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Cardiac Surgery > Ischemic Heart Disease > Flashcards

Ischemic Heart Disease Flashcards

1
Q

What are the 2023 Class 1 indications for CABG?

A
  1. Left main disease (CABG>PCI)
  2. DM and mvCAD with LAD involvement (CABG (LIMA to LAD) > PCI)
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2
Q

What are the 2023 Class 2a indications for CABG?

A

mvCAD with complex/diffuse disease (SYNTAX>33)

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3
Q

What are the 2023 Class 2b indications for CABG?

A

DM with LM stenosis and low-to-intermediate complexity, can consider PCI as an alternative to CABG

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4
Q

What are the indications for pre-op carotid duplex?

A

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

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5
Q

What is the timing for CABG after carotid work?

A

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)

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6
Q

When should you do CABG after STEMI?

A

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)

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7
Q

Pre-op tests for radial artery conduit?

A

radial artery studies documenting patent palmar arch
Do not take radial from dominant hand

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8
Q

Management of air-hit when weaning ?

A
  1. Check TEE for air in LV, root, or coronary/subendocardium
  2. Back on bypass
  3. Trendelenberg
  4. Drive MAP>80
  5. Wait 10 min for air embolus to resolve
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9
Q

Patient presents in STEMI but cardiologist cannot stent. What do you do?

A

Have cardiologist place IABP, perform focused H&P to find out time of total ischemia, STAT echo

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10
Q

In STEMI with failed PCI, how does approach differ based on lenght of ischemia?

A

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

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11
Q

Approach if performing CABG MVR but small left atrium

A

distals then mitral (give dose of plegia, snare caval tapes)

  1. Transspetal (identify fossa ovalis and incise towards SVC)
  2. If need more exposure, open L pleural cavity and pull up on umbilical tapes
  3. 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
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12
Q

CABG Conduit options for diabetics?

A

Absolutely contraindicated to use BIMA on diabetics (relatively contraindicated in morbidly obese, COPD, or otherwise high risk for sternal wound infections)

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13
Q

Stenosis cutoffs for radial?

A

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)

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14
Q

Mortality Risk for redo-CABG

A

2-3%

If AS and CAD, cannot do TAVR unless can do PCIs first, then 1 month plavix, then TAVR

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15
Q

Pre-op workup for redo CBAG?

A

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)

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16
Q

Dark blood welling up from mediastinum during re-entry for redo-cabg. What do you do?

A

Pack incision, change femoral lines to cannaulae, go on bypass

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17
Q

Redo case with prior CABG. How do you manage LIMA?

A

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

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18
Q

How to manage prior vein grafts in redoCABG?

A

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

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19
Q

Redo AVR options in patient with prior CABG?

A

Sternotomy and temporary occlusion of LIMA
RAMT - cool to 25 and do not identify/occlude arterial grafts

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20
Q

Prior LIMA to LAD. Would you offer CABG?

A

Only if symptomatic ischemia 2/2 sclerotic vein grafts

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21
Q

Factors favoring reoperative CABG over PCI

A
  1. Late stenosis (>5 years)
  2. Multiple stenotic vein grafts
  3. Diffusely stenotic grafts
  4. No patent IMA graft
  5. Decreased LVEF
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22
Q

What are STS Risk Score ranges?

A

Prohibitive: > 15%
High risk: 8-15%
Intermediate 4-8%
Low: <4%

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23
Q

How to handle fibrillation upon redo entry?

A
  • 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
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24
Q

What are the guidelines for concomitant CABG + CEA?

A
  1. Prior stroke/TIA with significant carotid disease (>50% in men, >70% in women)
  2. Asymptomatic but bilateral >=50%
  3. Asymptomatic unilateral >=50% with contralateral occlusion
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25
Q

Indications for concomitant AVR during CABG?

A
  1. Mod-Sev AS or AI
  2. Mild AS + Rapid progression of trans valvular gradients (15-20mmHg/year)
  3. Mild AS + Rapid decrease in AVA (0.3 cm2)
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26
Q

Indications for Concomitant CABG during AVR or MVr/R?

A
  1. Lesions >=70% reduction in major coronaries
  2. Can consider lesions >=50% that have reasonable targets
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27
Q

Describe operation for CABG + AVR:

A
  1. TEE
  2. Aortic+ Dual stage venous
  3. LV Vent
  4. XC and ante/retro (if AI, antegrade given directly via Ostia after aortotomy)
  5. Distal vein graft and give plegia down coronary conduit
  6. Oblique aortotomy into noncoronary sinus
  7. AVR, close aortotomy
  8. Distal mammary anastomosis
  9. Proximal graft anastomoses
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28
Q

Indications for concomitant MVr/R and CABG?

A
  1. Moderate or severe IMR not likely to resolve with coronary revacsularization alone
  2. Mild MR with HF symptoms
  3. Moderate -to-severe MS
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29
Q

Indications for MVR in AS + CAD?

A

mod-severe mitral regurg

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30
Q

What is the maximum arterial cannula pressure gradient?

A

100mmHg

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31
Q

What is the complete heart block rate after myectomy? When are patients at higher risk?

A

2%, higher risk after RBBB

Alcohol ablation takes out right bundle; surgical resection takes out L bundle

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32
Q

Patency rates of CABG conduits

A

IMA: 90-95% at 10-20 years
Vein: 50% at 15 years
Radial: 92.5% at 7 years
GEA: 70% at 10 years

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33
Q

Only proven benefit of delNido?

A

Reduced need for defibrillation (return of spontaneous rhythm)

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34
Q

Criteria for using radial artery grafts?

A

Circ >70% or RCA>90%

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35
Q

Most common causes of hemorrhagic pericardial effusion

A

Malignancy (other cases are idiopathic, pericarditis, trauma, uremia)

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36
Q

Differences between restrictive and constrictive?

A

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

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37
Q

Indications for CRT

A

EF<=35% with LBBB With QRS>150 and NYHA II-IV sx on GDMT (class I)

QRS>120 (Class IIa)

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38
Q

Indication for carotid-subclavian bypass pre-TEVAR

A

Compromise of end organ perfusion (prior LIMA graft, or PICA (posterior inferior cerebellar artery) syndrome

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39
Q

Management of pregnancy with Marfan’s syndrome

A

<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

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40
Q

ICD indications:

A
  1. EF at or below 35% 90 days post-revasc with NYHA II or III heart failure
  2. EF at or below 30% regardless of NYHA class (expected meaningful surgical of at least one year)
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41
Q

Heart transplants VAD survival?

A

LVAD 4 year survival approx 50%

OHT 75% at 5 years, >50% at 10 years

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42
Q

Screening for family for pt with aneurysm?

A

All first degree get echo (if echo abnormal, CT or MRA)

Genetic testing if >1 member with aneurysm or suspicious physical exam findings

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43
Q

Factors affecting survival in cardiac sarcoma?

A

Most common in LA
Location and ability for complete resection affect survival (not histologic subtype)

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44
Q

MRSA Endocarditis abx?

A

Linezolid and dapto

45
Q

Strep endocarditis coverage?

A

Penicillin G and gentamicin

46
Q

Bacteria associated with endocarditis after tooth cleaning?

A

Strep viridans

47
Q

Bacteria most commonly associated with endocarditis from IVDU

A

S aureus

48
Q

Most common organism for prosthetic valve endocarditis?

A

Coag neg staph (like. S epidermidis)

49
Q

How long can you extend DHCA without cerebral perfusion?

A

40 min at 18 deg

50
Q

How to distinguish true vs false lumen in dissection

A

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)

51
Q

Criteria for conservative management of IMH?

A

IMH thickness <1.0cm
Asc aorta <5.0cm

52
Q

How far to extend TEVAR if malperfusion?

A

LSA to celiac if rupture
LSA to T7-8 if malperfusion

53
Q

Benefits of LAA ligation in permanent AF

A

Low utliity of MAZE
Clip has lower readmissions for thromboembolism and improved mortality at 3 years post-op

54
Q

PPM risk after MAZE?

A

6.3% for L side
13.8 for biatrial

Factors predicting AF recurrence are duration of AF, LA size, age of pt

55
Q

How to manage plavix pre-CABG?

A

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

56
Q

Criteria for surgery for R sided endocarditis?

A

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

57
Q

When and what abx prophylaxis should you give before surgery?

A

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

58
Q

Management of LV endocardial leads?

A

Surgical removal to prevent embolic debris

If not a candidate for surgery, then can anticoagulate with warfarin

59
Q

Management of coumadin during pregnancy and during delivery?

A

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

60
Q

Age cutoff for treatment of coarctation?

A

Cannot surgically resect and anastomose end-to-end after 8 years age

61
Q

When to place new ICD or PPM system if pocket infection?

A

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

62
Q

Criteria for ICD?

A

HCM with 1 risk factor (prior arrest, VT, syncope, fam hx, LV thickness >3cm, abnormal BP response to exercise)

63
Q

Diagnostic criteria for Marfans:

A

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

64
Q

Surveillance intervals for mild/mod/sev AS

A

mild 3-5 years
mod 12-18 mo
sev (with preserved EF) 6-12 mo

65
Q

Indications for surgery for AI

A

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)

66
Q

Potential causes for mechanical valve obstruction and how to treat?

A

Thrombus (early), pannus (late), mechanical valve malfunction

for thrombus:
If < 5mm, AC
if larger, systemic thrombolysis (or surgery)

67
Q

Who gets prophylaxis prior to dental work?

A

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

68
Q

Which portion of aorta is most commonly aneurysmal in Marfans?

A

Root

69
Q

Most common location for ventricular aneurysm?

A

Anterior apical (LAD territory)

70
Q

Contraindication to ventricular aneurysm repair?

A

Reduced LV cavity size

If MR, repair through aneurysmectomy

71
Q

Management for bio vs mechanical prosthetic valve thrombosis?

A

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)

72
Q

Name HACEK Organisms and treatment?

A

Haemophilus
Actinobacillus
Cardiobacterium
Eikenella
Kingella

All gram neg bacili
Need 4-6 weeks CTX or fluoroquinolone (start before waiting for susceptibilities)

73
Q

How fast to to rewarm after circ arrest?

A

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

74
Q

Indication for pulmonic replacement in repaired tetralogy of fallot

A

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

75
Q

Indication for PVR for PR after isolated congenital PS?

A

Symptoms OR RV dysfunction
if not, don’t replace even if severe PR

76
Q

How to manage massive air embolism?

A

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

77
Q

Where should LV epicardial leads be for CRT?

A

Lateral wall

78
Q

How to distinguish tamponade from constrictive pericarditis/restrictive cardiomyopathy?

A

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

79
Q

What is unique to constrictive pericarditis vs restrictive and tamponade?

A

Discordant ventricular pressures during respiration (in constriction, lower LV systolic presssure –> septum shifts to L –> inc RV systolic pressure)

80
Q

Difficulty weaning off with inferior wall hypokinesis after mitral annuloplasty in L dom circulaitn?

A

Suspect LCx injury

If intra-op dx, revise sutures or emergency CABG

if ICU diagnosis, cath lab (unless fully ligated by annular stitch)

81
Q

How to determine stroke risk in postop AF and who get oral AC?

A

CHADS2VASC score
CHADS2VASC>=2, CHADS2 >= 1, or age >=65 gets oral AC per guidelines

82
Q

Fever, chest pain, sepsis, neuro sx 3-6 weeks after catheter AF ablation. Dx? Best test? Tx?

A

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)

83
Q

Benefit of root cause analysis squared vs RCA?

A

identify and implement systems based processes to avoid event happening again (other than education)

84
Q

Most common type of healthcare associated infection?

A

Catheter associated UTI; 75% are associated with Foley

85
Q

Cervical vs transthoracic drainage for descending necrotizing mediastinits?

A

if below carina anteriorly or 4th thoracic vertebra posteriorly, need thoracic approach

86
Q

Pulmonary zygomycetes tx?

A
  • 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
87
Q

Treatment of alkali ingestion?

A

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)

88
Q

Suspicion for ARDS after transseptal mitral. What do you suspect?

A

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

89
Q

What are the key predictors of failure of VA ECMO for post-cardiotomy cardiogenic shock/

A

Low EF
increased age
DM
SBP <90
persistent metabolic aciodsis on ECMO
prolonged CPB during case

90
Q

What therapies have proven survival benefit if lung-protective ventilation fails to cure hypoxemia?

A

proning
48 hr paralysis

inhaled nitric does not have long-term survival benefit

91
Q

Which drugs are best for delirium?

A

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

92
Q

Components of 4T score?

A

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

93
Q

Most common organisms responsible for post-op mediastinitis?

A

MSSA (45%), MRSA (16%), GNR, coag-neg staph, strepG

94
Q

Goals of low tidal volume ventilation for ARDS?

A

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)

95
Q

Causes for increased pulmonary vascular resistance?

A

Hypoxia, hypercarbia, acidosis

96
Q

How do you correct life-threatening bleeding on warfarin??

A

PCC + Vit K (plasma + vit K only if PCC not available)

97
Q

reversal for dabigatran

A

idarucizumab

98
Q

When is systemic thrombolysis recommended for PE?

A

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

99
Q

Management of subsegmental PE?

A

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)

100
Q
A
101
Q

Post op CABG with previous aCE-I use on high dose pressors on .03 vaso. Next step?

A

Methylene blue

Inhibits guanylyl cycles, reducing c-GMP and smooth muscle relaxation

Improves mortality in vasoplegia

102
Q

Risk factors for postoperative narcotic addiction

A

Young age
Low socioeconomic status
CHF
preop ACE inhibitors (also preop SSRI, benzos)
Pulmonary disease
DM

103
Q

Risk factors for postoperative narcotic addiction

A

Young age
Low socioeconomic status
CHF
preop ACE inhibitors (also preop SSRI, benzos)
Pulmonary disease
DM

104
Q

Role of gabapentinoids in post op pain management

A

Enhance opioid analgesia bd prevent opioid tolerance. Unlikely to be of benefit as sole agents (without opioids) for acute peri-operative pain

105
Q

Berlin definition of ARDS

A

4 components:
- onset within 1 week of known physiologic insult
- bilateral opacities
- edema non cardiogenic
- Hypoxia

106
Q

ARDSnet lung protective protocol

A

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%

107
Q

ARDSnet lung protective protocol

A

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%

108
Q

Severe COPD exacerbation and retaining CO2 but doesn’t want intubation. What do you do?

A

BiPAP is excellent first line
CPAP is uncomfortable to breathe against continuous pressure

Cardiac Surgery (6 decks)

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