Ischemic Heart Disease Flashcards
What are the 2023 Class 1 indications for CABG?
- Left main disease (CABG>PCI)
- DM and mvCAD with LAD involvement (CABG (LIMA to LAD) > PCI)
What are the 2023 Class 2a indications for CABG?
mvCAD with complex/diffuse disease (SYNTAX>33)
What are the 2023 Class 2b indications for CABG?
DM with LM stenosis and low-to-intermediate complexity, can consider PCI as an alternative to CABG
What are the indications for pre-op carotid duplex?
Guidelines Class 2a: age >65, L main coronary stenosis, PVD, history of stroke/TIA, hypertension, smoking, DM
SESATS: age >75. Triple vessel disease, L main disease
If positive, confirm with CTA or MRA given low positive predictive valve of U/S
Isolated carotid built without other risk factors —> do NOT screen with U/S
What is the timing for CABG after carotid work?
Wait 6 weeks after carotid stenting before CABG (2 weeks for initial hyperperfusion phase and 6 weeks for GpIIb/IIIa inihibitor requirement
Wait 2 weeks after carotid endarterectomy (2 weeks for initial hyperperfusion phase to resolve)
When should you do CABG after STEMI?
Reduction in risk if you can wait 1 week, unless angina makes delay impossible
If STEMI, do not stop plavix (risk of stent closure worse than risk of bleeding)
Pre-op tests for radial artery conduit?
radial artery studies documenting patent palmar arch
Do not take radial from dominant hand
Management of air-hit when weaning ?
- Check TEE for air in LV, root, or coronary/subendocardium
- Back on bypass
- Trendelenberg
- Drive MAP>80
- Wait 10 min for air embolus to resolve
Patient presents in STEMI but cardiologist cannot stent. What do you do?
Have cardiologist place IABP, perform focused H&P to find out time of total ischemia, STAT echo
In STEMI with failed PCI, how does approach differ based on lenght of ischemia?
After 6 hours, unlikely to recover contractive function
After 8 hours, theoretically no benefit of revascularization
If 6 hrs –> CABG
If >8 hrs –> MCS/HF pathway
Approach if performing CABG MVR but small left atrium
distals then mitral (give dose of plegia, snare caval tapes)
- Transspetal (identify fossa ovalis and incise towards SVC)
- If need more exposure, open L pleural cavity and pull up on umbilical tapes
- If still can’t see, extend incision over dome of LA towards root of aorta, making sure to leave enough atrium adjacent to aortic root to close
CABG Conduit options for diabetics?
Absolutely contraindicated to use BIMA on diabetics (relatively contraindicated in morbidly obese, COPD, or otherwise high risk for sternal wound infections)
Stenosis cutoffs for radial?
Never use for stenosis <70% (or (per SESATS) R sided stenosis < 90%)
Use IV dilt or other peripheral CCB for 48 hours post-op to prevent vasospasm
Anastomose off vein hood of proximal, or specific dedicated vein hood, or Y off LIMA (can compromise LIMA if not careful)
Mortality Risk for redo-CABG
2-3%
If AS and CAD, cannot do TAVR unless can do PCIs first, then 1 month plavix, then TAVR
Pre-op workup for redo CBAG?
PA/CXR, TTE, carotid U/S, noncon CT
PET/CT if hypo/dyskinetic wall on TTE
Conduit studies (vein mapping, radial artery mapping w/ Allen’s test)
Dark blood welling up from mediastinum during re-entry for redo-cabg. What do you do?
Pack incision, change femoral lines to cannaulae, go on bypass
Redo case with prior CABG. How do you manage LIMA?
Issues with re-entry and myocardial protection
Search for IMA between L edge of aorta and medial aspect of L Lung
Place atraumatic clamp to occlude IMA during arrest period. If IMA cannot be controlled, lower temp to 25 C and leave IMA alone
How to manage prior vein grafts in redoCABG?
Avoid manipulation to avoid embolization of prior atherosclerotic debris
Anastomose LIMA distal to previous vein grafts
If no disease distal to prior distal anastomotic site, remove vein graft and leave small cuff and sew new graft to that cuff
Redo AVR options in patient with prior CABG?
Sternotomy and temporary occlusion of LIMA
RAMT - cool to 25 and do not identify/occlude arterial grafts
Prior LIMA to LAD. Would you offer CABG?
Only if symptomatic ischemia 2/2 sclerotic vein grafts
Factors favoring reoperative CABG over PCI
- Late stenosis (>5 years)
- Multiple stenotic vein grafts
- Diffusely stenotic grafts
- No patent IMA graft
- Decreased LVEF
What are STS Risk Score ranges?
Prohibitive: > 15%
High risk: 8-15%
Intermediate 4-8%
Low: <4%
How to handle fibrillation upon redo entry?
- have external pads on prior to prepping; shock at 100-200 J if necessary
- avoid cautery near LV
- if unstable, cannulate (peripheral or central) and go on CPB; if heart distends, manually vent or insert vent
ideally vent through RSPV. - If unable, can stab LV apex if exposed, or clamp aorta –> aortotomy –> direct handheld cardioplegia to arrest
What are the guidelines for concomitant CABG + CEA?
- Prior stroke/TIA with significant carotid disease (>50% in men, >70% in women)
- Asymptomatic but bilateral >=50%
- Asymptomatic unilateral >=50% with contralateral occlusion
Indications for concomitant AVR during CABG?
- Mod-Sev AS or AI
- Mild AS + Rapid progression of trans valvular gradients (15-20mmHg/year)
- Mild AS + Rapid decrease in AVA (0.3 cm2)
Indications for Concomitant CABG during AVR or MVr/R?
- Lesions >=70% reduction in major coronaries
- Can consider lesions >=50% that have reasonable targets
Describe operation for CABG + AVR:
- TEE
- Aortic+ Dual stage venous
- LV Vent
- XC and ante/retro (if AI, antegrade given directly via Ostia after aortotomy)
- Distal vein graft and give plegia down coronary conduit
- Oblique aortotomy into noncoronary sinus
- AVR, close aortotomy
- Distal mammary anastomosis
- Proximal graft anastomoses
Indications for concomitant MVr/R and CABG?
- Moderate or severe IMR not likely to resolve with coronary revacsularization alone
- Mild MR with HF symptoms
- Moderate -to-severe MS
Indications for MVR in AS + CAD?
mod-severe mitral regurg
What is the maximum arterial cannula pressure gradient?
100mmHg
What is the complete heart block rate after myectomy? When are patients at higher risk?
2%, higher risk after RBBB
Alcohol ablation takes out right bundle; surgical resection takes out L bundle
Patency rates of CABG conduits
IMA: 90-95% at 10-20 years
Vein: 50% at 15 years
Radial: 92.5% at 7 years
GEA: 70% at 10 years
Only proven benefit of delNido?
Reduced need for defibrillation (return of spontaneous rhythm)
Criteria for using radial artery grafts?
Circ >70% or RCA>90%
Most common causes of hemorrhagic pericardial effusion
Malignancy (other cases are idiopathic, pericarditis, trauma, uremia)
Differences between restrictive and constrictive?
Restrictive: slow ventricular filling, minimal respiratory variation, LVEDP>RVEDP esp with fluid bolus
Constricitve: rapid early diatonic flow though mitral, high respiratory variation, equalization of end-diastolic pressures
Indications for CRT
EF<=35% with LBBB With QRS>150 and NYHA II-IV sx on GDMT (class I)
QRS>120 (Class IIa)
Indication for carotid-subclavian bypass pre-TEVAR
Compromise of end organ perfusion (prior LIMA graft, or PICA (posterior inferior cerebellar artery) syndrome
Management of pregnancy with Marfan’s syndrome
<40 mm: vaginal delivery
40-45mm: monthly evaluation, elective c-section at/near term
If diameter exceeds 45mm or >5mm increase in foster during pregnancy: terminate or c-section and do aortic surgery
ICD indications:
- EF at or below 35% 90 days post-revasc with NYHA II or III heart failure
- EF at or below 30% regardless of NYHA class (expected meaningful surgical of at least one year)
Heart transplants VAD survival?
LVAD 4 year survival approx 50%
OHT 75% at 5 years, >50% at 10 years
Screening for family for pt with aneurysm?
All first degree get echo (if echo abnormal, CT or MRA)
Genetic testing if >1 member with aneurysm or suspicious physical exam findings
Factors affecting survival in cardiac sarcoma?
Most common in LA
Location and ability for complete resection affect survival (not histologic subtype)
MRSA Endocarditis abx?
Linezolid and dapto
Strep endocarditis coverage?
Penicillin G and gentamicin
Bacteria associated with endocarditis after tooth cleaning?
Strep viridans
Bacteria most commonly associated with endocarditis from IVDU
S aureus
Most common organism for prosthetic valve endocarditis?
Coag neg staph (like. S epidermidis)
How long can you extend DHCA without cerebral perfusion?
40 min at 18 deg
How to distinguish true vs false lumen in dissection
False lumen has
1. beak
2. larger (except proximal aorta, where true is larger)
3. More peripheral than true lumen
4. Presence of thrombus (cobwebs/filamentous strands)
Criteria for conservative management of IMH?
IMH thickness <1.0cm
Asc aorta <5.0cm
How far to extend TEVAR if malperfusion?
LSA to celiac if rupture
LSA to T7-8 if malperfusion
Benefits of LAA ligation in permanent AF
Low utliity of MAZE
Clip has lower readmissions for thromboembolism and improved mortality at 3 years post-op
PPM risk after MAZE?
6.3% for L side
13.8 for biatrial
Factors predicting AF recurrence are duration of AF, LA size, age of pt
How to manage plavix pre-CABG?
Hold 5 days
If recent stent, bridge with IV med
If emergency, even discontinuation for few days is recommended to reduce bleeding and transfusion risk
Criteria for surgery for R sided endocarditis?
Treat with 4-6 weeks abx
Surgery if
1. persistent bacteremia
2. difficult to eradicate organisms
3. Persistent vegetations >20mm
4. Signs of R heart failure
When and what abx prophylaxis should you give before surgery?
First generation cephalosporin + glycopeptide
Give within 60 min of incision, continue for no longer than 48 hours
Topical abx and nasal mupirocin reduce skin contamination and infection risk
Management of LV endocardial leads?
Surgical removal to prevent embolic debris
If not a candidate for surgery, then can anticoagulate with warfarin
Management of coumadin during pregnancy and during delivery?
If <= 5 mg/day, continue through all 3 trimesters (2a)
(OR LMWH for 1st trimester, then warfarin for 2nd and 3rd (2b))
If > 5 mg/day, LMWH bid for first trimester, then warfarin for 2nd and 3rd trimester (Class 2a) (OR LMWH for all 3 trimesters)
During delivery:
switch to bid LMWH or IV UFH at least 1 week before planned delivery
switch to UFH at least 36 hours before pregnancy and stop UFH 6 hours before planned vaginal delivery
If urgent delivery and on warfarin 🡪 reverse, then C-section
Age cutoff for treatment of coarctation?
Cannot surgically resect and anastomose end-to-end after 8 years age
When to place new ICD or PPM system if pocket infection?
Remove generator and leads
If no vegetation –> 3 days after neg BCx with IV abx
If vegetation –> 14 days after neg Bcx
Place on contralateral side
Criteria for ICD?
HCM with 1 risk factor (prior arrest, VT, syncope, fam hx, LV thickness >3cm, abnormal BP response to exercise)
Diagnostic criteria for Marfans:
2 of the following:
-mutation
-ectopia lentis
- aortic root dilation Z>2 (or >3 if under 30yo)
- fam hx
OR root dilation/fam hx + physical findings
Surveillance intervals for mild/mod/sev AS
mild 3-5 years
mod 12-18 mo
sev (with preserved EF) 6-12 mo
Indications for surgery for AI
Class 1: sx; asx but EF<55 (if no other cause for systolic dysfunction); severe + other cardiac surgery
Class 2a: asx severe and EF>55 + LVESD>50 (indexed>25), moderate + other cardiac surgery
Class 2b: asx+ EF>55 +l ow risk, if progressive decline in EF on 3 serial studies to low-normal range (55-60) or inc in LV dilation to sev range (LVEDD>65)
Potential causes for mechanical valve obstruction and how to treat?
Thrombus (early), pannus (late), mechanical valve malfunction
for thrombus:
If < 5mm, AC
if larger, systemic thrombolysis (or surgery)
Who gets prophylaxis prior to dental work?
Any dental work involving manipulation of gingiva/periapical region or oral mucosa with:
- prosthetic valve or graft
- previous IE
- congenital heart disease (unrepaired, repaired within 6 mo, defect next to prosthetic material)
- prior heart transplant with valve disease
Prefer 2g amoxiciin. If not, ancef, ampicilin, CTX, keflex, clinda are options
Which portion of aorta is most commonly aneurysmal in Marfans?
Root
Most common location for ventricular aneurysm?
Anterior apical (LAD territory)
Contraindication to ventricular aneurysm repair?
Reduced LV cavity size
If MR, repair through aneurysmectomy
Management for bio vs mechanical prosthetic valve thrombosis?
Usually presents within 2 years
Mechancial - presentation acute and critical: thrombolysis or surgery
Bio: indolent presentation: IV heparin and warfarin for goal 3-3.5 (for mitral)
Name HACEK Organisms and treatment?
Haemophilus
Actinobacillus
Cardiobacterium
Eikenella
Kingella
All gram neg bacili
Need 4-6 weeks CTX or fluoroquinolone (start before waiting for susceptibilities)
How fast to to rewarm after circ arrest?
Arterial to venous gradient no more than 10 deg C
Rewarm less than .5 deg C per min
Arterial no higher than 37C to prevent cerebral hyperthermia
Indication for pulmonic replacement in repaired tetralogy of fallot
Asymptomatic moderate PR if 2 of following:
- mild or mod RV or LV dysfunction
-sev RV DILation
- RVSP>=2/3 systemic pressure
-progressive reduction in objective exercise tolerance
Indication for PVR for PR after isolated congenital PS?
Symptoms OR RV dysfunction
if not, don’t replace even if severe PR
How to manage massive air embolism?
Clamp venous and arterial lines and de-air
Tredelenberg
Re-institute bypass and cool
RCP with aspiration via root vent
corticosteroids, hyperbaric O2 within 5 hrs of surgery, and barbituate coma may all help
Where should LV epicardial leads be for CRT?
Lateral wall
How to distinguish tamponade from constrictive pericarditis/restrictive cardiomyopathy?
Both have pulsus paradoxus and equalization of filling pressures
Constriction and restriction has rapid diastolic filling with plateau when reaches limit set by pericaridum –> square root sign look on hemodynamics in cardiac cath
What is unique to constrictive pericarditis vs restrictive and tamponade?
Discordant ventricular pressures during respiration (in constriction, lower LV systolic presssure –> septum shifts to L –> inc RV systolic pressure)
Difficulty weaning off with inferior wall hypokinesis after mitral annuloplasty in L dom circulaitn?
Suspect LCx injury
If intra-op dx, revise sutures or emergency CABG
if ICU diagnosis, cath lab (unless fully ligated by annular stitch)
How to determine stroke risk in postop AF and who get oral AC?
CHADS2VASC score
CHADS2VASC>=2, CHADS2 >= 1, or age >=65 gets oral AC per guidelines
Fever, chest pain, sepsis, neuro sx 3-6 weeks after catheter AF ablation. Dx? Best test? Tx?
Dx: atrioesophageal fistula
Test: CT scan with IV contrast (do NOT do diagnostic EGD or esophagram b/c risk of emboli)
Tx: broad spectrum abx, strict NPO, emergent surgical repair (primary repair of LA and esophagus for definitive repair)
Benefit of root cause analysis squared vs RCA?
identify and implement systems based processes to avoid event happening again (other than education)
Most common type of healthcare associated infection?
Catheter associated UTI; 75% are associated with Foley
Cervical vs transthoracic drainage for descending necrotizing mediastinits?
if below carina anteriorly or 4th thoracic vertebra posteriorly, need thoracic approach
Pulmonary zygomycetes tx?
- aggressive correction of underlying issue
- antifungals (amphotericin B, or if not, posaconazole)
- early, aggressive debridement of tissue (lobectomy or pneumonectomy if needed) with muscle flap for bronchial stump
Treatment of alkali ingestion?
Alkali - coagulation necrosis of esophagus and stomach (full thckness)
Acid- superifical liquifactive necrosis that affect stomach more
If acidosis, peritoneal findings, or evidence of perforation –>surgical exploration mandatory (laparotomy, thoractomy if suspicion of plerual spread)
Suspicion for ARDS after transseptal mitral. What do you suspect?
residual ASD causing L to R shuting, pulmonary HTN, hypoxemia
Get TTE and if TTE nondiagnostic, get TEE
IF ASD then increasing PEEP will worsen hypoxemia 2/2 R to L shunting
What are the key predictors of failure of VA ECMO for post-cardiotomy cardiogenic shock/
Low EF
increased age
DM
SBP <90
persistent metabolic aciodsis on ECMO
prolonged CPB during case
What therapies have proven survival benefit if lung-protective ventilation fails to cure hypoxemia?
proning
48 hr paralysis
inhaled nitric does not have long-term survival benefit
Which drugs are best for delirium?
Dex lowers duration of delirium compared to prop and benozos
Haldol - use only for delirium if 2/2 alcohol withdrawal
atypical antipsychotics (seroquel) - use for dangerous behaviour but doesn’t decrease duration or severity of delirium
Compared to prop and bentos
Components of 4T score?
Thrombocytopenia degree
Timing of plt fall
Thrombosis or other sequale
Other cases of thrombocytopenia
if high score, stop hep/lovenox, order platelet factory, start argatroban if HIT + or return of assay delayed
Most common organisms responsible for post-op mediastinitis?
MSSA (45%), MRSA (16%), GNR, coag-neg staph, strepG
Goals of low tidal volume ventilation for ARDS?
Tidal volume 4-k mL/kg predicted body weight
PaCO2 up to 65 and pH low as 7.15 tolerated (if no intolerable inc in PVR)
FiO2 <= 60% to avoid O2 injury
inc’d PEEP for oxygenation, but plateau <30
PaO2 low as 55 tolerated
if oxygenation still not adequate, then proning, paralysis, ECMO (all shown to improve survival) (inhaled vasodilators improve oxygenation but not survival)
Causes for increased pulmonary vascular resistance?
Hypoxia, hypercarbia, acidosis
How do you correct life-threatening bleeding on warfarin??
PCC + Vit K (plasma + vit K only if PCC not available)
reversal for dabigatran
idarucizumab
When is systemic thrombolysis recommended for PE?
acute PE with hypotension (SBP<90) without high bleeding risk
or if deteriorate after starting AC but not hypotensive yet and low bleeding risk
do NOT give if no hypotension
Management of subsegmental PE?
subseg PE and no proximal DVT:
low risk for VTE and high risk bleeding –> surveillance
high risk VTE and low risk bleeding –>AC
if low risk VTE, must still confirm no prox DVT (if DVT –>AC)
Post op CABG with previous aCE-I use on high dose pressors on .03 vaso. Next step?
Methylene blue
Inhibits guanylyl cycles, reducing c-GMP and smooth muscle relaxation
Improves mortality in vasoplegia
Risk factors for postoperative narcotic addiction
Young age
Low socioeconomic status
CHF
preop ACE inhibitors (also preop SSRI, benzos)
Pulmonary disease
DM
Risk factors for postoperative narcotic addiction
Young age
Low socioeconomic status
CHF
preop ACE inhibitors (also preop SSRI, benzos)
Pulmonary disease
DM
Role of gabapentinoids in post op pain management
Enhance opioid analgesia bd prevent opioid tolerance. Unlikely to be of benefit as sole agents (without opioids) for acute peri-operative pain
Berlin definition of ARDS
4 components:
- onset within 1 week of known physiologic insult
- bilateral opacities
- edema non cardiogenic
- Hypoxia
ARDSnet lung protective protocol
PH 7.3-7.45
Tidal volume goal 6 mL/kg of predicted body weight
Plateau <30 on inspiratory hold
Oxygenation 55-80 mmHg or SpO2 88-95%
ARDSnet lung protective protocol
PH 7.3-7.45
Tidal volume goal 6 mL/kg of predicted body weight
Plateau <30 on inspiratory hold
Oxygenation 55-80 mmHg or SpO2 88-95%
Severe COPD exacerbation and retaining CO2 but doesn’t want intubation. What do you do?
BiPAP is excellent first line
CPAP is uncomfortable to breathe against continuous pressure
3 most common causes for pericardial effusion
Neoplasm, idiopathic, uremia
Loud, high-pitched sound in early diastole + dyspnea, cough, leg swelling
Pericardial knock
Constrictive pericarditis
Pericardial lesions found during pericaridextomy. What do you do?
Pericardial metastases found in
approximately 1-20% of all cancer patients
most common: lung, esophageal cancer, breast cancer, and melanoma, leukemia, and lymphoma are also common.
Pericardial lesions are reason to pause in any patient undergoing a pericardiectomy, and this is especially true in a patient with a history of lymphoma.
If pericardial lesions are encountered, a sample should be sent for frozen pathology. If pathology demonstrates malignancy, the operation should be aborted and the patient referred to oncology for further work-up and management.
Incidental mass on aortic valve with neg blood cultures and no H/o IVDU
Due to the high risk of embolization, most PFEs should be resected, especially those with high risk features.
High risk features: left-sided lesions, patients with a patent foramen ovale, lesions larger than 1 cm, and lesions with a stalk. Lesions not meeting these criteria may be observed.
Patients with a PFE undergoing another cardiac procedure should also have their lesions removed so long as doing so does not add considerable risk to the operation. Most masses can be removed without damage to the underlying valve, thus making a valve replacement unnecessary.
H/o bacteremia or IVDU and BCx can distinguish between endocarditis
How to manage cardiac lipoma and lipomatous hyoertrophy of septum?
Respect lipomas bc of complications as tumor evolves
Hypertrophy of septum: resect if symptomatic or easy to do during concomitant procedure
How to manage cardiac lipoma and lipomatous hyoertrophy of septum?
Respect lipomas bc of complications as tumor evolves
Hypertrophy of septum: resect if symptomatic or easy to do during concomitant procedure
Management of cardiac angio sarcoma
Often rapidly metastatic
Poor survival (<1 year)
Don’t respect
22 yo M incidental LA mass. Fam hx of such masses and hyperparathyroidism. Skin lesions. Dx and tx?
Carney’s complex:
Autosomal dominant
Cutaneous lentiginosis, endocrine hyperactivity, atrial myxomas (usually f>M but in Carney’s M>F)
In pt with family cause for myxoma, resect tumor and interstitial septum
What percent of primary cardiac tumors are benign?
75%
Most cardiac tumors are lets Mets from
Other primaries
What percent of primary cardiac tumors are benign?
75%
Most cardiac tumors are lets Mets from
Other primaries
Describe the AF classifications:
Paroxysmal: AF Ihat terminates sponanteously within 7 days
Persistent: AF that fails to self-
terminate within 7 days or lasts less than seven days but requires pharmacologic or electrical cardioversion
Long-standing persistent: AF that has lasted for more than 12 months
Permanent: AF in which the clinician and patient have decided to no longer pursue rhythm control strategies
Stratify AF ablation indications by class?
Class I- with another procedure
Class II- stand alone AF ablation (Randomized data for failure or med management, nonrandomized for sx)
Class I, Level A: surgical ablation at the time of concomiitant mitral valve
operations
Class I, Level B (non-randomized):
surgical ablation at the time of concomitant isolated aortic valve
replacement (AVR), isolated CABG, and
AVR with CABG operations
Class IIA, Level B (randomized): Surgical ablation for symptomatic AF in the abscence of structural heart diseas that is refractory to class I/III anti-arrhythmic drugs or catheter-based therapy or both
Class IIA, Level B (non-randomized):
Surgical ablation for symptomatic persistent or long-standing AF in the absence of structural heart disease
What vessel at risk during MAZE
LCx during lesion for L pulm vein to mitral annulus
Risk lower if using cryo or if maintain flow using antegrade plegia
Describe carpentier classification:
I = normal leaflet motion (annular dilation or leaflet perforation)
II = excesssive motion (prolapse, flail)
III = restricted opening (a, like rheumatic) or closure (b, IMR or FMR)
Chordal shortening vs transfer benefits?
Shortening largely replaced by transfer due to high reported failure rates
Echo criteria for severe MR?
ERO >=0.4cm2
Regurg frac >= 50%
vena contract width >= 0.7cm
Jet area > 50% of LA area
Valve area cutoff for critical MS?
Pressure gradeitn for sev ms?
<1 cm2
Gradient: mean >10 mmHg is severe, 5-10 is mod
Contraindications for PMBC?
Atrial thrombus
MR that is mod or gerater
Wilkins score cutoff for percutaneous tx?
<8
(normal thickness, minimal chordal thickening, valve calcification confined to leaflet margins, decreased mobility of leaflets at midportion)
Where to place transvenous leads for CRT?
atrial lead placed in RA Appendage
RV lead placed in septum or inferior apical area of RV (avoid free wall or RVOT)
if needed for CRT, LV lead placed via coronary sinus or epicardially
What does applying magnet over pacemaker do?
Inactivates sensing function and rate response
will keep firing at AOO, VOO, or DOO
Normal sensing threshold for A and V for pacemaker?
A: 0.4-10mV
V: 0.8.- 20mV
Is decreased functional status/ life expectancy due to non-cardiac conditions a contraindication to pacemaker placement?
Yes
How to treat acute PE?
Hemodynamically unstable: ECMO and OR
HDS: hep gtt, duplex/echo
How to treat cardiac txp rejection with hemodynamic compromise?
- Prompt methylprednisolone 1g IV (for 3 days)
- inotropic support
- Swan ganz insertion
- Thymoglobulin/OKT3 to remove T cell receptors from cell surface
Mediators of hyperacute vs acute vs chronic rejection?
Hyperacute (Rare) - preformed host ab against host HLA epitopes
acute - lymphocytic attack
chronic - multifactorial, cardiac allograft vascuopahty
humoral- host ab against antigens in donor endothelium. inc vascular permeability and microvascular thrombosis. under immnofloresnce on bx, fibrinogen and immunoglobulins
Most common infections after heart transplant
Most common sites are lungs and urinary tract
Bacterial present early (in 1st month)
Viral seen later
CMV most common, tx with valganciclovir promptly (life threatening)
Risk factors for increased rejection
Younger age
Female
Number of HLA mismatches
Effect of mannitol in TAAA repairs?
Renal and pulmonary protective
Most common complication after TAAA repair?
Resp failure and reop for bleeding
Crawford classification for TAAA
I: LSA to suprarenal
II: LSA to bifurcation of aorta
III: distal thoracic aorta to aortic bifurcation
IV: abdominal aorta below diaphragm
Motor evoke potentials is more or less accurate than SSEP in TAAA repair?
More accurate
SSEP only
Detects ischemia in dorsal spinal cord
Sx pt with severe PPM but mod AS per gradient. Tx?
Redo AVR
When doing. Same side TAVR what are the 2 arterial
Sticks for?
Pigtail superior
Valve inferior
Survival do AS with sx?
Angina - 5 years
Syncope - 3 years
Dyspnea and HF- 2 years
Survival do AS with sx?
Angina - 5 years
Syncope - 3 years
Dyspnea and HF- 2 years
Are BB encouraged or avoided in AS?
Avoided- decrease cardiac output and worsen sx
When should patient stay inpatient for AVR?
Severe, sx AS with:
Pulmonary edema
Congestive Cardiac failure
Recurrent syncope
Chest pain at rest
In who is aldosterone blockade indicated?
h/o MI with low EF and intact renal function
causes retention of K kidneys –> higher K in serum and blocks aldosterone effect on heart
Mediators of different types of protaimine reactions?
Type 1: histamine - hypotension from rapid administration
Type 2: anaphyalxis, IgE antibodies - chlorphenamine can help
Type 3: complement adn TXA2
