Random Lecture Notes

Question 1

What are the guidelines for primary prevention of CVD?

Answer 1

Assess risk (10 yr ASCVD risk)
>5%-7.5% (borderline) may require statin.
7.5%-20% (intermediate) if risk and enhancers favor statin, add mod-intensity.
>20% (high risk) requires high-intensity statin.
Emphasize adherence to healthy lifestyle.

High-intensity statin if LDL >190.
Moderate-intensity statin if DM and >40 yrs old.

Question 2

When assessing CVD risk, what score is the best test in predicting CAD event?

Answer 2

Coronary artery calcium score.
>100 increases risk.
Can modify risk upward for borderline patients who want to avoid statin.

Question 3

Calcium score >100, what med should be added (other than statin after risk assessment)?

Answer 3

Aspirin.

Benefit more pronounced if calcium score >400.

Question 4

If a patient is getting risk assessed for coronary disease, and their calcium score is 0, what does that do to their risk classification?

Answer 4

Modifies risk downward.

Best test to predict low risk.

Question 5

Venous cannula is kinked. What immediate complication occurs?

Answer 5

Low volume in the venous reservoir.

Question 6

On CPB. Kink in the centrifugal pump. What does this cause?

Answer 6

Low BP

Question 7

The venous line of dual stage cannula is chattering. What is happening?
What do you do?

Answer 7

It’s hypovolemic - the wall of the vein/atria is collapsing and flapping around it.
Turn down the venous suction.
“Make a fast change.”
Can also try repositioning.

Question 8

Which cannula in the CPB machine is only one way?

Answer 8

Pump suckers.

Arterial can go both ways, venous can go both ways.

Question 9

What is the purpose of a L side vent on CPB?

Answer 9

Drain the pulmonic circulation.
Prevent distention of the heart.

Question 10

What cause of high arterial line pressure can be diagnosed by cerebral oximetry - different readings on left and right?

Answer 10

Cannulation of an aortic arch vessel.

Question 11

The perfusionist asks if you want to RAP. What will it do to the pump prime volume?

Answer 11

Decrease it.

If BP is ok and not ischemic, you can use blood to displace the crystalloid prime from the pump.

Question 12

Femoral arterial pressure is usually higher than radial artery pressure when (during CPB run)?

Answer 12

Rewarming.

The further down the arterial tree you go, the more muscular and less capacitance. Normally, BP is higher at the extremities.

Question 13

What factors determine oxygen delivery while on CPB?

Answer 13

Hgb level, cardiac index, FiO2 on MV.

Question 14

Pink or red tinge in urine is a consequence of what on CPB?

Answer 14

Cardiotomy suction, shear stress on RBCs, air-blood contact, time of exposure to CPB machine

Question 15

Trace a RBC’s path through the CPB machine.

Answer 15

Patient, venous line, venous reservoir, centrifugal head/pump, oxygenator, filter, arterial line, patient.

Question 16

Coming off bypass checklist?

Answer 16

Temperature.
Rhythm and rate: shock if needed, speed up if slow; best to worst is NSR, atrial paced, AV paced, then V paced.
Vascular tone.
Lytes, Hgb, ABG should look ok.

Question 17

SVG patency at 10 years?

Answer 17

50%

Question 18

How can you expose a lateral OM for a distal anastomosis?

Answer 18

Retracting the heart to the right, place sponges on the lateral heart, twisting the heart, using a positioning or suction device.

Question 19

When placing a coronary sinus catheter for retrograde plegia (not directly), how can you confirm you’re in place?

Answer 19

The catheter faces the L shoulder and doesn’t move side to side.
There’s ventricularized pressure of dark blood returning.
Palpate the back of the heart.
TEE.

Question 20

What is the tradeoff in mechanical vs bioprosthetic valves?

Answer 20

Mechanical - bleeding and drug interactions w/ warfarin. Ticking. ESRD pts probably shouldn’t get mech valve.
Bioprosthetic - reoperation.

Question 21

What are some indications for short term percutaneous non-IABP MCS?

Answer 21

1. Very high-risk PCI w/ a large territory and EF <35.
2. Acute MI c/b acute MR or VSD w/ cardiogenic shock.
3. Advanced RHF or LHF during stabilization of critical pts while making decisions about longer-term support - “bridge-to-a-bridge.”
4. High risk perc valve procedures if needing support.
5. Support for pts undergoing EP procedures w/ severe LV dysfx and who may not tolerate sustained VT/VF.
6. Medically refractory arrhythmias assd w/ ischemia.
7. Acute heart txp failure or RV failure.

Question 22

What patients may not be candidates for MCS?

Answer 22

AR 
Metallic aortic valve
Aortic aneurysm or dissection
Severe PAD
LV or LA thrombus
Bleeding diathesis 
Uncontrolled sepsis

Question 23

Explain the role of SVI in the evaluation of AS.
What scenario would this come up?
What must be controlled before making this measurement?

Answer 23

Used to diagnose severe low-gradient AS. OR paradoxical low-flow severe AS.
The scenario would be a patient who presents with exertional dyspnea/decreased exercise tolerance and is found to have an AVA <1cm or AVAi <0.6.
BUT the gradients aren’t severe (mean <40, V <4), AND they have EF >50.

The suspicion arises when the LV wall is thick, or the chamber is small, or there is restrictive diastolic filling. These patients have a normal EF, but the stroke volume is too low to generate a gradient/velocity. Use the SVI to identify this group.

Make sure BP is <140.

Question 24

In the workup of AS, who would be considered prohibitive for SAVR, but good for TAVR?

Answer 24

Prohibitive for SAVR: STS ≥8%, ≥2 frailty measures, ≥2 organ system failure, procedure specific impediment.
Good for TAVR: Life expectancy w/ acceptable QoL >1 yr, suitable anatomy after workup.

Question 25

Pt has indication for AVR. Decide b/w SAVR and TAVI.

Answer 25

Make sure no prohibitive risks for SAVR (STS 8, frailty at 2, organ system failure at 2).
Age is next major consideration.
1) Rule out bio valve.
<50 should get Ross.
<65 (over 50) should get mechanical, but can opt for bio. Even if bio, this group should get SAVR.

If bio valve candidate, then consider TAVR first…
>80 should get TAVR.

The tough group is 65-80. Get TAVR eval, and if feasible, both should be offered.

Question 26

What pt should get transcatheter edge-to-edge MV repair?
Any difference b/w primary or secondary MR?

Answer 26

2a.
SECONDARY MR after GDMT (supervised by HF specialist).
Severe MR (RVol >60, RF 50%, ERO >0.40).
No need for CABG (otherwise should get mitral surgery).
EF <50 but >20. LV ESD <70. PASP <70.
Anatomy favorable.

Prohibitive surgical risk in PRIMARY MR?

Question 27

What are the class 1 indications for TV surgery?

Answer 27

Severe TR at time of L side surgery.

Question 28

Optimal medical therapy for Type B dissection?
What if more acute or complicated presentation?
What are the parameters?
What meds?

Answer 28

Doesn’t matter how acute/complicated. This is first.
BP <120 systolic. HR <70.
Beta block until HR reached. Add Ca channel blocker if not.
ACE and ARB will be oral agents.

Question 29

What is the predominant risk for TBAD (type B aortic dissection)?

Answer 29

Aortic degeneration and subsequent aneurysm. This is why “close clinical follow-up” is a COR1 recommendation.

Question 30

What morphologic feature pose high risk of late sequelae in type B aortic dissection?

Answer 30

These may predispose to more rapid disease progression:
- primary entry tear at greater curve of distal arch
- short proximity of entry tear to L SCA
- initial aortic diameter >40
- initial false lumen >22
- higher number or larger size of fenestrations b/w true/false
- stent graft creates new tear
- partial false lumen thrombosis

Question 31

In patients w/ TBAD and high-risk features, why might it be reasonable to delay TEVAR?
What specifically are you trying to avoid? What increases risk for this?

Answer 31

COR IIb.
May reduce early adverse events.
Specifically - retrograde type A dissection.
- oversizing
- proximal bare spring stent
- arch dilation
- proximal tear site
- “bird-beaking”
- landing proximal to L SCA

Question 32

What makes TBAD classified as “complicated?”

Answer 32

rupture or malperfusion

Question 33

Average age of presentation of TBAD in Marfan patients?

Answer 33

40 (as opposed to 64 in general population)

Question 34

In patients with genetically triggered TBAD treated with TEVAR, how is the risk of retrograde dissection and intervention compared to general population?
What about SINE (stent graft induced new entry)?
Marfan’s open conversion rate?

What does all this suggest?

Answer 34

Higher for all - Open surgical repair over TEVAR is reasonable for more durable treatment in patients with connective tissue disorders and TBAD who have progression of disease despite OMT.

Question 35

When would type B dissection need intervention?

Answer 35

If aneurysmal: 5.5 cm or growing 1 cm/yr.
Pain. Malperfusion.
Re-dissection.
Rupture.