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RCE Guidelines Studying > Laflamme- Chapter 7 (Congenital Heart + Pregnancy) > Flashcards

Laflamme- Chapter 7 (Congenital Heart + Pregnancy) Flashcards

1
Q

Describe the Right atrial appendage?

A

-Large base, Triangular shape, Numerous pectinate muscles

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2
Q

What is left atrial appendage morphology?

A

-Narrow base, finger-shaped

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3
Q

What is the ductus venosus?

A

-Allows oxygenated umbilical blood to short-circuit the liver and reach the IVC

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4
Q

What is the foramen ovale?

A

-Allows blood derived from the IVC to go directly to the left heart perfusing the coronary arteries

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5
Q

What is the PDA?

A

Allows blood to go from the right heart to the aorta (to the placenta)

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6
Q

Order the 4 types of ASD by prevalence

A

-Secundum ASD (80%): In the fossa ovale

-Primum ASD (15%): Close to the AV valves associated with the AV canal defect

-Sinus Venosus (5%): Close to the origin of the SVC, associated with pulmonary venous connection

-Coronary sinus ASD (1%): Communication between the coronary sinus and the LA, associated with left sided SVC

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7
Q

What are two things that make an ASD large?

A
  • > 10mm size
  • Qo/Qs > 1.5:1
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8
Q

What is Lutembacher’s syndrome?

A

ASD + Rheumatic MS

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9
Q

What is Holt Oram syndrome?

A

-Autosomal dominant, TBX5 mutation, abnormalities of hands, secundum ASD

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10
Q

What are 4 physical exam findings of ASD?

A

-Fixed split S2

-Left parasternal heave

-TR murmur in the presence of right heart failure

-Palpable dilated PA

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11
Q

What are four complications of ASD?

A

-Right heart failure

-Atrial arrhythmias

-Paradoxical embolism

-PHT

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12
Q

Name 5 indications for closure of ASD?

A

-Dilation of right chambers

-Paradoxical embolism

-Platypnea-orthodexia

-PHT with marked left to right shunt > 1.5 :1 or with significant reactivity to vasodilator

-Do not close if irreversible PHT with sPAP > 2/3 SBP or PVR > 2/3 SVR

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13
Q

Name 3 anatomic criteria for percutaneous closure of ASD?

A
  • Secundum ASD < 38mm with adequate margins
  • > 5mm distance from AV valves, Coronary sinus, origin of SVC/IVC
  • Normal pulmonary venous return

Also: ASVD ASD, Unroofed coronary sinus, Venosus ASD

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14
Q

What % of patients have PFO?

A

25%

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15
Q

How many beats needed within to see shunt/PFO on bubble study?

A

3 beats

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16
Q

What are the 4 types of VSD and describe them

A

Subarterial: Below the Ao and P valves , associated with AR

Membranous: Membranous septum, adjacent to Ao or T valves

AV canal: Below AV valve

Muscular: Completely surrounded by muscle

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17
Q

Name 7 complications of VSD?

A

-Left heart failure

-Pulmonary hypertension

-Progressive AR

-Double chamber RV

-Progressive subaortic stenosis

-Arrhythmias: AF, PVCs, NSVT, Post op block

-Endocarditis

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18
Q

What are 5 indications for VSD closure?

A

-Significant VSD: Symptoms or LV dysfunction, Qp:Qs > 2:1 or sPAP > 50mmhg

-Subarterial or membranous VSD with AR > moderate

-In the presence of severe PHTN (sPAP > 2/3 sbp or PVR > 2/3 SVR) closure should only be considered i nthe case of left to right shunt >1.5:1 or significant reactivity to vasodilators

-Double chamber RV with significant obstruction (MG > 40mmhg)

-Endocarditis

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19
Q

Name 5 complications of AV septal defect?

A

-Left and right AV regurgitation

-Left heart failure

-Right heart failure

-PHTn

-Arrhythmias

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20
Q

Name 6 physical exam findings of PDA?

A

-Continuous machinery murmur in left 2nd left IC space

-Increased pulse pressure

-Bounding pulse

-LV dilatation

-S3

-Associated thrill

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21
Q

What is echo finding of PDA?

A

-Flow reversal from aorta to PA visible on PSAX

-Diastolic flow reversal in the descending aorta

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22
Q

What are 4 complications of PDA?

A

-Left heart failure

-Progressive PHTn

-Arrhythmias

-Endarteritis/Ductus aneurysm

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23
Q

What are the consequences of supravalvular aortic stenosis?

A

-Coronary artery dilatation, stenosis, early CAD (due to high pressures on the coronaries)

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24
Q

What do you see on Ventriculography on Supravalvular stenosis?

A

-Ballerina foot pattern of LV

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25
Q

What genetic complex is associated with subvalvular aortic stenosis?

A

-Shone complex

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26
Q

What is the pathology for Aortic Coarctation?

A

-Stenosis in the region of the ligamentum arteriosum

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27
Q

Name 6 associated abnormalities with Aortic Coarctation?

A

-BAV

-Turner syndrome

-Shone complex

-VSD

-Aneurysm of the circle of willis

-Aortopathy

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28
Q

What are 4 congenital abnormalities associated with Turner Syndrome?

A

-Coarct

-BAV

-ASD

-VSD

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29
Q

What is criteria for significant coarct?

A

-HTN in the arms with trans-CoA gradient on catheterization > 20mmhg or with SBP in arms > 20mmhg higher than SBP i nlegs

30
Q

What are physical exam findings in the absence of collaterals with coarct? absence of collaterals?

A

-Absence: HTN in arms, SBP in arms higher than in legs, radiofemoral delay on palpation of pulse, interscapular ejection murmur

-Presence: continuous crescendo-decrescendo murmur in left parasternal region of left scapula

31
Q

What CXR sign do you see with coarctation and what is it caused by?

A

-3 sign: indentation of the aorta at the site of CoA with distal and proximal dilatation

32
Q

What is the characteristic echo finding of Aortic Coarctation on echo?

A

-Increased velocity in descending aorta with diastolic extension of anterograde flow

-Decreased velocity of systolic flow and diastolic extension of antegrade flow

33
Q

What are the 4 features of TOF?

A

-VSD

-Overriding Aorta

-RVH

-Subpulmonary stenosis

34
Q

Describe the three steps of corrective surgery for TOF?

A

VSD closure -> RVOT disobstruction -> infundibulectomy or subannular patch or transannular patch

35
Q

What are 4 associated abnormalities with TOF?

A

-DiGeorge syndrome (22q11 deletion)

-Right aortic arch

-Secundum ASD

-Congenital coronary artery anomalies

36
Q

What are 7 post correction complications for TOF?

A

-PR

-RV dysfunction

-Residual RVOT obstruction

-Residual VSD

-LV dysfunction

-Aortic root dilation

-Arrhythmia (atrial or VT)

37
Q

What are 6 indications for post-corrective surgery for TOF?

A

-Severe PR with mod-severe RV dilatation (EDV > 170)

-Residual VSD shunt >1.5:1

-Moderate to severe RVOT Obstruction

-Severe AR

-Aortic root > 55mm

-RVOT aneurysm or false aneurysm

38
Q

What are 5 risk factors for VT for TOF?

A

-Inducible VT on EPS

-QRS > 180 msec

-Significant PR or RVOT

-NSVT on holter

-Syncope

39
Q

Describe DTGA

A

-AV concordance, VA discordance

-RA connected to the RV which is connected to the Ao

-Position of the aorta is anterior to the right of the PA

40
Q

What are associated abnormalities with D-TGA (5)?

A

-VSD, LVOT obstruction, ASD, Coart, Congenital coronary artery anomalies

41
Q

Describe the two procedure that fix D-TGA ?

A

-Atrial Switch/Mustard: Blood is redirected to the atria by means of a conduit made from pericardium allowing physiological correction towards the subpulmonary LV Pulmonary venous blood is redirected towards the subaortic RV

-Arterial Switch: Switching of the Ao and PA

42
Q

What are complications post DTGA repair? (7)

A

Systemic RV failure
Systemic RV ischemia
Systemic AV regurgitation
Obstruction of the baffle
Baffle leak
Arrhyhtmias
Subpulmonary obstruction

43
Q

What is the criteria for Ebsteins anomaly?

A

-Apical displacement of the TV > 8mm

44
Q

What are three associated abnormalities with Ebsteins?

A

-Accessory pathways

-Secundum ASD

-RVOT obstruction

45
Q

What are four ECG findings of Ebsteins?

A

-RA dilatation/Himalayan P waves

-Pre-excitation

-RBBB

-Q waves in V1

46
Q

What is the genetics of Marfan syndrome?

A

-Autosomal dominant FBN1 gene mutation

47
Q

What are 5 cardiac issues with Marfan syndrome?

A

-Aortic dilatation
-MVP
-TVP
-AR
-Left heart failure

48
Q

What are indications for Aortic repair for TAA in marfan?

A
  • Ascending Ao > 50mm

-Ao > 45mm with progression > 5mm/year or progressive AR or family history dissection

-Ao > 40mm before pregnancy

49
Q

What cut off is pregnancy contraindicated in TAA?

A

45 mm

50
Q

Name 6 extra cardiac signs with Marfan?

A

-Pectus Carinatum

-Pectus excavatum

-Long limbs (Arm span to height ratio > 1.05)

-Long fingers

-Flat foot

-Lens dislocation

51
Q

Describe ALCAPA syndrome

A

Anomolous left coronary artery arising from the PA

52
Q

What are 6 clinical features of anomalous coronary arteries?

A

-Sudden death

-Retrosternal chest pain

-Arrhythmia

-LV dysfunction

-Syncope

53
Q

What are 4 indications for surgery for anomalous coronary arteries?

A

-Coronary artery coursing between the great vessels with documented ischemia

-Ectopic origin of the LMCA coursing between the Ao and Pa

-Ectopic origin of the right coronary artery coursing between the Ao and PA with documented ischemia

-Ectopic origin of the LAD coursing between the Ao and Pa.

54
Q

Name 5 hemodynamic changes with pregnancy?

A

-Increase 40-50% of plasma volume

-Increase 10-20% of HR

-Increase 30-50% of CO

-Decrease PVR

-Increase venous pressure in legs

55
Q

Name 7 changes to the physical exam of a normal pregnant woman?

A

-Tachycardic

-Increased CVP

-Hyperdynamic state (pulse, apex)

-Laterally displaced apex

-Accentuated S2 split

-S3

-Left parasternal ejection murmur

56
Q

What % of predicted functional capacity indicates a high risk pregnancy?

A

< 70%

57
Q

What are the 4 components of the CARPREG score?

A

-History of HF, TIA, Stoke, Arrhythmia

-NYHA III or cyanosis

-MVA < 2 or AVA < 1.5 or LVOT > 30mmHg

-LVEF < 40%

58
Q

Name 7 conditions where pregnancy is relatively contraindicated?

A

-Severe PAH

-Severe LV dysfunction

-Previous PPCM with residual impairment of LV function

-Severe MS or AS

-Marfan Ao > 4.5

-BAV Ao > 5

-Unrepaired Coa

59
Q

How to monitor LMWH during pregnancy?

A

-Dose according to anti-Xa level 4h post injection (target 0.8-1.2) review once a week, replace by UFH > 36h

60
Q

How to anticoagulate during pregnancy when Warfarin dose 5mg or less a day?

A

-Continue warfarin, replace by UFH at the end of pregnancy prior to planned delivery

61
Q

How to anticoagulate in pregnancy if Warfarin > 5mg daily

A

-LMWH or IV heparin during the first trimester, replace by Warfarin for 2nd and 3rd trimesters, then replace by UFH prior to planned delivery

62
Q

What are 5 risk factors for PPCM?

A

-Twin pregnancy

-AA

-Advanced age

-Pre ecmlampsia

-Smoking

63
Q

How to manage PPCM?

A

-Hydralazine/Nitrates, Beta blocker, Digoxin, Diuretics

64
Q

What is this?

A

Ballerina Foot Pattern -> Supravalvular Aortic Stenosis

65
Q

What is this?

A

3 Sign -> Aortic Coarctation

66
Q

What are 2 features of Severe PR?

A

-Continuous doppler regurgitation envelope is dense and reaches zero before the end of diastole

67
Q

What are 4 prerequisites for a Fontan?

A

mPAP < 15mmhg

Normal sized PA

Normal RV function

Absence of significant AV regurgitation

68
Q

What is this?

A

Scimitar Syndrome (Anomolous Pulmonary Vein into the IVC)

69
Q

4 complications of Coronary AV fistula?

A

Dilation of the nutrient artery

Ischemia

Rupture

Endarteritis

70
Q

6 contraindications for oral contraceptives?

A

-Cyanotic Heart Disease

-Atrial Fibrillation

-Mechanical Valve

-Thromboembolic history

-Fontan

-LVEF < 40%

RCE Guidelines Studying (52 decks)

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