increases the chance of recurrent arch gradient. Indications for intervention in the setting of recurrent coarctation include hypertension and a peak-topeak gradient across the area of stenosis >20 mmHg, both of which are present in the patient described. Guidelines from the American College of Cardiology and the American Heart Association recommend percutaneous catheter intervention as the preferred treatment of choice for the management of discrete recoarctation. This is based, in part, on the fact that mortality for re-operation is significant at 1% – 3%, and it can be as high as 5% – 10% if there is significant left ventricular dysfunction."

Question 307

PAPi definition

Answer 307

PA pulsatility index = PAPP (pulse pressure) ÷ CVP = “how much pressure is the RV able to generate relative to RA pressure” (BTK)

Question 308

PAPi normal limit

Answer 308

≥5.5

Question 309

SVR normal limit

Answer 309

800-1200

Question 310

definition of cardiogenic shock

Answer 310

CI\<2.2

Question 311

PCWP normal limit

Answer 311

4-12

Question 312

type of valvular dysfxn with a *diastolic* murmur

Answer 312

regurg

Question 313

type of valvular dysfxn with a *systolic* murmur

Answer 313

**s**tenosis = **s**ystolic

Question 314

Where is the central fibrous body & what structures comprise it?

Answer 314

NCC base/nadir membranous septum + R trigone