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From Flashcardlet big > Hamad Notes > Flashcards

Hamad Notes Flashcards

1
Q

List the major side effects of transplant drugs

A

Tacrolimus (FK 506) — nephrotoxcity

OKT3—increased rate of infection

MMF (cellcept) anemia or hypertension

prednisone– hypertension/DM

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2
Q

List 5 absolute medical contra-indication for donation of a heart for transplantation

A

severe structural heart disease

severe coronary artery disease
active malignancy (exlcuding primary brain or skin cancer)
prior myocardial infarction
HIV positive

prolonged cardiac arrest

HIV positive

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3
Q

How does cyclosporine work

A

prevents development of T-cells by the inihibition of IL-2. It effects gene activation necessary for IL-2 production by inhibiting the function of calcium calcineurin which is essential for IL-2 gene activation

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4
Q

What is mechanisms of action of steroids

A

inhibit a variety of intracellular enyzmes that DNA, RNA, and protein synthesis, thereby depressing cell-mediated immunity

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5
Q

What is mechanism of action of thymoglobin

A

is polyclonal antibody that decreases the level of circulating T cells by attaching to circulating lympohycytes and promoting cytolysis

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6
Q

What is mechanism of OKT3

A

is a monoclonal anti-T-cell antibody that binds to CD3 T-cell receptor site on cytotoxic cells interfering with antigen recognition.

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7
Q

4 possible etiologies for neurological dysfunction after CPB

A

Macroembolization ( gas atheroma)
Micro embolizatoin
Inadequate cerebral of gas
inadequate cerebral perfusion which may be result of reduced flow

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8
Q

What happens to the pH and PCO2 when a patient is cooled on CPB

A

The pH rises (more alkaloitc) and the PCo2 falls

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9
Q

What is alpah stat and what is one advantage

A

alpha-stat management keep pH at 7.40 and the PCO2 at 40 mmHg as measured at 37 degrees thus would make the patients blood alkalotic and hypocarbonic at the actual patient.

maintains cerebral autoregulation and optimizes intraceullular enzyme function.

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10
Q

What is pH stat and one advantage

A

keep the pH at 7.40 and the PCO2 at 40 mmHg as measured by the in vivo temperature thus the blood would be acidotic and hypercarbic if measured at 37 degrees. This results in increased cerebral blood flow, increased cerebral oxygenationand better cerebral cooling

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11
Q

What are the steps when CPB appears like it’s clotting

A

Immediate unclamping of the cross clamp of the aorta
ventilate the patient
commence open cardiac massage
immediate clamping of the venous and arterial pump lines
Trendelenburg to auto transfuse
Administration of blood and/or crystalloids
consider pharmacological brain protection
ask for help to exchange the oxygenator and tubing

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12
Q

List 3 alternative to protamine

A

Recombinant platelet factor 4
Heparinase
Heparin–

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13
Q

What are options to use if satefy

A

Heparin _ psostabyclin
Danaparoid or r-hirudin
Defibrinogenating agent

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14
Q

How and where do you cannulate the axillary artery

A

Exposure is obtained at the proximal part of the artery, using a sub-clavicular incision. FIbers of Pectoralis major muscle are split and delto-pectoral fascia is opened

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15
Q

How and where do you cannulate the axillary artery

A

Exposure is obtained at the proximal part of the artery, using a sub-clavicular incision. FIbers of Pectoralis major muscle are split and delto-pectoral fascia is opened

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16
Q

What is the relation between the artery and its immediate surronding structures

A

The artery lies deep and superior to the axillary vening and inferior to the brachial plexus

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17
Q

How would you cannulate the artery

A

Cannulation is easier using a dacron graft sutures to the artery with insertion of the annula in the graft

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18
Q

While on CPB you experience “poor venous return/volume loss”

A 
Loss of blood (disconnected line) 
Large urine output
inadequate draining venous cannulaue 
aortic clamo off and aortic valve Insufficently 
Aortic vent failure
rare birds like PDA
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19
Q

What chamber is is prone to hypoventilation with RCP?

What % of nutrient flow drains by

Left coronary sinus

Right coronary sinus

Ventricles

A

Right ventricle

Left coronary ostium 30%
Right coronary ostium 3%
Ventricles =695

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20
Q

List 4 additional neuroprotection techqniues

A 
Packing the head with ice
I V steroids
IV barbituatons 
selective antegrade
retrograde cerebral perfusion
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21
Q

List in any order the 3 most common causes of death following cardiac transplantation

A

Infection
Rejection
Accelerated coronary disease

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22
Q

What is complete orthotopic heart transplant technique

A

The right sided anastomosis are done to the SVC and IVC. The left sided anastomosis are done to two cuffs of the left atrium (one surrounding the left upper and lower pulmonary veins and the second to another cuff surrounding the right upper and lower pulmonary veins

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23
Q

What is standard Shumway/Lower heart transplant technique

A

The left and right atria are anastomosed at the atrial level

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24
Q

What is Bicaval heart transplant techqnique

A

The recipients entire right atrium is excised and the asnastomosis on the right side are done to the SVC and the IVC

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25
Q

What is heterotopic heart transplant

A

the individuals heart is left in place and transplant heart is piggybacked onto the recipients heart

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26
Q

What is autograft

A

organ or tissue from same individual is re-implantated

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27
Q

What is allograft

A

Organ or tissue from another non-identical individual of same species is tranplanted

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28
Q

What is Heterograft

A

Organ or tissue from another non-identical individual is tranplanted

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29
Q

Xenograft

A

Organ or tissue from individual of another species is tranplanted

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30
Q

List 5 histological changes currently used to grade the severity of cardiac rejection as per ISHLT

A 
Lymphocytic infiltration 
Necrosis
Myocyte damage
inflammatory infiltration 
polymorphous infiltration 
Edema
Hemmorrhage
Vasculitis
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31
Q

Describe the ISLT rejection statues

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

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32
Q

On which cells are class I antigens expressed

A

All cells of an organism

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33
Q

On which cells are Class II antigens (DP, DQ, DR) expressed

A 
B lymphocytes
Activated T lymphyocytes 
Macrophages
dentritic cells 
Endothelial cells
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34
Q

What is peak oxygen consumption

A

Oxygen consumption during exercise provides an index of overall cardiovasular reserve that is useful both to quatitate function limitation and to estimate limitation
10 to 14 ml Kg min indicated very poor prognosis–cut off for transplantation

peak Vo2 over 16 to 18 have surivival rates similar to that of transplantation

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35
Q

Patient post tranplant with Po2 that’s 50mmHg despite increasing Fi02 and things getting worse with PEEP what is it?

A

Missed PFO or ASD in donor heart

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36
Q

What is physiology of ASD causing hypoxia

A

Post transplant the right ventricle is stiff and dysfunctinon. Also, post transplant patients have a degree of pulmonary hypertension. This increases the afterload on the right side. This is made worse if the donor is smaller than the recipient. This causes are large shunt from right to left.

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37
Q

Why does PEEP make it worse

A

PEEP increases the right ventricular afterload and will increase the degree of right to left shunting

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38
Q

What is treatment for this shunt problem

A

decreasing right ventricular afterload with meds—Milrinone, nitric oxide.
Stop PEEP
Dobutamine
Close the shunt percutaneous or surgically

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39
Q

Describe PRA and its importance for transplant

A

Prior to transplant the serum of potential recipient is exposed to panels of cells that express most HLA types. This allows if a potential recipient has pre-formed antibodies to common HLA antigens. If a candidate is known to react to more then 10% of the panel of specific pre-transplant cross matching between the donor and the recipient is required.

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40
Q

List 4 direct manifestations of CMV infection on heart transplants recipients

A 
Fever
Mononucleosis 
Pneumonai 
myocardidits 
Hepatitis 
GI ulceration
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41
Q

Tremor post cardiac transplantation

A

likely do to Cyclosporine

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42
Q

What is treatment for cardiac rejection

A

A steroid pulse of IV methlprednisolone (500 to 1000mg/day x 3 days)
Pulse of increased oral prednisone (100mg/day x 3 days)
Course of biological agent such as ATG, ALG, OKT3

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43
Q

What are indirect effects of CMV

A

allograft rejection
bacterial superinfection
Immunosuprresion
chronic graft rejection

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44
Q

What are types of “Bridges when it refers to transplant

A

Mechanical bridge to recovery implies that the device is implatned until the “stunned” myocardium recovers
Bridge to transplant means only hope is transplant.

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45
Q

For a middle aged active women what would you accept as minimally acceptable indexed EOA in the mitral valve

A

1.25 cm2/m2

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46
Q

How do you calculate indexed EOA

A

first BSA is (ht x wt/3600) square root. then you go EAO (cm2) divided by BSA (m2)

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47
Q

7 indications for surgery of left sided valve endocarditis

A 
Congestive heart failure related to valve disruption 
Severe AI 
Extra valve extension (annular abscess) 
Persistent infection 
vegetations
New onset heart block 
multiple emboli
infection by resistant organisms
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48
Q

What is management of type A IMH

A

IMA is related but different then aortic dissection. Hemorrhage into the aortic media in the abscence of intimal tear

Optimal management not clear. Reported medical managment mortality is 50%
1/3 of patients progress to classic dissection.
The risk is higher with aortic diameters of > 5 cm.
Conventional aortic dissection surgery is the treatment of choice.

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49
Q

What is most common organism of infection for mechanincal valve proshesis

A

Staph Epi

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50
Q

What are minor duke critieria

A 
Predisposition (heart condition or IV drug user) 
Fever
Vascular phenomenon
Immunologic phenomenon
Microbiology evidence
Echocardiogram
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51
Q

List 7 complications of valvular substitutes

A 
anticoagulation 
thromboembolism 
strucutural vavle degeneration 
endocarditis 
heart block 
bleeding
patient prosthesis mismatch 
Hemolysis 
Perivalvular leak
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52
Q

3 options for addressing aortic valve at the time of dissection repair

A

Resuspension of the aortival valve comissures to the aortic wall before replacing the ascending aorta

Valve sparing aortic root replacement with attachment of the valve inside the aortic graft and reimplntation of the coronary ostia

aortic root replacment with mechanical or composite graft or a stentless porcine aortic root bioprosthesis and reimplntation of the coronary ostia

53
Q

What form of coarctation repair is associated withe development of aneursysm opposite the patch

A

lateral Patch aortoplasty with dacron (or gortex)

54
Q

List ways to reduced risk of paraplegia during aortic aneursym repair

A

Distal perfusion via femoral vein (or pulmonary artery)
distal perfusion via left atrium
Distal perfusion via Gott shunt (ascending aorta to femoral artery/descending thoracic aorta)
use of cardiopulmonary bypass and profound hypothermic circulatory arrest
thoracic spinal fluid drainage
reimplantation of intercostal arteris
steroid/Somatosensory evoked potential monitoring.

55
Q

3 most commonly employed techniques for cerebral protection

A

Deep hypothermic circulatory arrest
Deep hypothermic circulatory arrest with retrograde cerebral perfusion
Deep hypothermic circulatory arrest with selective antegrade cerebral perfusion

56
Q

List 3 most common approaches to traumatic disruption of the proximal descending thoracic aorta

A

Left heart bypass
Femoral-Femoral full CPB
Clamp and Sew

57
Q

When you fix, what are principles, and what kills from aortic dissection

A

Emergent

Resection of the aortic segment involved with the intimal tear
Blood flow must be directed to the true lumen by tacking the dissection membrane to the outer aortic wall

aortic rupture, coroanry artery dissection and MI, aortic valve insufficieny and heart failure, pericardial tamponade

58
Q

How you manage the septum (the flap of media and intima between the true and false lumen)

A

In acute dissection the false lumen should be obliterated by directly re-approximating the septum to the adventitia.

In chronic dissection, the septum must NOT be reapproximated so that both the true and false lumen have distal flow of blood.

59
Q

List 5 conditions that predispose to aortic dissection

A

Hypertension (excessive mechanical and metabolic strain on the media)
Pregnancy (hypertension and loosing the connective tissue owing to the hormonal changes
Inheritable disorders (marfan, Turner, Noonan syndrome, Ehlor-Danlso syrdome…this causes rerangement of the assembly and deposition of fibrillin
Unicupsid and bicuspid valve.
Trauan

60
Q

List 4 contra-indications for mechanical support as a bridge to tranplantation d

A

Systemic life-threatening illness
Irreversible renal dysfunction
Ireversible haptic dysfunction
Patient is not a candidate for transplantation

61
Q

List complications of IABP

A 
Vessel perforation 
Arterial branch occlusion 
Acute AI 
Gas escape
Acute aortic dissection 
Wound problems 
Chronic claudication 
Femoral neurlagia
Pseudo0aneurysm
Peripheral thromboembolism
62
Q

How really benefits from sinus rhythm (as opposed to VVI)

A

Those with ventricular hypertrophy
Those in congestive heart failure
Mitral stenosis

63
Q

How does a rate responsive pacemaker work

A

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 a detection of the item increase, the pacemaker output rate will increase; as the sensed parameter decreases, the pacemaker response will also decrease.

64
Q

Life 5 items that may be tracked and used to modulate the rate in a rate responsive pacemaker

A 
Lactic acid
Movement
Heat 
Carbond dioxide 
Electricity/electromyogram
intra-cardiac pressure
65
Q

Two ways to placed a PPM in a pt with a mechanical valve in triscuspid position

A 
Epicardial pacing (subxyphoid or anterior thoractomy approach
Transvenous, transcoronary sinus, coroanry vein LV wall pacing
66
Q

List indications for which you cannot close an adult ASD percutaneous

A 
Location of ASD
	Primum 
	sinus venosus defect
	deficient septal rim 
Size of defect
	over 2.5 cm
Associated anomialies
	pulmonary hypertension 
	partial anmalous venous return 
	azygous continuation
67
Q

What changes do you make regarding surgery and CPB in a pregnant patient

A

position with a 30-60% right lateral pelvic tile to eliminate IVC compression by the relaxed uterus, which can can reduce venous return and cause arterial hypotension

accept at hematocrit of 30% on bypass

Maintain a flow of 20-40% higher than normal flow and a mean pressure of above 60 to 80 mmHg

Do you not sue systemic hypothermia

68
Q

List 3 way that retrograde cerebral perfusion may help

A

Meets the metabolic needs of the brain
maintains brain hypothermic
migrates against the effects of particulate emboli

69
Q

What is pathophysiology of elevation of pulmonary artery hypotension and systemic hypotension with protamine administration.

A

Pulmonary vasoconstriction occurs because of non-immunological anaphylactoid reaction

systemic hypotension is usually an inability to transfer blood across the lungs rather then systemic vasodilation

The mediators involved are complement fractions C3A and C5A and thromboxane

70
Q

What is first response response of severe protamine reaction

A

Bronchospasm

71
Q

How should a patient be managed if they have had a protamine reaction in the past and need another surgery

A

SInce response is non-allergic in origin, it is safe to administer protamine follow anaphylactoid reaction. Rate can be 2 mg per minute

when a true allergic reaction occurs (likley from histamine) the skin become flushed, the PA/CVP generally are low it’s possible that pretreatment with corticosteroids along with a histamine receptor blockage can moderate the response to subsequent protamine administraion

72
Q

What are steps when you see massive air in aortic line

A

stop the pump
open the aorta
establish retrograde cerebral perfusion with cold blood for 15-20 minutes
deair the ascending aorta
close the asecending aorta and reestablish antegrade perfusion
maintain hypothermia at least below 25 degrees
administer barbiturates
complete operation
inform family of gravity of situation

73
Q

Describe Manougian root enlargement

A

The incision crosses the annulus through the commissure between the left and noncoronary sinus

74
Q

Describe Nicks

A

An oblique incision in the anterior anscending aorta steers inferioly and to the right and crosses the aortic annulus in the middle of the non coroanry sinus and extends for variable distance into the base of the anterior mitral leaflet.

75
Q

list 3 contraindications to the Ross procedure

A

Marfan and other collagen disorders
Vavular heart disease secondary to auto-immune or other systemic disorders (AS, RA, ARF, libman-sacks endocarditis)
Anatomical abnormalities on the pulmonic vavle
Poor LV
Multiple valve disease
severe aortic annular dilation

76
Q

List contraindications to Aortic valve sparing

A

Annular dilation (> 30mm??)
moderate to severe cusp calcification
multiple fenestrations in the leaflets

77
Q

List 6 echo findings for ischemic mitral insufficiency

A 
Left ventricle dilation 
Left ventricle posterolateral wall motion abnormality 
Normal leaflet motion morphology 
restricted leaflet motion 
plane of coaptation below the annulus 
Annuluar dilation 
central jet of MR
78
Q

What are 3 essential anatomic components of myxomatous mitral valve prolapse

A

Interchordal ballooning (hooding) of the mitral leaflets or portions therof, with or without elongated, thinned or ruptured chords

Diffuse leaflet thickening

annular dilation

79
Q

List 4 echocardiographic elements used to evaluate a patient for suitability for balloon valvuloplasty or surgical commusurtomy

A

valve mobility
sibvavular thickening
leaflet thickening
calcification

80
Q

List 5 methods of repairing anterior mitral valve leaflet prolapse

A

transfer of secondary chord to the unsupoorted free edge
quadrangular resection of the posterior leaflet and transerring that portion of the posteriorleaflet with its supporting chord to the anterior leaflet
chordal replacement with expanded PTFE
chordal shortening: the papillary muscle is split and the chord is shortened by embedding it in the muscle
resectino of a triangular wedge of the anterior leaflet
alfieri stich

81
Q

What are features of mitral valve

A

Normal surface of mitral valve 4 to 6 cm2

Symptoms of mitral stenosis occur at 1 cm2

A pressure gradient occurs that may influence cardiac output occurs at 2cm2

82
Q

List techniques for tricuspid valve repair

A

Partial leaflet resection with annuloplasty
tricuspid valve resection
triscuspid vale replacement
Abscess drainage with annular reconstruction

83
Q

List indications to operate on tricuspid valve endocarditis

A

persistent sepsis despite antibiotic therapy
presistent annular or myocardial abscesses
recurrent septic pulmonary emboli
right heart failure secondary to valve insufficiency

84
Q

List 5 complications of AMI constiuting indications for immediate surgical therapy

A

Ventricular septal rupture
LV free wall rupture
Mitral insufficiency (with hemodynamic instability)
Cardiogenic shock
Intractable ventricular arrhythmias
Evolving MI not responsive to medical therapy

85
Q

What is diastolic dysfunction

A

Loss of compliance/loss of relaxation with abnormal distensibility abnormal filling

86
Q

Risk factors for diastolic dysfunction

A 
Age
diabetes
hypertension 
preop ischemia 
(female) gender
87
Q

4 strategies that can be used to treat diastolic dysfunction

A 
oxygen 
IABP 
diuretcis
Milrinone
Beta blockers
ACE inhibitors 
vasodilators 
techqniues to maintain sinus rhythm
88
Q

List potential advantages of skeletonized LITA

A

Less reduction in sternal blood flow resulting in reduced rate of mediastinal infection
longer length of ITA
easier construction of sequential anastomoses
easier recognition of injury to the artery than with the full pedicle

89
Q

A patient with heart failure of ischemic etiology is being assessed for CABG. LVEF is 20%

What condition of the myocardium predicts benefit from CABG

List 3 months this can be assessed

A

Prescense of myocardial viability

Thallium 201 rest/redistribution scan 
Technetium 99 SPECT 
Exercise Dobutamine stress echo
Constrast eco 
constrast/enchanced MRI 
PET scan
90
Q

In stress thallium scan name 3 findings associated with high incidence of future cardiac events

A

increase lung uptake
stress relatated ventricular dilatation
large area of reversible dilation

91
Q

Describe 3 mechanisms that ventricular aneurysms adversely affect left ventricular function

A

loss of contractile tissues in the area of the aneurysms reduces segmental and global LV ejection fraction

the resultant increase in ventricular size increase systolic wall stress by Laplace Law and thus the myocardial oxygen consumption

paradoxical expansion of the aneursym reduces forward stroke volume

92
Q

What is definition of stunned myocardium

A

myocardium characterized by reduced controactility, reduced compliance, following an ischmia-reperfusion injury of insufficient magnitude to cause cellular necrosis

stunned myocardium is fully reversible

93
Q

List 6 procedures used to assess atherosclerosis of the ascending aorta

A 
CT-scan 
TTE
TEE
Coronary angiogram 
manual palpation 
epi aortic ultra sound scanning
94
Q

4 options to deal with calcified aorta

A

off pump cardiopulmonary bypass
femoral or axillary cannulation, on pump, circulatory arrest, replace ascending aorta
femoral or axillary cannulation, on pump, fibrillation arrest
Close patient and do PCI or continue medical management

95
Q

Indications for surgical resection of left ventricular aneurysm

A 
Concomittant angina
Peripheral embolism 
malignant arrythmias
concomittant cardiac surgery 
recurrent episodes of congestive heart failure
96
Q

When assessing Doppler blood flow of a coronary bypass conduit, what characteristics will a LITA graft show compared to a graft

A

The LITA flow pattern is biphasic (systolic and diastolic perfusion)
The vein flow pattern is monophasic

97
Q

List 4 criteria to select a radial artery as a coronary bypass conduit

A 
Younger patient
Normal Allen test
High grade coronary stenosis (>90% on right) and >70% on left
Radial not calcified 
No saphenous veins conduits available
98
Q

Reasons why radial arteries failed

A

poor harvest technique

unavailability of antispasmodic drugs

99
Q

Explain why radial artery has more propensity to spasm than the internal mammary artery

A

In radial artery the myocytes are organised into multiple tight layers while in the internal thoracic artery the muscle cells are less organized are irreggular in shape. This, together with the wider thickness of the media of the radial artery, may at least in part explain the propensity of the RA to spasm

Different arterial graft endothelia function properties

100
Q

What is the nature and mechanism of Abciximab

What effect does it have on ACT

How do you decrease blood loss

A

Abciximab (Reopro) is a GPIIB/IIIA antiplatelet agent. It binds to the platelet membrane IIb/IIIA and prevents the binding of both fibrinogen and vonwillebrand factor to the receptor, thus preventing activated platelets from aggregating

prolongs ACT

Give platelets

101
Q

List 3 devices or techniques to provide target stabilization and exposure during Off pumpt

A 
Suction stabilizer
compression-type stabilizer
silastic snare
intraluminal snare
misted blower
102
Q

List 4 possible advantages of OPCAB over conventional CABG cardiopulmonary bypass

A 
Avoidance of the inflammatory response to CPB 
Reduction of aortic manipulation 
avoidance of global myocardial ischemia
Lower risk of neurologic injury 
lower risk of renal dysfunction 
less transfusion requirement 
shorter hospital stay
103
Q

What are risk of coronary artery endarterectomy

A

The perioperative MI rate is 5-30% and the peri-operative mortality rate s 0 to 10%

104
Q

What are mechanisms of failure of SVG
0-3 months
1-3 years
After 8 years

A

technical problem

Intimal hyperplasia

graft atherosclerosis

105
Q

List 2 nerves and the area of innervation that may be encountered during artery dissection of the forarm

A

Lateral antebrachial cutaneous nerve provides sensory innervation of the radial aspect of the volar forearm

superficial branch of the radial nerve innervates the radial aspects of the thumb and dorsum of the hand.

106
Q

List 3 most common non-myxomatous benign cardiac masses

A

Lipoma
papillary fibroelastoma
rhadomyoma

107
Q

3 most common primary malignant tumours of the heart

A

Angiosarcoma
Rhabdomyosarcoma
Mesothelioma
Fibrosarcoma

108
Q

List 5 causes of culture negative endocarditis

A

Preceding antiobiotic therapy
Blood cultures not properly extracted and processed
atypical bacteria
yeast
some pathogenic agent require more time in the case of bacteria with a long generation period or slow growth
Tricuspid valve endocarditis which takes a chronic course, is also more difficult to diagnose on the base of hemocultures
Due to antigen properties of enterococci, candida, cryptococci, histoplama, buncella, chlaydia, salmonella, aspegillus, mycoplasma

109
Q

During dissection of the SUV for bicaval cannulation you have have bleeding. What are possible sources

A

Injury to the SVC itself
Injury to azygous vein
injury to the right pulmonary artery

110
Q

What is the incidence of AF after CABG

What are the predictors of post op AF

A

20% (20 to 50%)

Age greater then 70
History of congestive heart failure 
history of per-operative AF 
History of chronic lung disease
Valve disease 
beta blocker withdrawal

you should anticoagulate when AF lasting more then 28 hours

111
Q

What are ways to decrease pulmonary vascular resistance

A

High FiO2
Pulmonary vasodilators (NTG, PGEI)
Low PaCo2 (alkalosis)
Beta 2 agonists (isuprel)

112
Q

5 days after CABG pt develops thrombocytopenia and a blue toe. what is management

A

Stop all heparin
stop coumadin
anticoagulate pt with a heparin substitue such as agatroban or danaparoid
monitor platelet count and start counamin when greater then 100 000

113
Q

List common pulmonary complications post CPB

A 
Atelectasis
increased capillary permeability and interstitial edema
decreased pulmonary compliance 
increased intrapulmonary shunt
pulmonary edema
pneumonia
SIRS
pulmonary embolism
114
Q

List 4 complications that may results from atrial fibrillation using radiofrequency as an energy source

A

circumflex artery infarction
esophageal injury with perforation
pulmonary vein stenosis
full thickness tissue necrosis with hemorrhage

115
Q

What part of the heart is beleived to be the most common site for initiation of AF

A

Micro re-entrant circuits within the pulmonary vein orfices

116
Q

What are two test for HITT

A

Functional test: the patients plasma causes platelet aggregation or secretion of serotonin in the presence of heparin

serologic test: Antobodies to Heparin-PF4 complexes or platelets-associated IgG are detected in pts patients serum

117
Q

What is practical approach to HITTT

A

A 4T score for HIT
Thrombocytopenia, Timing, thrombosis, Alternative possible cause

First screening test is aimed at detecting antibodes of heparin-PF4-ELISA (enzyme-linked immunsorbent y). Detects all circulating antibodies and may also falsely identify antibodies.

The next test uses platelets and serum from the patient. the platelets are washed and mixed with serum and heparin. The sample is then tested for the release of serotonin (a marker of platelet activation). If this serotonin release assay (SRA) shows high serotinin release, the diagnossis is confirmed.

118
Q

What are the 3 agents used when you have HITT

A

Danaparoid
lepirudin
argatroban

119
Q

List the gross anatomic features of Idiopathic Hypertrophic Sub-Aortic Stenosis

A

Left ventricular wall and interventicular septum
asymmetrical hypertrophy
mild and upper septal hypertrophic bulge
plaque on upper septum
Left atrium
dilated
Left venticular cavity
small
Mitral valve
area of abrasion on anterior leaflet at level of SAM contact with interventricular septum

120
Q

List histological features of myocardium of IHSS/HOCM

A

Myocardial disarray

Whorling configuration of hypertrophied myofibril

121
Q

What are geneticsof HOCM

A

Autosomal dominant

Variable expression and penetrance

122
Q

List two criteria which would depict the ideal candidate for pulmonary thromboenarterectomy

A

Thrombi must be accessible (thrombi with extension in main or lobar arteries, minimal small vessel involvement)

Vascular obstruction must be causing hemodynamic or ventilatory impairment

absence of co-morbid conditions (age is not an absolute contraindication_

123
Q

Define HIT type I

A

Thrombocytopenia is moderate (greater than 100 000, early asymptomatic, and transient, resovling spontaneously despite further heparin administration

124
Q

Define HIT type II

A

Thrombocytpenia is severe, persistent and often is associated with thromboembolic and hemorrhagic event

125
Q

A patient is unable to tolerate AF meds. List 3 surgical procedures

A

The Cox-Maze III operation
Endocardial radiofrequency/microwave/laser ablation
Epicardial ablation

126
Q

What are boundaries of Triangle of Koch

A

Tricuspid annulus or base of septal leaflet

Coronary sinus

Tendon of Todaro (continuation of the eustachian valve that runs to the central fibrous body)

127
Q

What are the 7 roles of CANMEDS

A 
Medical Expert
Communicator
Collaborator
Manager
Health Advocate 
Scholar Professional
128
Q

List 5 main principles of Canada Health Act

A 
Universality 
Portability 
Accessbility 
Public Administraion 
Comprehensive
129
Q

What are Debakey Class of aortic dissections

A

Type I– Dissection involves the ascending aorta, transverse arch, and decending thoracic aorta
Type II–only involves ascending aorta
Type IIIa-Involves the descending thoracic aorta only
Type IIIb- is the same as A but extends into the abdominal aorta and occasionally the iliac artteries

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