Multiple choice questions Flashcards
What are features of total anomlaous venous return
ASD must be present
The shunt is right to left
pulmonary venous obstruction is common.
PGE1 cannot be used to treat cyanosis
What are side effects of cylcosporine
elevated creatinine
hypertension
elevated potassium
The best treatment for hyperhirosis
sympathectomy
During CPB with hypothermia what happens to pH
Goes up
The full hammersmith dose of aprotinin is
240 mg
With a perimembranous VSD, the conduction system lies
posterior and inferior
The PDA is derived from
distal left 6th aortic arch
Nitric oxide does the following
causes vasodilation
inhibits PMNs
Inhibits smooth muscle proliferation
inhibits platelet aggregation
Stone heart is defined by
tetanic contraction after reperfusion
What is the action of reopro?
monoclonal antibody to the platelet receptor
What can result from untreated VSD?
AI
Infundibular stenosis
endocarditis
Not cyanosis
List complications of untreated ASD
Paradoxical embolism
stroke
pulmonary vascular disease
endocarditis is not a feature of untreated ASD
All of the following are complications after fontane circulation
Pleural effusions
protein losing enteropathy
ascities
ECMO has the best results in
Meconium aspiration
List features of Shone complex
Parachute mitral valve
Subaortic stenosis
coarctation
Supravalvular mitral membrane
All of the following are complications of Glenn shunt
SVC syndrome
AV fistula from right lower lobe
phrenic nerve damage
What are features of ARDS
Increase in A-a gradient
there is an increase in shunt fraction
the FRC is decreased
The best technique to diagnose post transplant coronary artery disease is
IVUS
The aortic arch is derived from
4th arch
The nerve root most likely to be damaged during ductus is
Recurrent nerve
You have opened the chest of an infant and see a very large azygous vein. You think
Interrupted inferior vena cava
Most common vascular ring
Double aortic arch
Pulmonary vascular resistance is increased in
Acidosis
hypothermia
alph adrenergis
hypoxia
Propanolol decreases tet spells by
decreasing infundibular muscle tone
The Rastelli classification deals with
Anatomical description of complete AV canal defects
What are principles of cardioplegia arrest
Rapid diastolic arrest is achieved most effectively with potassium by blocking the inward sodium current, thereby preventing the initial phase of cellular depolarization.
By causing diastolic arrest, potassium preserves ATP and creatine phosphate stores for postischemic work.
What is purpose of glucose in cardioplegia
Substrate (i.e., glucose) should be provided to support anaerobic or aerobic energy production during aortic cross-clamping. However, the energy available is far greater if the cardioplegia solution contains oxygen (i.e., blood).
What are buffers in cardioplegia solution
buffer additives (sodium bicarbonate, tris-[hydroxymethyl]-aminoethane
Membrane stabilization with calcium supplementation or other additives is important.
Osmolarity and colloid osmotic pressure must be maintained to avoid producing myocardial edema iatrogenically during cardioplegia infusion
3 ways to determine coronary sinus cath is in correct place
1) observation of dark (deoxygenated) blood return following insertion (myocardial oxygen consumption is generally higher than peripheral oxygen consumption);
2) palpation of the tip at the base of the left atrial appendage; and
3) pressure monitoring during infusion.
What are physical signs of tricuspid disease
Tricuspid regurgitation features a high-pitched, blowing, holosystolic murmur.
Tricuspid stenosis a low-pitched, rumbling diastolic murmur with a presystolic crescendo if the patient is in normal sinus rhythm.
each is best heard at the lower sternal border and each increases in intensity during inspiration due to augmented right ventricular filling
What are different symptoms between TR and TS
Both are the consequence of systolic venous congestion, including ascites, peripheral edema, hepatomegaly, pulsations of the liver, and positive hepatojugular reflux (enhanced jugular venous pulse with liver compression).
Gross jaundice and cirrhosis do not generally occur with tricuspid regurgitation
What are rates of tricuspid valve thrombosis
thrombosis rate of mechanical valves in the tricuspid position is lowest with bileaflet valves.
thrombosis of a mechanical prosthesis in the tricuspid position may be insidious.
therapy is the initial treatment of choice but it may not be successful in all cases due to the chronicity of the process.
Calcification of bioprosthetic valves is less common in the tricuspid position than in the aortic or mitral position.
What are indications for functional tricuspid surgery
1) significant pulmonary hypertension, especially if it is long-standing or minimally reversible; 2) long-standing right ventricular dilation, especially with tricuspid annular enlargement;
3) tricuspid regurgitation that has been clinically significant and constant with persistent evidence of right heart failure.
What at features of hemolysis post valve repair
Unconjugated or indirect bilirubin is a reliable guide to the presence of increased heme catabolism and is elevated in patients with hemolysis.
The serum level of conjugated or direct bilirubin is normal unless the patient has associated hepatic or biliary dysfunction.
Jaundice is apparent if the serum bilirubin level is higher than 2mg/dL, but with hemolysis, unconjugated bilirubin never exceeds 5.0mg/dL.
Haptoglobin, which binds to hemoglobin, is low with intravascular hemolysis
Lactic dehydrogenase is often markedly elevated with hemolysis.
What is natural history of mitral valve replacment
durability of porcine valves is less in the mitral position than in the aortic position.
related to differences in the pressures the cusps are subjected to during the cardiac cycle.
aortic position, the diastolic pressure is the maximal closure pressure applied. In the mitral position, the higher left ventricular systolic pressure is applied at closure. Other shear and turbulent forces act upon the closed, high-profile bioprosthesis as blood is ejected through the left ventricular outflow tract in a tangential direction.
What influences durability of mitral valve replacment
directly proportional to the patient’s age. Structural valve deterioration is extraordinarily rapid in children and young adults under age 40. In these cases, mechanical prostheses are better suited to avoid early reoperation. In patients with hypercalcemia related to hyperparathyroidism or chronic renal failure, the durability of bioprostheses is further shortened, and they generally are not recommended. Improved anti-calcification treatments applied to new generations of bioprostheses may change this.
What are rates of SVD for mitral valve
35 year old undergo bioprosthetic mitral valve replacement, the risk of required reoperation for structural valve deterioration is 50% at 10 years.
adult patient younger than 30 years this is approximately 75% at ten years
What at rates of valve related complications
incidence of thromboemboli whose anticoagulation is well managed is similar to patients with bioprosthetic valves without anticoagulation, which is 1.5-2% per patient-year.
The incidence of anticoagulant-related hemorrhage is related to patient age and to anticoagulation control.
INR maintenance between 2.5-3.5 this complication has an incidence of 1-2% per patient-year. In elderly patients (>70), the risk of bleeding approaches 10% per patient per year
Why place co2 in the surgical field
Nitrogen is the main component of ambient air (80%). Of the three components of interest (also oxygen and CO�) it is the least soluble in blood. Carbon dioxide is the most soluble and it is infused into the pericardial well in an effort to displace nitrogen and enhance clearance of intracardiac and intravascular gas after cardiotomy. The benefit of this approach is unproven but logical.
Air bubbles rise and as a result intracardiac air will tend to enter the right coronary artery and anteriorly placed aortocoronary bypass grafts.
What are predicts for post vsd mortality
preoperative hemodynamic instability, left main coronary artery disease, right heart failure, renal dysfunction, previous myocardial infarction, posterior defect location and age.
What is long term survival of post mi vsd pts
mortality is high, most survivors do well and many patients are NYHA Class I or II.
Additional procedures are not routinely required.
Long-term survival of operative survivors is limited by pre-existing coronary artery disease, postoperative renal failure and residual postoperative shunts.
60 to 80% survival in 5 years
What incidence of papillary muscle rupture
anterolateral papillary muscle has a dual blood supply (LAD and circumflex), while the posteromedial papillary muscle has a single source (posterior descending branch of the right coronary).
Papillary muscle rupture is a complication of about 1% of acute infarcts and involves the posteromedial papillary muscle most frequently.
What importance of true and false aneurysm
True ventricular aneurysms should be differentiated from false aneurysms because large false aneurysms are prone to rupture whereas true aneurysms are not.
True aneurysms which result from expansion of an infarct often have a broad or no neck.
False aneurysms that result from a contained ventricular rupture have a narrow neck.
The presence of a ventricular aneurysm is suggested by persistent ST elevation on the electrocardiogram despite the absence of pain.
What are post op,concerns for TMR
cardiac complications (myocardial infarction, low cardiac output, and ventricular arrhythmias) are the most common adverse events associated with TMLR (about 50%). Low cardiac output results from myocardial injury, either from ischemic areas that are not addressed or from additional myocardial damage from the laser therapy. There is a rise in CPK-MB and a 50% incidence of ischemic EKG changes in the first 48 hours after TMLR
What are outcomes pericardiectomy
Perioperative mortality has decreased to 5-10%, but long-term survival remains limited and has not improved greatly.
Five year survival for the idiopathic group is in the range of 85-90%; it approximates 66% for postcardiotomy patients and 30% for post-irradiation constriction.
In patients who survive, early symptomatic improvement can be expected in 90%.
How good is Epi aortic scanning
epi-aortic scanning detected atherosclerotic disease in 90% of patients compared to 76% by digital palpation.
Epi-aortic scanning is currently the most sensitive and accurate technique, and it represents the “gold standard” for assessing atherosclerotic aortic disease in the operating room.
Describe history and patterns of OHT rejection
Forty percent of cardiac transplant recipients will have a rejection episode within the first month, 60% within 6 months and 66% by one year.
The risk of rejection decreases after the first year to a constant low level.
Ninety-five percent of these rejection episodes are in the setting of hemodynamic stability.
What are risk factors for rejection
Female gender, younger age, African American heritage, cytomegalovirus infection, HLA-DR mismatch, previous serious infection, and prolonged ischemic time
What is PTLD
There is a higher incidence in children (13-26% vs. 10% in adults)
What are risk factors for PTLD development
associated with Epstein-Barr virus infection.
Other factors
the organ transplanted, type of immune suppression (anti-CD3 monoclonal antibody and tacrolimus) and its intensity , and CMV infection.
There is a higher incidence in children
What is treatment of PTLD
reduction or temporary cessation of immumsuooression.
Advanced stage disease has clear features of malignancy and is usually treated with combination chemotherapy. Anti-CD20, interferon alfa-2a and anti-viral drugs may be beneficial
What is penetrating atherosclerotic ulcer
ulcerations in the wall of the aorta secondary to rupture of an atherosclerotic plaque through the internal elastic lamina.
local disruption of the media occurs and aortic rupture may ensue.
Describe IMH
An intramural hematoma (IMH) is caused by a vaso vasorum rupture that creates a localized hemorrhage into the aortic media.
What is blood flow to spinal cord
the anterior spinal artery (fed by the vertebral arteries),
the lumbar arteries of the abdominal aorta and
segmental intercostal arteries from the descending thoracic aorta.
The artery of Adamkiewicz, originates from intercostal arteries from T8 to T12
How do you distinguish cp from rp
both conditions, right and left ventricular diastolic pressures are elevated.
In restriction, however, diastolic pressure in the left ventricle is higher than in the right ventricle at rest and during exercise, usually by at least 3-5mmHg.
pulmonary hypertension is common with restrictive cardiomyopathy but rare in constrictive pericarditis.
Marked right ventricular systolic hypertension (>60mmHg) usually indicates restrictive cardiomyopathy.
List the acynaotic lesion of heart disease
VSD ASD AVSD PDA APW
List the acyanotic obstructive left sided disorders
Aortic coartations Congenital AS supravalvular valvular Subvalvular HOCM Tunnel Membranous Interruped arch Congenital MS
List cyanotic lesions (right to left)
TOF pulmonary stenosis Tricupsid atresia Ebstein's anomaly Pulmonary atresia
List cynatic lesions with mixing
TGA
TAPVD
HLHS
Truncus arteriosus
What is incidence of PDA
20 to 30% of pre-term infants
up to 75% incidence in 28 to 30 weeks GA
List ways that PDA contributes to morbidity
NEC Renal failure abnormal cerebral blood flow respiratory distress chronic lung disease
What are other complications from PDA
Infective endocarditis
ductal aneursym
Aortic aneursym
pulmonary artery aneurysm
List other lesions that are associated with PDA
Aortic stenosis BAV mitral stensosis VSD subaortic stenosis
How do adults with CoArc present
unexplained HTN Headache Epistaxis visual disturbances exertional dyspnea CVA, aortic rupture/Dissection/aneursym
34% mortality by age 40
Mechanism of HTN in CoArc
Renin-angiotensin system disruption
Abnormal endothelial function proximal to stenosis
increased stiffness of prestenotic aortic wall
abnormal baroreceptor function
What are 5 most common associated anomlaies in Interrupted aortic arch
VSD Truncus TGA DORV AP window
List important features of DiGeorge Syndrome
Calcium metabolism
Immunologic abnormalities
learning difficulties
22q11
What is the management of Junctional ectopic tachycardia
Core Cooling to 34 to 35 degrees
Reduction in inotropes
Atrial pacing above JET
antiarrhythmic therapy–amio
What are Ransons Criteria for pancreatitis
Age > 55 WBC > 16 000 Blood glucose 200mg/dl Serum LDH 350 AST > 250
During 48 hrs HCT fall > 10% BUN increase > 8 Serum ca Arterial PO2; estimated fluid sequestration > 600 ccl BE
What are risk factors for AV groove disruption during mitral valve surgery
Non conservation of posterior leaflet and subvavular apparatus
Too aggressive decalcification of the annulus
Cutting the PM too close to the wall
Too much tension on tissues when excising the valve
Ancoring suture too deep in the muscle
malalignment of sutures not perpendicular
Too big or too small prosthetis
High profile valve
Damage with cardiotomy
HTN crisis
List side effects of cyclosporine A
Nephrotoxcitiy Neurotoxicity (tremor/seizure) Gingival hyperplasi pericaridal effusion abonormal hair growth
What are signs of traumatic aortic rupture of CXR
Large mediastinum > 8 mm Abnormal aortic contour, larger (0.7cm) Left main bronchus displaced in lower position Trachea displaced to the right increased angle between trachea and left main bronchus narrowing of the left main bronchs left pleaural cap liquid on the chest flail chest right deviation of the NG tube
Going on bypass with retrograde carioplegia cath. Position is good but you have very low coronary sinus pressure. You think?
This indicates patent left superior vena cava.
elevated pressure from kinking, valve obstruction.
