Previous exam 2007 Flashcards
6 anatomical layers cross with axillary artery cannulation
Skin subcutaneous tissue/fat pec major Clavico-pectoral fascia pec minor axillary sheath wall of artery (adventitia)
2 ways to cannulate are 1) Direct 2) through an end to side Dacron graft (8 or 10 mm)
4 possible advantages of axial flow pumps and 1 disadvantage
Minimal aticoagulation Quiet Small size Less power consumption durability
Disadvantage
Hemolysis/shear forces
non-pulsatile
Potential for negative ventricular pressure (air embolism, device thrombosis)
What is difference between dilated cardiomyopathy and hypertrophic cardiomyopathy
LVEF (reduced, normal)
LVEDV (increased, reduced)
LVESV (increased, reduced)
LV mass (increased, increased)
LV mass/volume (decreased, increased)
LV chamber thickness (deceased, increased)
Wall tension (increased, normal/increased)
What is Vo2 max effect on survival
if < 10 (50% die in one year)
if 10 to 18 (65-80% survival in one year)
if > 18 then (>95% survival in one year)
List factors that make SAM worse
Inotropes
Decrease in afterload
decrease in preload
tachycardia
What are risk factors for SAM
increase height of posterior leaflet of mitral valve
small left ventricle
narrow angle between mitro-aortic angle
Hypertrophic septum
What is JVP tracing in patient with AF…Draw it
No a wave, small x descent, large v wave, prominent y descent
What is the relevance of Intravascular ultrasound
Mean lumen diameter of 4.0 mm2 has been assessed as being a the cutoff threshold for intervention.
What are 5 complications from Fontan physiology
Protein losing enteropathy Arrhythmias cyanosis Conduit obstruction failing fontan circulation (higher PVR, single ventricle failing) exercise intolerance Thromboembolic Hepatic dysfunction
Strategies to reduce the risk of neuro dysfunction on pump CABG
hypothermia slow rewarming epiaortic scanning minimal manipulation of aorta higher perfusion pressures lower CPB times anti-inflammatory strategies Avoid cardiotomy suction
Describe approach to a root abscess under left main
Adequate debridement, closure of abscess cavity, assessment of anterior leaflet of mitral valve, assessment of left main coronary artery involvement. Reconstruction of the root with dacron or pericardial patch, new valve implantation, protect LM from emboli, retrograde cardioplegia
Name 3 possible substitues for aortic valve in the case of annular abscess
Homograft
Stented bioprosthesis
stentless aortic valve
mechanical aortic valve
What are 6 causes of tricuspid valve regurgitation in a 71 year old female with normal coronary arteries
Primary
myxomatous/degenerative changes, rheumatic, carcinoid, infectious
Seconday
Myxoma, high pulmonary vascular resistance, mitral regurgitation, right ventricle/annulus dilation
Name 2 most common malignant carid tumors and survival time. Name 1 clinical and 1 anatomical feature prior to planning a surgery
Angiosarcoma–50% death at 6 months
Rhadomyosarcoma–50% at 6 months
Angiosarcoma – if not resected 90% die within 1 yr.
Rhabdomyosarcoma – < 12months even with resection
???feature: local disease that is resectable with no evidence of metastasis
Transplant with hypertension given 10mg of nifedipine, 1 hour later BP 70/30, HR 110 T 37.9
List 4 possible causes
3 tests necessary
3 immunosuppression agent all transplant patient will taking
Hypovolemia
Sepsis
Rejection
Pericardial effusion
Echo
Biopsy
Septic work
Calcineurin inhibitor
Antimetabolites
Steroid
Name 3 studies that compare CABG vs multivessel PCI
What is freedom from re-intervention for PCI and CABG at 2 years
Syntax, freedom, sos
At 5 year in syntax, repeat revasc in PCI was 26 % and 13% in CABG
At 1 year in freedom, repeat revasc in PCI was 17 % and 5% in CABG
List 5 advantages of stent graft, main disadvantage, how much oversizing, how long proximal landing zone
Over sizing 20%
Landing zones 1.5 to 2 cm
Less invasive No CPB No or few heparin Faster Less paraplegia Less renal insufficiency Less bleeding
Irradiation
Long term unknown
Not always available
Anatomical restriction
Patient with end stage cardiomyopathy and EF of < 25%
Name 4 medications he should be on
name 4 other options/interventions that could be considered for this pt
What are results of rematch trial at 2 years
Bb
Acei
Aldactone
Lasix or digoxin
CRT
VAD
Transplantation
ICD
Rematch at 2 year, survival VAD 23% vs med 8%
interpret pulmonary function test in a patient with severe dyspnea
3 ways to assess respiratory reserve
What are the cut offs for FEV1 and FVC
FEV1<65% OF VC OR <1-1.5L
Patient with CHF and COPD at ER
1 peptide that can help differentiate between decompensation of COPD and decompensated Heart failure?
Why does it react so fast?
What are physiological side effects (3)
BNP
Respond to ventricular stretch
Vasodilatation
Diuresis
Natriuresis
Inhibition RAAS
Intra-operative hemorrhage is ongoing and all blood products are given.
Anesthiology suggests one off label solution?
What is this drug?
What is dosage?
What is physiological mechanism of action?
What is evidence for its use?
Recombinant factor VII
40-90 mg/kg
Used in hemophilia, trauma and rescue in cardiac surgery
Multiple case reports and series that have demonstrated its efficacy in non-hemophilic cases
In a multi-institutional study by McLaren et al: off label use in pts (92%) demonstrated efficacy in selected groups (those with pH>7.20)
2008 meta-analysis of 22 randomized controlled trials of rFVIIa in 3184 patients without hemophilia in which 15 percent died and 7.8 percent had thromboembolic events. Results included:
What is mechanism of Dobutamine, side effects
Has predominately B1 effect, increasing the force of contraction and heart rate
Mild B2 and Alpha effect. Will cause decrease in pulmonary and systemic vascular resistance
Side effects: Tachycardia, ectopic beats
Side effects : tachycardia, arrhythmia, hypotension
What is mechanism of action of milrinone, side effect and 3 physiological effects
Phosphodiesterase III inhibitor
Intotropy, vasodilatation systemic and pulmonary
Side effects: hypotension, arrhythmia
What are 3 indications for pacemaker in a patient with sick sinus syndrome
Symptomatic brady
Chronotropic incompetence
Syncope with unknown etiology
Patient with A. flutter, has received ami bolus, still remains in AF. Atrial wires remain. What are options
Electric cardioversion
Overpacing
Bb
VF post op in a pt with AF and on amio.
What is most probable diagnosis on ECG
What part of ECG is abnormal before VF
Normal value of this part of ECG?
Torsades
QT interval
Normal value QTc <440
What are aspects of antegrade cerebral perfusion
How do you monitor pressure–what is optimal
What is optimal flow?
Temperature, normally at 18
Right radial monitoring, usually 50-70 mmHg
10 cc/kg/min
IMH in ascending aorta.
What anomalies of aorta lead to this condition?
What is management?
Ruspure of vasavasorum
Treat as dissection
5 things you must explain to a patient before surgery to ensure he gives informed consent?
Disease with natural evolution Treatment options, indications Surgery Risks Answer questions
Previous AVR mechanial and now with MS and TR
How to do a redo for MVR.
1 thing that will complicate surgery on top of difficult sternal reentry
4 heart incisions to access MV and TV
MVR with aortic prosthesis in place
LA
Transseptal standard
Extended transseptal (Guiraudon)
Vertical transseptal (Dubost)
Pt is 2 vessel disease and doing off pump. At 1/4 through anastomosis on LAD you develop ST changes and hyoptension.
What are 2 options.
Shunt
Change position
Ballon pump
CPB
Associated anomalies with TOF
1) ASD
2) PDA
3) Rt Aortic arch
4) Multiple VSD
5) Persistence LSVC
6) AVSD
List 5 cardiac abnormalities associated with TOF
PDA ASD MAPCAS PA stenosis Aberrant coronary anatomy Additional VSD
What are risk factors for PA rupture
1) PHTN
2) Anti-coagulation
3) Overinflation of the balloon
4) Inflation of the balloon with fluid rather than air
5) very distal balloon positioning
6) Anti-coagulation
What is managment of PA rupture
b. management
1) maintain airway
2) Isolate bad lung with double lumen ETT or ET with bronchial occluder
3) keep pt in lateral position with bad lung down
4) brochoscope to identify the site of bleeding
5) reverse anti-coagulation
6) If not resolving with conservative Mx will need pulmonary angiogram and embolization
7) If embolization fails, thoracotomy with resection of the effected segment
c. mortality
40-70%
The day after on pump CABG, with TEE monitoring, patient develops resp failure, leukocytosis, fever and pleural effusion. pH of pleural fluid is 7.2
What is diagnosis
Initial management
Surgical managment
Esophageal perforation
Chest tube, NPO, NG, Barium swallow, Broad spectrum Abx, CT thorax
Thoracic surgery consult, debridement of esophageal tear, primary closure of mucosa, sub mucosa, adventitia
