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Previous exam 2011 Flashcards

1
Q

List 4 indications for CABG in stable

A

3vd (class 1)
left main (class 1)
2vd with proximal lad (class 1)
2vd without proximal LAD, with significant myocardial ischemia (IIa)
1vd with proximal LAD (IIa)
1 or more significant stenosis with unacceptable angina (I)

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2
Q

What are indications for MVR in chronic severe MR

A

Symptomatic patients with LVEF > 30% and LVESD < 55mm
Asymptomatic with LV dysfunction LVESD > 45mm and/or LVEF < 60%

Class IIa
Asymptomatic with preserved LV function and new onset AF or pulmonary hypertension (Systolic PA > 50mmgh)
asymptomatic pts with preserved LV function, high likelihood of durable repair, and LVESD > 40 mm

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3
Q

What are indications of surgery in an adult with Ebsteins anolmaly

A 
Symptoms
Cardiothoracic index over 65
Desat under 90
Severe TR with symptoms
Stroke or TIA
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4
Q

Partner A

A

TAVI vs Surgery
Outcome – death from any cause 35 vs 33.9%
Stroke + TIA – increased with TAVR 11.2 vs 6.5% at 2 years
Increased major vasc complication at 2 years 11.6 vs 3.8%
More paravalvular leak in TAVR

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5
Q

Partner B

A

TAVI vs med thereapy
AVA 0.8, NYHA class II or more, inoperable
Inclusion = inoperable i.e. deemed inoperable by 2 surgeons/1 cardiologist (STS risk of morb/mort >50%,
Exclusion – Bicuspid valve, MI, 3+ MR, annulus <18 or >25, LVEF <20%, recent TIA stroke, sever CRF
Death from any cause = 43% vs 68%, rehosp 35.0 vs 72.5%
STS >15%, no difference in outcome (~ 50% vs 60%)
Class I or II 83.1% vs 42.5%

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6
Q

Describe the syntax 3 year results

A

1800 patients, 85 centers, LM or 3vd
Decreased MACCE with CABG (20.2 vs 28.0%)
Revasc 10.7 vs 19.7
MI 3.6 vs 7.1%
Cardiac death favors CABG 3.6 vs 6.0%
Composite safety (death/stroke/MI) 12.0 vs 14.1% no difference
Stroke 3.4 vs 2.0% (p=0.07)
LM – MACCE not different 22.3 vs 26.8%
3vd – MACCE favors CABG 18.8 vs 28.8%
MACCE increased with PCI in entire cohort and 3vd with sntax score >22, in LM with syntax >33
LIMITATIONS – inadequately powered to detect low frequency evetns (stroke, MI), short term followup for now, LM and 3vd not prespecified
Worse outcomes with 3vd, syntax >22

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7
Q

Describe the STITCH hypothesis II, limitations, end-points

A

1000 patients
CABG + med Rx vs CABG + SVR + med Rx
Followup = 48 months
Outcome – primary = Death from any cause and hospitalization for cardiac cause. 59% vs 58%
Limitations: inadequate volume reduction, selection bias (paients that were thought to benefit most were not randomized)

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8
Q

Describe the PREVENT IV results

A

Saphenous vein graft patency treated with edifoligide or not, at 12-18 months
Non-randomized comparison of ESVH vs Open
Decreased patency (46.7 vs 38.0%)
Increased MI, death, repeat revasc (20.2 vs 17.4%)
Increased Death or MI (9.3 vs 7.6%)
Increased death (7.4 vs 5.8%)

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9
Q

Describe the ROOBY trial endpoints

A

2203 patients, 18 VA medical centers
minimum 20 OPCAB per surgeon
Outcomes:
Primary - Short term: composite death and complicaitons within 30 days (reop, new mechanical support, cardiac arrest, coma, stroke, renal failure)
Long term: at 1 year - Composite death, repeat revac, nonfatal MI,
Secondary – completeness of revasc, graft patency, neuropsy, use of major resources
Short term – no difference (7.0 vs 5.6 %)
Long term – against OPCAB 9.9 vs 7.4%, increased cardiac death
Decreased graft patency

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10
Q

List the classification of anti-arrhymtics and list one example of each

A

I. Inhibit sodium channel. Lidocaine
II. Inhibit beta receptor. Metoprolol
III. Inhibit potassium channel. Amiodarone
IV. Inhibit calcium channel. Verapamil

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11
Q

Name 2 antiepilpetic medications

A 
Valproic acid (usually 250 to 750 mg) 
Dilantin (Phenytoin)
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12
Q

List 3 methods of cerebral protection

A

Deep hypothermic circulatory arrest
Antegrade cerebral perfusion
Retrograde cerebral perfusion

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13
Q

Describe pathophysiology and treatment for vasoplegic syndrome post operatively

A

Activation inflammatory cell with CPB, release cytokines
CRP,SR, WBC
Support: vaso, levo

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14
Q

Post op MRI is needed, what devices are compatible and what are not?

A

Coronary stents are all safe
Heart Valve prostheses are safe
Metal wires, medistinal clips, temporary pacer wires ok

ICD, and PPM are not safe.

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15
Q

CTA is needed pre-operatively. What hinders good visualization

A

Tachycardia

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16
Q

What are contraindications to TEE

A

Recent oesophageal surgery
Oesophageal diseases ( neo,fistula, stricture, varices)
Upper GI bleeding
Cervical instability

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17
Q

FFR definition, mechanism, and condition used

A

Pressure distal to lesion divide by pressure before the lesion at maximal dilatation (adenosine)

Fame < .80. Defer < .75 for signification

For lesion with unclear severity

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18
Q

What are cellular and sub-cellular changes causing ventricular reverse remodeling after VAD

A

Reduce cellular length, diameter and mass
Increase beta 1 receptor density
Reduce inter acellular calcium

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19
Q

What are the most common malignant cardiac tumors? What are contraidicatoins to repair

A 
angiosarcoma
rhabdomyosarcoma
fibrosarcoma
leiomyosarcoma
liposarcoma
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20
Q

What are contraindications of Ross Procedure

A

Connective tissue disorder
Pulmonary valve anomaly
Aberrant coronary artery over RVOT
Autoimmune disorder

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21
Q

What is classification and grading of DORV

A

Location of VSD

Subarterial
Subpulmonary
Noncomitted
Double comitted

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22
Q

What are options for treatment of right sided heart failure after transplant

A 
Optimize the fluid balance
decrease PC@ < 40 mmHg
treat acidosis
Increase RV contractility 
	Epinephrine
	Milrinone
Keep high perfusion pressure
Make need to have atrial kick (atrial pacing) 
Pulmonary vasodiltor
IABP
RVAD
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23
Q

Management of a TOF

A

< 3 months do a BT shunt if symptomatic
if Symptomatic and > 12 week you could do a primary repair
Asymptomatic do a primary repair at 6 to 12 months
If LAD cross RVOT do a BT shunt and then full repair between 3 to 5 years

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24
Q

What is surgical management of TOF

A

Median sternontomy
Trans atrial approach
Patch the VSD with avoiding the area of the conduction system
resection of the muscular bands and pulmonary valvotomy
possible RV to PA conduit/transannular patch

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25
What is management of TOF tet spell
``` Fluid sedation oxygenation increase SCR intubation ventilation ``` beta blockers are used for prevention
26
Post pump pancreatiis. What is Ransons criteria
``` Age > 55 WBC > 16 000 BG > 200 LDH > 350 AST > 250 ``` at 48 hours ``` HCT fall > 10% BUN > 8 increase base excess low arterial PO2 low serum ca estimated fluid sequester > 600 cc ```
27
What are principles and management of post infarction septal rupture
Expeditious establishment of total CPB mod hypothermia meticulous myocardial protection Trans infarvation approach to VSD Trimming of LV margins of the infarct back to viable myocardium to prevent delayed rupture of the closer conservative trimming of the RV Inspection of the papillary muscle, possible replacement of MV Closure of the VSD without tension Closure of infarcetectomy with out tesnion and use prosthetic material Buttress suture lines with pledgets or strips of felt to prevent from cutting through muscle.
28
4 year old with ASD, classifcaiton, work-up and why and when would you fix
Secendum ASD (80%) Sinus venosus ASD (5-10%) Coroanry sinus ( ASD) Premmium ASD Workout ECG/CXR/ECHO/Cath-calculate shunt and assess other cardiac anomlaies ``` when to fix if 4 year old ASD with symptoms ASDY asymptomatic withe RV overload QP:QS> 1.5 Associated PAPVD Associated tricuspid or mitral valve disease ```
29
Benefits of ASD closure in child
``` Increase life expectancy Increase exercise tolerance in future Avoid late complications A Fib RV failure leading to cyanosis pulmonary hypertension paradoxical emboli problems during pregnancy ```
30
What does surgery for Ebsteins Anomaly involve
Tricuspid valve repair or replacement atrial septal defect closure arrhythmia surgery and likely CABG
31
Name adult congenital repairable lesions
Fotan Revision Right Ventricular outflow tract reconstruction Atrial Septal Defects Ebsteins's Anomaly Left ventricular outflow tract reconstruction Arrhythmia surgery
32
“case scenario”: patient with multiple devices and prosthesis needs MRI for seizures? List the MRI - safe and MRI – unsafe prosthetics.
.
33
ECHO grades of diastolic LV dysfunction and findings for each grade
1) Impaired relaxation, E/A reversal 2) Pseudonormal – Elevated LAP, E/A normal but slope changed 3) Reversible restrictive – reversible with valsalva 4) fixd restrictive diastolic dysfunction
34
“case scenario: post op seizures ”: List 2 IV anticonvulsants and doses
Dilantin – 1g IV | Midazolam – 2 mg IV
35
List five oral anti-failure medications with mechanism of action
BB ACEI Loop diuretics Spironolactone – aldosterone antagonist, inhibists sodium potas exhanige in dital convoluted tubule Digoxin – inhibits sodium potassium ATPase thus increasing intracellular Ca
36
case scenario: malignant effusion” A- define Kaussmal sing / Pulses paradoxus B- six signs and symptoms of tamponade
Kussmaul – increased JVP with inspiration Pulsus paradoxus – decrease of BP by 10mmhg with inspiration Muffled heart sounds, hypotension, increased JVP, fatigue, dyspnea, decreased cardiac output
37
Epidemiology : test of significance/ meta-analysis limitations
Meta analysis limitations – publication bias, more positive studies get published Search bias, miss studies due to incomplete search of the literature Selection bias, dependent upon person choosing which studies to include (should be more that one person) Heterogenity of individual studies
38
Indications for OR in Ebsteins
``` Limited exercise capacity increasing heart size (ratio >65%) cyanosis (O2 sat <90%) severe TR with symptoms TIA/stroke ```
39
list 4 short term MCS / what is the best current long term MCS / name and design of trial (HM2 trial)
IABP, impella, tandem heart, ECMO (biomedicus) Heartmate II LVAD had RCT and FDA approval Heartmate II Trial design: RCT, 2:1 vs heartmate XVE (134 VS 66) Improved survival free from disabling stroke, and reop to repair/replace device at 2 years 46% vs 11% survival 58 vs 24%
40
Mechanism and histology of micro re-entry in a fib
shortened atrial refractory period, atrial tissue heterogeneity, electrical remodeling leads to micro reentry. Need trigger, substrate histology – atrial fibrosis ,decreased muscle mass
41
case scenario: post op hemodynamics” SIRS/mechanism/markers/ treatment (three iv medications)
cytokine release, WBC activation, during CPB markers = increased WBC, CRP, ESR Meds to treat what? Levophed, methylene blue, inotropes?
42
List 8 steps to air embolism
``` Stop pump Clamp lines Steep trendelenberg Aortic cannula in SVC with proximal clamp, at 300-500cc/min until no more air, start cooling Aspirate air from aorta Aortic cannula in aorta and cool to 18 degrees Steroids, barbiturates Complete cardiac intervention Postop monitoring for seizures Consider hyperbaric oxygen chamber Discuss with family ```
43
Four energy sources for MAZE
RF (monopolar vs bipolar), Cryo, microwave, HIFU, laser
44
Milrinone; mechanism / receptor / secondary messenger
Inotrope, PDE-3 inhibitor, prevents cAMP degradation -> increased PKA -> increased Ca channel phosphorylation -> -> increased Ca influx -> increased myocardial contractility
45
What are indications for Ascending aorta surgery
``` >5.5 cm, asymptomatic CTD 4.0-5.0 Growth >0.5 cm/yr >4.5cm undergoing aortic valve surgery symptomatic aneurysm ```
46
What is definition of threshold and options when failure to shock occur
Threshold = minimum amount of energy required to reliably depolarize the chamber being tested Failure to shock – reposition, change vector (coil vs box), increase voltage, change algorithm
47
Class I indications for AICD
Following sudden cardiac death due to VF or HD instability with VT after excluding reversible causes Structural heart disease and spontateous sustained VT Syncope of unclear origin and inducible VF or VT on EPS LVEF <35% due to MI, 40 days post MI, NYHA II-III DCM, LVEF <35%, NYHA II-III LVEF 30%, prior MI, NYHA class I NSVT due to prior MI, LVEF <40%, , VF or VT on EPS
48
5 things to manage a borderline donor heart
Thyroxine, cortisol, , vasopressin, insulin, (dopamine) (sabiston, dopamine not listed)
49
Factors that influence CT angiogram
Heart rate, heart rhythm, calcification
50
Class I indications for Tricuspid valve surgery
Class I – Severe TR undergoing mitral surgery IIa – severe symptomatic primary TR Replace if severe secondary TR if valve abnormal not ameable to repair IIb – less than severe TR undergoing mitral valve surery with PTHN or annular dilatation
51
What is Wilkins Score
Leaflet mobility, calcification, thickening, subvalvualr apartus thickening
52
List ways for cerebral protection during aortic surgery
ACP, RCP, steroids, barbiturates, packing with ICE, NIRS, BIS
53
A- Causes for culture negative endocarditis B- indications for surgery in IE
a. antimicrobial therapy, fastidious organism, non-bacterial endocarditis b. Severe AI/MR with CHF or increased LVEDP, Virulent organism, abcess/fistula/heart block, recurrent emboli, positive culture despite ABx, >10mm vegetation
54
Three hereditary connective tissue disorders associated with arch aneurysms
Marfan, Loez dietz, ehlers danlos
55
List VW classification and examples of each
Class I – Na channel blocker, prolongs AP, Lidocaine Class II – BB, blocks beta adrenergic receptors, metoprolol Class III – potassium channel blocker, amiodarone Class IV – CCB, diltiazem, verapamil
56
Describe FFR
Ratio of pressure distal and proximal to a coronary lesion (FFR = prox/dist) with maximal vasodilation of the distal coronary bed, physiologic measurement of coronary stenosis after coronary stenosis to before Indication – during coronary angio with stenosis of unclear significance List the two studies and the ratios used Defer = <0.75, Fame = <0.80
57
List 3 outcomes with TTD
Pulsatility index (measures resistance), Flow (ml/cm2), % diastolic flow
58
List complications with calcium removal from the annulus
VSD, heart block, mitral leaflet perforation, annular perforation, calcium embolism
59
“Case scenario : traumatic aortic tear” : TEVAR; Advantages & Limitations
Advantages: Shorter operative time, no CPB, decreased risk of bleeding with concomitant injuries, decreased paraplegia Disadvantage: requires long-term followup long term outcomes unknown, limited availability
60
“case scenario” : Causes of RV dysfunction after Bentall procedure
Coronary button problem Air embolism Inadequate myocardial protection
61
Two features of the most common morphology of BAV
Left-right cusp fusion ? | 1 raphe
62
4 types of vascular rings
``` Double arch Right arch with aberrant left subclavian, left ligamentum Left arch with aberrant right Circumflex aorta Pulmonary artery sling ```
63
“case scenario”: patient with multiple devices and prosthesis needs MRI for seizures? List the MRI - safe and MRI – unsafe prosthetics.
Starr-Edwards ball cage valve (although no report of complication 1 MRI safe PPM (Medtronic)
64
What are ways to deal with elevated PRA in transplant
``` IVIG Plasmapheresis Rituximab Cyclophsphamide MMF Steroids Donor-recipient crossmatch ```
65
Indications for VSD closure in adults
Class I 1) ‘significant’ VSD (symptomatic; left ventricular [LV] volume overload; deteriorating ventricular function due to volume [left ventricle] or pressure [right ventricle] overload, pulmonary-to- systemic flow ratio [Qp:Qs] of at least 2:1; pulmonary artery systolic pressure greater than 50 mmHg). (Level B) 2) Sgifnicant RVOT obstruction 3) perimembranous or subarterial with more than mild AI 4) Severe pulmonary HTN Class IIa History of endocarditis, especially recurrent To prevent paradoxical emboli with transvenous pacing
66
Indications for CABG in stable angina
left main stenosis left equivalent (proximal LAD and proximal circumflex) Three-vessel disease Two-vessel disease with proximal LAD and EF < 50% or demonstrable ischemia Disabling angina refractory to medical therapy One or Two-vessel disease without proximal LAD but with a large territory at risk and high-risk criteria on noninvasive testing

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