CCS ACHD 2022

Question 1

Indications to close ASD (4)

Answer 1

-Symptoms and Qp/Qs > 1.5 if PAP < 50% MAP, PVR < 1/3 SVR (Reasonable if < 2/3 SVR, MAP after consultation with ACHD and PH experts) (Strong)

-Qp/Qs > 1.5 (weak) or RV enlargements (Weak)

-Stroke/TIA/Embolism (Weak)

-Orthodexia/Platypnea (Weak)

-Chronic Pacing/Indwelling Catheters needed (Weak)

Question 2

3 contraindications to close ASD (3)

Answer 2

-PVR > 2/3 SVR

-PAP > 2/3 MAP

-Right to Left shunt

Question 3

When to close VSDs? (5)

Answer 3

-Qp:Qs > 1.5 or LV enlargement (Reasonable if < 2/3 SVR, MAP after consultation with ACHD and PH experts) (Strong)

-Pulmonary Hypertension (PAP   50% systemic and/or PVR > 1/3 SVR but Qp:Qs   1.5 at baseline or in response to vasodilator challenge) (Weak)

-Recurrent Endocarditis (Weak)

-If pacing or chronic indwelling venous catheter required (Weak)

-Progressive Aortic Regurgitation (Weak)

Question 4

When to close PDA? (2)

Answer 4

-LV enlargement with left to right shunt

-Endarteritis

Question 5

Indications to close AVSDs? (3)

Answer 5

-Qp:Qs > 1.5

-LVOT gradient > 40mmhg (Or if < 40mmhg but symptoms, LV dysfunction or progressive Aortic Regurgitation)

-Severe left sided AV valve regurgitation (As per guideline directed recommendations)

Question 6

When to operate on BAV aortopathy when going for OHS? (1)

Answer 6

4.5 cm

Question 7

When to operate on Turners aorta? (1)

Answer 7

Aorta measures > 2.5 cm/m2

Question 8

When to operate on Subaortic Stenosis? (3)

Answer 8

Symptoms with LVOT gradient > 40mmhg

Symptomatic patients with moderate LVOT gradient (20-40mhg) with moderate or more AR

Asymptomatic with LVOT Gradient > 40mmhg with one of the following: Moderate or severe AR, Decrease in BP to exercise, LVH or LV dysfunction

Question 9

When to operate on Supravalvular stenosis? (3)

Answer 9

-Symptoms with MG > 40mmhg

-Asymptomatic MG > 40mmhg if surgical risk low (weak)

-Symptoms or LV dysfunction < 40mmhg attributable to obstruction

*At time of repair of ostial stenosis of LMCA then Angioplasty/CABG recommended

Question 10

When to intervene on Aortic Coarctation? (1)

Answer 10

-Gradient > 20mmhg or 50% narrowing of the aorta with concomitant systemic hypertension

Question 11

Indications for RVOT obstructions? (2)

Answer 11

-Symptomatic moderate-severe PV stenosis

-RV dysfunction

Question 12

When to operate on PR post TOF repair? (4)

Answer 12

-Severe PR and symptoms

-Severe PR and RV enlargement (> 160 ml/m2), RV dysfunction or decrease in objective exercise capacity

-Severe PR who need other valves fixed

-Severe PR with atrial arrhythmias and sustained ventricular arrhythmias

Question 13

When to operate on Ebstein’s Anomaly?

Answer 13

-Symptoms and Severe TR

-Asymptomatic with Severe TR and progressive RV dysfunction or dilation, or objective evidence of declining exercise capacity

Question 14

When to reoperate Atrial switch for TGA? (4)

Answer 14

-Symptoms with Severe TR if RVEF > 45%

-Symptoms from stenosis or obstruction of systemic venous baffle

-Symptoms with interatrial baffle leaks

-Residual shunt Qp:Qs > 1.5

Question 15

When to reintervene on Arterial switch?

Answer 15

-Coronary obstruction with obstruction

-Symptoms and RVOT obstruction

-Severe AR with LVEF < 50%

-Aortic dilation > 5.5 cm

• TAA > 4.5cm going for OHS

Question 16

When to replace systemic AV valve in LTGA?

Answer 16

-Symptomatic severe regurgitation

-Asymptomatic severe regurgitation with mild RV dysfunction or dilatation

Question 17

When is transplant recommended in CCTGA?

Answer 17

-Severe systemic RV dysfunction with NYHA III-IV symptoms

Question 18

7 indications to intervene on Fontan? (7)

Answer 18

-Obstruction to systemic venous return in the Fontan circuit

-Obstruction of branch Pulmonary arteries

-Obstruction of pulmonary venous return

-Veno-venous collaterals or a PA malformation

-Residual ASD or fenestration resulting in significant right to left shunt in absence of elevated PVR

-Significant LVOT Gradient

-Significant SAVV regurgitation

Question 19

Review algorithm for Supravalvular stenosis management?

Answer 19

Question 20

Review TOF repair indications?

Answer 20

Question 21

Review Fontan repair algorithm?

Answer 21

Question 22

Label the following ASDs

Answer 22

1: Secundum

2: Primum

3 + 4: Sinus Venosus (Inferior and Superior)

5: Unroofed Coronary Sinus

Question 23

How to decide if Stent or surgical repair for Aortic Coarctation?

Answer 23

-Focal/discrete -> Stent

-Long or concomitant arch hypoplasia -> Surgical

Question 24

What lesion is this?

Answer 24

Tetralogy of Fallot

Question 25

What are two indications for device closure of interatrial communication in Ebsteins?

Answer 25

-Paradoxical Emboli

-Desaturation at rest