cardiology surgery incorrects Flashcards
patient with a heart attack undergoes cardiac catheterization. sudden onset hypotension, tahcycardia, flat neck veins and back pain
diagnosis?
1st line investigation?
management?
retroperitoneal hematoma
CT scan of abdomen and pelvis with contrast!!!!
bed rest, monitoring, IV fluids
in ACUTE mitral regurgitation, what is the atrial size? LV size? left ventricular ejection fraction?
left atrial and lv are normal as there is no time for dilation. as result the pressure transmitted to lungs causing pulmonary edema -> crackles.
lv ejection fraction is normal or increased
pregnant woman experiencing palpitations. midsysolic murmur at upper left sternal border. echo shows a dilated right ventricle
most likely cause?
atrial septal defect - left to right shunting via atriums cause RIGHT sided volume overload. (risk of right sided heart failure.
(as atriums on top and ventricles below). atrial stretching -> a fib.
echo shoes dilated atrium and ventricle
NOT a VSD or PDA as these are distal to atrioventricular valves. left to right shunt as well, but it just means that more blood is pumped from right ventricle to lungs -> LEFT SIDED volume overload
patient was undergoing a laparascopic cholecystectomy and immediately the needle was placed in the peritoneal space, patient developed severe bradycardia, and AV block.
most likely cause?
peritoneal stretching!!!
laparascopic surgery requires insufflation of CO2 in to abdomen. intraabdominal pressure -> stretch receptors on abdomen -> increase in vagal tone -> bradycardia, av block, sometimes asystole
patient after a fall, CXR shows widened mediastinum. severe chest pain. most likely diagnosis?
other findings in this situation?
what investigation confirms the diagnosis??
blunt aortic injury
pseudocoarctation - upper extremity HTN and lower extremity hypotension
hoarse voice - left recurrent laryngeal nerve compression
CT angiography!!
patient just had heart surgery.
clicking when he bends over, on palpation of sternum, there is rocking and clicking.
most likely diagnosis?
management?
sternal dehiscence
may also be diagnosed via displaced sternal wire on radiography.
abdominal pain, fever and leukocytosis shortly after abdominal aortic aneurysm repair. most likely diagnosis?
3 months of fatigue, low grade fevers and palpitations. now has acute left sided weakness.
brain imaging reveals multiple small, acute infarcts.
echo shows a mass in left atrium.
most likely diagnosis?
intracardiac tumour!! - aka myxoma!!
embolization of tumour fragments -> stroke, acute limb ischemia
valve obstruction -> murmur, dyspnea, syncope
constitutional symptoms - fever, weight loss
not infective endocarditis - as echo would show valvular vegetations not a mass
not rhuematic heart disease as mitral stenosis develops yearss after intial event
multiple embolic strokes due to endocarditis investigations?
investigation for malignancy -> CT scan of chest and abdomen, colonoscopy
hypercoagulability work-up
patient with chronic back pain, intermittent bilateral heel pain. impaired spinal mobility and limited chest expansion
exertional shortness of breath and apical impulse diplaced to left
most likely diagnosis?
aortic regurgitation!!!
complication of ankylosing spondylitis!!!!
Revised cardiac risk index
for cardio surgery.
learn it, especially when no further testing is needed
following cardiothoracic surgery. signs of infection of the sternum. Condition is called?
diagnosis and management?
acute postoperative mediastinitis
chest and sternal imaging!!!
INTRAVENOUS antibiotics and surgical debridement
expected hemodynamic alterations in mitral stenosis -> elevated pulmonary artery pressures and normal LV pressure
surgery is indicated in patients with severe MR both symptomatic and ASYMPTOMATIC if LVEF is </= ?
60%
how does a left ventricular aneurysm present months after a myocardial infarction?
ECG findings?
echo findings
HEART failure!!!! most common -> raised jvp, bibasilar crackles.. heart failure because the aneurysm has distorted the ventricle wall and reduced the ejection fraction
less commonly- ventricular arrhythmia, systemic embolization, chest pain
ECG - persistent ST elevation and deep Q waves!!!!
echo = thin and diskinetic ventricular wall
patient with a mechanical heart valve undergoing routine colonoscopy?
what antibiotic prophylaxis is needed?
none!!!!
as this is a GI/GU procedure not taking place in setting of active infection
also dont need for c sections/vaginal deliveries
you need for gingival work, respiratory mucosa incision etc.
first step in management of acute limb ischemia?
IV heparin
later = CT angiography
Prosthetic valve dysfunction (murmur over a mechanical heart valve) -> prompt evaluation with echo.
damage to tricupsid valve during pacemaker insertion can cause T regurgitation -> right sided HF
acute limb ischemia in the setting of pre existing PAD = due to atherosclerotic plaque disruption
sudden onset acute limb ishcemia = an embolism
in addition to rate control/rhythm control. what is important in management of atrial flutter/atrial fibrillation?
anticoagulation
Cardiac tamponade is a complication of heart surgery eg CABG
Signs
First step in management?
Hypotension
Signs of shock eg reduced urine output
Elevated heart pressure eg in right atrium , right ventricle
ECHO!!
Learn the complications of aortic dissection. In a patient with hypotension and fluid In pleural space, most likely complication?
Hemothorax
Post cardiac surgery pleural effusions managed conservatively if?
Early onset 1-2 days post surgery
Small and not enlarging
No resp symptoms
abdominal pain, fever and leukocytosis shortly after abdominal aortic aneurysm repair. most likely diagnosis?
And ABPI of what is diagnostic of PAD?
<0.9
Patient with 2 weeks of worsening dyspnea. Enlarged heart/ cardiac silhouette on CXR. Clear lung fields. History of lung necancer. Most likely diagnosis?
Best next step in management?
Treatment ?
Malignant pericardial effusion
Echo
Pericardiocentesis
What happens to cardiac index in cardiac tamponade?
Decreases as restricted filling of heart chambers
Cardiac index is cardiac output per body surface area
SVR increases
To gain informed consent you must discuss risks of not undergoing procedure
Blunt chest trauma if stable you do what ix first?
CXR and ECG
If abnormal move to ct chest
MI complications and how they present
- Papillary muscle rupture?
- Left ventricular free wall rupture?
- Iterventricukar septum rupture?
- Left ventricular aneurysm
- MR
- Pericardial effusion with tamponade -> shock and cardiac arrest
- Left to right ventricular shunt and murmur
- Heart failure, arrhythmia, thin dyskinetic heart wall
How does post cardiac injury syndrome present
Causes?
Mechanism?
Treatment?
Acute pericarditis plus fever leukocytosis, pericardial effusion
MI = dressers
Cardiac injury or surgery
PCI
Immune mediated inflammation
NSAIDs and colchicine
Woman with mitral stenosis want to become pregnant. Management?
Surgery before pregnancy
Complications of cardiac catheterisation
Via femoral artery? How do they present
AVF = continuous murmur, palpable thrill. Swelling tenderness - can cause lim edema , limb ischemia, high output heart failure
Pseudoaneurysm = pulsatile mass and systolic mass rather than continuous
Femoral artery dissection = acute lower extremity ischemia = pain and pallor
Peripheral nerve = injury = paresthesia
Hematoma = mass, expands to retroperitoneum = flank pain and hypotension
Persistent tachycardia and arrhythmia eg premature ventricular contractions are concerning for? Further management?
Blunt cardiac injury
Echo
Long term management of malignant pleural effusion following pericardiocentesis?
Pericardial window!! Or prolonged catheter drainage
In a patient with HOCM undergoing surgery, most important thing to ensure?
Adequate intravenous hydration
Mechanism that results in tricuspid valve regurgitation?
Dilatation of the tricuspid valve annulus
Pancreatic surgery receives red blood cells. Now low bp, high hr, hig(resp rate, bibasal crackles. Low spo2. Low cardiac index and raises PCWP. Most likely diagnosis?
MI!
Perioperative MI that has caused shock.
Risk factors = intraoperative haemorrhage requiring blood transfusion
Classic chest pain not typically present.
Impaired cardiac contractility causes low CI and high PCWP
Not trali as LVF won’t be impaired thus CI and PCWP normal
Indications for surgery in infective endocarditis?
Acute HF = aortic or mitral valve regurgitation
Extension of infection = abscess, fistula, heart block.
Difficult to eradicate organism = fungus, Mdr pathogen
Persistent bacteremia on antibiotics
Large vegetation, persistent septic emboli
74 YO man, persistent back pain. Smoking history. Pain from epigastric to supraumbilicus region. X ray normal except prevertebral calcifications. Next step in evaluation?
Ct abdomen!
Signs of AAA
Abdominal flank or groin pain depending on lesion site , flank echymosis, limb ischemia
If hemodynamically unstable = USS if diagnostic uncertain
Erectile dysfunction, pain in hip, gluteal and thigh muscles. Next step in management?
ABPI
Leriche syndrome - blood flow through iliac arteries limited. Diminished femoral pulses may also occur
Fevers, chills, leukocytosis, moderate chest pain and moderate pericardial effusion. Arrthymias eg atrial fibrillation and tachycardia, after antibiotics next step in management?
Pericardiocentesis
This is purulent pericarditis
Urgent pericardiocentesis needed not echo. So u can confirm and treat
Risk factors = chronic hemodyalisis, cardiothoracic surgery,
Short stature, amen Orr he’s = turners = aortic dissection risk
indication for aortic valve replacement?
aortic velocity of 4 m/s,
Or transvalvular a mean pressure gradien of ≥40 mmHg,
Usually aortic valve area (AVA) of ≤1 cm2 but not required
So the above = severe AS
Plus one of symptoms, LVEF <50%, undergoing other cardiac surgery eg CABG
Man with aortic stenosis, no symptoms but transvalvular gradient consistent with severe AS. Ejection fraction is 45%. Next step in management?
Surgical replacement
Both ASD and pulmonary stenosis has splitting of S2, but in pulmonary stenosis, the splitting varies with respiratory cycle
Also PS is an ejection click then crescendo decree endo systolic murmur
ASD is a mid systolic murmur
