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Utah / kirklin > General Cardiac 2 > Flashcards

General Cardiac 2 Flashcards

1
Q

Post infarct LV Aneurysm

Pathological characteristics

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

Post infarct LV Aneurysm

Characteristic LV wall motion

A
  1. Akinetic or Dyskinetic
  2. Depressed LVEF (<35%)
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3
Q

Post infarct LV aneurysm vs False aneurysm

A

Ventricular aneurysm - full thickness

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

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4
Q

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

A

LV Aneurysm:

50% will devellop thrombus

20% of which will devellop thromboembolism

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5
Q

LV aneurysm

Most common location

A

LV Aneurysm:

85% near the apex

5-10% are posterior near the base

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6
Q

LV Aneurysm

Posterior aneurysms

A

Posterior LV Aneurysms

50% are false aneurysms

True posterior aneurysms are associated with MR

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7
Q

Natural history of the evolution of LV Aneusysm

A

Evolve over 6 months - unlikely to enlarge beyond one year

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8
Q

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

A

20%

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9
Q

LV aneuysm

which is worse dyskinesia or akinesia

A

dyskinesia

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10
Q

Frequency of Ventricular arrhytmia with LV aneurysm

A

15-35%

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11
Q

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

A

the septum

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12
Q

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

A

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

A/C not indicated

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13
Q

Clear indicaitons for surgical repari of a left ventricular aneurysm

A
  1. Large LVA + Angina
  2. CHF
  3. Recurrent VT
  4. Risk of late rupture
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14
Q

posssible indications for Left ventricular aneurysm repair

A
  1. Small LVA with other cardiac surgery
  2. Segmental akinetic LV (“ventricular restoration”)
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15
Q

Criteria to AVOID surgery for a Left Ventricular aneurysm

A
  1. Diffuse hypokinesis without a discrete LVA
  2. Severe LV dysfunction (? Transplant)
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16
Q

Fontan Stitch

A

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

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17
Q

Surgical repair of left ventricular aneurysm

Operative mortality(%)

A

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

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18
Q

Most common complication of the surgical repair of an LV aneurysm

A

Acute cardiac failure - occurs in 64% of patients

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19
Q

Preoperative risk factors for surgical repair of an LV Aneurysm

A
  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
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20
Q

Results of surgical treatment of an LV Aneurysm

A

May not be demonstrated via echocardiography

  • LVEF may not be shown to improve on ECHO

Results are demonstrated via improved symstoms and exercise testing

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21
Q

STITCH TRIAL

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

STITCH Trial

  1. Surgical Treatment for Ischemic Heartfailure Study
  2. It hypothesized that SVR + Cabg would decrease hospitalization for CHF.
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22
Q

STITCH Trial

Conduct of the trial

A

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

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23
Q

STITCH TRIAL

Conclusion and controversies

A
  • 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
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24
Q

Post infarction VSD

Results of Repair Overall survival

A

35% early mortality

5 year survival ~50%

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25
Q

Most common causes of death after surgical repair of a post infarction VSD

A
  1. CHF: 50-90%
  2. 20% technical failures (bleeding residual VSD)
  3. 10% sudden death
  4. CHF Chronic intractivble
  5. Stroke CVA
    6.
26
Q

Type IIIa Mitral Regurgitataion

A

Type III - leaflet tethering

IIIa - diastolic teathering

27
Q

Guideline for repair of tricuspid regurgitation

A

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)
28
Q

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

#####

A

Class I indication for surgery

######

29
Q

Approprite treatent for patients with symptomatic primairy severe TR

A
  • 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)
30
Q

Appropriate treatment for:

Tricuspid regurgitaion ( in patients undergoing Mitral surgery w/ Pulmonary HTN ?

A

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)

31
Q

Appropriate treatment:

Patients with TR

A

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
32
Q

Appropriate treatment for patient with tricuspid regurgitation in asymptomatic patients

with normal mitral valve and PAs < 60 mmHg?

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)

33
Q

Tirone David 1

A

Original

Reimplantation of the coronaries

Just a sleeve all the way down

34
Q

Tirone David 2

A

Miller: “Same as a Yacoub 1 “

anastomosis to the sinuses

Reimplant

35
Q

Tirone David 3

A

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

36
Q

Tirone David 4

A

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

37
Q

hypothesized mechanisms of Stunning

A
  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
38
Q

How long can myocardial cells tolerate hypoxia

A

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

39
Q
A
40
Q

The “untethering hypothesis”

A

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

41
Q

Risk factors for LV rupture following mitral valve replacement

A

(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

42
Q

Mitral valve replacement

10 and 15 year survival for middle-aged

A

(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.
43
Q

Bleeding following mitral valve replacement - mechanical vs bioprosthetic prosthesis?

A

More common after mechanical MVR

(HR: 3.3; p = 0.022)

44
Q

Thomboembolic events following mitral valve replacement :

Mechancial vs Bioprosthetic prosthesis?

A

more common after mechanical MVR

(HR: 4.7; p = 0.01)

45
Q

Mitral valve replacement -

Overall freedom from major adverse prosthesis related events (MAPE) at 10 years-

mechanical vs biologic prosthesis ?

A

freedom from MAPE:

53% after mechanical MVR vs. 61% after bioprosthetic MVR

46
Q

Mitral valve replacement

  1. what is patient prosthesis mismatch ?
  2. what is the impact on survival ?
A

indexed effective orifice area ≤ 1.25 cm2/m2

impact on 10 year survival:

  1. with Patient prosthesis mistmach 65%
  2. Without PPM: 75%,
47
Q

Components of the Cox III lesion set

A

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

48
Q

What is the ratio of EF to mortality rate for

  • isolated CABG
  • Isolated Valve
A

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

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

49
Q

what is the ratio of EF to mortality for isolated CABG

A

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

50
Q

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

A

Isolated valve: 10% drop EF —> 9% inc mortality

51
Q

What is the ratio of EF to mortality ratio for:

  • MV repair / CABG:
  • AVR/ CABG :
  • MVR/CABG:
A
  • 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
52
Q

What is the ratio of EF to mortality ratio for:

MV repair + CABG:

A

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

53
Q

What is the ratio of EF to mortality ratio for:

AVR/ CABG :

A

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

54
Q

What is the ratio of EF to mortality ratio for:

MVR/CABG:

A

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

55
Q

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

A
  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
56
Q

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

A
  1. If Cerebral edema is anticipated:
    1. Steroids
    2. mannitol
    3. barbiturate.
57
Q

ECG indication of ventricular aneurysm ?

A

A ventricular aneurysm is suggested by:

persistent ST elevation & the absence of pain

58
Q

Scale of Aortic valve patient prosthetic mismatch

A

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

59
Q

Severe aortic valve Patient Prosthetic mistmatch

EOAI ?

Reccomendations

A

EOAI: < 0.65 is severe

Avoid in every patient undergoing an AVR

60
Q

Moderate aortic valve patient prosthetic mismatch ?

A
  • Moderate PPM is an EOAI: < 0.85
  • Avoid in patients:
    1. LV dysfunctioin
    2. Concominant MR
    3. Young < 65 yo patients
    4. Athletes
61
Q

Class III Evidence for tricuspid regurgiation )

A

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)

Utah / kirklin (12 decks)

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