Congenital Heart Disease Flashcards

Question

PDA associated infections?

Answer 1

TORCH Toxoplasmosis Other: syphilis, varicella-zoster, parvovirus) Rubella CMV Herpes

Answer 2

Indomethacin (Prostaglanin inhibitor) Surgical or catheter closure - Ligation & division - Intravascular coil - Mortality is <1%

Answer 3

R –> L shunt ... body-body Tetralogy of Fallot Total anomalous pulmonary venous return Truncus arteriosus Transposition of the great arteries Tricuspid atresia Hypoplastic left heart syndrome (also obstructive)

Answer 4

most common right obstructive lesion - RV hypertrophy - overriding aorta with mixed blood - R --> L shunt - PVR > SVR and diminished pulmonary blood flow - cyanotic, no murmur may have aortic ejection click

Answer 5

Heavy premedication Consider IM ketamine or inhalation induction but get rapid control of airway. (crying worsens hypoxia) Keep SVR up and PVR down, maintain heart rate Intraoperative TEE Oral premed/induction midazolam + ketamine

Answer 6

Increase in PVR or decrease in SVR leading to Right to Left shunt Tet Spells pre induction (crying/anxiety) Polycythemia and bleeding - (polycythemia d/t kidneys sensing hypoxia, releasing more erythropoietin to make more RBCs) Air embolus RV failure (d/t pulmonary pressures being high and volume overload)

Answer 7

Maintain adequate tissue oxygenation and minimize R-->L shunt Avoid increasing O2 demand ***Maintain SVR, systemic BP - ketamine - vasopressin - phenylephrine Minimize PVR Avoid myocardial depression Avoid dehydration (especially if polycythemia is present) Minimize RVOT obstruction and PVR - O2 - Betablocker: propranolol - no air in lines - no N2O - infectious endocarditis prophylaxis

Answer 8

Maybe: nitroglycerin phentolamine tolazoline prostaglandin E1 nitric oxide

Answer 9

Tachycardia - pallor - loss of consciousness - seizures - cardiac arrest Treatment Knee-chest position: to relax stenosis while maintain SVR O2 Morphine 0.1 to 0.2 mg/kg IM or IV: to decrease resp drive, and provide comfort Phenylephrine - to keep SVR UP and increases peripheral return by vasoconstriction of arterioles Propranolol 0.1 mg/kg: relieves spasm of infundibular muscle of the RVOT ABG - NaHCO3 if necessary Surgery

Answer 10

Pulmonary veins do NOT return back to LA TYPES: "Supra" cardiac : Pulm veins attached to Superior Vena cava "Infradiaphragmatic" : pulm veins -- inferior vena cava "Intra-cardiac": pulm veins - RA "Mixed" L veins to supra, and R veins to infra

Answer 11

reroot the pulmonary veins to the LA and repair the ASD

Answer 12

Maintain Cardiac output with adequate HR Continue PGE1 Reduce PVR and maintain SVR Opioid/pancuronium technique Blood loss may be significant – As with all cardiac surgical procedures.

Answer 13

Aortic and Pulmonary artery are ONE single vessel... VSD is essential for oxygenated blood --> brain and body

Answer 14

- Digoxin: CA to strengthen the heart muscle and squeeze - Diuretics: for water balance - Ace inhibitors: to dilate vessels and decrease afterload, making it easier to pump

Answer 15

aorta and pulmonary artery SWAPPED - has PDA and PFO -- essential - RV is responsible for systemic pumping which its not ready for - LV hypotrophic -- not enough strength to pick up systemic pumping after correction

Answer 16

Mustard repair -- older surgery, patients now 30-60 yrs Arterial switch -- newer, swap with carotids switched

Answer 17

Maintain Cardiac output with adequate HR Continue PGE1 Reduce PVR and maintain SVR Opioid/pancuronium technique Blood loss may be significant – As with all cardiac surgical procedures.

Answer 18

- More than 70% patients are severely cyanosed due to inadequate pulmonary flow through the PDA - Need a systemic to pulmonary shunt: Variety used, most common Fontan - Where pulmonary flow is high the PA is banded; Assessment of RV function is important here - Definitive repair leads to a cavopulmonary anastamosis (Fontan) and this is sometimes two staged, i.e. Hemi-Fontan or Bidirectional Glenn being the intermediary stage. - Patients present for BT shunt often on PGE1 - Meticulous airway management is key to maintain flow balances

Answer 19

Hypoxemia: hypovolemia, low PBF CHF: volume shifts, anemia, and HTN Thrombosis: vena cava, RA, and pulmonary artery repair cant be done until 6-8weeks

Answer 20

Monitor RA pressure via RA catheter, and maintain baseline pressure maintain systemic BP near baseline minimize myocardial depressants no air in line no N20 High FiO2 Normal HCT

Answer 21

Definitive repair leads to a cavopulmonary anastamosis (Fontan) and this is sometimes two staged, i.e. Hemi-Fontan or Bidirectional Glenn being the intermediary stage. Patients present for BT shunt often on PGE1 Meticulous airway management is key to maintain flow balances

Answer 22

cyanotic and obstructive disease -- blood flow via PDA (keep on PGE1s) - also have aortic atresia, LV and mitral valve hypoplastic pulmonary over circulation - inadequate systemic circulation - PULM HTN

Answer 23

Two options: 1. Cardiac transplantation 2. 2 or 3 stage procedure: New aorta created from the pulmonary artery Atrial defect is created to completely mix blood Pulmonary flow improved by shunt e.g. BT Later: Fontan (+/-preceded by a hemi Fontan)

Answer 24

Maintain HR, preload and PGE1 Balance SVR and PVR Avoid too high PaO2 May need CO2 to avoid pulmonary over perfusion and hence systemic hypo perfusion Inotropic support may be necessary to support the ventricular (Milrinone, caution d/t decrease in PVR)

Answer 25

Asymptomatic w/mild PS Mod – severe = RV failure Prominent jugular a-wave Split 2nd heart sound Ejection click Heart failure and cyanosis in severe cases

Answer 26

Mild – no intervention – close F/U Mod – Severe – relieve stenosis - Balloon valvuloplasty - Surgical valvotomy

Answer 27

obstruction to outflow from LV TYPES: 1. valvular (common) 2. subvalvular or subaortic - poor CO and forward flow 3. supervalvular (@ ascending aorta)

Answer 28

Narrowed Aorta ...

Answer 29

Diminution or absence of femoral pulses Higher BP in the upper extremities as compared to the lower extremities 90% have systolic hypertension of upper extremities Pulse discrepancy between R and L arm Severe = Heart Failure - LE hypoperfusion – acidosis– shock II/VI systolic ejection murmur LSB Cardiomegaly

Answer 30

Severe coarctation – maintain ductus with = PGE1 - initial meds with inotropes and diuretics Surgical intervention to prevent LV dysfunction Angioplasty - balloon angioplasty @ 18months

Answer 31

Congenital cardiac abnormalities are in 1% live births Rapid growth in corrective and palliative procedures Increasingly likely that anesthesia providers will encounter these cases coming for non-cardiac surgery

Answer 32

the anesthetist understands the pathophysiology of the lesion and the pharmacology of the drugs used

Answer 33

Spectrum of disease: Congenital heart disease NOT YET treated Surgically corrected and symptom-free Surgically corrected but with residual problems Surgically palliated but stable Surgically palliated but still with severe symptoms or new problems

Answer 34

Questions to ask: Should the patient be referred for specialist cardiology service before surgery? Is entire procedure more suited to a specialist center? If we decide to proceed or are forced by an emergent event to proceed what do we need to know?

Answer 35

VSD: L-R shunts and pulmonary overload pre-correction Endocarditis and arrhythmias post-correction - no air in lines - no N2O - endocarditis prophylaxis - maintain PVR - normal ventilation with PaCO2 = 40s - FiO2 <100% - Lower SVR via inhalational agents and propofol

Answer 36

ASD: L-R shunts and pulmonary overload pre-correction Potential for paradoxical air embolus Endocarditis and arrhythmias post-correction

Answer 37

Hypoxia Hypercarbia Metabolic acidosis Hypothermia IPPV Alpha adrenergic stimulation

Answer 38

Oxygen Hypocarbia Metabolic alkalosis Volatile anesthetics Vasopressin PDE inhibitors

Answer 39

Late problems rare once corrected

Answer 40

Common in Down’s syndrome Can cause heart failure and pulmonary HTN Mitral regurgitation may persist after correction Endocarditis and arrhythmias post-correction

Answer 41

Before surgery pulmonary circulation needs a patent duct Three stage palliative surgery lead to single ventricle and pulmonary flow through cavopulmonary connections Palliation may lead to heart failure and arrhythmias

Answer 42

Balloon septoplasty in first few hours of life Arterial/atrial switch performed depending age Residual risks of endocarditis, arrhythmias and right ventricular (systemic) failure.

Answer 43

Indicates persistent abnormality Associated with polycythemia altered hemostasis Ensure hydration, maintain SVR and reduce PVR Use high FiO2 Avoid sudden increase in oxygen requirement Meticulous removal of air

Answer 44

Treatment and outcome depend on a VSD Repeat palliations and residual cyanosis possible

Answer 45

R --> L Shunt (body-body): slower inhalational, faster IV L --> R (lung-lung): inhalational maybe fater, IV slower

Answer 46

Associated pulmonary lesions, vascular rings, compression form shunts, phrenic or RLN damage Rising PVR can eventual lead to a Rt to Lt shunt through an ASD or VSD, Eisenmenger’s syndrome End-tidal CO2 will frequently underestimate PaCO2 due to reduced pulmonary flow and increased dead space

Answer 47

Elective surgery should be postponed In emergent situation, invasive monitoring is mandatory and usually IPPV should be helpful except where there are cavopulmonary shunts that cause passive blood flow to the lungs

Answer 48

Common problems post correction SVT, VT and complete heart block all seen

Answer 49

- Endocarditis risk has to be assumed in all but the most simple congenital cardiac lesions especially if uncorrected - Generally speaking anticoagulated patients should be switched from coumadin to heparin closer to the time of surgery and then d/c perioperatively - Emergent surgery, on balance, should call for reversal of anticoagulation

Answer 50

- HLHS or pulmonary atresia with intact septum - Shunts inevitably cause some degree of cyanosis (eg BT shunt) - As child grows pulmonary flow inadequate and cavopulmonary shunts are needed (Fontan) - Spontaneous (negative pressure) ventilation - Morphology of “ventricle” determines outcome - Arrhythmias and ventricular failure are real risks

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Congenital Heart Disease Flashcards

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