Corey Prediction 2013 Exam Flashcards
1
Q
Define Diastolic function
A
Limitation of the ventricle to fill to normal end-diastolic volume without an abnormal increase in end-diastolic pressure at rest or during exercise.
Loss of compliance/loss of relaxation with abnormal distensibility abnormal filling
2
Q
What are echo signs of Diastolic dysfunction
A
- Prolonged Transmitral E wave deceleration time (normally adults less than 220 ms)
- Prolonged Isovolumetric relaxation time (interval in the cardiac cycle, from the aortic component of the second heart sound, that is, closure of the aortic valve, to onset of filling by opening of the mitral valve, greater then 80)
- Reversal of transmitral E:A ratio (impaired relaxation (E:A reversal i.e. E is < A)
- Delayed ratio of transmitral A wave duration to pulmonary atrial reversal wave duration ( > 30)
- Blunting of systolic pulmonary vein flow to Diastolic ratio (systolic blunting, a decrease in the height of the S wave)
3
Q
What are echo predictors of SAM post mitral valve repair
A
Septum > 15mm Small LV cavity Hyperdynamic LVEF 65% Aorto mitral angle < 120 (some say 130) Short coaptation-septal distance< 25 mm Too small annuloplasty ring Excessive height of posterior leaflet post repair (>15mm)
4
Q
What are details of first generation LVAD
A
Pulsatile, volume displacement using a pusher plate system.
The pump senses when the chamber is full and activates the pusher plate. It has porcine xenograft valves.
35% device failure in 2 years;
Heartmate XVE
5
Q
What are details of Second Generation LVAD
A
Continuous flow, rotary pump, smaller, eliminating the reservour chamber and valves that was needed for first generation.
Rotary blood pump is in axial blood flow path, with an internal rotor suspended on bearings.
Inflow at apex of LV and outflow in ascending aorta.
Risk of negative intraventricular pressure. INR 2.5- 2.5
Heart mate II
6
Q
What are details of 3rd Generation LVAD
A
eliminated need for “bearings”
Using hydrodynamic or electromagnetic suspension of an impeller to reduce mechanical wear and trauma to blood cells
contact free rotation
7
Q
List contraindications to LVAD
A
sepsis anuria CVP < 16 Revised Columbia score > 5 (mortality 47% if score > 5) likelihood of recovery low
8
Q
What are features of Barlows mitral valve
A
young age, long history of symptoms myxoid infiltration Bulky, billowing and tall leaflets multi-segment prolapse Calcification of annulus atrialization of leaflets chordal thickening/elongation late SEM with mid click
9
Q
What are features of Fibroelastic defiencey
A
older, usually sudden onset impaired connective tissue thin leaflets prolapse of single segment ruptured chord holosystolic murmur thickened and excess chord only at prolapsing segment
10
Q
What are criteria for Brain Death
A
Unresponsive to central pain stimulus Absence of brain stem reflexes a. no occular movements b. no corneal reflex Apnea a. measure po2 and pco2 after 8 minutes of apnea b. if pco2 > 60 or 20 point increase normothermia, no toxins, two physicians, clinical evidence of cns event keeping with brain death
11
Q
List features of Ebstein Anomaly
A
Dysplasia of Triscuspid valve resulting in
- fused perforated or absent leaflets and abnormal chordaie
- apical displacement of the septal and posterior leaflets into the body of the right ventricle
- thin atrialized right ventricle
- right ventricle dysfunction
- rhythm abnormalities (wpw)
- often severe TR
12
Q
What are echo features of TR
A
- Vena contracta > 0.7cm
- systolic flow reversal in hepatic vins
- Effective Regurgitant volume > 45ml
- Effective regurgitant orifice area > 0.40cm2
13
Q
List features of Carcinoid Heart
How do you test for it
A
50% develop valve disease
Primary lesion is located in the small intestine
Mainly right sided lesions
Usually TR or TS
plaques are on the downstream of the valves leading to adherence of the leaflet on the underlying structures
Regurgitation and may constrict the annulus leading to stenosis
Pulmonary valve replacement
*test urine of 5-HIAA serotonin
14
Q
Describe atrial senning operation
A
Atrial switch concept was first successful accomplished Senning in 1959
Relocating the walls of the right atrium and the atrial septum
Pulmonary and systemic venous return rerouted by incising and realigning the atrial septum over the pulmonary veins and using the the right atrial wall to create a pulmonary venous baffle.
15
Q
Describe ISHLT classification of rejection
A
Grade 0 No rejection
Grade 1A Focal, mild, no necrosis
Grade 1B Diffuse infiltrate, no necrosis
Grade 2 Focal, moderate, one focus of aggressive infiltration with myoctye damage
Grade 3A Multifocal aggressive infiltration
Grade 3B Diffuse–diffuse inflammatory, myocyte necrosis
Grade 4 Severe rejection,Hemorrhage, vasculitis, Diffuse aggressive, edema
16
Q
List INTERMACS
A
Class 1: Critical cardiogenic shock Class 2: progressive decline Class 3: stable on inotropes Class 4: recurrent Advanced Heart failure Class 5: Exertion intolerant Class 6: Exertion limited Class 7: NYHA III
17
Q
Describe HIT
What percentage of pts develop HITT type II and how many develops thrombosis
A
IgG antibody binds to complex of platelet factor 4 and heparin leading to the formation of an immune complex.
The immune complex binds to platelets via platelet Fc receptors producing intravascular platelet activation, thrombocytopenia, and thrombosis
1- 5% develop Type II HIT and 20% of those develop thrombosis
18
Q
Contraindications to Ross
A
Pulmonary valve disease Marfan Autoimmune disorders Poor LV function/Anatomical issues aberrant coronary anatomy mismatch of PA and Aorta
19
Q
Mechanism and dosing of Factor VIIa
A
Stimulates the coagulation cascade by activation of thrombin at the site of tissue injury by tissue factor dependent and independent mechanisms
Tissue dependent results in factor X activation and thrombin generation
Tissue factor independent mechanisms include activation, aggregation, recruitment and stabilization of platelets.
65 ug/kg to 100 ug/kg
20
Q
What is Ticagrelor
A
Nonthienopyridine, oral pyrimidine derivative, direct-acting, and reversible antagonist of the ADP receptor P2Y12 with a plasma half-life of about 12 hours
More rapid, potent and consistent effect on platelet function compared with clopidogreal.
PLATO trial improved rates of MI/Death/Stent thrombosis
21
Q
Who should get a PA band
A
Unbalanced AV canal
Multiple VSD “swiss cheese”
Contraindication to cardiopulmonary bypass “weight”
VSD with Coarctation
Late presentation TGA (3 weeks..then place for 1 week before doing switch)
22
Q
List cancers associated with post transplant
A
Basal Cell Squamous Cell B cell lymphoma Cervical *rare Vulvar * Kaposi sarcoma *
23
Q
What are 5 signs of positive exercise stress test
A
Abnormal symptoms (chest pain, syncope) Abnormal ECG (ST depression) Abnormal Blood pressure (drop in BP) Abnormal Heart rate Inability to achieve 6 mets
24
Q
List 7 factors that a rate responsive pacemaker will respond
A
Body vibration Body temp respiratory rate shortened QT interval Acceleration in motion RV systolic pressure RV systolic volume
25
What are 2012 indications for CRT
```
EF < 35%
Sinus rhythm
LBBB with QRS > 150 msec
NYHA II, III or IV
on optimal medical therapy
```
26
List predictors for RVAD placement after LVAD
```
Cardiac index < 2.2
RV stroke work index < 0.25
Severe RV dysfunction
Pre-operative increase in serum creatinine
previous cardiac surgery
Systolic blood pressure < 90 mmg
```
27
List causes of restrictive cardiomyopathy
```
Amyloid
Endomyocardial
post radiation
Sarcoid
Eosinophilic
```
28
What are features of Constrictive pericarditis
```
RVEDP> 1/3 RVSP
RAP and LAP are equal and > 10 mmhg
RVEDP = LVEDP (equalization within 5)
atrial size is normal
Ejection fraction is > 40%
Square root sign on right ventricle tracing
Pulmonary artery pressure is usually low
```
29
List health Edwards classification of Pulmonary artery hypertension
1. medial hypertrophy without intimal hyperplasia
2. media hypertrophy with intimal hyperplasia
3. medial hypertrophy with fibrosis
4. areas of vascular occlusion with fibrosis
5. angiomatoid lesions
6. necrotizing arteritis
30
What are causes of organic TR
```
Rheumatic
Carcinoid
Marfans
Endocarditis
Trauma
Anorexectic drugs
Whipples disease
SLE
```
31
What are causes of functional TR
RV failure --ischemia
Pulmonary hypertension -mitral valve disease/left sided lesions
RVOT obstruction --Pulmonary embolism/chronic
Core Pulmonale-- congenital disease/left to right shunting
32
How does Milrinone work
What is loading dose and typical infusion rate
Inhibitor of Phosphodiesterase enzyme, which normally converts cAMP to its inactive form of 5 -AMP. So by being a phosphodiesterase inhibitor it increase the cAMP and subsequently creates a greater influx of calcium into myocardial cells
loading dose is 50ug/kg and 0.5ug/kg/min
33
How to adrenergic drugs effect cardiac contractility
stimulate adnylate cyclase which catayses the conversion of ATP to cAMP.
increases the amount of calcium introduced to into the cell for contraction
34
What does DDAVP stimulate
Increase VIII and vWF
35
What are ideal indications for fontan procedure
1. minimal age 4
2. sinus rhythm
3. normal caval drainage
4. right atrium normal
5. mean pulmonary pressure < 15 mmhg
6. pulmonary artery resistance < 4
7. no impairing effects of previous shunts
8. competent atroventricular vavle
9. normal ventricles
10. pulmonary-artery-to aorta-diameter ratio of > 0.75
36
What is natural history of AS
Median survival of 2-3 years after symptoms
Progression of decrease 0-15 mmHg/year
angina = 5 years, syncope = 3 years; dyspnea 1-2 years
37
What is natural history of AI
```
Latent period of 3-10 years
6%/year develop symptoms
3-5% develop LV dysfunction
25% will develop symptoms if LV is dysfunction
10%/year die when symptoms develop
```
38
Describe steps of Norwood stage I operation
Stage I reconstruction is performed shortly after birth via median sternotomy and deep hypothermic circulatory arrest (DHCA)”
1. atrial septectomy
2. Construction of a neoaorta from the pulmonary valve by division of the PA at the bifurcation and anastomosis of the aorta to the proximal PA
3. Placement of a systemic-to-pulmonary modified Blalock-Taussig shunt (mBTS) or RV to PA conduit
39
What is Natural History of VSD
80% close at birth
25% will close if not closed at 12 months
50% will develop pulmonary HTN at 20 years of age if left open
40
Surgical indications to close VSD
```
CHF
Failure to thrive beyond 6 months
Sub-arterial VSD at any age
History of endocarditis
plan for transvenous pacing
```
41
Define Left ventricular aneursym?
List 4 causes
What is natural history of symptomatic and asymptomatic LV aneurysms
```
Area of abnormal left ventricular diastolic contour with systolic or paradoxical bulging (dyskinetic movement)
1. 95% Coronary artery disease
2. Chagas Disease
3. Trauma
4. Sarcoidosis
5. Congenital
Excellent 10 year survival about 80-90% if no symptoms
50% 10 year year survival if symptomatic
```
42
What are contraindications for LV aneursym surgery
Excessive anesthetic risk
Impaired function of residual myocardium outside the aneurysm
Resting CI less then 2.0
Significant MR
Evidence of nontransmural infarction (hibernating myocardium)
lack of discrete and thin walled aneurysm with distinct margins
43
List clinical ways to distinguish between post MI VSD and papillary muscle rupture
1. murmur of septal rupture is more prominent @ the left sternal border and is louder and associated with a thrill.
2. murmur of pap muscle rupture is best heard at apex and is softer with no thrill.
3. VSD rupture is most likely associated with anterior infarctoin and conduction abnormality while a pap muscle is likely posterior with no conduction
***bonus criteria**
septal rupture show > 9% step up in oxygen saturation between RA and PA
papillary muscle shows classic V waves in the pulmonary artery wedge tracing
44
List 4 major differences between true aneurysm and false aneurysm
The wall of false aneurysm contains no viable myocardial cells
False aneurysm are more likely to form posteriorly
False aneurysm have a narrow neck
False aneurysm have an increased risk of rupture
45
List risk factors associated with needed redo CABG
Young age, Normal LV function, single and double vessel disease at time of initial operation
Not using ITA, incomplete revascularization
NYHA status III or IV at time of initial operation
46
What are survival indications to perform redo CABG
Atherosclerotic (late > 5 years) stenosis with vein grafts to LAD
multiple stenotic vein grafts that supply large areas of myocardium
multi-vessel disease with proximal LAD lesion/and or abnormal LV function based on native vessel or stenotic vein grafts or a combination of the two.
47
Define peak oxygen consumption and list cut offs for long term outcomes
peak oxygen consumption during exercise provides an index of overall cardiovascular reserve
value of 10 to 14 ml/kg/min or lower indicates a very poor prognosis and is generally the cuff off for transplantation
48
Define Hibernating and Stunned myocardium
Hibernating: contractility depressed myocardial function secondary to chronic ischemia that improves clinically immediately after revascularization
Stunned myocardium: left ventricular dysfunction without cell death that occurs after restoration of blood glow after an ischemic/reperfusion episode
49
4 ways to repair free wall rupture
Horizontal mattress sutors with felt
Infarct excision and closure with a patch
Horizontal mattress with felt and teflon patch
Simply Glue a patch to the epicardial surface
50
List 2007 AHA recommendations for antibiotic prophalaxis
Prosthetic heart valves
Previous infective endocarditis
Cardiac transplantation recipients who develop cardiac vavlulopathy
Serious Congenital conditions including unrepaired or incompletely repaired cyanotic congenital heart disease
a. palliative shunt/conduits/ TOF/TGA/Ebsteins/Tricuspid/interrupted arch/coarctation of aorta
Completely repaired CHD with prosthetic or device during first 6 months after procedure
51
What is mechanism of LVAD reverse remodelling
Improvement in myocardial contractility and calcium handling
altering the extracellular matrix
decreasing myocardial fibrosis
up-regulation of Beta receptors
52
What is evidence for IABP in a pt with cardiogenic SHOCK
what is mortality in pt with SHOCK post MI
80 % mortality for pt presenting in SHOCK
evidence for IABP is minimal. No improvement in survival with SHOCK II trial. mortality at 300 days was same
53
What are surgical options for anomalous coronary artery
Unroofing procedure: Open the slit-like ostium longitudinally start at the anomalous coronary os continuing into the correct sinus. A segment of the common wall between the aorta and the coronary is excised and the intimal surfaces are approximated.
creation of neo-ostium: probe passed through the intramural segment of the ACA into the correct sinu. The coronary artery is opened where it exits the aortic wall and then neo-ostium is created there.
Coronary artery translocation with reimplntation: coronary artery is excised with a button
Coronary bypass with either vein or artery can be performed.
54
What are contraindications for TAVI
Absolute contraindications
Absence of a heart team and no cardiac surgery on the site
Appropriateness of TAVI as an alternative to AVR, not confirmed by a heart team
Estimated life expectancy of < 1 year
Improvement of quality of life by TAVI unlikely because of comorbidities
Severe primary associated disease of other valves with major contribution to the patients symptoms that can treated only by surgery
Inadequate annulus size ( < 18 mm or > 29 mm)
Thrombus in the left ventricle
Active endocarditis
Elevated risk of coroanry ostium obstruction (asymmetric valve calcification, short distance between annulus and coronary osium, small aortic sinuses)
Plaques with mobile thrombi in the ascending aorta or arch
For transfemoral/subclavian approach: inadequate vascular acess (vessel size, calcification, tortuosity)
Relative indications
Bicuspid or non calcified valves
Untreated CAD
LVEF < 20%
55
What are factors in Child classification of Liver failure and risk of cardiac mortality
Bilirubin, Albumin , INR , encepalopathy , ascities
<7 cardiac surgery mortality is not affected
7-9 cardiac mortality is 41 to 80%
> 9 (1-3 month survival, cardiac surgery mortality is 100%)
56
List 4 types of Experimental Validity
Internal Validity
External Validity
Construct Validity
Statistical conclusion validity
57
List Bias associated with meta anlalysis studies
What techniques can be done to reduce bias?
What technique to test for Heteogenity
List 2 strengths of Meta-analysis
1. Publication bias/Search Bias/Selection bias
2. "Funnell plot"
3. Forest Plot--and a subsequent cochran Q- test
4. Strengths:
a. Increased Effective sample size which greatly increases more outcomes and variable that can be examined
b. Allows examining of rare events
58
What is major strength of RCT compared to Observational study?
List 2 ways that Observational studies attempt to account for weakness
List 3 potential limitations of RCT
RCT eliminates selection bias
Propensity analysis and Risk adjustment techniques (such as regression or analysis of variance)
weakness of RCT
a. decreased generalizability--specific inclusion/exclusions
b. Inadequate statistical power --expensive to enroll pts
c. Follow-up and approach to treatment may not be representative of real life
59
What is Everst II study
N = 279 pts (2:1 radndomization)
184 to mitra clip and 95 mitral repair
Primary composite endpoint---freedom from death, surgery for mitral dysfunction, and freedom from MR > 3+ at 12 months
Primary safety endpoint---included transfusion of >2U of Blood
60
What is results of Everest II study
mitral clip 55%
Surgery 73%
safety event was 15% with mitral clip and 48% with surgery. This was because of the blood transfusion data.
61
What is current for off pump CABG
What was difference between CORONARY and ROOBY
rate of Death, myocardial infarction, stroke, or new renal failure as a composite outcome showed no difference at 30 days or 1 year (12.1% vs 13.3%)--CORONARY
Repeat revascularisation has trend toward increase in off pump
rate of bleeding requiring, respiratory complications, and rise in serum creatinen were trending to wards benefit in off pump.
CORONARY had more pts (over 4000, expert based surgeons, more women and more left main)
62
What are microscopic features of HOCM
1. Disorganized myocytes and contractile elements withing cells (myofiber dissarray)
2. Extreme myocyte hypertrophy
3. Interstitial fibrosis
63
What is physiology of allograft Coronary artery disease
1. Diffuse, distal disease
2. Few collaterals
3. Concentric and neointimal proliferation
4. Months to develop
5. Not amenable to revascularization
6. always multivessel
64
What are allograft risk factors
1. Total ischemic time
2. CMV
3. Hyperlipidemia
4. Number of acute refection episdoes
5. Catecholamine-indiced ischemic injury in the donor
65
5 complications of the senning/mustard procedure
```
Sudden death (7-15%)
RV failure
L-sided pulmonary vein stenosis
SVC/IVC thrombosis
Baffle leak
Brady/tachy rhythms
Pulmonary HTN
Endocarditis
```
66
What factors to consider when planning a Biventricular repair in pulmonary atresis with intact ventricular septum
1. echo criteria for RV size which is based on the tricuspid Z score of RV hypoplasisa
2. RV morphology
3. Presence of RV dependent coronary circulation
4. Presence of Ebsteinoid TV with severe TR
67
5 effects of NO on vascular endothelium
```
Vasodilation
inhibits platelet aggregations and adhesion
inhibits vascular smooth muscle growth
Inhibits neutrophil adhesion
inhibits adhesion molecule expression
```
68
What are types of Pulmonary atresia with intact VSD
Type A: Confluent central PA and no MAPCAS
Type B Confluent central PAs with MAPCS
Type C: Non-confluent central PA with MAPCS (2 to 6)
69
What are the types of MAPCAS
Bronchial arteries
Indirect arteries arising from the aortic arch
Primitive intersegmental arteries that failed to involute
70
What is natural history and pathology of Pulmonary atresisa with intact ventricular septum
Complete obliteration of the RVOT at the level of valve and the pulmonary arteries are usually normally developed.
Severe cyanosis on the first day of life
Source of pulmonary blood flow is exclusively from PDA- MAPCAS are rare
Coronary flow is from coronary sinusoids or RV-coronary fistula
71
What are features of Congenital corrected TGA
```
L-Looping TAG--aorta anterior and to the left of the PA
AV and VA discordance
Blood flow--RA-LV-PA: and LA-RV-Aorta
95% have a VSD
90% have Tricuspid anomalies
15% have complete heart block
```
72
What are components of the Norwood operation
Atrial septectomy
Division of the PA and enlarging it with the PA patch
A modified BT shunt or RV-PA conduit
Arch augmentation with a patch
73
What are acceptable Epicardial pacing thresholds
```
ventricular pacing threshold < 0.7mV
R wave(sensing) amplitude > 5mV
P wave(sensing) amplitude > 1.5mV
Lead impedence 400 to 1000 ohms
absence of diaphragmatic pacing at 10mV
```
74
What type of Pacemaker in who
Bradycardia with intact AV node---DDI
Bradycardia with unreliable AV node--DDD
Bradycardia with episodes of atrial tachy--VDD or DDD
Bradycardia with chronic atrial tachy---VVI
SA incompetence with intact AV node---AAI
SA incompetence with unreliable AV node--DDD
*can add rate modulation to any of the above for you and active patients
75
List 4 meds that most patients should be on post CABG and why
ASA--improved vein graft patency and survival benefit
beta blocker-reduce post op arhythmias, and survival benefit in post MI pts
Statin: improved graft patency with reduction in inflammation prevent disease progression
ACE- reduced afterload and enhance LV remodeling in pts with low EF/DM
76
What are indications for LVAD
1. Class 4 Heart failure and failed OMT for at least 60 to 90 days
2. Left ventricular ejection fraction of < 25%
3. Functional limitation with a peak oxygen consumption of < 12 ml/kg/min or
4. Continued need for intravenous inotropic therapy owing to symptomatic hypotension, decreasing renal funtion, or worsening pulmonary congestion
5. Appropriate body sise (BSA > 1.5)
1/3 of BTT pts are lose transplant candiancy
17% of DT receive transplant
77
Clinical differences between VSD and pap muscle rupture
1. murmur of septal rupture is more prominent @ the left sternal border and is louder and associated with a thrill.
2. murmur of pap muscle rupture is best heard at apex and is softer with no thrill.
3. VSD rupture is most likely associated with anterior infarction and conduction abnormality while a pap muscle is likely posterior with no conduction
***bonus criteria**
septal rupture show > 9% step up in oxygen saturation between RA and PA
papillary muscle shows classic V waves in the pulmonary artery wedge tracing
78
List 2 ways to assess patency of intra operative bypass grafts
1. Transit time Doppler
>50 percent diastolic flow and PI < 5
2. Immuno fluorescence imaging
79
What has CRT been shown to benefit
```
Quality of Life
Functional Class
Exercise Capacity
LVEF
Hospitalization
Mortality
degree of MR
```
80
What are primary prevention indications for AICD
Dilated Cardiomyopathy or IHD > 40 days post MI
LVEF < 35%
NHYA function II, or III despite OMT
and
Reasonable expectation of survival with a good functional status for more then 1 year
81
What are secondary prevention indications for AICD
Current or prior heart failure symptoms
Reduced LVEF < 35%
and
A history of Cardiac arrest, ventricular fibrillation, or hemodynamic destabilizaing ventricular tachycardia
82
What are Class I indications for CRT
```
LVEF < 35%
Sinus rhythm NHYA II, III, or IV on OMT
QRS > 150 w LBBB (CCS guidelines)
QRS > 120 (AHA)
*whatever you say add that it's cardiac dyssynchrony
```
83
What is most common test and results for Hemolysis
The blood smear--confirms it
Demonstrates microangiopathic red cell changes
other histological RBC changes are 1) schistocytes 2) burr cells 3) Fragmented red cells 3) elevated indirect bilirubin
84
What other tests for Hemolysis and expected results
```
Serum LDH--elevated
Serum Haptoglobin--depressed
Reticulocytosis--fragmented and in RBC peripheral smear
Methemalbumin-
Hemoglobinuria
Increase Serum hemoglobin
```
85
List 5 items which may be tracked and used to modulate the rate in a rate responsive pacemaker
```
Heat
Carbon dioxide
Lactic acid
Movement
Intra-cardiac pressure
Electricity/EMG
QT interval
```
86
How does a rate responsive pacemaker work
The particular item is a product of increased metabolism and will be sensed by a transducer.
This results in an electrical signal being sensed by the pacemaker electronic circuit and changes the pacemaker automatic interval and therefore the escape rate.
As the detection of the item increases, the pacemaker output rate will increase; as the sensed parameter decreases, the pacemaker response will also decrease
87
Quickly list locations for all VSD
1. Membranous VSD--under the commissure of the anterior and septal leaflet of TV. Bordered superiorly by ventricular infundibular fold, anteriorly and inferiorly by the septum and posteriorly by tricuspid
2. Inlet: under the commissure of the septal and posterior leaflet.
3. Muscular: surrounded by rim of muscle. located anywhere in interventricular septum
4. Doubly committed sub arterial VSD: fibrous continuity between the leaflets of the pulmonary and aortic valve.
88
4 week old with Tricuspid Atresia. List the 3 operations that would be used for a staged repair and the age at which each should occur
BT shunt--control cyanosis in newborn period.
Bidirectional Glenn anastomosis--6 to 12 months of age
Fontan operation after 3 year
89
List 4 anatomical vascular rings
1. Double aortic arch
2. Right aortic arch with left ligamentum arteriosum and left subclavian
3. Pulmonary Sling
4. Anomalous innominate artery compression syndrome
5. Anomalous right subclavian artery (dysphagia lusoria)
* Pulmonary artery sling--the left pulmonary artery passes anterior to the esophagus while all other vascular rings run posteriorly.
90
List 3 components of the Rastelli repair for TGA with LVOT obstruction
Tunneling of VSD to aortic root
RV-PA conduit
closure of main PA
closure of ASD *not really part of it*
91
What percentage of pts Do NOT have a intact circle of Willis and what do you do?
about 10 to 15%
Place a balloon tipped cath selectively into the Left common carotid.
Check with NIRS and you should see return from the left even before you place balloon tipped. Look for this
92
List Carpentiers classification of Ebsteins's Anomaly
Type A: small atrialized, normal RV
Type B: large atrialized--mobile anterior leaflet, normal to wall RV
Type C: restricted leaflet motion, small RV
Type D: triscuspid sac "Uhl's syndrome"
93
List 3 subsets of single ventricle anomalies
Tricuspid atresia
Double inlet left ventricle
mitral atresia
94
List the classification of tricuspid atresia
Type I: 70%--Normally related great vessels
Type II: 30 %--D-TGA
Type III --L-TGA (super rare)
Subsets--A pulmonary atresia
B pulmonary stenosis
c- normal pulmonary valve
95
what other lesions are associated with Vascular rings?
Tracheomalcia
96
List anatomy of Hypoplastic left ventricle
Hypoplastic LV and ascending aorta
Aortic atresia/stenosis
mitral atresia/stenosis
restrictive inter-atrial communication
Coarctation in 80% of cases
97
Describe 2 posterior and 1 anterior root enlargement techniques
Nicks: incision through non coronary sinus and annulus, up to attachment of anterior mitral leaflet
Manougian: incision between the left coroanary and non coronary sinus, through the intravlvular trigone and the central fibrous origin of the anterior mitral leaflet
Konno: longitudinal incision in the anterior wall extended to the left of the RCA across the annulus and into both the IV septum and the RV anterior wall
dacron patch sewn to the LV side of the IV septum to close the VSD, prosthetic valve inserted, rest of dacron used to close aortotomy.
pericardial patch to close the RVOT
98
What are factors to consider when planning a repair for pulmonary atresia with intact ventricular septum
right ventricular dependent coronary artery ciculation
size of triscuspid valve
size of right ventricle
Morphology of right ventricle
99
What are clinical manifestations of rheumatic fever
Polyarthritis: temporary migrating inflammation of the large joints, usually starting in the legs and migrating upwards.
Carditis: Inflammation of the heart muscle which can manifest as congestive heart failure with shortness of breath, pericarditis with a rub, or a new heart murmur.
Subcutaneous nodules: Painless, firm collections of collagen fibers over bones or tendons.
Erythema marginatum: A long-lasting reddish rash that begins on the trunk or arms as macules, which spread outward and clear in the middle to form rings, which continue to spread and coalesce with other rings, ultimately taking on a snake-like appearance.
Sydenham's chorea (St. Vitus' dance): A characteristic series of rapid movements without purpose of the face and arms.
100
What are factors of Severe AI
Regurgitant fraction ≥ 50%,
vena contracta width (narrowest diameter of the flow stream) > 6 mm,
regurgitant volume ≥ 60 mL,
jet width/LVOT ≥ 65%,
effective regurgitant orifice (ERO) area ≥ 0.3 cm2.”
101
What are measurements of severe MR
```
“Severe MR is characterized by a vena contracta width ≥ 0.7 cm,
ERO ≥ 0.4 cm2,
regurgitant volume ≥ 60 mL,
regurgitant fraction ≥ 50%,
jet area > 40% of LA area.”
```
102
What is mechanism of action of Dabigitran?
Name two other meds in this class with similar action?
What was study and outcome that was assessed with this drug?
Oral, direct competitive thrombin, inhibitor
Rivaroxaban and Apixaban
Re-Ly study showed in AF that 110 vs warfarin was equal and 150 vs warfarin resulted in less stroke 1.69 vs 1.11% with similar bleeding
Limitation was the time spent in therapeurtic range on warfarin was limited for pt. when pts were in therapeutic range greater >70%) of time there was no difference.
