preparation

Question 1

surgery risks

Answer 1

low- endoscopic, superficial, cataract, breast, ambulatory surgery
-intermediate- intraperitoneal and intrathoracic, carotid endarectomy, head/neck surgery, ortho, prostate
high- aortic and other major vascular surgery, peripheral vascular surgery

Question 2

patient risks

Answer 2

major-
intermediate-
minor-

Question 3

cardiac surgery risk assessment

Answer 3

• euroscore

- bayes model

Question 4

non cardiac surgery risk assessment

Answer 4

• ACC/AHA stepwise approach
• RCRI
• ACS-NSQIP

Question 5

PCI

Answer 5

• early phase
• granulation and tissue remodeling
• in stent restenosis-peaks 4-12 months

Question 6

echocardiography

Answer 6

most widely used cardiac diagnostic tool for structural/functional capabilities
-regional wall motion abnormalities- diagnostic for CAD. assess wall thickening
1=normal
2=hypokinetic
3=akinetic
4=dyskinetic

Question 7

METs

Answer 7

1 met= BMR (3.5ml O2/kg/min)

Question 8

Valvular lesions

Answer 8

Mitral: normal 4-6
mild stenosis: 1.5-4
mod. stenosis: 1-1.5
severe stenosis: <1 
mild regurg: <30%
mild-severe: 30-50%
Severe regurg: >50%
*preload dependent
*conduction abnormalities
*a. fib

aortic: normal 2.6-3.5
mild: >1.5
moderate: 1-1.5
severe: <1
mild regurg: <30%
moderate: 30-50
severe: >50%

Question 9

stress echo

Answer 9

add hemodynamic stressor during echo

manifests as wall motion abnormalities

Question 10

myocardial nuclear scintigraphy

Answer 10

most common diagnostic tool for evaluation of myocardial ischemia and variability in preop.

• radioactive substance is injected. decay of substance around heart is picked up. poorly perfused areas have less decay because agent cant get to it.
• negative study is a strong indicator for no CAD

Question 11

Cardiac CT

Answer 11

only validated in patients without CAD.
lots of radiation but good for high risk patients to avoid angio
good for eval of prosthetic valves

Question 12

Cardiac MRI

Answer 12

gold standard for quantitative assessment of biventricular volumes, EF, and mass
gold standard for right side evaluation, chronic thoracic aneurysm evaluation
-highest negative predictive value

Question 13

coronary angiography/hybrid OR considerations

Answer 13

• angio is gold standard for coronary anatomy and extent/severity of CAD
• lots of contrast- allergy, kidney disease, metformin
• max dose contrast= 4ml/kg

Question 14

Left sided cath

Answer 14

• femoral artery approach- sheaths introduced- 2 coronary catheters: L/R coronary and L ventricle
• anticoagulate if more than 30min
• complications: MI, VT, embolism, stroke, hematoma, contrast injury

Question 15

right sided cath

Answer 15

• brachial, femoral, or IJ vein approach

- complications: RBBB, heart block, valve damage

Question 16

coronary arteriography

Answer 16

• direct assessment of coronary vessel/structure and stenosis
• stenosis= % of diameter reduction 50% is significant

Question 17

EP lab considerations

Answer 17

• place external cardioversion electrodes
• femoral vessel cannulated
• systemic heparin
• long procedures
• usually MAC
• volatiles depress AV node and accessory pathways (physician needs to see those to know where to ablate)
• avoid sympathetic stimulation