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Cardiology Flashcards

1
Q

HFrEF definition

A
  • Symptoms and signs of HF

- AND LVEF <50%

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2
Q

HFpEF Definition

A
  • Symptoms and signs of HF
  • AND LVEF >/=50%
  • AND obejective evidence of:
  • -Relevant structural heart disease (LV Hypertrophy, LA enlargement)
  • -OR Diastolic dysfunction w/ high filling pressure shown by cath, TTE, elevated BNP, or exercise
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3
Q

SGLT2 evidence in CCF

A

Shown to reduce hospitalisation and CCF in patients with CCF and diabetes or without diabetes

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4
Q

Indications for CRT

A
  1. NSR, LVEF <35%, and QRS >150 ms despite optimal medical Mx
  2. Maybe in NSR, LVEF <35% and QRS 130-149 ms
  3. Maybe in LVEF <50% with high grade AV block requiring pacing to decrease hospitalisation with HF
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5
Q

Benefits of CRT

A

Decreases mortality
Decreased HF related hospitalisation
Improved QoL

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6
Q

Contraindication to CRT

A

QRS <130 ms due to possible harm

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7
Q

Which type of BBB has the best benefit from CRT

A

LBBB >RBBB

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8
Q

When can there be an acheived benefit with CRT when a patient has AF

A

Only if they are essentially pacing dependent, at least 92% of the time, otherwise no benefit in AF

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9
Q

Who benefits from an ICD insertion for primary prevention

A

Strongest evidence:
-HFrEF due to IHD and an LVEF <35% to decrease mortality

Can be considered in dilated cardiomyopathy with an LVEF <35%, but not as much benefit as IHD

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10
Q

What does evidence show in regards to when catheter ablation for AF should be considered

A

HFrEF with LVEF <35% with recurrent admissions for symptomatic AF to decrease mortality and hospitalisation

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11
Q

Evidence for iron transfusions in CCF for anemia

A

Transfuse if Tsat <20% and Ferritin <300 OR if Ferritin <100

Shown to improve QoL and hospitalisations

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12
Q

BNP cut off

A

Good test for ruling ot CCF

BNP <100 pg/ml = 83% accuracy

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13
Q

Why can’t BNP be used for testing when on an ARNI

A

Increased levels due to blockade

Use NT Pro BNP instead

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14
Q

Red flags for Advanced HF

A
  • Hypotension: persistent SBP <90
  • Persistent NYHA 3+ Sx
  • Hospitalisations 2+ in 12 months
  • Recurrent 2+ ICD shocks
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15
Q

Early cause of heart transplant failure

A

Rejection

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16
Q

Late cause of heart transplant failure

A

CAD

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17
Q

Evidence of stenting non culprit lesion as well as culprit lesion during AMI

A

Reduced mortality in stenting non culprit lesions, but timing is unclear and concern for possible complications during index procedure

Usually manage bystander disease with staged PCI

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18
Q

Evidence for Thromboaspiration in STEMI

A

Does not improve mortality or reduce infarct size

Increased risk of strokes

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19
Q

Evidence for radial vs femoral access for PCI

A

Radial Access:
-Reduced mortality, reduced bleeding, reduced vascular complications

Particularly for STEMI patients

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20
Q

What is a significant FFR

A

<0.8

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21
Q

DES vs BMS

A

DES less instent restenosis

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22
Q

Evidence for Aspirin in primary prevention

A

No clear benefit of aspirin as primary prevention

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23
Q

Evidence for supplemental O2 in STEMI

A

A/W larger infarct size, more recurrent MI and more major arrhythmia

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24
Q

Pharmaco-Invasive Approach for STEMI

A

Thrombolysis then PCI 3-24 hours post thrombolysis

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25
Q

STEMI: PCI time for PCI capable centre

A

Ideally <60 min door to PCI time

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26
Q

STEMI: PCI time for NOT PCI capable centre

A

If PCI possible <120 mins, then transfer for PCI

If not possible to have PCI <120 min, then thrombolysis within 30 mins

  • If successful - PCI in 3-24 hrs
  • If unsuccessful immediate Rescue PCI
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27
Q

High Sensitivity Troponin T

A

Higher negative predictive value
Reduces troponin blind period
Elevation of 13 fold limited positive predictive value

Done at 0 and 2 hours

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28
Q

Contraindications for prasugrel

A

Previous stroke/TIA
Age > 75
Weight <60 kg

Increased bleeding risk

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29
Q

Benefits of Stress echo vs nuclear

A

Nuclear has higher sensitivity and Stress echo has higher specificity

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30
Q

Current TGA indications for loop monitors

A 
Syncope F.I
Cryptogenic stroke (?AF)
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31
Q

Familial hypercholesterolaemia

A

AD
Very elevated LDL usually >4.9
Xanthomata highly suggestive
AMI <45 usually

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32
Q

FH Genetics

A

ApoB/E receptor mutation

Gain of PSCK9 function

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33
Q

Highest points for criteria of FH

A 
LDL >8.5 (8points)
Tendon Xanthomata (6 points)
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34
Q

Mx of FH

A

Screen al first degree relatives
Statins first line
If LDL >3.3 then PSCK9 inhibitors next

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35
Q

Familial combined hyperlipidaemia profile

A

High chol
High TG/LDL
Low HDL

LDL to apo-B ratio <1.2

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36
Q

Dyslipidamia profile in T2DM

A

High Tg
High LDL
Low HDL

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37
Q

Dyslipidamia profile in cholestatic liver/PBC

A

Marked chol increase - accumulation of lipoprotein X

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38
Q

Dyslipidamia profile in nephrotic syndrome

A

Marked total chol and LDL increase

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39
Q

Dyslipidamia profile in CKD

A

Less prominent increase in LDL and Tg

Low HDL

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40
Q

Dyslipidamia profile in hypothyroidism

A

Raised LDL predominantly

Sometimes high Tg

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41
Q

Dyslipidamia profile in obesity

A 
High chol
High LDL
High VLDL
High Tg
Low HDL
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42
Q

Dyslipidamia profile in smoking

A

Low HDL

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43
Q

Dyslipidamia profile in ETOH

A

Raised Tg

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44
Q

PCSK9

A

This protein mainly expressed in the liver and intestines but also present in plasma binds to and degrades LDL-R
Statins increase PCSK9 expression and hence combination therapy should have a synergistic effect

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45
Q

PBS indication for PCSK9 inhibitor

A

Familial homozygous hypercholesterolemia
AND
LDL >3.3

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46
Q

Meds that can be used in a hypertensive crisis

A

Hydralazine
SNP
GTN
Labetalol

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47
Q

Target BP for control

A

<130/80

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48
Q

Urinary Gopamine is elevated in what condition

A

essential HTN

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49
Q

B1 adrenergic effect

A

chronotropy/inotropy/lusitropy (relaxation)/dromotropy (increased conduction)

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50
Q

B2 adrenergic effect

A

bronchodilation, vascular smooth muscle relaxation (vasodilation)

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51
Q

B3 adrenergic effect

A

sympathetic mediation of lipolysis and thermogenesis

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52
Q

Reversible causes in Arrest - 4 H’s

A

Hypoxia
Hypovolemia
Hypo/Hyperkalemia/metabolic
Hypothermia/Hyperthermia

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53
Q

Reversible causes in Arrest - 4 T’s

A

Thrombosis
Tension pneumothorax
Tamponade
Toxins

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54
Q

Drugs in shockable rhythm

A
  • Adrenaline 1mg after 2nd shock (then every 2nd)

- Amiodarone 300mg after 3rd shock (then every 2nd)

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55
Q

Drugs in nonshockable rhythm

A

-Adrenaline 1mg immediately (then every 2nd)

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56
Q

Amount of shock given in CPR

A

200J biphasic

360J monophasic

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57
Q

Targeted temp post cardiac arrest

A

33-36 celsius

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58
Q

Indications for PPM

A
  1. SND
    - Only if symptomatic
  2. AV block
    - Pace even if symptomatic in Type 2 AV block, high degree AV block, CHB
    - Otherwise only if symptomatic
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59
Q

Indication for HIS bundle pacing

A

Consider if EF 35-50% and will need >40% pacing

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60
Q

Mx of inferior infarct with new CHB

A

Reversible CHB

Monitor and temporarily pace, but likely will not need PPM

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61
Q

Genetic disorders at risk of SCD that benefit from ICD

A 
Long QT syndrome
Brugada
HOCM
ARVC (Arrhythmogenic right ventricular cardiomyopathy)
Catecholaminergic polymorphic VT
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62
Q

RHC Waveforms in order

A

RA>RV>PA>PCW

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63
Q

PCWP =?

A

PCWP = LA = LVEDP

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64
Q

Atrial pressure waveform: A wave

A

Atrial systole

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65
Q

Atrial pressure waveform: X descent

A

Atrial Contraction

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66
Q

Atrial pressure waveform: V wave

A

Ventricular contraction

(<a>A in LA)</a>

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67
Q

Atrial pressure waveform: Y descent

A

Atrial emptying

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68
Q

Large V wave and prominent y descent

A

TR

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69
Q

Prominent X and y descent

A

Constrictive pericarditis

70
Q

Large A wave

A

TS

71
Q

Which atrial waveforms are not seen in AF

A

A and v wave

72
Q

Kussmaul’s sign: Inspiratory rise or lack of decline in RA pressure: ?Cause

A

Cosntriction or RV ischemia

73
Q

Causes of Constrictive pericarditis

A 
TB pericarditis
REcurrent pericarditis
PRevious mediastinal RTx
Uraemia
CTD
74
Q

Causes of Restrictive cardiomyopathy

A 
Idiopathic
Infiltrative
-Amyloidosis
-Sarcoidosis
-Haemochromatosis
Post radiation
Endocardial fibroelastosis
75
Q

Mx of Constrictive pericariditis

A

Pericardial stripping

76
Q

Mx of restrictive cardiomyopathy

A

Medical therapy

Transplant

77
Q

Differentiating Constrictive pericariditis and Restrictive cardiomyopathy on Ix

A

TTE:

  • Both have diastolic function
  • Eprime low in restriction (if >8, then constriction)

CT chest - thickened pericardium suggestive of constrictive

78
Q

HOCM inheritance and pathophysiology

A

AD
Proteins encoding proteins of thick and thin myofilament contractile components of the cardiac sarcomere or Z-disk

Most commonly involves beta-myosin heavy chain (40%) and myosin-binding protein C (40%)

79
Q

Diagnosis of HOCM

A

Wall thickness > 15mm in one or more LV myocardial segments

Not explained by other conditions

80
Q

Mx HOCM

A

Treatment of Symptomatic LVOTO

  • BB (reduce LVOTO and Ventricular arrhythmia)
  • Central CCB (2nd line)
  • Disopyramide (Class 1 A antiarrhthymic
  • Amiodarone for AF
  • Myoectomy in some cases
  • ICD in medium to high risk
  • ICD if previous VT/VF arrest
81
Q

ARVC

A

Dilation and myocardial thinning of the RV, particularly inflow, outflow and posterolateral LV

Replacement of myocardium with fibrofatty tissue

Genetic mutations predominantly of desmosomal proteins (intercellular adhesion complexes that provide connections between myocytes)
-Desmoplakin, Plakoglobin

82
Q

ARVC ECG

A

Prolonged S-wave upstroke
Epsilon wave
Twave inversion V1-V3

83
Q

ARVC Mx

A

Activity restriction (risk of arrhthymia and CCF)

BB

ICD if high risk

84
Q

Drugs causing Long QT

A 
Psychotropics
Class 2 antiarrhythmics (amiodarone, sotalol)
TCAs
SSRIs/SNRIs
Macrolides
HCQ
85
Q

LQT Genes

A

LQT1: KCNQ1 (K+Channel)

LQT2: KCNH2 (K+ Channel)

LQT3: SCN5A (Na Channel)

86
Q

LQT1

A

Most common form
Loss of function mutation of KCNQ1
Associated with sensorineural hearing loss

Triggered by exercise

87
Q

LQT2

A

Loss of function mutation of KCNH2

Triggered by sleep and emotion, post partum, auditory triggers

88
Q

LQT3

A

Gain of function mutation of SCN5A - sodium channel

Triggered by sleep

89
Q

Tx of Long QT

A
  1. BB (Propanolol is best)
  2. Left cardiac sympathetic denervation
  3. ICD
90
Q

Tx of Torsades

A 
MgSO4 2g (20ml of 10%) up to 6 g
Correct K
Isoprenaline
Temporary pacing
DCR
91
Q

Brugada

A

More common in males
Associated with SCZ
Due to loss of function mutation in SCN5A and SCN10A

Fever can be a precipitant

92
Q

Brugada Mx

A

Antipyretics
ICD if previous arrest
Quinidine/amiodarone
Catheter ablation to reduce freq of arrhythmia

93
Q

Best way to differentiate constrictive pericarditis from restrictive cardiomyopathy

A

Systolic area of index
(Ratio of RV pressure: LV pressure in inspiration vs expiration)

> 1.1 = Constrictive pericarditis

Constrictive pericarditis = Increase in RV pressure with inspiration

94
Q

Elevated RVSP

A

= Pulmonary HTN or RVOTO

95
Q

What Mx will have the most improvement in 6MWT in Pulm HTN

A

Exercise training

96
Q

Oximetry sampling in shunts: ASD

A

Step up in RA

97
Q

Oximetry sampling in shunts: VSD

A

Step up in RV

98
Q

Oximetry sampling in shunts: PDA

A

Step up in PA

99
Q

Types of ASD

A

Ostium Primum

  • More common in Down syndrome
  • Partial AVSD

Osteium Secundum

  • Most common
  • Amenable to percutaenous closure

ASD associated with right ventricular volume overload

100
Q

Sinus Venosus

A

SVC more common than IVC

Associated with anomalous pulmonary venous return

101
Q

When to close an ASD?

A 
Symptoms
RV enlargement
Qp:Qs >1.5
Paradoxical embolism
Playpnea-orthodeoxia syndrome
102
Q

When not to close an ASD

A

Eisenmenger

103
Q

VSD presentation

A

Murmur
CCF (dilated LV)
Endocarditis
Cyanosis (PHTN)

104
Q

When to close VSD

A 
Symptoms
LV enlargement
Qp:Qs >2:1
PHT with net L to R shunt
Endocarditis
AR
RVOTO
105
Q

PDA presentation

A

Continuous murmur

If large CCF

106
Q

When to close PDA

A

Left chamber enlargement
PHTN (net left to right shunt)
Previous endarteritis
Audible murmur

107
Q

Most common cause of eisenmenger in order

A

PDA>VSD>ASD

108
Q

Coarctation presentation

A

HTN in upper limbs
-Reduced femoral pulses, femoral-femoral delay, Arm-leg BP gradient

Exercise intolerance
-Angina, claudication

109
Q

Coarctation associations

A

Bicuspid Aortic valve +Aortopathy
Cengenital heart disease (VSD, PDA, etc)
Berry aneursyms

110
Q

Mx Coarcatation

A

Stenting

Monitor afterwards for residual HTN and risk of wall complication (aneurysm)

111
Q

Causes of pulmonary stenosis

A

Noonans Syndrome
-AD, skeletal abnormalities, learning difficulties

William’s syndrome

“Double chamber RV”

112
Q

Ebstein anomaly

A

Tricuspid valve regurg
Accessory pathway
80% have ASD or PFO as well

Tx: Closure of ASD/PFO and repair of TVR

113
Q

Tetralogy of Fallot

A

VSD
Overriding Aorta
RVH
RVOTO (Pulmonary stenosis or pulmonary atresia)

114
Q

High risk cardio conditions in pregnancy

A 
Severe PHTN
Eisenmenger Syn
Cardiomyopathy (NYHA2+, EF <40%)
Severe obstructive cardiac lesion (AS, PS, MS)
Marfan Syn with aortic root >40 mm
Previous severe peripartum CM
115
Q

Which patient groups get endocarditis prophylaxis

A

Prosthetic cardiac valve
Congenital heart disease (unrepaired cyanotic, repaired with residual disease)
PRevious endocarditis
Cardiac transplant patients with valvular disease

116
Q

Procedure that will need endocarditis prophylaxis in high risk groups

A

Dental with manipulation of gingival tissue
Invasive resp tract procedures
Procedure within infected skin, tissue

Tx:
Single dose Amoxy or Clinda 30-60 mins pre op

117
Q

AF ablation in patients with HF

A

Evidence shows reduced mortality and HF hospitalisations

118
Q

2 Most common genes in HOCM

A

MYBPC3 (cardiac myosin binding protein C)

MYH7 (Beta-myosin heavy chain)

119
Q

Catecholaminergic polymorphic VT gene

A

RYR2

120
Q

Causes of MS

A
  1. Rheumatic heart disease
  2. Mitral annular calcification
    Radiation
    Carcionid
    SLE/RA
    Fabrys, Whipple’s
121
Q

MS severity based on area

A

Mild: >1.5 cm2
Mod: 1.0-1.5 cm2
Severe: <1.0 cm2

122
Q

MS severity based on Gradient (mmHg)

A

Mild <5
Mod 5-10
Severe >10

123
Q

Effect on gradient in MS with exercise

A

Gradient increases with HR and exercise, so can get APO

124
Q

Mx of MS

A

MEdical therapy
-BB, diuretics if overloaded

Balloon valvuloplasty

125
Q

Indications for Balloon valvuloplasty in MS

A

Mod to severe MS (<1.5 cm2 area)

Symptomatic

Asymptomatic +

  • New AF
  • PASP >50mmHg at rest
126
Q

Contraindications for balloon valvuloplasty in MS

A

> mild MR
LA thrombus
Heavy calcification
Predominant subvalvular involvement

127
Q

Wellen’s Syndrome Definition and ECG

A

Severe proximal stenosis of LAD, usually with a rich collateral supply

Usually no chest pain but recent severe angina in the last 24-48hrs

• Classic ECG: Deep and symmetric T wave inversion in V1-V6, aVL and I (at least V2-V5), no ST changes. *highest risk if aVL and I are involved

Mx: Urgent Angio

128
Q

Acute instent thrombosis

A

<24 hours

129
Q

Subacute instent thrombosis

A

<30 days

130
Q

Late instent thrombosis

A

1-12 months

131
Q

Very late instent thrombosis

A

> 12 months

132
Q

Stent restenosis

A

• Gradual renarrowing of the stented segment (usually after 3-12 months)

133
Q

Greatest predictor of death post MI

A

REduced LVEF

134
Q

Evidence for PCI of occluded vessels when asymptomatic

A

Even if post AMI

Shown to increase mortality and worsen LV function if PCI performed

Only PCI if symptomatic

135
Q

Geneticsi n MArfan’s Syndrome

A

AD

FBN1 gene for protein fibrillin-1

136
Q

Diagnostic Criteria for Marfan’s Syndrome

A

W/O FHx:
-Aortic cteria +one other major criteria or FBN1 mutation

W/ FHx
-Any one of the major criteria

Major:

  • Aortic diameter Z >2 if above 20 yo, Z>3 if below 20 yr old, or aortic root dissection
  • Ectopia Lentis
  • Systemic score >7 based on smaller clinical findings
137
Q

Features suggesting successful thrombolyisis

A

Improvement/relief of chest pain
reduction by 50% of the initial ST-segment elevation within 60–90 minutes
reperfusion arrhythmias (e.g. accelerated idioventricular rhythm)
restoration of haemodynamic and/or electrical stability

138
Q

ECG Changes suggestive Right ventricular infarct

A

ST elevation in the right-sided leads (V3R-V6R)
• ST elevation in V1 – the only standard ECG lead that looks directly at the right ventricle.
• ST elevation in lead III > lead II – because lead III is more “rightward facing” than lead II and hence more sensitive to the injury current produced by the right ventricle.
• ST elevation in V1 + ST depression in V2 (= highly specific for RV MI).

139
Q

Exam Findings: Hypotension, jugular venous distension, clear lungs

A

Right ventricular infarct

140
Q

What medication should be given with thrombolysis

A

Aspirin and clopidigrel loading

Enoxaparin (IV better than SC)

141
Q

Absolute contraindications to thrombolysis

A
  • Previous ICH or stroke of unknown origin at anytime
  • Ischemic stroke in the last 6 months
  • CNS damage/neoplasma/AV malformations
  • REcent major trauma/surgery/head injury within last month
  • GI bleeding in last month
  • Known bleeding disorder
  • Aortic dissection
  • Non compressible punctures in last 24 hours
142
Q

Relative contraindications to thrombolysis

A 
TIA in last 6 months
-Oral anticoagulant therapy
-Pregnancy or within 1 week postpartum
-Refractory HTN SBP >180
-Advanced lvier disease
IE
-Active peptic ulcer
-Prolonged or traumatic resus
143
Q

Indication for CABG

A

Multivessel disease
Left main disease
Proximal LAD disease
T2DM with multivessel disease

144
Q

What risk factor has the greatest risk of extension of a pre-existing AAA

A

Smoking

145
Q

Mx of CHB

A

Unstable:

  • Atropine
  • Transcutaneous pacing
  • If unable to pace: isoprenaline
  • Low BP: Dopamine
  • HF: IV dobutamine
  • Normal BP and no HF: Transvenous pacing

Stable:

  • Transcutaneous pacing
  • Look for reversible causes
  • None: PPM
146
Q

Diagnostic criteria for pericarditis

A 
At leas 2:
Typical chest pain
Pericardial friction rub
Suggestive ECG changes
New or worsening pericardial effusion
147
Q

Mx of Aortic Dissection

A

Aim SBP <120 and HR <60

IV BB, SNP, or GTN

148
Q

Biggest risk factor for arrhythmia post CABG

A

AF most common

Age is greatest risk factor for AF post CABG

149
Q

Mx of stable VT

A

IV amiodarone/lignocaine
IF fails can consider retrial or cardioversion
Treat underlying cause too

150
Q

CHADSVASC

A
  • Congestive heart failure / left ventricular dysfunction
  • Hypertension
  • Age ≥ 75 (x2)
  • Diabetes
  • Stroke (x2)
  • Vascular disease
  • Age 65-74
  • Sex (female) (x2)
151
Q

HASBLED

A
  • Hypertension
  • Abnormal renal/liver function
  • Stroke
  • Bleeding history or predisposition
  • Labile INR
  • Elderly
  • Drugs/alcohol
152
Q

MAjor risk factors for stroke in AF

A
  • Major: past stroke, age >75, valve disease, mitral stenosis, mechanical valve
  • Alone are indications for anticoagulation
153
Q

Which antihypertensive should not be prescribed in HFrEF

A

Moxonidine

154
Q

Benefit of AF ablation in HF

A

Improves survival

155
Q

MR and LV dysfunction relationship

A

Irreversible LV contractile dysfunction may occur despite “normal” EF and without symptoms

Early: Increase in EF because ejecting into low pressure LA (decrease afterload and increase preload)

Late: Increase LV size and interstitial fibrosis (increase afterload) leads to decrease EF into “normal range” (70-60%)

156
Q

Indications for AR repair

A

If Symptomatic - Treat

If asymptomatic:

  • Resting EF <50%
  • Cardiac surgery/CAGS
  • Rest EF >50%, but LV Diastolic >70mm or LV systolic >50 mm
157
Q

Moderate AS

A

Gradient 20-40
Area 1-1.5
Velocity <0.25

158
Q

SEvere AS

A

Gradient >40 mmHg
Area <1 cm2
Velocity <0.25 DI
Flow 4

159
Q

Indication for TAVI

A

Symtomatic severe AS

160
Q

CI to TAVI

A 
Aortic annulus too small
LV apical thrombus
Peripheral vascular access issues
Active endocarditis
Life expectancy <1 yr
161
Q

Tavi Cx

A

Heart block
AR
Tavi thrombosis

162
Q

SAVR Cx

A

AKI
New AF
Major bleeding

163
Q

Flecainide MOA and CI

A 
Blocks fast inward sodium channels (class 1c)
•
ECG effects prolonged PR, QRS widening

CI: structural heart disease, CAD

164
Q

Amiodarone MOA

A

Multiple sites of action potassium channels,
alpha/beta adrenoceptors, others (sodium and calcium
channels)

165
Q

Sotalol MOA

A

Inhibits rapid component of delayed potassium
rectifier Ikr current (class III) and beta receptors
•
ECG effects sinus brady, AV blockade, QT
prolongation (significant TDP risk)

Reduce dose in renal impairment

166
Q

Digoxin MOA

A

Inhibits sodium potassium ATPase –> increases
intracellular Ca 2+2+–> positive inotropic effect
•
Increases vagal tone –> slows AV conduction

167
Q

Sacubitril valsartan MOA

A

Sacubitril inhibits neprolysin –> raises levels of
endogenous vasoactive peptides (natriuretic
peptides, bradykinin)

168
Q

Type 1 MI

A

Spontaneous MI due to primary coronary event

169
Q

Type 2 MI

A

MI secondary to ischemia due to either increased O2 demand or decreased supply

170
Q

Type 3 MI

A

Sudden unexpected cardiac death

171
Q

Type 4 MI

A

4a - assocaiated with PCI

4b - stent thrombosis

172
Q

Type 5 MI

A

Associated with cardiac surgery eg. CABG

Bpt (15 decks)

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