General Cardiac 2

Question 1

Post infarct LV Aneurysm

Pathological characteristics

Answer 1

1. Scar: deliniated, thin, white, haline tissues
2. FULL THICKNESS
3. Endocardium: smooth non trabeculated
4. 50% Mural thrombus
5. Overlying pericaridum adherent

Question 2

Post infarct LV Aneurysm

Characteristic LV wall motion

Answer 2

1. Akinetic or Dyskinetic
2. Depressed LVEF (<35%)

Question 3

Post infarct LV aneurysm vs False aneurysm

Answer 3

Ventricular aneurysm - full thickness

False aneurysm - rupture contained by pericardium– an indication for surgery

Question 4

LV aneurysm: Frequency of mural thrombus, and how many will devellop thromboemboism

Answer 4

LV Aneurysm:

50% will devellop thrombus

20% of which will devellop thromboembolism

Question 5

LV aneurysm

Most common location

Answer 5

LV Aneurysm:

85% near the apex

5-10% are posterior near the base

Question 6

LV Aneurysm

Posterior aneurysms

Answer 6

Posterior LV Aneurysms

50% are false aneurysms

True posterior aneurysms are associated with MR

Question 7

Natural history of the evolution of LV Aneusysm

Answer 7

Evolve over 6 months - unlikely to enlarge beyond one year

Question 8

How much LV function must be lost to have enlargment of the LV

Answer 8

20%

Question 9

LV aneuysm

which is worse dyskinesia or akinesia

Answer 9

dyskinesia

Question 10

Frequency of Ventricular arrhytmia with LV aneurysm

Answer 10

15-35%

Question 11

LV Aneurysm - if ventricular arrhythmia devellop which area of the ventricle is most likely involved?

Answer 11

the septum

Question 12

LV Aneurysm - if a thrombus is present, what should be done about anticoagulation?

Answer 12

Thromboembolism is infrequent despite 50% thrombus rate - only 0.35% per year

A/C not indicated

Question 13

Clear indicaitons for surgical repari of a left ventricular aneurysm

Answer 13

1. Large LVA + Angina
2. CHF
3. Recurrent VT
4. Risk of late rupture

Question 14

posssible indications for Left ventricular aneurysm repair

Answer 14

1. Small LVA with other cardiac surgery
2. Segmental akinetic LV (“ventricular restoration”)

Question 15

Criteria to AVOID surgery for a Left Ventricular aneurysm

Answer 15

1. Diffuse hypokinesis without a discrete LVA
2. Severe LV dysfunction (? Transplant)

Question 16

Fontan Stitch

Answer 16

Purse string around the defect after an LV aneurysm is resected.

Usually made of a 3-0 Prolene

Best to ensure that the stitch is NOT TOO TIGHT

Question 17

Surgical repair of left ventricular aneurysm

Operative mortality(%)

Answer 17

Operative mortality of the surgical repair of an LV aneuysm is 5%

Question 18

Most common complication of the surgical repair of an LV aneurysm

Answer 18

Acute cardiac failure - occurs in 64% of patients

Question 19

Preoperative risk factors for surgical repair of an LV Aneurysm

Answer 19

1. Resting LV Dysfunction
2. Chronic CHF
3. Reduced Cardiac output
4. Elevated LVEDP
5. Decreased septal systolic wall motion
6. Poor segmental wall motion

Question 20

Results of surgical treatment of an LV Aneurysm

Answer 20

May not be demonstrated via echocardiography

• LVEF may not be shown to improve on ECHO

Results are demonstrated via improved symstoms and exercise testing

Question 21

STITCH TRIAL

1. what does it stand for?
2. what was the hypothesis?

Answer 21

STITCH Trial

1. Surgical Treatment for Ischemic Heartfailure Study
2. It hypothesized that SVR + Cabg would decrease hospitalization for CHF.

Question 22

STITCH Trial

Conduct of the trial

Answer 22

Pts with EF of <35% were randomized into CABG vs CABG + SVR

Question 23

STITCH TRIAL

Conclusion and controversies

Answer 23

• Jones et al (2009) found SVR + CABG did not have improvement
• Criticizim by Buckberg et al
• Wrong Operation:
  
  • previously, >40% LV Reduction needed for benefit,
  • Stitch protocol was 30% –> 19% in final analysis
• Wrong Patients :
  
  • initial protocol LV volume >60ml/m2 and >35%. akinesia … in final was on 38% had echo and only half had a kinesia

Question 24

Post infarction VSD

Results of Repair Overall survival

Answer 24

35% early mortality

5 year survival ~50%

Question 25

_Most common_ causes of **death** after *surgical repair* of a **post infarction VSD**

Answer 25

1. CHF: 50-90% 2. 20% technical failures (bleeding residual VSD) 3. 10% sudden death 4. CHF Chronic intractivble 5. Stroke CVA 6.

Question 26

Type IIIa Mitral Regurgitataion

Answer 26

Type III - leaflet tethering IIIa - diastolic teathering

Question 27

Guideline for repair of tricuspid regurgitation

Answer 27

_Guidelines for Tricuspid Regurgitaion_ 1. **Class I:** * Severe TR in patients with MV disease requiring MV surgery (level of evidence B) 2. ###### **Class IIa:** * Tricuspid valve replacement or annuloplasty is reasonable for severe primary TR when symptomatic (level of evidence C) * Tricuspid valve **replacement** is reasonable for severe TR secondary to diseased/abnormal tricuspid valve leaflets not amenable to annuloplasty or repair. (Level of Evidence C) 3. ##### **Class IIb:** * ###### Tricuspid **annuloplasty** may be considered for less than severe TR in _patients undergoing MV surgery_ when there is pulmonary hypertension or tricuspid annular dilatation (Level of Evidence C) 4. ##### **Class III:** * ###### (a)Tricuspid valve replacement or annuloplasty is not indicated in asymptomatic patients with TR whose pulmonary artery systolic pressure is less than **60 mm Hg** in the presence of a normal MV. (Level of Evidence C) * ###### (b)Tricuspid valve replacement or annuloplasty is not indicated in patients with mild primary TR (Level of Evidence C)

Question 28

Appropriate step for severe TR in patients with MV disease requiring MV surgery ? #####

Answer 28

**Class I indication for _surgery_** ######

Question 29

Approprite treatent for patients with symptomatic primairy severe TR

Answer 29

* Tricuspid valve replacement or annuloplasty is reasonable for severe primary TR when symptomatic (level of evidence C) * Tricuspid valve replacement is reasonable for severe TR secondary to diseased/abnormal tricuspid valve leaflets not amenable to annuloplasty or repair. (Level of Evidence C)

Question 30

**_Appropriate treatment for:_** **Tricuspid regurgitaion** ( _in *patients undergoing Mitral surgery* w/ Pulmonary HTN ?_

Answer 30

**_Tricuspid annuloplasty_** may be considered for _less than severe TR in patients_ _undergoing MV_ surgery when there is **pulmonary hypertension** or **tricuspid annular dilatation** (Level of Evidence C)

Question 31

**_Appropriate treatment:_** Patients with TR

Answer 31

**Tricuspid annuloplasty** may be considered for less than severe TR in patients undergoing MV surgery when there is pulmonary hypertension or tricuspid annular dilatation * Level of Evidence C

Question 32

Appropriate treatment for patient with **tricuspid regurgitation** in **asymptomatic** patients with **normal mitral** **valve** and **PAs \< 60 mmHg**?

Answer 32

Tricuspid valve replacement or annuloplasty is *not* indicated in asymptomatic patients with TR whose pulmonary artery systolic pressure is less than 60 mm Hg in the presence of a normal MV. (Level of Evidence C)

Question 33

Tirone David 1

Answer 33

Original Reimplantation of the coronaries Just a sleeve all the way down

Question 34

Tirone David 2

Answer 34

Miller: "Same as a Yacoub 1 " anastomosis to the sinuses Reimplant

Question 35

Tirone David 3

Answer 35

Miller: " TD II with external synthetic strip added between left and right mitral trigones"

Question 36

Tirone David 4

Answer 36

TD I with graft chosen 4mm larger, distal portion plicated circumferentially

Question 37

hypothesized mechanisms of _Stunning_

Answer 37

1. **_"free radial hypothesis":_** 1. oxidative stress and generation of free oxygen radicals (and depletion of antioxidants) results in cell damage. 2. **_"calcium hypothesis":_** 1. accumulated intracellular ionized calcium from low pH activated opening of Na-Ca channels during reperfusion. 3. Phosphate: Depletion of intracellular energy stores (i.e., ATP) and disruption of phosphorylation ratios can also have a significant impact on myocardial contractility

Question 38

How long can myocardial cells tolerate hypoxia

Answer 38

Myocardial cells can withstand *severe* hypoxia for about five minutes without significant lasting damage.

Question 40

The "**untethering hypothesis**"

Answer 40

The "untethering hypothesis" argues that preservation of the posterior leaflet with its annular and ventricular attachments is important to prevent this complication.

Question 41

Risk factors for LV rupture following mitral valve replacement

Answer 41

(a) more common in women and elderly patients, but can also occur in young patients following decalcification for mitral repair. (b) Another study suggests significant risk factors for LV rupture: (c) older age (d) hemodialysis (e) preservation of the basal chordae of the posterior leaflet, (f) a end-diastolic LV dimension \< 50 mm

Question 42

Mitral valve replacement 10 and 15 year survival for middle-aged

Answer 42

(a)Aged 50-65 years: 1. 10 year: 1. Mechanical: 74% 2. Bioprosthetic: 78% 2. 15-year survival 1. 50% irrespective of the Prosthetic used.

Question 43

Bleeding following mitral valve replacement - mechanical vs bioprosthetic prosthesis?

Answer 43

More common after **mechanical** MVR (HR: 3.3; p = 0.022)

Question 44

_Thomboembolic_ events following mitral valve replacement : Mechancial vs Bioprosthetic prosthesis?

Answer 44

more common after **mechanical** MVR (HR: 4.7; p = 0.01)

Question 45

Mitral valve replacement - Overall _freedom_ from major adverse prosthesis related events (**MAPE**) at 10 years- mechanical vs biologic prosthesis ?

Answer 45

*freedom* from MAPE: 53% after mechanical MVR vs. 61% after bioprosthetic MVR

Question 46

_Mitral valve replacement_ 1. what is patient prosthesis mismatch ? 2. what is the impact on survival ?

Answer 46

indexed effective orifice area ≤ 1.25 cm²/m² impact on 10 year survival: 1. with Patient prosthesis mistmach 65% 2. Without PPM: 75%,

Question 47

Components of the Cox III lesion set

Answer 47

**A.** cavo-tricuspid lesion (inferior vena cava to tricuspid annulus). **B.** connecting incision from the left atriotomy to the mitral annulus. **D.** cryoablation of the coronary sinus. **E.** oversewing and cryoablation of the left atrial appendage *the lesion **C**. along the atrial septum is not required*

Question 48

What is the ratio of EF to mortality rate for - isolated CABG - Isolated Valve

Answer 48

isolated CABG : for every 10% drop EF , mortality up 20% Isolated Valve : for every 10% drop EF, mortality up 9%

Question 49

what is the ratio of EF to mortality for isolated CABG

Answer 49

CABG - 10% drop EF: there is a 19% increase in odds of op morality

Question 50

what is the ratio drop in EF to increase in mortality of an isolated valve?

Answer 50

_Isolated valve:_ 10% drop EF —\> 9% inc mortality

Question 51

What is the ratio of EF to mortality ratio for: * MV repair / CABG: * AVR/ CABG : * MVR/CABG:

Answer 51

* MV repair / CABG: 10% drop EF—\> 9% inc mortality * AVR/ CABG : 10% drop EF—\> 10 % inc mortality * MVR/CABG: 10% drop EF—\> 23% inc mortality

Question 52

What is the ratio of EF to mortality ratio for: MV repair + CABG:

Answer 52

MV repair + CABG: 10% drop EF—\> 9% inc mortality

Question 53

What is the ratio of EF to mortality ratio for: AVR/ CABG :

Answer 53

AVR/ CABG : 10% drop EF—\> 10 % inc mortality

Question 54

What is the ratio of EF to mortality ratio for: MVR/CABG:

Answer 54

What is the ratio of EF to mortality ratio for: AVR/ CABG : 10% drop EF—\> 10 % inc mortality **MVR/CABG: 10% drop EF—\> 23% inc mortality**

Question 55

Important steps in the resumption of CPB following finding air in the Circuit

Answer 55

1. Deep barbiturate anesthesia 2. Hypothermia, 3. Elevated perfusion pressures 4. Oxygen concentration at 100% 1. maximize blood content and to maximize the elimination gradient for nitrogen

Question 56

Following resumption of CPB after _air in the ciruit_ - how to treat the patient if cerebral edema is anticipated ?

Answer 56

1. *If Cerebral edema is anticipated:* 1. Steroids 2. mannitol 3. barbiturate.

Question 57

ECG indication of ventricular aneurysm ?

Answer 57

A ventricular aneurysm is suggested by: persistent ST elevation & the absence of pain

Question 58

Scale of Aortic valve patient prosthetic mismatch

Answer 58

_Moderate Indexed effective orifice area:_ \< 0.85cm²/m² _Severe Indexed effective orifice area:_ \< 0.65 cm²/m² although may be less relavent in paitient with BSA \< 1.7 m²

Question 59

**Severe** aortic valve _Patient Prosthetic mistmatch_ EOAI ? Reccomendations

Answer 59

EOAI: \< 0.65 is _severe_ Avoid in every patient undergoing an AVR

Question 60

Moderate aortic valve patient prosthetic mismatch ?

Answer 60

* Moderate PPM is an EOAI: \< 0.85 * Avoid in patients: 1. LV dysfunctioin 2. Concominant MR 3. Young \< 65 yo patients 4. Athletes

Question 61

Class III Evidence for tricuspid regurgiation )

Answer 61

Class III: Tricuspid valve replacement or annuloplasty is not indicated in: * _asymptomatic patients_ with TR whose pulmonary artery systolic pressure is \< 60 mm Hg in the presence of a normal MV. (Level of Evidence C) * Tricuspid valve replacement or annuloplasty is not indicated in patients with *_mild primary TR_* (Level of Evidence C)