Previous Exam 2005 Flashcards by Naser Zalloum

4 etiologies for high line pressure when on bypass

partial outflow obstruction 
malpositioning cannula
partial clamping of cannula
kinking of cannula 
aortic dissection

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List 4 reasons why you have to tell patient about a life threatening illness that wife doesn’t want you to tell

beneficience
autonomy
justice
nonmalficience

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Pt with coarctation repair at age 5. Now with pseudoaneursyn of 8 cm distal to left subclavian.
What was the method of the first operation
What are 4 ways to prevent paraplegia

likely a patch aorto-plasty
other options
resection with end to end anatomosis
resection with insertion of interposition graft
patch aortoplasty
subclavian-flap aortoplasty
4 ways to prevent paraplegia
CPB with hypothermic circulatory arrest
reattachment of thoracic and segmental intercostals and lumbar arteries (T8-L1)
sequential aortic clamping
CSF drainage
left heart bypass
measurement of sensory and motor evoked potentials.

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List 5 complications of coarctation repair

recurrent larnygeal nerve injury 
paraplegia
chylothorax
Horners sydrome
re-coarctation 
anastomotic aneurysm

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28 year old with transected aorta in MVC. Discuss appropriate for
Open repair
Stenting
Delayed repair

Open: recommended in stable patients not requiring laparotomy, craniotomy, or pelvic stabilitzation. If no other life-threatening injuries, it is the gold standard

Stenting: maybe used to those who cannot undergo immediate open repair. avoids heparin. allows patients to undergo simultaneous repair, avoids single lung

Delayed repair

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Patient with moderate to severe secondary TV going for MV operation
What would do you to TV
if TV is secondary and modearte what are some things that will sway you towards not repairing the TR

Indications
Severe primary or secondary TR in symptomatic pts not responding to meds
severe TR in pts underging MV surgery
mild or moderate TR in patients with dilated annulus (> 40mm)

Would not operate if there is 
	absence of RV dilation 
	absence of RV dysfunction 
	emergent OR for acute MR
	if repair is not feasible and you would have to replace

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Trauma pt with large L pleural effusion. CT drained 2L of milky fluid 
What is diagnosis
What 3 tests would confirm 
2 ways to treat medically 
3 ways to treat surgically

Chylothorax
Fluid for chylomicrons, high TG, lymphocytes

Medical treatment 
	TPN + NPO 
	Medium-chain fatty acids
	octreotide
Surgical treatment 
	thoracic duct ligation--between 8 and 12th thoracic vertebrai--usually through right chest
	pleurodesis 
	pleuroperitoneal shunt

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List 4 post acute MI complications that are amenable to immediate surgical repair

ischemic MR 
Ventricular rupture
Ischemic VSD
LV aneurysm (false and true) 
cadiogenic shock

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List 4 findings on stress thallium that can predict high likelihood of future events

Pulmonary captation (?)
reversible LV dilation
mult-teritory involvement

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Pt with 20% EF with LM 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

Viabilitity studies—assess if hibernating myocardium

Thallium, PET, MRI, Dobutamine

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Uneventful MVR in a female. POD # 2 sudden arrest on ward. After chest compressions, she regains consciouness with no neurologic deficit. HR and BP are normal. EKG 1st degree AV block

3 possible causes

Tamponade 
Arrhytmias
valve thrombosis/dysfunction
vaso-vagal
stroke
TIA
transient ischemia

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List echo findings of ischemic MR

Papillary muscle displacment (posterior and inferior) 
Ventricular dilation 
Seagull deformity of anterior leaflets 
annular dilation (posteior dilation) 
leaflet tethering

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Classification of Mitral valve pathology

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Female pt with 21 aortic bioprosthesis. Under what indexed EFO do you expect PPM

What percentage of patients with PPM will experience residual symptoms
What percentage of these patients will experience improvement in 1-2 NHYA classes

0.85cm2/m2 for mismatch. Severe is .65cm2/m2

30% of patients with PPM will have residual symptoms

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List 3 most common non myxomatous cardiac tumors

lipoma
papillary fibroelastoma
hemangioma

rhabdomyoma * in kids*

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Common malignant tumors

angiosarcoma
rhabdomyosarcoma
meotheliomo
fibrosacroma

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With respect to aortic root enlargement procedures
Describe the incision of a Nicks

How is manougian different

How much annular diameter would you get from these techqniues

Nicks–through the non-coronary sinus into annulus

Manougian
in comissure b/w LCC and NCC and continues down to anterior leaflet of mitral valve
1 valve size (2mm) for a Nics
2 sizes (4mm) for Manourgian

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List 5 cath findings of constrictive pericarditis

equalization of pressures (LVEDP and RVEDp are within 5 mmHg)
elevation of mean atrial pressure (> 10 mmhg is suggestive of tamponade or constriction)
square root sign (on ventricular pressure tracing: gradual onset of diastolic filling is interrupted by an abrupt dip as the ventricle encounters constrictive pericardium)
prominent Y descent (in right atrial tracing)
elevated RVEDP (> 1/3 RVESP)
left ventricular ejection fraction is > 40%

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Patient with post op AF and cannot tolerate meds. List 3 other options

Cardioversion
ablation with pacing
OR for maze

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Pt with an intramural hematoma. What is the definition and etiology? What is the natural history? How would you treatm?

Collection of blood in the media of the aortic wall without flap or flow

etiology–rupture of vaso vasorum or penetraiting atherosclerotic

Natural history–33% mortality for ascending aorta, 9.7% for descending aorta
If anasecnding aorta then treat like a type A. if in descending then treat like a type B

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What are options for ascending aortic dissection with moderate AI

Bentall
Supracoronary tube graft
Aortic valve repair (reimplantation vs remodeling)

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Describe mechanism of action and the role of spinal cord stimulation in the treatment of angina

Stimulation of the dorsal aspect of the T1 and T2 spinal cord suppresses pain associated with myocardial ishcmia by modulation of activity of intrinsic cardiac neurons.

Five year old patient with ASD. List 4 situations that would preclude percutaneous device closure

If not a secundum–ASD or PFO
Other anomalies requiring heart surgery
orifice must be wide enough to accomadate the deice
adquequate rim
access vessels not large enough to accmodate shearth

You need to close an ASD in a patient with decompression illness because after treatment in hyperbaric chamber for decompression there is a increased risk of pardoxical emboli.

TOF repair with anomalous vessel crossing RVOT from right to left.

What is it?
List 3 options of dealing with this scenario

Anomalous LAD

Options
transatrial transeptal approach is usually effective, allowing a short transannular patch
RV-PA conduit
The extent of the RV ventriculotomy will be limited
palliative shunt

Name 4 classes of meds that all patients post CABG should be on

Beta-Blocker (metoprolol) Statin ACE Anti-platelet agetn

List 3 classes of anti-thrombotic meds used in acute coronary syndrome

``` GPIIb/IIIa--abciximab--repro tirofiban (aggrastat) eptifibatide (integrelin) ASA Clopidogrel ```

List 5 absolute contraindications to the use of a donor heart

``` Age Presence of the follow prolonged cardiac arrest prolonged severe hypotension preexisiting cardiac disease intracardiac drug injection sepsis positive serologies of HIV, Hep B, Hep C ```

List 5 indications for severe, chronic MR

``` symptoms EF < 60% with LVESD > 45mm recent A fib PHTN EF < 30% _ LVESD > 55m in whom chordal presevation is highly likely. ```

List 4 physiologic changes that occur during pregnancy

``` increased blood volume increased red cell mass increased heart rate decreased peripheral vascular resistance increased cardiac outout decreased BP caval compression hypercoagulable state ```

List 4 absolute contraiidcations to TEE

``` tumor Recent suture lines Diverticula C spine injury (C1 and C2 degernation) esophageal stricture ```

Definitions of types of heart transplants

Orthotopic: removal of recipients heart, replacement with donor heart Hetertopic: recipients heart is conserved for severe PHTN, RV failure

List 2 options for implanting a PPM in a patient with mechanical ticuspid valve

coroanary sinus epicardial around the valve annulus

What are boundaries of triangle of kock

tendon of tordaro septal leaflet of tricuspid valve coronary sinus

List 3 mechanisms of how LV aneurysms cause LV dysfunction

Increased wall tension: increased MVo2 loss of LV synchrony for organized contraction spherical shape

Review definitions of heart transplant biopsy

Definition of grade 1A rejection: Focal inflammatory infiltrate: repeat biopsy.

What is diastolic dysfunction What are risk factors for diastolic dysfunction

refers to disturbance in ventricular relaxation, distensibility or filling. Regardless of whether the ejection fraction is normal is depressed Hypertension Unstable angina old age, female, diabetes, CAD

4 treatments of diastolic dysfunction

``` slower heart rate PDI inhibitors improve filling pressures AV synchrony afterload reduction ```

Define Crawford I, II, III, and IV aneurysms

Crawford I: left subclavian to renal arteries Crawford II: Left subclavian to Iliac arteries Crawford III: Mid descending thoracic aorta to iliac arteries Crawford IV: supraceliac aorta (below diaphragm) to iliac arteries

4 advantages of internal mammary artery skeletonization

``` length less neuropathy easier sequential flow increased less pain ```

Define Structural valve dysfunction

any change in function (decrease of one NYHA functional class or more) of an operated valve resulting from intrinsic abnormality of the valve that causes stenosis or regurgitation

Define valve thrombosis

any thrombus, in the absence of infection, attached or near an operated vavle that occludes part of the blood flow path, or that interferes with the function of the valve.

List 3 options for the management of an ischemic leg in pt with IABP.

Remove IABP and switch to other side embolectomy/local reconstruction Fem-Fem bypass

5 indications for early operative intervention for type B dissection

``` Pain unresponsive to treatment refractory Hypertension Malperfusion Sizable false aneursym Aortic rupture pending?? ```

Define alpha stat

Adding CO2 because pH adjusted to temperature during cooling. Results in improved cooling.

Define alpha stat

pH measured at 37 decreases and not adding CO2

What investigations are important for patient thromboembolic disease on pulmonary function testing

Diffusing capacity is often reduced Most patients have room air arterial oxytension between 50 to 85toor. Co2 tension is reduced and compensated by reduced HO3

List 5 steps of management for 3rd time redo when gush of dark blood occurs

Reclose chest Expose femoral vessels Heparin Cannulate arterial and vein and start CPB Re-open sternum with suction, relieve tension, dissect, and repair

List 4 mechanisms of neurologic injury on CPB

``` Mirco-emboli (air bubbles, fat dropplets) Marco-emboli Hypoperfusion Ischemia Inflammatory Intracranial bleeding ```

Patient in cath lab has a dissection. What is management?

Would do surgery ASAP Keep heparin on to the OR. If on plavix then ask for platelet. If possible delay for 5 days

Pertaining to AS

Normal AVA 3- 4 cm Mild AS 1.5 to 3 Moderate 1.0 to 1.5cm2 Severe < 1 cm2

Pertaining to rate responsive pacemakers what are 5 variable that they can sense

``` Heat Resp rate Body vibration QT interval RV stroke volume Intracardiac pressure CO2 lactic acid Svo2 RV stroke volume ```

What is advantage of pH statt

Increased CBF compared to alpha stat preferential in children allows uniform cooling of the head Rate of brain oxygen depletion during DHCA is slower Disadvantage addition of CO2 may lead to brain acidosis and CNS injury during rewarming increased CBF might increase the cerebral embolic load decreased ability to maintain autoregulation at low pressures

what is advantage of alpha stat

may provide the greatet cerebral protection during hypothermia for adults easier

``` 25 year old drug addict with high fever Name 2 diagnostic tests What valve is most likely involved 5 indications for surgical intervention in TV endocarditis 4 surgical options Most common organism ```

Transthoracic echo and Blood cultures Triscuspid 5--multiple emboli after appropriate abx; uncontrolled sepsis; large vegetation; evidence of abscess; onset of conduction disturbance; symptoms of right heart failure; large vegetation ``` 4 surgical options local excisoin of vegetation and pericardial patch bicuspidization excision of tricuspid valve tricuspid valve replacement most common organism is staph aerus ```