Previous Exam 2005 Flashcards
4 etiologies for high line pressure when on bypass
partial outflow obstruction malpositioning cannula partial clamping of cannula kinking of cannula aortic dissection
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
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.
List 5 complications of coarctation repair
recurrent larnygeal nerve injury paraplegia chylothorax Horners sydrome re-coarctation anastomotic aneurysm
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
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
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
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
List 4 findings on stress thallium that can predict high likelihood of future events
Pulmonary captation (?)
reversible LV dilation
mult-teritory involvement
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
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
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
Classification of Mitral valve pathology
.
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
List 3 most common non myxomatous cardiac tumors
lipoma
papillary fibroelastoma
hemangioma
rhabdomyoma * in kids*
Common malignant tumors
angiosarcoma
rhabdomyosarcoma
meotheliomo
fibrosacroma
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
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%
Patient with post op AF and cannot tolerate meds. List 3 other options
Cardioversion
ablation with pacing
OR for maze
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
What are options for ascending aortic dissection with moderate AI
Bentall
Supracoronary tube graft
Aortic valve repair (reimplantation vs remodeling)
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
