Previous exam (2005) Flashcards
Failure to arrest heart with antergrade cardioplegia
The problem is aortic insufficiency
Could stop, vent through the root and give again at high pressure
attempt placement of retrograde
Arterial line showing low pressure (24mmHg) ECG tracing asystole, PAP 2mmHg, retrograde has a pressure of 32 mmHg, arterial line pressure is 80mmHg.
This patient has hypotension from either vasodilation or hypovolemia
Increase pump flow
Add vasopressors
*increase fluid
Hemodynamics show a retrograde tracing of 32mmHg, and arterial line pressure of 260mmHg
Cardioplegi pressure is too high
possible etiologies kinked line catheter too far clamp on line cardioplegia not right?
rideout upper queens, kingston (straight…down and up hill. right
Patient with a coactation repair at age 5. Now with pseudoaneursym of 8 cm just distal to left subclavian
what is the method of repair at first operation?
List 4 methods to protect the spinal cord during the repair operation
Likely end to end
Hypothermia Cerebrospinal fluid drainage maintain adeuqate perfusion pressure distal perfusion support minimize ischemic clamp time preserve intercostals
What is the preferred method of repair of coarctation for
neonate?
adult?
Neonate: extended end to end; subclavian flap
Adult: interposition graft; end to end; angioplasty/stent
List 5 complications of carctation repair
Recurrent laryngeal nerve injury thoracic duct injury paralplegia paradoxical hypertension late true aneurysm pseudoaneursym intermittent visceral ischemic pain recoarctation
CT scan showing transected aorta just distal to the left subclavian
discuss appropriateness of each of the following
Open repair
Stenting
Delayed repair
Open repair: viable option for pt w/o life threatening instability or other severe life threatening injuries.
Stenting: when readily available with suitable anatomy, useful in pts with other major concomitant injuries. Becoming more common. Carries risk of endoleak, branch vessel occlusion, infection, hematoma, paraplegia, stroke
Delayed repair: when stenting not available and pt has other severe life threatening injuries.
Patient with moderate to severe secondary TR going for MV operation
What would you do? If the TR is secondary and moderate what findings sway you to no repairing
Tricuspid ring Right ventricle is normal size tricuspid annulus not dilated (<30mm) Right ventricle functioning well minimal pulmonary hypertension
Trauma pt with a large L pleural effusion, CT drained 2L of milky fluid
Likely diagnosis is chylothorax
3 tests are
TG > 1.1 mmol
Cell count: lymphocytes > 80%
Cell > 1000 microlitre
2 ways to treat medically are medium chain triglyceride diet; TPN
3 ways to treat surgically: tube thoracostomy; pleurodesis; duct ligation; pleuroperitonal drainage
List 4 post acute MI complications that are amenable to immediate surgical repair
Left ventricle perforation
rupture papillary muscle rupture
Ventricular septal defect
Cardiogenic shock secondary to heart failure
List 3 findings on a stress thallium scan that predict high likelihood of future cardiac events
Left ventricle dilation with stress
Increased pulmonary activity
Extensive reversible ischemia of multiple segments
reverse redistribution
Patient with 20% EF , LF and LAD disease, No angina, symptoms of CHF. What would you like to know about the myocardium? List 3 tests that can be used to predict benefit from revascularization
Viability
Stress thallium scan
PET scan
Sestamibi scan
Dobutamine echo
Uneventful MVR in a female. POD # 2 sudden arrest on ward. After chest compressions regains…EKG shows 1st degree AV block. What are 3 possible causes
Ventricular arrhythmia
vagal episode
AV conduction block (3rd degree)
Peri-infarct VT, VF arrest–now post op CABG X 3 month. Management is what?
If EF is restored to normal
EP study if positive AICD if negative continue post op medical management
If EF remained at 30%
AICD
List 5 echocardiographic findings of ischemic MR
displaced papillary muscle annular dilation restricted posterior leaflet motion elongated papillary muscle Rwma?(not sure what this is?)
Carpentier Classification of mitral valve pathology
I normal motion
II excessive motion
IIa restricted systolic and diastolic motion
IIb restricted systolic motion
Female patient with 21 mm aortic bioprosthesi. With respect to PPM and aortic root enlargement
1) under what indexed EFO do you expect PPM
2) What % of patients with PPM will experience residual symptoms
3) What % of these patients will experience improvement of 1-2 NHYA classes
0.85cm/m2
37% will experience residual symptoms
90% will experience improvement of 1-2 NHYA class
List 3 most common benign non-myxomatous cardiac tumors
rhabdomyoma
lipoma
papillary fibroelastoma
With respect to aortic root enlargement procedures
1) Describe the incision of a Nicks aortoplasty
2) How is a Manougian difference
3) How much annular diameter would you expect to gain from these techniques
Nicks aortoplasty: incision made in the middle of non coronary sinus up to annulus
Manouguain: incision made between the non and left coronary cusp and onto anterior leaflet of mitral valve (close to roof of LA)
Can expect 2 mm (2 sizes with a Nicks) and 4 mm with a Manougian
5 cath findings of constrictive pericarditis
square root sign of right ventricle pressure tracing during diastole inspiratory increase in right CVP prominent y descent decreased cardiac output equal CVP/PAD/PCWP/RA/PV pressure
Patient with post operative atrial fibrillation. Cannot tolerate medical treatment List 3 options at restoring sinus rhythm
DC cardioversion
Pharmacologic cardioversion
AV node ablationand permanent pacing
Patient with chronic hypertension presents with acute back pain. CT shows intramural hematoma
What is the definition and etiology of IMH?
What is the natural history of this lesion?
How would you treat?
Presence of IMH without dissection of aortic layers–two etiologies
rupture of vasa vasorum
intimal disruption with contained hematoma and no dissection
Natural history is 1/3 aneursym, 1/3 improve and 1/3 remain the same
I would treat a surgical type A IMH with surgical managment
With regards to AV managment in ascending aortic dissection with moderate AI. What are 3 options
Resuspend aortic valve
Bentall
Valve sparing aortic root replacement
Describe the mechanism of action and the role of spinal cord stimulation in the treatment of angina
Mechanism: produces a functional sympathectomy and alters pain perception
The role for this is in patients with non-revascularizable CAD who have ongoing angina
Five year old pt with ASD.List 4 situations that preclude percutaneous device closure
No Landing rim primum AS Large ASD (> 20mm) Sinus venosus defect pervious failed percutaneous repair
TOF repair. You open the pericardium and there is an anomalous vessel curing the RVOT from right to left
What is it?
List 3 options for dealing with this scenario
Anolmalous LAD from RCA
Repair TOF through a trans atrial approach only
Repair RVOT through combined atrial/transpulmonary approach
Transverse ventriculotomy beneath coronary to remove RV muscle bundles
Use of RV to PA conduit with intracoronary ventriculotomy
Patient comes to office post CABG surgery and list 4 classes of medication and rational for each
Beta blockers: Survival benefit in those who have had a MI
Statin: shown to have a positive impact on CAD with graft longevity
ACE: control hypertension and reduced future events especially in setting of previous MI
Aspirin: improves graft patency and reduction of events related to CAD
List 3 classes of anti-thormbotic mechanism used in the treatment of ACS
Antiplatelet agents—plavix, ASA
Anticoagulatnt: Heparin
Thrombolytics: TNK, streptokinase
Placement of chest tube into the colon. 5 management steps with Gen surg
Removal of CT and closure of mediastinal-peritoneal communication
Broad antibiotic coverage
Extensive irrigation
Laparotomy
Repair of colonic laceration
placement of chest tube in remote location
List 5 absolute contraindications to the use of a donor heart
ABO mismatch
Prolonged CPR, hypoxia or hypotension
HIV infection, HCV, HBV
High inotropic requirements
List 5 indications for surgery fro severe, chronic MR
Low ejection fraction NHYA II, III, or IV New onset of atrial fibrillation LV dilation (LVESD > 45mm) Setting of concomitant procedure Pulmonary hypertension (PAS > 50mmHg)
List 4 physiologicl changes that occur during pregnancy that can exacerbate an existing cardiac condition
Increased heart rate
increased circulating volume
Anemia
decreased systemic vascular resistance
List 4 absolute contraindications to insertion of a TEE probe
Esophageal perforation Esophageal stricture Esphagleal diverticulum Esophageal laceration Espophageal spasm
relative: antlanto-axial instability associated with arthritis; large hiatus hernai; upper GI bleed; significant dysphagia, cervical arthritisi
With current Canadian standards for blood products what are the infection rates for HIV, HCV HBV CJD
HIV 1 in 4 Million
HCV 1 in 3 Million
HBV 1 in 275 000
CJD 1 in 10 Million
Definitionas of type of Heart transplants
Orthotopic–replaces organ in the anatomic position
Classic Shumway–biatrial
Bicaval venous inflow anastomiss of patients SVC and IVC to transplant organ
complete: 2 separate pulmonary vein islands and SCV and IVC anastomosis
2) Heterotropic in a non anatomic position
List 2 options for implanting a permanent ventricular pacemaker in a patient with a mechanical tricuspid valve
Epicardial
Ventricular lead through the coronary sinus
List 3 mechanims of how LV aneurysms cause LV dysfuntion
Increase global LV wall tension thereby decreasing global subendocardial perfusion
Paradoixcal dyskinetic motion of LV aneursym reduces systolic efficiceny
Increased wall tension on normal myocardiaum leads to global remodeling with overal LV dilation with systolic and diastolic dysfunction
What are boundaries of the triable of koch
Coronary sinus
Tricuspid annulus corresponding to septal leaflet of tricuspid valve
Tendon of Todaro
Patient 1 week post OHT and has a biopsy showing grade 1A rejection
What is definition of 1A rejection? how would you manage it
Repeat shows grade IIIB, what would be managment
What are revised definition of of ISHLT
If grade 1A just manage with current medical management and make sure its optimized
Grade IIIb– high dose iv steroids and switch maintenance drugs; repeat biopsy if still positive then consider repeat iv steroids or ATG
0—no rejection
1—mild lymphocytic infiltrates without myocytosis OR one focus of infiltration with myocytolisis
2—-moderate, multifocal sites of infiltration and myocytolisis
3 —- severe, generalized infiltration and mycocytolisis with edma and hemorrhage, vasculitis, and necrosis
treat grade 2 and 3
List 5 presentations of a left atrial myxoma
Embolism Congestive heart failure Fevers, arthralgias, myalgias, malaise, constitutional symptoms Endocarditis rhythm disturbances
What are the mechanisms of action for cyclosporin ATG OKT3 Azathioprine Prednisone
Cyclosporin–Calcineurin inhibitor–results in IL-2 and subsequent lymphocyte inhibition
ATG–ployclonal antiobodies to thymocytes resulting in rapid T cell depletion
OKT3–Monoclonal antibody to thymocytes resulting in rapid T cell depletion
Azathoprine—anti-proliferative which inhibits lymphocyte proliferation by inhibiting de novo and salvage purine biosynthesis
Prednisone–inhibit lymphyocyte proliferation by inhibiting macrophage production of IL-1 and IL-6.
List 3 methods of cerebral protection in someone undergoing DHCA
Adequate hypothermia antegrade cerebral perfusion retrograde cerebral perfusion topical cooling (pack head in ice) pharmacoligcal (largely unproven)
78 year old female with low cardiac output post CABG
what is diastolic dysfunction?
What are risk factors for diastolic dysfunction?
List 4 treatments for diastolic dysfunction?
Impaired compliance of the ventricular myocardium with resultant increased stiffness ultimately leading to poor ventricular filling, decreased preload and decreased cardiac output
Risk factors for diastolic dysfunction: diabetes, hypertension, ischemia, cardiopulmonary bypass, female sex, elderly
treatments; ensure maximal preload, reduced afterload, cAMP dependent inotropy, intra-aortic balloon pump
Compare and contrast “bridge to transplant” to “bridge to recovery”
Both instance require use of mechanical assist device to support myocardial function
Bridge to transplant has goal of temporary support until a suitable organ becomes available for transplant versus bridge to recovery which may employ longer support to allow wean from device when pts own myocardium can support the circulation
Bridge to recovery is applied in scenarios where recovery is likely (viral or post cardiotomy stunning) whereas disease processes with no potential for recovery should not be managed this way
Define Crawford type I, II, III, and IV
Type I: above T6 to above renals
Type II: above T6 to below renals
Type III: below T6 to varying degree of abdominal aorta
Type IV: varying extent of abdominal aorta only from above renals but below diaphragm
4 potential advantages of skeletonization of ITA
increased length preserve sternal vascularity decreased parasthesia associated with higher graft flows associated with larger anastomotic diameters
Calculate shunt fraction when given right and left heart cath saturations
.
Define the following
Structural valve dysfunction: change in function of any operated valve related to intrinsic abnormality of the valve that causes stenosis or regurgitation
Non structural: Abnormality resulting in stenosis or regurgiation of the operated valve not intrinsic to the valve itself.
Valve thrombosis : any thrombus not related to endocarditis on or near the valve that occludes part of the path of flowof blood
Bleeding event: any episode of major internal or external bleeding that causes death, injury, requires hospitalization or transfusion
Embolism: any embolic event that occurs in the abscence of infection in the immediate postoperative period
.
IABP with an ischemic leg: List 3 options for mangement
Remove IABP
Anticoagulation
Thormbectomy
What are 5 indications for early operative surgery for type B dissections
Refractory hypertension–unresponsive to medical therapy
Refractory pain–unresponsive to medical therapy
End organ malperfusion symdome (visceral, renal, limb)
rupture
aneurysm formation
progressive dissection
Define pH stat and alpha stat and list 1 advantage of each
pH stat: active correction of alkalosis associated with cooling by adding CO2 while on CPB
increase ratio of cerebral blood flow to cerebral oxygen demand (
increases rate of cooling
alpha stat: no active correction of alkalosis associated with cooling
easy to accomplish
in adults may be preferable not to increase cerebral flow to minimize embolization while on CPB
preserves cerebral autoregulation at low blood pressure better then pH stat
60 year old female with chronic pulmonary thromboembolic disease
List 2 abnormalities or either ABG or PFT
What are 2 absolute contraindications for pulmonary thromboenartectomy
Reduced PO2 on ABG
Moderate reduction of DLCO
Type IV thromboembolic disease no upper limit of PVR precluding surgery Significant and severe parenchymal disease Severe PVD (relative) other send stage terminal illness
55 year old undergoing 3rd time sternotomy and during opening dark blood. List 5 steps for management
administer full dose heparin, volume, and RBC as necessary
compress/pack sternum with cell saver suction recovery of blood
cannulate femoral vessels
initiate cardiopulmonary bypass with cooling and use of pump suckers
carry on with careful dissection
List 4 mechanisms of neurologic injury for a patient on CPB
altered cerebral blood flow
microemboli
cerebral ischemia/reperfusion injury
whole body inflammatory repsonses
Cath Lab with an LAD dissection. Patient is stable but on UFH ad received plavix. What is management
Discontinue plavix and stay on UFH
If stable its ok to wait?
Pertaining to AS
Normal AVA - 2-4 cm2 Mild AS 1.5 to 2 cm2 Moderate AS < 1.5 cm2 Severe AS < 1cm Congenital is all based on pressure.
Pertaining to rate responsive pacemakers. What are 5 variable that they can sense?
What are the basic components of rate responsive pacemakers
Respiratory movement motion temperature with dedicated lead QT interval RV stroke volume through impedance RV pressure with dedicated lead
Generator/battery
sensor
pacing leads
response algorithm
25 year old with IVDU and fever: What tests? What valve most likely inovolved? 5 indications for TV endocarditits? 4 surgical options? most common organisms?
Blood cultures and TTE required
Tricuspid
Heart failure/uncontrolled sepsis/antiobiotic reistance/type of organism/large vegetation/multiple emboli/abscess/intracardiac fistula
Valve repair/valve replacement/valvectomy
Most common organisms are staph aureus/gram negative/candida
