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
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
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
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
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
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.
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
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
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.
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
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
12
Q
List 3 alternative to protamine
A
Recombinant platelet factor 4
Heparinase
Heparin–
13
Q
What are options to use if satefy
A
Heparin _ psostabyclin
Danaparoid or r-hirudin
Defibrinogenating agent
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
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
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
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
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
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
20
Q
List 4 additional neuroprotection techqniues
A
Packing the head with ice I V steroids IV barbituatons selective antegrade retrograde cerebral perfusion
21
Q
List in any order the 3 most common causes of death following cardiac transplantation
A
Infection
Rejection
Accelerated coronary disease
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
23
Q
What is standard Shumway/Lower heart transplant technique
A
The left and right atria are anastomosed at the atrial level
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
25
What is heterotopic heart transplant
the individuals heart is left in place and transplant heart is piggybacked onto the recipients heart
26
What is autograft
organ or tissue from same individual is re-implantated
27
What is allograft
Organ or tissue from another non-identical individual of same species is tranplanted
28
What is Heterograft
Organ or tissue from another non-identical individual is tranplanted
29
Xenograft
Organ or tissue from individual of another species is tranplanted
30
List 5 histological changes currently used to grade the severity of cardiac rejection as per ISHLT
```
Lymphocytic infiltration
Necrosis
Myocyte damage
inflammatory infiltration
polymorphous infiltration
Edema
Hemmorrhage
Vasculitis
```
31
Describe the ISLT rejection statues
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
32
On which cells are class I antigens expressed
All cells of an organism
33
On which cells are Class II antigens (DP, DQ, DR) expressed
```
B lymphocytes
Activated T lymphyocytes
Macrophages
dentritic cells
Endothelial cells
```
34
What is peak oxygen consumption
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
35
Patient post tranplant with Po2 that's 50mmHg despite increasing Fi02 and things getting worse with PEEP what is it?
Missed PFO or ASD in donor heart
36
What is physiology of ASD causing hypoxia
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.
37
Why does PEEP make it worse
PEEP increases the right ventricular afterload and will increase the degree of right to left shunting
38
What is treatment for this shunt problem
decreasing right ventricular afterload with meds---Milrinone, nitric oxide.
Stop PEEP
Dobutamine
Close the shunt percutaneous or surgically
39
Describe PRA and its importance for transplant
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.
40
List 4 direct manifestations of CMV infection on heart transplants recipients
```
Fever
Mononucleosis
Pneumonai
myocardidits
Hepatitis
GI ulceration
```
41
Tremor post cardiac transplantation
likely do to Cyclosporine
42
What is treatment for cardiac rejection
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
43
What are indirect effects of CMV
allograft rejection
bacterial superinfection
Immunosuprresion
chronic graft rejection
44
What are types of "Bridges when it refers to transplant
Mechanical bridge to recovery implies that the device is implatned until the "stunned" myocardium recovers
Bridge to transplant means only hope is transplant.
45
For a middle aged active women what would you accept as minimally acceptable indexed EOA in the mitral valve
1.25 cm2/m2
46
How do you calculate indexed EOA
first BSA is (ht x wt/3600) square root. then you go EAO (cm2) divided by BSA (m2)
47
7 indications for surgery of left sided valve endocarditis
```
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
```
48
What is management of type A IMH
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.
49
What is most common organism of infection for mechanincal valve proshesis
Staph Epi
50
What are minor duke critieria
```
Predisposition (heart condition or IV drug user)
Fever
Vascular phenomenon
Immunologic phenomenon
Microbiology evidence
Echocardiogram
```
51
List 7 complications of valvular substitutes
```
anticoagulation
thromboembolism
strucutural vavle degeneration
endocarditis
heart block
bleeding
patient prosthesis mismatch
Hemolysis
Perivalvular leak
```
52
3 options for addressing aortic valve at the time of dissection repair
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
What form of coarctation repair is associated withe development of aneursysm opposite the patch
lateral Patch aortoplasty with dacron (or gortex)
54
List ways to reduced risk of paraplegia during aortic aneursym repair
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
3 most commonly employed techniques for cerebral protection
Deep hypothermic circulatory arrest
Deep hypothermic circulatory arrest with retrograde cerebral perfusion
Deep hypothermic circulatory arrest with selective antegrade cerebral perfusion
56
List 3 most common approaches to traumatic disruption of the proximal descending thoracic aorta
Left heart bypass
Femoral-Femoral full CPB
Clamp and Sew
57
When you fix, what are principles, and what kills from aortic dissection
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
How you manage the septum (the flap of media and intima between the true and false lumen)
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
List 5 conditions that predispose to aortic dissection
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
List 4 contra-indications for mechanical support as a bridge to tranplantation d
Systemic life-threatening illness
Irreversible renal dysfunction
Ireversible haptic dysfunction
Patient is not a candidate for transplantation
61
List complications of IABP
```
Vessel perforation
Arterial branch occlusion
Acute AI
Gas escape
Acute aortic dissection
Wound problems
Chronic claudication
Femoral neurlagia
Pseudo0aneurysm
Peripheral thromboembolism
```
62
How really benefits from sinus rhythm (as opposed to VVI)
Those with ventricular hypertrophy
Those in congestive heart failure
Mitral stenosis
63
How does a rate responsive pacemaker work
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
Life 5 items that may be tracked and used to modulate the rate in a rate responsive pacemaker
```
Lactic acid
Movement
Heat
Carbond dioxide
Electricity/electromyogram
intra-cardiac pressure
```
65
Two ways to placed a PPM in a pt with a mechanical valve in triscuspid position
```
Epicardial pacing (subxyphoid or anterior thoractomy approach
Transvenous, transcoronary sinus, coroanry vein LV wall pacing
```
66
List indications for which you cannot close an adult ASD percutaneous
```
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
What changes do you make regarding surgery and CPB in a pregnant patient
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
List 3 way that retrograde cerebral perfusion may help
Meets the metabolic needs of the brain
maintains brain hypothermic
migrates against the effects of particulate emboli
69
What is pathophysiology of elevation of pulmonary artery hypotension and systemic hypotension with protamine administration.
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
What is first response response of severe protamine reaction
Bronchospasm
71
How should a patient be managed if they have had a protamine reaction in the past and need another surgery
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
What are steps when you see massive air in aortic line
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
Describe Manougian root enlargement
The incision crosses the annulus through the commissure between the left and noncoronary sinus
74
Describe Nicks
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
list 3 contraindications to the Ross procedure
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
List contraindications to Aortic valve sparing
Annular dilation (> 30mm??)
moderate to severe cusp calcification
multiple fenestrations in the leaflets
77
List 6 echo findings for ischemic mitral insufficiency
```
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
What are 3 essential anatomic components of myxomatous mitral valve prolapse
Interchordal ballooning (hooding) of the mitral leaflets or portions therof, with or without elongated, thinned or ruptured chords
Diffuse leaflet thickening
annular dilation
79
List 4 echocardiographic elements used to evaluate a patient for suitability for balloon valvuloplasty or surgical commusurtomy
valve mobility
sibvavular thickening
leaflet thickening
calcification
80
List 5 methods of repairing anterior mitral valve leaflet prolapse
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
What are features of mitral valve
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
List techniques for tricuspid valve repair
Partial leaflet resection with annuloplasty
tricuspid valve resection
triscuspid vale replacement
Abscess drainage with annular reconstruction
83
List indications to operate on tricuspid valve endocarditis
persistent sepsis despite antibiotic therapy
presistent annular or myocardial abscesses
recurrent septic pulmonary emboli
right heart failure secondary to valve insufficiency
84
List 5 complications of AMI constiuting indications for immediate surgical therapy
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
What is diastolic dysfunction
Loss of compliance/loss of relaxation with abnormal distensibility abnormal filling
86
Risk factors for diastolic dysfunction
```
Age
diabetes
hypertension
preop ischemia
(female) gender
```
87
4 strategies that can be used to treat diastolic dysfunction
```
oxygen
IABP
diuretcis
Milrinone
Beta blockers
ACE inhibitors
vasodilators
techqniues to maintain sinus rhythm
```
88
List potential advantages of skeletonized LITA
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
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
Prescense of myocardial viability
```
Thallium 201 rest/redistribution scan
Technetium 99 SPECT
Exercise Dobutamine stress echo
Constrast eco
constrast/enchanced MRI
PET scan
```
90
In stress thallium scan name 3 findings associated with high incidence of future cardiac events
increase lung uptake
stress relatated ventricular dilatation
large area of reversible dilation
91
Describe 3 mechanisms that ventricular aneurysms adversely affect left ventricular function
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
What is definition of stunned myocardium
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
List 6 procedures used to assess atherosclerosis of the ascending aorta
```
CT-scan
TTE
TEE
Coronary angiogram
manual palpation
epi aortic ultra sound scanning
```
94
4 options to deal with calcified aorta
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
Indications for surgical resection of left ventricular aneurysm
```
Concomittant angina
Peripheral embolism
malignant arrythmias
concomittant cardiac surgery
recurrent episodes of congestive heart failure
```
96
When assessing Doppler blood flow of a coronary bypass conduit, what characteristics will a LITA graft show compared to a graft
The LITA flow pattern is biphasic (systolic and diastolic perfusion)
The vein flow pattern is monophasic
97
List 4 criteria to select a radial artery as a coronary bypass conduit
```
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
Reasons why radial arteries failed
poor harvest technique
| unavailability of antispasmodic drugs
99
Explain why radial artery has more propensity to spasm than the internal mammary artery
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
What is the nature and mechanism of Abciximab
What effect does it have on ACT
How do you decrease blood loss
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
List 3 devices or techniques to provide target stabilization and exposure during Off pumpt
```
Suction stabilizer
compression-type stabilizer
silastic snare
intraluminal snare
misted blower
```
102
List 4 possible advantages of OPCAB over conventional CABG cardiopulmonary bypass
```
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
What are risk of coronary artery endarterectomy
The perioperative MI rate is 5-30% and the peri-operative mortality rate s 0 to 10%
104
What are mechanisms of failure of SVG
0-3 months
1-3 years
After 8 years
technical problem
Intimal hyperplasia
graft atherosclerosis
105
List 2 nerves and the area of innervation that may be encountered during artery dissection of the forarm
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
List 3 most common non-myxomatous benign cardiac masses
Lipoma
papillary fibroelastoma
rhadomyoma
107
3 most common primary malignant tumours of the heart
Angiosarcoma
Rhabdomyosarcoma
Mesothelioma
Fibrosarcoma
108
List 5 causes of culture negative endocarditis
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
During dissection of the SUV for bicaval cannulation you have have bleeding. What are possible sources
Injury to the SVC itself
Injury to azygous vein
injury to the right pulmonary artery
110
What is the incidence of AF after CABG
What are the predictors of post op AF
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
What are ways to decrease pulmonary vascular resistance
High FiO2
Pulmonary vasodilators (NTG, PGEI)
Low PaCo2 (alkalosis)
Beta 2 agonists (isuprel)
112
5 days after CABG pt develops thrombocytopenia and a blue toe. what is management
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
List common pulmonary complications post CPB
```
Atelectasis
increased capillary permeability and interstitial edema
decreased pulmonary compliance
increased intrapulmonary shunt
pulmonary edema
pneumonia
SIRS
pulmonary embolism
```
114
List 4 complications that may results from atrial fibrillation using radiofrequency as an energy source
circumflex artery infarction
esophageal injury with perforation
pulmonary vein stenosis
full thickness tissue necrosis with hemorrhage
115
What part of the heart is beleived to be the most common site for initiation of AF
Micro re-entrant circuits within the pulmonary vein orfices
116
What are two test for HITT
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
What is practical approach to HITTT
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
What are the 3 agents used when you have HITT
Danaparoid
lepirudin
argatroban
119
List the gross anatomic features of Idiopathic Hypertrophic Sub-Aortic Stenosis
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
List histological features of myocardium of IHSS/HOCM
Myocardial disarray
| Whorling configuration of hypertrophied myofibril
121
What are geneticsof HOCM
Autosomal dominant
| Variable expression and penetrance
122
List two criteria which would depict the ideal candidate for pulmonary thromboenarterectomy
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
Define HIT type I
Thrombocytopenia is moderate (greater than 100 000, early asymptomatic, and transient, resovling spontaneously despite further heparin administration
124
Define HIT type II
Thrombocytpenia is severe, persistent and often is associated with thromboembolic and hemorrhagic event
125
A patient is unable to tolerate AF meds. List 3 surgical procedures
The Cox-Maze III operation
Endocardial radiofrequency/microwave/laser ablation
Epicardial ablation
126
What are boundaries of Triangle of Koch
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
What are the 7 roles of CANMEDS
```
Medical Expert
Communicator
Collaborator
Manager
Health Advocate
Scholar Professional
```
128
List 5 main principles of Canada Health Act
```
Universality
Portability
Accessbility
Public Administraion
Comprehensive
```
129
What are Debakey Class of aortic dissections
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
