Previous exam 2011 Flashcards
List 4 indications for CABG in stable
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)
What are indications for MVR in chronic severe MR
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
What are indications of surgery in an adult with Ebsteins anolmaly
Symptoms Cardiothoracic index over 65 Desat under 90 Severe TR with symptoms Stroke or TIA
Partner 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
Partner B
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%
Describe the syntax 3 year results
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
Describe the STITCH hypothesis II, limitations, end-points
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)
Describe the PREVENT IV results
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%)
Describe the ROOBY trial endpoints
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
List the classification of anti-arrhymtics and list one example of each
I. Inhibit sodium channel. Lidocaine
II. Inhibit beta receptor. Metoprolol
III. Inhibit potassium channel. Amiodarone
IV. Inhibit calcium channel. Verapamil
Name 2 antiepilpetic medications
Valproic acid (usually 250 to 750 mg) Dilantin (Phenytoin)
List 3 methods of cerebral protection
Deep hypothermic circulatory arrest
Antegrade cerebral perfusion
Retrograde cerebral perfusion
Describe pathophysiology and treatment for vasoplegic syndrome post operatively
Activation inflammatory cell with CPB, release cytokines
CRP,SR, WBC
Support: vaso, levo
Post op MRI is needed, what devices are compatible and what are not?
Coronary stents are all safe
Heart Valve prostheses are safe
Metal wires, medistinal clips, temporary pacer wires ok
ICD, and PPM are not safe.
CTA is needed pre-operatively. What hinders good visualization
Tachycardia
What are contraindications to TEE
Recent oesophageal surgery
Oesophageal diseases ( neo,fistula, stricture, varices)
Upper GI bleeding
Cervical instability
FFR definition, mechanism, and condition used
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
What are cellular and sub-cellular changes causing ventricular reverse remodeling after VAD
Reduce cellular length, diameter and mass
Increase beta 1 receptor density
Reduce inter acellular calcium
What are the most common malignant cardiac tumors? What are contraidicatoins to repair
angiosarcoma rhabdomyosarcoma fibrosarcoma leiomyosarcoma liposarcoma
What are contraindications of Ross Procedure
Connective tissue disorder
Pulmonary valve anomaly
Aberrant coronary artery over RVOT
Autoimmune disorder
What is classification and grading of DORV
Location of VSD
Subarterial
Subpulmonary
Noncomitted
Double comitted
What are options for treatment of right sided heart failure after transplant
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
Management of a TOF
< 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
What is surgical management of TOF
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
What is management of TOF tet spell
Fluid sedation oxygenation increase SCR intubation ventilation
beta blockers are used for prevention
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
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.
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
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
What does surgery for Ebsteins Anomaly involve
Tricuspid valve repair or replacement
atrial septal defect closure
arrhythmia surgery
and likely CABG
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
“case scenario”: patient with multiple devices and prosthesis needs MRI for seizures? List the MRI - safe and MRI – unsafe prosthetics.
.
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
“case scenario: post op seizures ”: List 2 IV anticonvulsants and doses
Dilantin – 1g IV
Midazolam – 2 mg IV
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
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
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
Indications for OR in Ebsteins
Limited exercise capacity increasing heart size (ratio >65%) cyanosis (O2 sat <90%) severe TR with symptoms TIA/stroke
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%
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
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?
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
Four energy sources for MAZE
RF (monopolar vs bipolar), Cryo, microwave, HIFU, laser
Milrinone; mechanism / receptor / secondary messenger
Inotrope, PDE-3 inhibitor, prevents cAMP degradation -> increased PKA -> increased Ca channel phosphorylation -> -> increased Ca influx -> increased myocardial contractility
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
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
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
5 things to manage a borderline donor heart
Thyroxine, cortisol, , vasopressin, insulin, (dopamine) (sabiston, dopamine not listed)
Factors that influence CT angiogram
Heart rate, heart rhythm, calcification
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
What is Wilkins Score
Leaflet mobility, calcification, thickening, subvalvualr apartus thickening
List ways for cerebral protection during aortic surgery
ACP, RCP, steroids, barbiturates, packing with ICE, NIRS, BIS
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
Three hereditary connective tissue disorders associated with arch aneurysms
Marfan, Loez dietz, ehlers danlos
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
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
List 3 outcomes with TTD
Pulsatility index (measures resistance), Flow (ml/cm2), % diastolic flow
List complications with calcium removal from the annulus
VSD, heart block, mitral leaflet perforation, annular perforation, calcium embolism
“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
“case scenario” : Causes of RV dysfunction after Bentall procedure
Coronary button problem
Air embolism
Inadequate myocardial protection
Two features of the most common morphology of BAV
Left-right cusp fusion ?
1 raphe
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
“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)
What are ways to deal with elevated PRA in transplant
IVIG Plasmapheresis Rituximab Cyclophsphamide MMF Steroids Donor-recipient crossmatch
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
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
