Fiser Chapter 26 CARDIAC

Question 1

Shunt causing cyanosis

Answer 1

R to L shunt

Question 2

Children squatting does what

Answer 2

Increases SVR and decreases R to L shunt

Question 3

Cyanosis from R to L shunt can lead to what

Answer 3

Polycythemia, stroke, brain abscess, endocarditis

Question 4

Eisenmenger’s syndrome

Answer 4

L -> R shunt switches to R -> L shunt

Sign of increasing pulmonary vascular resistant and pulmonary HTN, and is generally irreversible

Question 5

Shunt causing CHF

Answer 5

L to R shunt

Manifests as failure to thrive, tachycardia, tachypnea, hepatomegaly

Question 6

First sign of CHF in children

Answer 6

Hepatomegaly

Question 7

Causes of L to R shunts

Answer 7

VSD
ASD
PDA

Question 8

PDA causes what kind of shunt

Answer 8

L to R

Question 9

Causes of R to L shunts

Answer 9

Tetralogy of Fallot

Question 10

Ductus arteriosus

Answer 10

Connection between descending aorta and Left pulmonary artery; blood shunted away from lungs in utero

Question 11

Ductus venosum

Answer 11

Connection between portal vein and IVC; blood shunted away from liver in utero

Question 12

Fetal circulation at placenta

Answer 12

2 umbilical arteries (take blood away from fetus)

1 umbilical vein (brings blood to fetus)

Question 13

Most common congenital heart defect

Answer 13

VSD causing a L -> R shunt

80% close spontaneously by 6 months

Large VSDs usually cause symptoms after 4-6 weeks old, as PVR decreases and shunt increases

Cx: CHF (tachypnea, tachycardia) and FTT (failure to thrive)

Tx: Diuretics, digoxin, repair

Question 14

VSD timing of repair

Answer 14

FTT: most common reason for earlier repair

Medium (shunt 2-2.5): 5yo

Large (shunt > 2.5): 1yo

Question 15

ASD types

Answer 15

Ostium secundum is most common; centrally located

Ostium primum (or atrioventricular canal defects or endocardial cushion defects); can have mitral valve and tricuspid valve problems; frequent in Down’s syndrome

Question 16

ASD

Answer 16

L -> R shunt

Usually symptomatic when shunt > 2 -> CHF (SOB, recurrent infections)

Can get paradoxical emboli in adult hood

Tx: Diuretics and digoxin

Question 17

ASD timing of repair

Answer 17

1-2yo

If canal defects: 3-6 months old

Question 18

Tetralogy of Fallot

Answer 18

PROV:

• Pulmonic stenosis
• R ventricular hypertrophy
• Overriding aorta
• VSD

R to L shunt -> cyanosis

Tx: Beta blocker, repair at 3-6 months old

Question 19

Most common congenital heart defect that results in cyanosis

Answer 19

Tetralogy of Fallot

Question 20

Tetralogy of Fallot repari

Answer 20

-RV outflow tract obstruction removal, RVOT enlargement, and VSD repair

Question 21

PDA

Answer 21

L to R shunt

Tx: indomethacin to close, rarely successful beyond neonatal period, requires L thoracotomy for repair if persists

Question 22

MCC death in US

Answer 22

CAD

Question 23

CAD risk factors

Answer 23

• Smoking
• HTN
• Male
• Family hx
• HLD
• DM

Question 24

CAD medical tx

Answer 24

-Nitrates, smoking cessation, weight loss, statins, ASA

Question 25

Coronary arteries

Answer 25

LMA branches into LAD and LCx

Question 26

Where are most atherosclerotic coronary lesions?

Answer 26

Proximal

Question 27

MI complications

Answer 27

- Ventricular septal rupture | - Papillary muscle rupture

Question 28

3-7 days after MI, patient has hypotension, pansystolic murmur, and a step-up in O2 content between R atrium and pulmonary artery

Answer 28

Ventricular septal rupture Dx: Echo Tx: IABP and patch over septum

Question 29

3-7 days after MI, patient has severe mitral regurgitation with hypotension and pulmonary edema

Answer 29

Papillary muscle rupture Dx: Echo Tx: IABP, replace valve

Question 30

Incidence in restenosis in CAD revascs

Answer 30

Drug-eluting stent: 80% at 1 year Saphenous vein graft: 80% at 5 years Internal mammary artery (off subclavian): 95% 20 year patency when placed to LAD; collateralizes with superior epigastric artery

Question 31

What do you use to cause arrest of heart in diastole and keep heart protected and still while grafts are placed during CABG?

Answer 31

Potassium and cold solution cardioplegia

Question 32

CABG indications

Answer 32

Left main > 50% stenosis or at other site > 70% stenosis - Left main disease - 2-vessel disease involving LAD - 3 vessel disease (LAD, Cx, RCA) - Lesion not amenable to stenting

Question 33

High mortality risk factors for CABG

Answer 33

Pre-op cardiogenic shock is #1 risk factor Emergency operations Age Low EF

Question 34

Mechanism of aortic stenosis

Answer 34

Degenerative calcification

Question 35

Benefit of bioprosthetic tissue valves

Answer 35

- Do not require anticoagulation - But not as durable, last 10-15 years - Use for patients who want pregnancy, have contraindication to AC, are older >65, and unlikely to require another valve in their lifetime, or have frequent falls - Contraindicated in children and young patients d/t rapid calcification

Question 36

DOE, angina, syncope

Answer 36

Aortic stenosis Syncope is the worst with mean survival 3 years (versus 4 and 5 for angina and DOE)

Question 37

AS indications for operation

Answer 37

Symptomatic (usually have peak gradient > 50 mm Hg and valve area < 1.0 cm^2)

Question 38

Key index of disease progression in patients with MR

Answer 38

Ventricular function. Usually becomes dilated. Other symptoms: A fib, pulmonary congestion

Question 39

MR indications for operation

Answer 39

Symptomatic or severe MR

Question 40

Pulmonary edema, dyspnea, hx of rheumatic fever

Answer 40

MS

Question 41

MS indications for operation

Answer 41

Symptomatic (usually have valve area < 1 cm^2) Balloon commissurotomy to open valve often used as 1st procedure

Question 42

Patient with fever, chills, sweats, and heart murmur

Answer 42

Endocarditis, usually Staph aureus and Left sided (except drug users: pseudomonas? and Right sided)

Question 43

Most common site of native valve vs prosthetic valve infections

Answer 43

Native: mitral Prosthetic: aortic

Question 44

Endocarditis tx

Answer 44

Medical tx successful in 75%, sterilizes valve in 50% Surgery if failure of abx, severe valve failure, peri