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From Flashcardlet big > Previous exam 2011 > Flashcards

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
Q

What is management of TOF tet spell

A 
Fluid
sedation
oxygenation
increase SCR
intubation 
ventilation

beta blockers are used for prevention

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26
Q

Post pump pancreatiis. What is Ransons criteria

A 
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
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27
Q

What are principles and management of post infarction septal rupture

A

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
Q

4 year old with ASD, classifcaiton, work-up and why and when would you fix

A

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
Q

Benefits of ASD closure in child

A 
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
Q

What does surgery for Ebsteins Anomaly involve

A

Tricuspid valve repair or replacement
atrial septal defect closure
arrhythmia surgery
and likely CABG

31
Q

Name adult congenital repairable lesions

A

Fotan Revision
Right Ventricular outflow tract reconstruction
Atrial Septal Defects
Ebsteins’s Anomaly
Left ventricular outflow tract reconstruction
Arrhythmia surgery

32
Q

“case scenario”: patient with multiple devices and prosthesis needs MRI for seizures? List the MRI - safe and MRI – unsafe prosthetics.

A

.

33
Q

ECHO grades of diastolic LV dysfunction and findings for each grade

A

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
Q

“case scenario: post op seizures ”: List 2 IV anticonvulsants and doses

A

Dilantin – 1g IV

Midazolam – 2 mg IV

35
Q

List five oral anti-failure medications with mechanism of action

A

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
Q

case scenario: malignant effusion” A- define Kaussmal sing / Pulses paradoxus B- six signs and symptoms of tamponade

A

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
Q

Epidemiology : test of significance/ meta-analysis limitations

A

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
Q

Indications for OR in Ebsteins

A 
Limited exercise capacity
increasing heart size (ratio >65%)
cyanosis (O2 sat <90%)
severe TR with symptoms
TIA/stroke
39
Q

list 4 short term MCS / what is the best current long term MCS / name and design of trial (HM2 trial)

A

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
Q

Mechanism and histology of micro re-entry in a fib

A

shortened atrial refractory period, atrial tissue heterogeneity, electrical remodeling leads to micro reentry. Need trigger, substrate
histology – atrial fibrosis ,decreased muscle mass

41
Q

case scenario: post op hemodynamics” SIRS/mechanism/markers/ treatment (three iv medications)

A

cytokine release, WBC activation, during CPB
markers = increased WBC, CRP, ESR
Meds to treat what? Levophed, methylene blue, inotropes?

42
Q

List 8 steps to air embolism

A 
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
Q

Four energy sources for MAZE

A

RF (monopolar vs bipolar), Cryo, microwave, HIFU, laser

44
Q

Milrinone; mechanism / receptor / secondary messenger

A

Inotrope, PDE-3 inhibitor, prevents cAMP degradation -> increased PKA -> increased Ca channel phosphorylation -> -> increased Ca influx -> increased myocardial contractility

45
Q

What are indications for Ascending aorta surgery

A 
>5.5 cm, asymptomatic
CTD 4.0-5.0
Growth >0.5 cm/yr
>4.5cm undergoing aortic valve surgery
symptomatic aneurysm
46
Q

What is definition of threshold and options when failure to shock occur

A

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
Q

Class I indications for AICD

A

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
Q

5 things to manage a borderline donor heart

A

Thyroxine, cortisol, , vasopressin, insulin, (dopamine) (sabiston, dopamine not listed)

49
Q

Factors that influence CT angiogram

A

Heart rate, heart rhythm, calcification

50
Q

Class I indications for Tricuspid valve surgery

A

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
Q

What is Wilkins Score

A

Leaflet mobility, calcification, thickening, subvalvualr apartus thickening

52
Q

List ways for cerebral protection during aortic surgery

A

ACP, RCP, steroids, barbiturates, packing with ICE, NIRS, BIS

53
Q

A- Causes for culture negative endocarditis

B- indications for surgery in IE

A

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
Q

Three hereditary connective tissue disorders associated with arch aneurysms

A

Marfan, Loez dietz, ehlers danlos

55
Q

List VW classification and examples of each

A

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
Q

Describe FFR

A

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
Q

List 3 outcomes with TTD

A

Pulsatility index (measures resistance), Flow (ml/cm2), % diastolic flow

58
Q

List complications with calcium removal from the annulus

A

VSD, heart block, mitral leaflet perforation, annular perforation, calcium embolism

59
Q

“Case scenario : traumatic aortic tear” : TEVAR; Advantages & Limitations

A

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
Q

“case scenario” : Causes of RV dysfunction after Bentall procedure

A

Coronary button problem
Air embolism
Inadequate myocardial protection

61
Q

Two features of the most common morphology of BAV

A

Left-right cusp fusion ?

1 raphe

62
Q

4 types of vascular rings

A 
Double arch
Right arch with aberrant left subclavian, left ligamentum
Left arch with aberrant right
Circumflex aorta
Pulmonary artery sling
63
Q

“case scenario”: patient with multiple devices and prosthesis needs MRI for seizures? List the MRI - safe and MRI – unsafe prosthetics.

A

Starr-Edwards ball cage valve (although no report of complication
1 MRI safe PPM (Medtronic)

64
Q

What are ways to deal with elevated PRA in transplant

A 
IVIG
Plasmapheresis
Rituximab
Cyclophsphamide
MMF
Steroids
Donor-recipient crossmatch
65
Q

Indications for VSD closure in adults

A

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
Q

Indications for CABG in stable angina

A

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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