Previous exam 2004 Flashcards
What is management post PA rupture
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What are indications for Pulmonary valve replacement in a 15 year old with a TOF repair
PVR with RV failure or overload
symptomatic
arrythmias
severe TR
What is mechanism of amiodarone induced lung toxicity
Direct injury to lung accumulation of cellular drug phospholipid complexes that interfere with normal cell pathways toxic oxygen chronic inflammtion Indirect immunologic reaction
Treatment is just cessation of amiodarone and corticosteroids
How do you reverse dipyridamole toxicity
Persantine (antiplatelet agent) inhibits adenosine deaminase and phosphdiesterase which cases an ccumulation of adnonsine, cAMP. These inhibit platelet aggregation and may cause vasodilation
platelet transfusion to reverse effect
Mechaniam of protamine-induced pulmonary hypertension. What do you do if need to re-op
Protamine is administered at 1-2 mg/100units of heparin
heparin protaimine complex causes the release of thromboxane
Alternatives to protamine
Give a protamine test dose of 1 mg over 10 minutes
heparinases
recombinatn PF4
Hedadimethreine bromide
time
methylene blue
Torrential venous bleeding on dissecting out the SVC for bicaval cannulation. Name 3 potential sources
SVC Right pulmonary artery Right atrium Left atrial roof Azygous vein
Draw pressure volume loops…How do inotropes shift the curve.
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List 4 qualities on echo that would help determine if Balloon plasty for mitral stenosis is ok
Mitral regurgitation > 2+ Massive or bicommissural calcification left atrial thrombosis Severe aortic valve disease or severe tricusoid stenosis + regurgtiation severe CAD
VAD inserted for support..CVP gets elevated, decreased cardiac output, and urine output decreases
Likely cause is bleeding
Second option is right heart failure
Could be patent foramen ovale with left to right shunting and now you have RV overload and failure.
Echo, return to OR,
Indications to do CABG in shock situation
.
Indications for surgery of Left ventricular aneurysm
angina congestive heart failure selected ventricular arrhythmias increasing size embolism
List 8 symptoms of Left atrial myxoma
Heart Failure Embolization Fever Weight loss Elevated ESR Hemoystic anemia Leukocytosis Arthralgia Tumor plop Right sided heart failure--ascites, edema, heptomegaly
List 2 inclusion criteria for patients to receive cardiac resynchronization
advanced heart failure
intra-ventricular conduction delay
How does resynchronizatino improve symptoms
Improves ventricular contraction (Left ventricue)
improves the coordination of global contraction
Associated with reverse remodelling
Decreased MR jet areas
Reduction in LV mass
Improvement in hemodynamics
List 4 factors in determining decision to use a radial artery
Lack of conduits younger patient age extent of proximal stenosis target vessel run off -ive Allen test/vascular assessment
Two reasons why initial use of radial is associated with poor results
Vasospam
Use of vessels with low grade proximal stenosis
What is Laplace formula
Tension = Pressure x radius/ 2
4 reasons why you would develop mesenteric ischemia post AVR with calcium
Emboli
Aortic dissection
hypoperfusion 2nd to low blood pressure
Mesenteric vasoconstriction secondary to epinephrine
4 risk factors for post op AF after CABG
Advanced age
beta blocker withdrawal
preexisting AF
Extended cross clamp time
Incidence of AF post CABG is 25%
What are absolute contraindications to Ross Procedure
Advanced 3 vessel CAD
Extremes of Age (< 1 year or > 70)
Marfan syndrome
Multi system organ failure
Extensive multi valve pathology necessitating replacement of one or more valves
Large aortic root diameter (> 30mm)
Severely decreased left ventricular function
What are medical and surgical outcomes for major studies
CASS 4 years 88%(surgical) and 63% (medical)
VA 3 yeas 84% (surgical) and 60% (medical)
ECSS 3 years 93% (surgical) and 81% (medical)
Lose 700 cc blood over 30 minutes when on CPB. List 4 possible reasons for loss
volume in pleural space aortic dissection retroperitoneal hematoma Bleeding at cnnulation site Vasodilation, secondary to plegia/druga Aggressive diuresis
List 3 indications for surgery for chronic AI
Symptomatic patients (NYHA III or IV)
asymptomatic patients with LVEF < 50%
patients undergoing CAD or surgery of ascending aorta
Class IIa
asymptomatic patients with EF > 50% with severe LD dilation LVEDD > 70 mm or LVESD > 50 mm
4 complications of Endovascular stenting of descending aortic aneurysm
Aortic rupture
endoleak
stent migration
paraplegia
What is the Ratelli procedure
Performed for procedures such as
d-TGA
DORV and VSD
RVOTO
It consists of the a Gore Tex patch that directs oxygenated blood from the left ventricle to the aorta,while at the same time closing the VSD. The pulmonary valve is surgically closed and an artificial conduit and valve are constructed from the right ventricle to the pulmonary bifurcation
What are factors to consider when performing endovascular stenting
Adquate landing zone
Non tortuous aorta
Appropriate vascular access
Normal aorta of normal size at proximal neck
Normal aorta of normal size at distal neck
Absence of thrombus at landing zone
High vent pressure/return while on pump
List 3 causes
How would you exclude them
What would you do
Bradycardia
V.Fib/tachy
Aortic valve insufficiency
Distortion of heart/secondary incompentence of valve
repair the aortic valve Pace Defibrillate restore heart to normal anatomic position Arrest and unclamp while venting LV
List 8 common post op pulmonary complications
Atelectasis Pleural effusion Pneumothorax Pneumonia Hemothorax ARDS TRALI Chylothorax Pulmonary contusion post thoracotomy
Etiology that increases likelihood of aortic dissection
Hypertension Connective tissue disorder/Marfan Pregnancy Iatrogenic Drug use--Cocaine pre-existing aneurysm Congenital valvular abnormalities
What chamber is not well perfused with retrograde
What percentage returns to the right ostia, left, and RV
Right ventricle
Right ostia = 5-15%
Left ostia = 70-80%
Thesbian veins
Describe the Konno operation
Longitudinal aortic incision on the anterior wall
Incision continue to the left of the right coronary artery
across the aortic annulus
into the right ventricle below the pulmonary valve
into the interventricular septum
Ellipitcal piece of dacron to close the septal defect
place the valve
Close the aorta with a patch
What are current LDL, Choleserol and HDL ration for patients with CAD
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What test would you perform for myocardial contusion? What therapies? New murmur is detected?
TTE
Telemetry for 48 hours
2 Therapies Supportive IABP Telemetry Watch for mitral valve rupture and tricuspid rupture
What are hemodynamic effects of IABP
Left ventricle systolic pressure—-Decrease (afterload reduction)
Left diastolic pressure——-decrease (ventricular empyting is enhanced)
Aortic diastolic pressure—increases (balloon augmentation)
Aortic systolic pressure—decreases (after load reduction)
How does plavix work
Inhibits platelet aggregation
Inhibits ADPs ability to bind to the platelet receptor (P2Y12) and the ADP mediated activation of GPIIb/IIIa complex. This is irreversible.
What is mechanism of LMWH
Inhibits both factor Xa and thrombin
Not reversed with protamine and does not affect PTT and ACT
What is mechanism of HIT
severe immune mediated drug reaction.
Heparin binds to platelet factor 4 forming a highly reactive antigenic complex on the surface of platelets.
Patient then develops an antibody (IgG) to the heparin/PF4 antigenic complex
Antibody activates the platelets via Fc receptors
Thormbocytopenia develops
4 things in sequence for treatment of anticoagulation
Stop all Heparin Start Argatroban Danaparoid Lepirudin Warfarin after several days TTE
3 Ways that retrograde perfusion avoid neurologic injury
Washes out debris from arterial system
Improved cooling of the brain
improved nutritions of the brain
4 potential benefits of off pump CABG
Decrease whole body inflammatory response smaller heparin dose less hemodilution shorter LOS Shorter ICU fewer pulmonary complications
List the cardiac manifestations of carcinoid syndrome
Carcinoid heart disease is reported in approximately 50 to 60% of all patients with malignant carcinoid syndrome
occurs on the right side of the heart
Fibrous deposits adhering to the surface of the valvular endocardium
thickening of the endocardium of the cardiac chambers and papillary muscle and deformation of the valve cusps and chordae tendinae. Can result in combined diseases
Tricuspid valve is affected most commonly
Different ways to identify calcified aorta
CXR
CT scan
Epiaortic Scanning
Digital palpation
Techniques to repair mitral valve
Chordal transfer Neochords Triangular resection Chordal shortening Alfieri stitch leaflet extension
3 characteristics of ASD not amenable to Amplatz device closure
Rim insufficient to allow proper seating (minimum is 5 mm) Large ASD maximum 20 mm Small body wight < 10 kg Ostium Primum
Why close an ASD to avoid decompression sickness
Scuba diving can cause formation of inert bubbles that collect.
Formed in venous system and crosses into arterial system through ASD
Two types
I: emboli around skeletal join, knees, elbow, and shoulders
II: progress of type I to involve CNS and CVS
What are principles of surgery for constrictive pericarditis
Sternotomy
On or Off pump
Release ventricles from the densely adherent adhesions
Phrenic to phrenic anteriorly and posteriorly–from entrance of vena Cava and pulmonary veins to diaphragm
What is the Duke Criteria for Endocarditis
Major:
Minor: Predisposing condition fever immunological Oslers Roth spots vascular janeway septic emboli echo not meeting critieria mircobiologic phenomena
.
Define classifications of Aortic Dissections
Stanford A: involving the ascending aorta
Stanford B: dissection limited to the descending aorta, not involving the ascending aorta
Debakey I: involving the ascending aorta and extending into the descending aorta
Debakey II: dissection involving only the ascending aorta
Debakey IIa: dissection limited to the thoracic descending aorta
Debakey IIb: involving the whole descending aorta
