Previous exam 2010 Flashcards
What is mechanism of action of Vasopressin, what receptor types, location, physiological effect
causes peripheral vasoconstriction which increases blood pressure
second messenger system–acts on peripheral vasculature
Antidiruetic
increases calcium
Outline 6 limitation for a language barrier for obtaining onset
.
CANMEDS role for CVICU full with only 2 discharges but 8 cases booked. How do you manage?
.
List 4 CANMEDS roles and how each applies to the above situation
MR valve morpholoy thrombus High wilkins score Calcification
Pt has a DDD AICD for LVEF and VT and needs a bowel resection. Gen Surg Consult
What happens when you put magnet on?
If the pt has VT while magnet on what should be done
If the pt has a DDD pacemaker , what mode is the pacemaker in while magnet is on
List 2 options you advise the Gen surg team to do regarding safe cautery use for this case
Magnet stops the anti-tach
Bipolar
magnet—
Pt has HR 140 after pacemaker implant (Dd pacemaker mediated tachycardia)
What are 3 conditions required for this diagnosis
1 parameter you can change
If you change this parameter what is the consequence
retrograde conduction
Must have atrial sensing
Dual chamber
Risk of AV block**
loss of av synchrony
Describe function of following pacing modes AOO AAI DDI DDD VOO
Pacing
Sensing
Respond to sensing
Identify 3 acute aortic syndromes
Acute aortic dissection
Intra mural hematoma
Penetrating athersclerotic ulcer
Patient is hypertensive, chest pain, CT diagnosis IMH
What is the mechanism
What is the natural history
What would you do
Bleeding in the media without intimal tear secondary to vasavasorum rupture
Spontaneous or secondary to plaque rupture
Can heal or progress to dissection
With acute presentation more chance that will progress into dissection so manage as a dissection
What are 5 surgical techniques to avoid SAM
Avoid excessive under sizing of annuloplasty
Ensure posterior leaflet height of less than 15 mm
Resection of excessive septal hypertrophy
Chords to anterior leaflet
mitral valve replacement
*Avoid inotropes
Avoid Hypovolemia
Avoid tachycardia
Increase afterload
Pt needs redo CABG with patent LITA, occluded OM, stenotic RCA. 5 adverse event you consent this patient
Death Stroke MI Bleeding AKI
Radial artery use.
What’s the 1 most important prognostic factor
>5 year patency rate: Radial to LAD? Radial to RCA?
Ensuring you have a high grade lesion to avoid competitive flow (greater 90% on right and > 70% on left
Endovein vs open vein
List 4 advantages
List 4 limitations
less morbidity
wound complications are less
time, patency,
List 3 risk factors for recurrence/residual lesion after coarctation repair
end to end repair
subclavian flap
aortic arch hypoplasia
Peforming a TGA and notice that neonatal cerebral infrared spectrometer has changed. You’re on CPB.
List 4 management steps
Change position of cannula
avoid kinking/check pressure
Arch dissection after completion of a ? on CPB. Assume central cannulation. with a clamp proximal to the innominate
Outline 5 management steps
Iatrogenic aortic arch dissection
3 distinct mechanisms how NO works
inhibits angiotensin II
Increase cGMP leading to vasodilatation
Improve oxygenation by dilatation of ventilated area
Anti platelet effect
Inhibition of proliferation of smooth muscle
3 potential limitations of NO administration
inhaled
toxic byproducts
abnormal
List 3 requisite anatomical features of complete AV canal defect
common av valve
lack septum
Pt with TOF and has developed severe PI years after initial repair. List 5 indication for pulmonary valve replacement
Right ventricular dysfunction
Right ventricular end diastolic
Severe PI
Symptoms of TR
Ischemic MR. Recent literature states certain subgroups benefit from reverse remodelling
List 4 preoperative predicators that suggest improved remodeling after CABG + IMR repair
LVEDD < 65
LVESD < 50
Low shericity index
Acute RV failure post transplantation. List 5 steps of management
Milrinone NO pre-load IABP decreased PVR HR > 100
List 6 brain death criteria for organ Donation
Apnea test bilateral motor response explainable death brain stem warm @ 37 absecene of cofounding factors Two physician
Carcinoid valve disease
Cause TR
Also cause pulmonary valve stenosis
Patient has severe TR and AF, RVSO 40
Draw CVP tracing relative to ECG tracing
4 causes of isolated TR
6 cath signs of constrictive vs restrictive pericarditis
4 CRT indications
Only 1 class 1 indication
LV<35%, NSR, QRS >150 with LBBB, FCC 2,3 or ambulatory 4
LVAD insertion. Pt has previous mechanical AVR, has a PFO, moderate MR, moderate RC failure. The aortic valve is functioning well
Outline 3 important operative steps
Would you do a MV procedure in this patient
Replace mec valve for bio
Close PFO
Repair TV
No MVR for regurg
4 risk factors for RV failure post LVAD placement
Low RVSWI Pre-op pressors High bilirubin and ALT High creat and BUN Pre-op ventilation Tric regurg
Aortic valve repair:
List 3 ideal anatomic indications
List 4 techniques to repair aortic valve
Leaflet perforation
Leaflet prolapse
Dilatation of STJ or VAJ
Patch
Plication
STJ remodelling
VAJ annuloplasty
List 5 proved benefits of off pump CABG
reduced stay in hospital reduced transfusion requirement reduced release of cardiac enzymes reduced stay in ICU reduced time of post op intubation potential reduction in rates of acute kidney injury
Small aortic root. Can only fit a # 19 sizer. List 4 distinct operative techniques and options
posterior root enlargement
stentless aortic valve
another stented bioprosthetic aortic valve with low gradients
5 contraindications to SVR
RV dysfunction
Asymptomatic
Restrictive diastolic pattern
What is definition of FFR
How the physiological measurement is done
What is given to mimic this physiology condition
What’s the criteria for significant stenosis
.
What is Transit time flowmetry. What 3 variable are measured
- maximum peak flow, the minimum peak flow, the mean flow, the back flow
- pulsatility index (maximum peak flow – minimum peak flow/mean flow).
- Diastolic flow pattern and %
There are no strictly normal values (the flow in the graft is depending on the length of the graft, the driving pressure, the resistances to the flow and to the size of the graft itself), an acceptable value for the pulsatility index has to be 3 or below.
The presence of a huge diastolic flow guarantees an unrestricted flow into the graft
LVAD causing reverse remodeling of heart
What are 3 parameters that suggest positive remodeling at the organ level?
What is this reverse remodelling process called
2 histological features
2 hormonal features
.
What is mechanism of Diastolic dysfunction
inability of myocardial relaxation/loss of myocardial compliance
What is risk factors for diastolic dysfunction
3 pharmacological treatments
Age, diabetes, HBP
Volume, beta blockers, CCB
Pt is post op AVR + MVR with fever, low BP, CVP ok and fluid increases by BP low.
What condition is this?
3 biochemical markers in this condition?
3 pharmacological (or other treatment)
Distributive shock
Pressors, volume, antibiotics, steroid
Post op renal dysfunction with pre-op Cr 103.
List 4 preop risk factors for developing renal failure post op
What 1 medication will icnrease risk of ARF and is its effect
Pt develops high K. List 4 pharamacological treatment, doses and route while awaiting dialysis
Prep RF Age Diabetes Long CPB Redo CHF
ACEI, vasodilatation and renal hypoperfusion
Calcium Dextrose and insulin Beta 2 agonist Bicarbonate Diuretic Hydration
List 4 meds to treat pulmonary artery hypertension and route
NO inh
Milrinone inh or IV
Slidenafil PO
Epoprostenol inh
Patient requires CABG. on plavix.
What is mechanism of plavix
Half life of plavix?
How many days of platelet inhibition to wear off?
.
What are indications for native valve endocarditis. List 5
Symptoms of CHF because of local valve destruction/AI
persistent infection despite antibiotic coverage
recurrent embolic events
fungla/staph auerus blood cultures–highly virulent organism
presence of heart block/abscess fistula
Want to conduct RCT on new drug on 180 pts on composite mortality and stroke in high risk aortic cases. You conclude a negative study.
What single statisical test would you perform
2 theoretical reasons why this study might be negative
.
List 3 limitations for metanalysis
selection bias/publication bias/search bias
Heterogenity
Lack of control for confounding variable.
What is mode of inheritance in Marfan
What’s the genetic abnormality
Autosomal dominant
Mutation in FBN1 that encode for fibrillin-1
5 clinical manifestations of Marfan syndrome
Cardiac Ao root dilatation and dissection Mitral valve prolapse Mitral valve Ca PA dilatation
Eyes
Ectopic lentis
MSK
Pectus
Scoliosis
Arm span on height ratio over 1.05
4 features of Dresslers syndrome
Post MI or cardiotomy
Fever, malaise, pleuritic, effusion
Respond to Antiinflammatory or steroid
Traumatic aortic rupture
List 3 advantages of TEVAR
List 3 limitations of TEVAR
Avoid aortic cross clamping of aorta
avoid systemic hepar/thoractomy/single lung ventilation/complications associated with hypothermia
disadvantages
limited availability
possibility of anatomical restrictions including tortuous artery, small access peripheral vessels, lack of landing zone, requirement of coverage of close proximintt vessels, requirement for follow-up, long term results of device closure unknown.
List 3 absolute contraindications to IABP
Dissection
AI
AAA
Severe peripheral vasculopathy
List 5 major complications of IABP
Bleeding Infection Thrombocytopenia Leg ischemia Thromboembolic
List 3 things you have to do when it comes to a medical error?
Tell patient and family
Talk to medical team
Fill papers for hospital
Syntax trial What is the mean follow up period What is the primary endpoint Identify if the primary endpoint was increased, decreased, not significant when compared to stroke rate with PCI and CABG Mortality rate with CABG to PCI
2 limitations of syntax
.
4 classifications of vascular rings causing tracheal symptoms (stridor) and dysphagia
Double aortic arch
Right aortic aortic with abberant left subclavain and ligamentous arteriousm
Left aortic with abberanta right subclavian
pulmonary artery sling
What is the INTERMACs classification
Interagency registry for mechanically assisted circulatory support (INTERMACS)
They have 7 profiles of which 80% are implanted in 2 profiles.
Level 1 Crash and Burn (hypotensive, IABP
Level 2 Sliding on Inotropes (ok BP, worsening renal)
Level 3 Dependent stability (moderate hypotension
Level 4 Frequent flyer (usually
Level 5 Housebound
Level 6 walking wounded
Level 7 placeholder (NHYA II or III)
