SESATS CTS Adult Cardiac Flashcards
1
Q
Manage incidentally found pulmonary AVMs
A
embolize all, even incidentally found (risk of stroke, bleeding)
2
Q
Pt presents w/ flail chest, pain is controlled, unable to wean from vent. Consider what mgmt?
A
rib plating
3
Q
What is Haller index required for pectus surgery?
A
> 3.5
4
Q
Compare Nuss and Ravitch.
A
No difference in pain or cosmetic outcome except that Ravitch is open. Nuss may require removal of strut.
5
Q
Are PFTs affected by pectus surgery?
A
Usually no change in PFTs
6
Q
For penetrating lung trauma requiring intervention, what is ideal surgical procedure?
A
Tractotomy. Avoid lobectomy and pneumonectomy - c/b BPF.
7
Q
Solitary fibrous tumor appearance on PET?
A
Not FDG avid.
8
Q
Solitary fibrous tumor gross appearance on parietal and visceral pleura?
A
sessile on the parietal pleura and pedunculated on the visceral pleura
9
Q
Solitary fibrous tumor microscopy appearance?
What pathology finding denotes more aggressive tumor?
A
Spindle cells.
More aggressive when >4mitoses/HPF are present.
10
Q
Treatment for pulmonary solitary fibrous tumor?
A
Multidisciplinary care.
If possible, excise with negative margin and follow w/ yearly surveillance.
- Re-resect if margin positive.
- If cannot re-resect, can give adj radiation.
- If cannot initially resect, can give neoadj radiation.
- If more advanced (extensive local disease or mets), dacarbazine or doxorubicin.
- imaging - well-circumscribed soft tissue masses with a homogenous appearance, enhance w/ contrast
- majority of SFTs have indolent behavior with a very low risk of recurrence or metastasis
- STAT6 is sensitive and specific
11
Q
How do you monitor pulmonary ground glass opacities that have been incidentally found?
A
Monitor for development of solid component, size >8 mm.
12
Q
What do you do for GGO that is >8 mm or has solid component?
A
Can do wedge, or repeat CT imaging 3 mo, or PET/CT, or other biopsy.
13
Q
How do you manage a pleural effusion with high ADA?
A
Pleural biopsy to dx TB effusion. No drainage needed if positive, as these resolve w/o drainage.
14
Q
How do you image pancoast tumor to decide on approach?
A
MRI
15
Q
What treatment do you need before resection of any pancoast tumor?
A
Induction chemo BEFORE any resection
16
Q
How do you manage a pancoast tumor adherent to artery or vein?
A
Can resect and reconstruct artery and vein
17
Q
What structure, if invaded by pancoast tumor, cannot be resected?
A
Do not resect if C8 needs sacrificed
18
Q
What lymph node status precludes pancoast tumor resection?
A
Do not resect if N2 disease on workup
19
Q
What are indications for referral for lung transplant for COPD?
A
Disease is progressive despite smoking cessation, med optimization, pulm rehab, and supplemental O2.
BODE 5 or 6.
FEV1 <25% predicted.
20
Q
In lung volume reduction surgery, what is the vent strategy?
A
During single lung vent, advanced COPD pts can develop air trapping and hyperinflation, causing hemodynamic instability.
Using low TV (eg, 5 mL/kg), lower RR, and longer E-times (eg, an I:E ratio of 1:3 or 1:5), can help prevent trapping.
Lowering MV in this way may lead to alveolar hypoventilation -> inc PaCO2. This is permissive hypercapnic ventilation (PHV). pH is allowed to drop gradually to 7.35 - 7.2.
If pH drops <7.2, cautious increase in RR, suctioning of airway secretions, optimizing muscle relaxation, and administering inhaled bronchodilator therapy, should help.
If a patient should develop hyperinflation and hemodynamic instability, transient disconnection of the endotracheal tube from the ventilator usually leads to resolution over several seconds.
21
Q
What are lung volume reduction surgery criteria?
A
Results of NETT trial for emphysema:
- <75 yrs
- dyspnea w/ max med/pulm rehab
- FEV1 20-45
- DLCO >20
- air trapping: resid vol >150%, TLC >100%
- no smoking for >6 months
- 6 min walk >140m
- min pHTN (PA sys P <45)
- pulm rehab ability 6-10 wks
- CT w/ heterogenous disease focused in the upper lobes.
22
Q
Which esophageal cancers go straight to esophagectomy?
A
Straight to esophagectomy in T1b and low risk T2 (<3cm, well-diffx, no LVI); T1a can have EMR or RFA. Chemo adjuvant if nodes are positive; for any other esophageal cancer, start with induction chemoradiation and re-stage for possibility for resection (complete responders do best).
23
Q
What is added to esophageal cancer treatment if nodes are positive after resection
A
Chemo (fluoropyrimidine based).
If excellent PS, can use 3-drug regimen.
2-drug regimens are usually preferred d/t better sfx profile.
24
Q
When is neoadjuvant chemoradiation used in esophagectomy?
A
Straight to esophagectomy in T1b and low risk T2; T1a gets EMR or RFA. For any other esophageal cancer, start with induction chemoradiation and re-stage for possibility for resection (complete responders do best).
25
Non-small cell chemo strategy - first line if PD-L1 >1%?
| What if >50%?
Platinum based + Pembro is first line agent for advanced non small cell lung cancer with PD-L1 expression 1-49%.
If >50% PD-L1 expression, Pembro alone can be given. Atezolizumab or Cempiplimab-rwlc are options as well.
26
When to add EGFR TKI for non small cell lung cancer?
EGFR tyrosine kinase inhibitors (erlotinib) are indicated in patients with actionable EGFR mutations and stage IV disease; avoid using EGFR directed therapy as an adjuvant in people who have been resected since these can lose effectiveness within 1-2yrs; instead, use platinum based chemo after resection of stage II and stage III disease, and save the EGFR directed therapy for later.
27
A patient is going to undergo septal myectomy (for HCM). What in the history increases risk for postop complete heart block the most?
RBBB.
Overall heart block risk is 2%. Those with previous septal alcohol ablation are at highest risk for RBBB - transmural infarct created by the ablation is in the region of the R bundle.
LBBB should not influence the incidence of complete block.
28
Pt is s/p CABG and ready for DC. They have small effusions. What should their DC meds include?
Beta blockers and statin therapy are tracked by STS database - part of the star ranking. DAPT isn't specifically tracked, but antiplatelet therapy is.
CABG readmission is often 2/2 volume overload. In a patient with effusions, a discharge diuretic is indicated.
29
Describe ideal configurations for ITAs and radial grafts.
In-situ ITA to LAD. L and R have similar patencies. 2nd ITA to 2nd most important graft - usually lateral wall (circ system).
Radial artery is vulnerable to competitive flow - best in size-matched target w/ high grade stenosis; usually circumflex w/ 70% or R coronary w/ 90%.
Radial graft configurations don't have evidence of benefit of specific configurations - grafts off an in-situ ITA, free grafts off the aorta, or hoods of the venous grafts have similar patencies. Would avoid a direct radial-aortic anastomosis in cases of a small-friable thick-walled aorta.
30
What is basal inferior aneurysm/dyskinesis and why is it important in regard to mitral regurgitation?
It is a severe form of LV ischemic remodeling that incorporates the mechanistic properties of papillary muscle displacement, leaflet tethering, and annular dilation - all of which affect ischemic MR.
An inferior basal aneurysm may predict recurrent ischemic MR because it integrates both leaflet tethering and LV remodeling measures.
LV end systolic dimension and annuloplasty ring size were also significantly associated with a 1-year recurrence of MR.
31
How can you tell if your septal myectomy is complete?
| What do you do if it is not?
Need to know if there is a resolution of the LVOT obstruction - TEE and gradient measurement.
A provoked gradient (holding Valsalva on vent) >25 is bad/incomplete and requires resumption of bypass and additional resection. Ie complete the operation.
Do not just give volume, reduce HR, and remeasure.
32
Most common bacteria for infective endocarditis of the tricuspid valve
Staph aureus
33
Explain the difference in R sided infective endocarditis vs L sided management/tx.
R sided responds well w/ IV abx.
R HF AND severe tricuspid regurgitation; difficult to treat organisms; sustained infection; and vegetations 2cm or > w/ recurrent PEs should be considered for surgery.
In addition, patients w/ high risk for recurrence (IVDU) are less ideal candidates for early surgical intervention.
34
Is valvectomy a good first line option for tricuspid endocarditis?
No. IV abx will usually work. Also, valvectomy w/o replacement is associated w/ poor long-term outcome d/t hepatic dysfunction.
35
Do postop mitral or tricuspid bioprosthetic patients need anticoag or antiplatelet postop?
VKA (warfarin) for 3mo postop - this is the subacute phase that has inc stroke risk because epithelialization of the sewing ring has not occurred.
Lifelong DAPT shows no benefit and has inc bleeding risk.
ASA lifelong after 3 mo VKA is controversial.
36
What do you give postop mitral or tricuspid bioprosthetic patients if contraindication to anticoag?
Single-dose antiplatelet (ASA).
37
What intervention do you do with an ischemic heart disease (CAD) pt w/ EF 35-50%?
Class IIa recommendation for CABG over medical or PCI. Significant survival benefit regardless of DM.
38
If there is a CABG indication for acute ischemic heart disease, what is the timing?
Not emergent. CABG can convert bland infarct into hemorrhagic infarct and worsen ventricular function.
If non-transmural infarct, then delay for 6 hrs.
If transmural, then delay for 3 days (unless other over-riding indications are present).
39
Manage new isolated wall motion abnormality in pt on table for CABG w/ nl preop EF. The abnormality is in the distribution of one of the grafts.
Revise graft. Don't just try to de-air.
40
How do you manage a severely stenotic vein graft s/p remote CABG who is going back to the OR for heart surgery?
If patent, the prior graft should be left in place (despite some saying they should be replaced if >5 yrs old). If the previous graft stenosis is severe, it is unlikely to create competitive flow, so should be left in place as well.
A new bypass should be placed for severe stenosis.
41
Which CAD pts do you need to consider carotid disease in?
L main, triple vessel, older than 75.
| Do a good history. Get a duplex.
42
How do you manage a patient who has actively symptomatic carotid and operative/symptomatic coronary artery disease?
Active = within the last 3 months. Perform synchronous carotid endarterectomy and CABG.
43
How do you manage a patient who has actively symptomatic carotid and medically manageable (over short term) coronary artery disease?
Can start with CEA or carotid stent then staged CABG (6 wks after stent, 2 wks after CEA).
44
How do you manage a patient who has incidental asymptomatic carotid disease and actively symptomatic coronary artery disease?
CABG, then staged CEA.
45
What causes mitral regurgitation in patients with ischemic cardiomyopathy?
annular dilation
46
What to do with MV for patient with significant MV regurgitation undergoing CABG?
repair or replace; prefer repair if possible (ie with a complete and relatively undersized ring)
47
How do you eval after mitral valve repair (intraop)?
Wean CPB then use TEE to look for anything greater than mild regurgitation.
48
What to do if inadequate mitral valve repair when eval w/ TEE after weaning CPB intraop?
mitral valve replacement is durable and definitive (don't try smaller ring or placing edge-edge stitch)
49
Manage a VSD found after DES placement for ischemic cardiomyopathy
Med mgmt is 90% fatal. Emergent surgery is 45% fatal. Multi organ failure inc mortality to ~70%.
Start with VA-ECMO as a bridge to improve other organs (LVAD does not unload flow to the lungs and RV if acute resp failure).
Catheter devices can close defects <1.5 cm present for 10-14 days (sufficient scarring).
50
How does VSD after DES for MI usually present?
1-2% of MIs.
Most common scenario: after first MI in pt w/ single vessel dz. Antero-apical location (LAD territory).
Psx: CV decompensation 3-7 days after MI (esp if adequate flow is not re-established). Holosystolic murmur. Echo usually shows defect in anterior septum w/ L-R shunt. Take note of size of defect.
51
How do you manage anticoag in patient with mechanical valve undergoing minor procedure with low bleeding risk (cataracts, dental extraction)?
Continue VKAs w/ therapeutic INR. If the procedure is more invasive, it's ok to temporary interrupt without bridging.
52
What's the best way to manage worsening type B dissection despite optimal medical mgmt?
TEVAR (L SCA to celiac)
53
When do you operate for mitral regurgitation?
Causes insidious LV dysfunction. Early intervention in asymptomatic patients w/ severe MR when there is LV dysfunction (<60% EF) or enlargement (>40 mm).
In others w/ preserved EF and dimension, ok to do surgery if 95% likelihood of repair and mortality <1% (IIa).
Transcath MVr has no role in low-risk primary degen MR.
54
Manage functional mitral regurg.
FMR is different than primary degenerative MR.
Initial therapy is med therapy. Consider cardiac resynchronization therapy.
Surgery considered after optimization of medical therapy.
55
Manage acute, decompensated MR secondary to MI and ruptured papillary muscle.
Ruptured papillary muscle is a mechanical complication (as opposed to function).
It is a surgical emergency.
May require IABP at time of cath.
Definitive is urgent MV surgery (chordal-sparing replacement vs repair) and revascularization (assn w/ MI). Repair is preferred for long-term survival, but replacement is sometimes safest.
56
If acute type A dissection is suspected, how do you diagnose?
CT chest/abd. May need pelvis to eval femorals.
57
Manage uncomplicated type B dissection.
BP control (BB w/ goal HR 60) and serial imaging. Vasodilators can be used as adjunct.
58
Manage Marfan-related aortopathy
Replace ascending aorta or root >4.2 (TEE internal diameter) or >4.4 (CT or MRI external diameter).
If maximal cross-section area (sq cm) / patient height (m) is >10, then surgery is tx. Shorter pts have dissection at a smaller size. 15% of Marfan pts have dissection at size <5 cm.
59
What is ideal bypass in type A w/ dissected R axillary and rupture? How do you obtain neural protection?
CPB prior to sternotomy via femorals since axillary is not available. Antegrade and retrograde are both effective.
60
Marfan associations.
- fibrillin-1 gene (FBN-1) on 15q21.1
- incomplete microfibrillar system
- elastin is disordered and fragmented
- altered TGF-B d/t issues binding w/ fibrillin
- diagnosed clinically + fibrillin mutx tests
- ectopia lentis + aortic root dilation (Z-score >2; need CT scan) OR aortix dillation w/ fibrillin mutation is diagnostic
- also wrist/thumb sign, pectus deformity, pneumothorax, dural ectasia, scoliosis or kyphosis, MV prolapse
61
Characteristics of Loeys-Dietz syndrome
- aneurysms everywhere, aggressive
- skeletal problems
- craniofacial problems
- cutaneous findings
- pregnancy complications (uterine rupture)
- hx of allergies/inflammatory dz
- GI inflammation (eos esophagitis, IBD)
62
What is size indication for intervention in a pt w/ connective tissue disorder (eg Marfan) and aortic root pathology?
Diameter 4.5. Perform root replacement.
| Remodeling technique is not appropriate strategy for performing valve-sparing root replacement in pts w/ CTD.
63
In a patient with type B dissection and distal malperfusion, what is the management?
endovascular stent graft
64
How do you manage an elevated L hemidiaphragm in a patient s/p CABG?
Determine symptoms and atelectasis.
If a lot of atelectasis and volume loss, consider bronch.
If effusion, consider drain.
If diaphragm remains elevated after 6-12 mo of obs, then eval function and consider diaphragmatic plication.
Avoid complication by not carrying dissection too superior.
65
How does functional ischemic mitral regurgitation occur?
LV remodeling and dilation after MI results in tethering of the structurally normal leaflets with subsequent regurgitation. Associated with HF and death.
Repair via chordal sparing mitral valve replacement.
66
Potential advantages of off-pump CABG (OPCAB)?
Transfusion rates are lower.
| Periop mortality, MI rates, stroke, renal failure are comparable.
67
Does a pt w/ 3v CAD and mildly regurgitant bicuspid valve without root dilation need surgery for the valve?
No.
The ascending aorta needs to be replaced at the time of concomitant surgery if >4.5 cm.
The pt should be followed regularly if aorta is mildly dilated.
68
What is the preferred bypass conduit for 3v CAD?
all arterial
69
A patient is s/p TEVAR. He is still acidotic despite good hemodynamics, adequate filling pressures, good heart on echo, and pulses in femorals. What do you do?
Confirm you're in true lumen via angiogram or IVUS.
70
What is blood cardioplegia?
Adjunct in hypothermic myocardial protection.
O2 dissociation curve is shifted left in hypothermia.
Ie release of oxygen to tissue is dec during hypothermia.
Dissolved oxygen is essential for the efficacy of blood cardioplegia, ie the delivery of O2 for blood cardioplegia is most determined by the dissolved O2 content in blood cardioplegia.
71
Anomalous origin of the right coronary artery causes ischemia. How do you manage?
CABG w/ IMA vs ostioplasty w/ unroofing; the latter is simplest and safest
72
Del Nido advantages?
Long period of arrest (1L~90min).
Equivalent or non-inferior compared to blood cardioplegia.
May have improved return of spontaneous rhythm/dec need for defibrillation.
73
Advantages of using BIMAs?
Improved patency.
Improved survival.
Of note: preserve radials in pts w/ DM and CKD in case future Cimino is needed.
74
In a patient with aortic stenosis and hx of CAD, how can you tell if low EF is from the stenosis or the CAD?
Dobutamine stress echo.
In pts w/ LV dysfx w/ CAD and aortic stenosis, the dec SV may depress measured velocities and gradients across a severely stenotic valve - low-flow, low-gradient aortic stenosis.
Dobutamine can improve contractility and inc SV across the aortic valve. If the velocity is > 4m/s and gradient > 40 mm Hg, then low-flow low-gradient aortic stenosis is confirmed. The echo can also localize obstructive CAD.
75
Redo sternotomy, and you see bright red blood, suspect aortic injury. How do you manage?
Do not attempt primary repair.
Do not attempt to open the sternum. Close it with towel clamps.
Cool rapidly while obtaining femoral cannulation for bypass.
Can also place LV vent via lateral thoracotomy through the apex - protects heart from over-distention, especially if there is aortic insufficiency.
76
Options to protect the brain in total arch for type A.
DHCA
DHCA w/ retrograde cerebral perfusion
DHCA w/ antegrade cerebral perfusion
Moderate hypothermia w/ antegrade
Antegrade appears to be more protective than retrograde
77
What is the implication of a greater curvature tear in a type A dissection?
surgical resection and tx of primary tear remains a major surgical principle in aortic surgery
this anatomic location requires total arch replacement, with individual re-implantation of the head vessels as the ideal option
78
What should the stenosis percentage be in a target for radial artery?
greater than 70%; they are sensitive to competitive flow
79
If a standard heart cath injection (during coronary angio) cannot determine carotid disease quantity, what are other options to obtain this information?
determine FFR or IVUS; FFR may be more reliable in small/short stature patients
80
In a non-trauma, non-ischemic patient, what does the presence of a hemorrhagic effusion indicate?
likely malignancy
81
Workup for redo CABG
CT chest w/ contrast - eval grafts and close structures.
Echo - eval valves and EF.
FFR and IVUS is useful if need to eval for tight lesion on angiography.
82
Manage recurrent pericarditis
For initial episode, tx is usually ASA or NSAIDs. Response predicts reduced risk of recurrence. Glucocorticoid use is associated w/ inc risk of recurrence.
Colchicine and NSAID combo therapy is beneficial for recurrence.
Last resort is intrapericardial steroids.
83
Post-MI VSD best mortality predictor?
in order from most predictive to least: pre-op dialysis need, emergency status, shock, increased age, intra-aortic balloon pump requirement
84
What is the principal concern when using retrograde cardioplegia?
Variable drainage of the coronary venous system that prevents uniform cardioplegia delivery to the RV. May need antegrade or topical cooling as adjuncts.
85
Most common venous anomaly when considering bypass and cardioplegia?
Persistent L SVC.
86
What should be done in a patient w/ a persistent L SVC if the R atrium is to be opened?
Cannulate for venous drainage.
| If innominate open, can clamp below and all it to drain into current SVC cannula.
87
Differentiate restrictive cardiomyopathy and pericardial constriction in their presentation.
Hx of mediastinal radiation can lead to consideration of both diagnoses.
Respiratory variation of ventricular filling velocity is minimal in restrictive cardiomyopathy. Constriction patients have high variations (d/t non-compliant pericardium).
Hemodynamic catheterization can be a very important tool to further distinguish b/w these two entities.
LVEDP equalization is a hallmark of constriction (non-compliant pericardium).
LVEDP > RVEDP w/ pulm HTN is restrictive cardiomyopathy.
88
What is the mechanism of functional mitral regurgitation?
Papillary muscle displacement and chordal tethering, which prevents proper leaflet coaptation (Carpentier Type IIIB).
Functional = secondary.
Secondary to primary LV dysfx w/ otherwise normal leaflets/chords.
89
LVEF <35% in sinus rhythm w/ LBBB when QRS >150 ms w/ NYHA II - IV and w/ sx on guideline-directed medical therapy. How do you manage?
Cardiac resynchronization therapy (CRT) - pacing of the left and right ventricles to restore ventricular synchrony and thus improve left ventricular (LV) systolic function, symptoms of heart failure (HF), survival for selected patients with LV systolic dysfunction, and electrocardiographic evidence of dyssynchrony.
90
Results of COAPT trial?
Decreased mortality and heart failure readmission w/ catheter-based mitral intervention compared to medical control patients; however, the 29.1% all-cause mortality at 2 years in the treatment group is well above the expected mortality in heart transplant or implantable mechanical circ support.
91
Hemodynamic definition of CTEPH?
PA pressure >25 mmHg (P HTN).
Pulm cap wedge pressure <15 mmHg (P HTN not from heart).
Clinic psx of dyspnea.
Usually in setting of remote hx of PE, echo w/ R overload.
92
What is essential in the CTEPH workup?
History.
Echo.
V/Q scan; can be combined w/ CT w/ perfusion contrast.
R heart cath to assess hemodynamics.
Pulmonary artery angiography to confirm presence of CTEPH lesions.
93
What are absolute indications L SCA to carotid bypass in TEVAR that covers L SCA?
Most patients will not benefit from bypass and undergo unnecessary risk of bleeding and phrenic injury.
Most compelling indications - posterior cerebral circulation threat (ie is circle of Willis intact; is the posterior cerebellar artery a terminal artery) or a patent LIMA to LAD graft.
L handed individuals may also not tolerate the relative ischemia well.
94
Manage aortic aneurysm in pregnant woman with Marfan.
```
Determine aneurysm size and ob status.
<40mm root - usually tolerate well
>45 pre-pregnancy - needs intervention
40-45 and pregnant - monthly eval
>45 or 5mm inc - terminate if not viable (<20 wks), or after c-section if viable
```
Of note, if >40mm w/ progressive dilation - do not vaginally deliver
95
Define heparin resistance
Failure to achieve ACT of 480 after 450 iu/kg of heparin are given.
96
How do you treat ATIII deficiency that causes heparin resistance?
FFP has ATIII, and giving it can normalize the heparin-ACT dose-response curve. 2u FFP is the standard dose.
AT concentrate can also be given (1000 units). When compared to FFP, it requires less additional heparin; avoids thawing time, transfusion related ALI, viral transmission, and volume.
Can attempt rechecking ACT first, since sampling error is the most common cause for low ACT.
97
LVAD success is predicated on patient optimization. How do you manage a preop patient in acute renal failure (w/ hx of decompensated HF w/ biventricular congestion)?
Pulmonary catheter-directed therapy is indicated. Initiate inotropes to treat the heart failure, improve renal perfusion, and assist w/ diuresis.
98
When is an implantable cardioverter defibrillator (ICD) indicated?
Check CHF EF condition.
1) EF at or below 35% at 90 days post-revasc in pts w/ NYHA II or III HF.
2) EF below 30% regardless of NYHA class.
There must be an expected meaningful survival of at least 1 year.
99
How do you manage new HF patient w/ severe MR w/o primary leaflet pathology and tricuspid regurgitation?
Improve the cardiac status - guideline-directed medical therapy. Diagnose and treat the underlying myopathic process. Manage arrhythmias.
If severe, symptomatic MR persists despite maximal guideline-directed therapy, surgical valve repair or replacement can be considered.
For secondary MR, surgical correction of MR doesn't always improve quality of life or sx. Heart transplant or VAD should be considered.
100
A patient with advanced ischemic cardiomyopathy with Stage D heart failure presents acutely. What therapy has the best 5-year survival?
OHT. It is better than LVAD.
Guideline-directed medical therapy is generally first-line, but decompensated pts often can’t tolerate beta-blockers and afterload-reducing agents.
Active ischemia should be addressed if viability can be demonstrated. Post cardiotomy shock will be significant.
101
Oxygen delivery equation?
DO2 = CO2 x CaO2
102
Blood flow in at what rate in L/min/m2 can preserve adequate systemic/cerebral oxygenation (in terms of CPB)?
1.9-3.1
103
A patient with history of heart failure presents with edema, elevated filling pressures, low cardiac index, and low mixed venous oxygenation.
What is the diagnosis and initial management?
Cardiogenic shock.
| Inotropic support initially.
104
Guidelines for first-degree relative screening in patients with thoracic aortic disease?
Echo.
| CTA (or MRA) if abnormality found.
105
Based on the IRAD, what is the most common comorbidity for patients w/ acute aortic dissection?
HTN. >80% of pts either have the dx or present w/ it.
106
L atrial mass is resected w/ endocardium. Frozen shows sarcoma. Management?
Surgical resection, full thickness w/ patch - may require up to cardiac explantation w/ tumor resection, reconstruction, and auto transplantation.
NO cadaveric transplantation.
Medical/radiation therapies are largely ineffective.
Poor overall prognosis - depends on anatomic location and ability to perform complete resection.
107
Most common L atrial tumors?
| Management?
Myxomas.
| Simple excision.
108
In the context of CPB, how has modified ultrafiltration improved cardiac outcomes in adult cardiac surgery patients?
Higher post-bypass hematocrit, decreased blood transfusion, decreased postop bleeding.
Higher mean arterial BP in pediatric cardiac surgery.
Initiated after CPB - leave cannulas, blood aspirated from sideport of aortic into a hemofilter then returned to RA hemoconcentrated.
109
How can zero-balanced ultrafiltration (Z-BUF) help with ESRD in patients requiring CPB for cardiac surgery?
Adjunct for management of fluids, hyperkalemia, uremia, and inflammatory mediator toxicity.
110
What are some advantages of vacuum-assisted venous drainage?
Smaller cannula, elimination of air-lock, decreased in priming volume, drier operative field w/ improved venous drainage.
Vacuum must be below 100 mmHg or risk hemolysis.
111
Manage a persistent L SVC (no innominate) during case requiring bicaval bypass?
Without innominate, the L SVC has to be cannulated.
If innominate exists, L SVC can be clamped or snared.
L SVC normally becomes ligament of Marshall after development of brachiocephalic vein.
112
Seldinger type aortic cannulation for CPB causes type B dissection confirmed by TEE. How do you manage?
Switch the cannula to a short type (dispersion), and confirm flow in the true lumen.
NO femoral cannula (this can actually cause type B dissection).
NO emergency procedure unless malperfusion. Do emergent aortic endograft in this case.
113
What are cold agglutinins, how do they affect CPB, and how do you manage?
Cold agglutinins - auto-abs that agglutinate RBCs at low temps causing hemagglutination and hemolysis.
Can be precipitated in hypothermia and cold cardioplegia; can kill myocardium.
Manage by using warm blood cardioplegia and systemic normothermia.
If found intra-operatively, change CPB strategy to warm; consider using retrograde warm cardioplegia to remove coronary microemboli.
114
A patient with atrial fibrillation and mitral stenosis is to undergo mitral surgery. What scenario might a CMIV be excluded?
High predictor of recurrence in frail patient - advanced age, long duration of atrial fib, large LA size. CMIV is unlikely to be successful.
Ligation of LA appendage carries little risk and can be done quickly, so should be considered.
115
In a patient undergoing CMIV, what procedurally can impact need for PPM? Who likely will need this?
Biatrial lesion set is associated with an increased need for PPM (ie biatrial CMIV vs LA CMIV). Biatrial is often preserved for prolonged atrial fibrillation or with R side dz and RA enlargement.
SA node dysfunction is the primary indication.
If concurrent valvular surgery is performed, AV block can happen as a complication assd w/ AV nodal injury.
116
Current guidelines for stopping plavix before surgery?
5-7 days if DES placed over a year ago.
If DES <1 year ago, can stop before 5 days w/ short acting antiplatelet bridge.
Continuing plavix use up to CABG is associated with increased need for reoperation.
ASA should not be stopped. Should be dosed <100 mg.
117
ASA should be initiated within what time period to reduce SVG closure?
6 hrs. Usually ok if CT output is <100ml/hr.
No "loading" dose is required.
Benefit to SVG patency lost if initiated >48 hrs postop.
118
Recent ACS or PCI - what are DAPT recs?
12 months.
| Can also be used in pts s/p CABG w/ IIb recommendation.
119
Abx ppx in most standard cardiac cases?
first-gen cephalosporin (ancef) prior to skin incision (within 60 min), not to exceed 48 hrs
120
Abx ppx in pts w/ high-risk for S aureus, receiving a prosthetic valve, or pts getting vascular graft insertion?
first-gen cephalosporin and glycopeptide (vancomycin) prior to skin incision (within 60 min), not to exceed 48 hrs
121
Recommendations for timing of surgery for IE and a recent TIA or silent cerebral emboli?
Risk of postop neuro compromise is low, so early surgery is recommended.
Without evidence of hemorrhage, ok to proceed.
122
In a patient w/ R sided IE and hx of IVDU, what is the treatment regimen if there are no surgical indications?
4-6 wks of abx.
Surgery if persistent bacteremia, difficult to eradicate organism (normally just S aureus), persistent vegetation >20 mm, evidence of R HF.
123
What can be done preop to reduce colonization and possibly reduce postop sternal wound infections?
Topical abx for the skin and mupirocin for he nares.
124
For cardiac resynchronization therapy, where do the left ventricular leads need to be placed to be effective?
Lateral wall. If not lateral enough, will need placement of new, more lateral leads.
This will help delay need for cardiac transplantation.
125
What do the three letters in a pacer stand for?
1. Chamber paced: Atrium, Ventricle, Dual, O for none.
2. Chamber sensed.
3. Response to sensing: O-none, Inhibited, Trigger, Dual
4. programmability and rate modulation: O-none, Programmable, Rate modulation
5. anti-tachyarrhythmia function: O-none, Shock, Pacing, Dual
Example: DOO - both atria and ventricles paced w/o sensing or inhibition.
126
What is an R on T when a patient has temporary pacing?
When a patient has PVC with DOO pacing on the PVC T wave, an R on T can occur, which can precipitate ventricular fibrillation.
DDD can avoid susceptibility to PVCs (because it would sense the PVC).
127
How do you manage an R on T in a patient who codes postop w/ internal temporary pacing wires that were set to DOO?
Start compressions.
Turn off the pacer, reveal V-fib, external cardiovert w/ 150J. If the patient doesn't respond x3, open the chest.
If asystole or bradycardia are uncovered after pacer is off, then resume pacing with HR 80-100 at max amplitude.
128
How do you manage an inadvertent endocardial LV lead placement?
Rare. Placing pt at inc risk for thromboembolic events.
Need surgical exposure and removal w/ placement of RV lead.
NO transvenous lead extraction as there is excessive risk of dislodging embolic debris.
Warfarin can be considered in pts who are not surgical candidates.
129
Along the posterior annulus of the mitral valve, towards, P1, what are you in danger of injuring when placing stitches?
circumflex artery
130
What structure is immediately behind the anterior mitral leaflet?
non-coronary cusp of the aortic valve
131
During mitral surgery, if sutures are placed too deep behind the anterior mitral leaflet, how is the complication manifested?
aortic valve incompetence and LV distention
132
When does warfarin embryopathy occur?
Occurs b/w 6-12 wks gestation (1st trimester) and is dose dependent starting at 5 mg/day.
During the 2nd and 3rd trimester, warfarin is recommended if needed.
Ok to continue during 1st trimester if dose <5 mg.
133
How do you treat coarctation of the aorta?
Transcatheter stent placement.
| Prevent coarctation complications of rupture, heart failure, and intracranial hemorrhage.
134
How do you manage an infected ICD generator after attempted abx w/ the device exposed?
*Know PM status…
Complete device AND lead removal w/ placement of a new system.
If the patient is not pacemaker-dependent, the device can be placed after the wound has healed sufficiently.
If they are pacemaker dependent, may require temporary active fixation leads as a bridge after 3 days of neg blood cx.
135
Patients with family hx of HCM and sudden cardiac death (SCD) require what prophylactic therapy?
ICD placement.
Also required in HCM pts w/o fam hx in following scenarios: If pt has prior arrest, spontaneous VT, syncope, LV thickness >3cm, abnormal BP response to exercise.
136
Pts w/ prior MI, NYHA Class 1 HF and EF <30% require what mgmt in regards to HF?
Other indications for this mgmt?
ICD therapy in addition to best medical mgmt.
| Also for NYHA II and III sx if EF <35%.
137
In a patient undergoing coronary revascularization with moderate aortic regurgitation, what should be done with the aortic valve?
AVR at time of surgery (IIa recommendation)
138
Compare TAVR to SAVR
TAVR: higher rates of PVL, lower rates of bleeding complications, lower rates of AKI and a-fib
139
Manage an atherosclerotic coronary artery aneurysm in patient undergoing CABG.
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Benign natural history (unlike Kawasaki related aneurysm). At the time of CABG (if has other indication), large aneurysms should be opened and ligated proximally and distally. Distal bypass also should be done.
If small (<2cm), distal bypass should be enough.
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140
During TEVAR for type B dissection, the patient develops a retrograde type A. How do you manage?
Aortic arch replacement with sewing of the ascending/arch graft to the stent graft.
141
An adult pt w/ hx of rTOF has pulmonic subvalvular stenosis. How do you manage?
Need transfer to congenital institution.
| Percutaneous vs open valve.
142
How do you confirm pulmonary valvar stenosis in patient w/ repaired TOF?
First line mgmt?
Cardiac MRI.
| Perc balloon valvuloplasty is likely first line if confirmed.
143
A patient has severe aortic valve regurgitation and severe mitral regurgitation (central regurg). How do you manage?
Aortic valve replacement.
| Mitral valve REPAIR is preferred.
144
If retrograde cardioplegia is given, and the heart does not arrest w/ low line pressures, what could be the cause?
How do you manage?
Consider persistent L SVC. Can drain into coronary sinus and interfere w/ retrograde cardioplegia.
Occlude the L SVC during cardioplegia or use antegrade.
145
What is the benefit of retrograde cerebral perfusion during aortic arch surgery?
Elimination of air and debris from cerebral circulation.
146
POD1 CABG x3 patient has v-fib w/ ST elevation after cardioversion. Management?
IABP and coronary angiography.
| V-fib is concerning. If angio shows issues, may need to redo.
147
S/p mech mitral valve replacement 5 wks ago, pt has valve obstruction w/ thrombus formation. How do you manage?
TEE diagnostic - how big?
<5mm w/ min clinical impact - anticoagulation alone.
>5mm - fibrinolysis (IV tPA) or reoperation (risky d/t adhesions).
148
Indications for cardiac resynchronization therapy
LVEF ≤35% – on optimal evidence-based med tx for 3 mo after dx, and after dx and tx of any reversible causes of persistent HF (ie MI or tachycardia-induced cardiomyopx).
- QRS ≥150 ms w/ LBBB & NYHA II-IV HF: CRT (and IHD)
- QRS ≥150 ms w/ non-LBBB & NYHA III-IV
- QRS <150 ms w/ LBBB & NYHA II-IV
149
Current AHA guidelines for abx ppx for dental procedures?
| Which pts and what abx?
Only if involves manipulation of the gingiva or periapical area of the teeth or perforation of the oral mucosa.
In the following conditions: prosthetic material in heart, previous IE, CHD, first 6 mo after procedure, OHT pts w/ valvulopathy.
Amoxicillin 2mg 30-60 min preop.
Keflex/Ancef or clinda if allergic.
150
For the prevention of endocarditis, is abx ppx required prior to GI or GU procedures?
No. Not for IE prevention.
151
Mitral valve repair is performed and SAM is discovered coming off bypass. How do you manage?
Volume load to expand the LV, beta block to inc diastolic filling time, and reduce inotropes as much as possible.
If SAM persists, attempt to salvage (especially if young pt) w/ posterior leaflet sliding plasty (decreases posterior leaflet height and moves coaptation line away from LVOT).
Replace MV if repair not possible.
152
Acute mitral regurgitation with pulmonary edema d/t ruptured chord to posterior leaflet causing flail - management?
Emergency mitral valve repair
153
Explain the mechanism of neuroprotection during cardiac arrest, specifically DHCA. How is it confirmed to be adequate?
Minimizing cerebral rate of oxygen consumption.
Electrocerebral inactivity on EEG is assd w/ least amount of cerebral activity. There is not a specific temperature or time within a temp.
154
Bioprosthetic valve thrombosis management?
Usually, systemic heparin until INR 3-3.5 then lifelong coumadin.
Surgery is reserved if no response or if in shock - replace valve with mechanical prosthesis.
Mechanical valve thrombosis is often more acute and requires immediate intervention.
155
Risk of stroke with 30 min of DHCA?
7.5%
156
A patient requires cerebral perfusion for DHCA but has an aberrant R SCA off the distal arch. What is the strategy?
ACP via direct cannulation of carotids
157
How is ACP normally performed for DHCA?
R SCA w/ chimney graft and occlusion of the innominate artery, L carotid, and L SCA with clamps or balloon catheters
158
How do you treat endocarditis caused by HACEK organisms assuming no surgical indication exists?
Ceftriaxone or fluoroquinolone for 4-6 wks.
159
How do you treat mild-moderate post-cardiotomy shock?
Initiate and escalate inotropic support. If that fails, then mechanical circulatory support should be considered.
Milrinone and dobutamine can be added if not hypotensive or tachycardic.
160
Initiation for CPB is begun, there is low volume in the venous reservoir, flows are low, MAP is low, the RA is collapsed. How do you manage?
Add volume to the venous reservoir.
This could be vasodilation as well, but that is unlikely to happen early.
If the RA is decompressed, it is unlikely inadequate drainage (ie placing a second cannula will not help).
161
During ACP, regional cerebral oxygen saturation decreases asymmetrically. How do you manage?
Insert another carotid cannula in opposite side.
Can increase flow rates, as long as arterial P isn’t >80.
Retrograde cerebral perfusion can yield uniform cooling, but antegrade studies suggest superior outcomes.
162
A patient has undergone DHCA. What is the maximum temperature gradient when rewarming?
Max temp?
Max rewarm rate?
The gradient, measured from the arterial outlet to the venous return temp, should not exceed 10 C to prevent formation of gas emboli.
Max temp should be 37 to prevent cerebral hyperthermia.
The max rewarm rate should be < 0.5 C per min.
163
S/p LVAD, a patient has elevated pulm pressures, elevated CVP, and low cardiac output despite a normal MAP w/ epi. What's the next best agent to add?
RV is the problem.
Add milrinone - PDE inhibitor that prevents cAMP degredation and increases intracell Ca. Inc contractility w/ dec PVR and some dec SVR.
164
Diffuse coagulopathy occurs after DHCA. Pressure, packing, topical agents don't work. Coag labs are corrected via transfusion of platelets, cryo, and FFP. No surgical bleeding. What's next?
Factor VII at a low-dose - has been shown to dec postop bleeding and postop transfusion
165
What can be given to reduce incidence of peri-operative atrial fibrillation?
Beta-blockade reduces risk of POAF, but it does not have any impact on post cardiac surgery stroke, MI, or mortality.
166
In patient with LVAD destination therapy, what should be MAP goal be to prevent hemorrhagic stroke?
What should the INR target be?
MAP <90
INR 2-3
DAPT has NO proven benefit.
167
What PVR in Woods units should heart transplant likely be excluded?
>5, though there is no absolute cutoff.
| The reasoning is that healthy donors have RVs untrained for pulm HTN, and are prone to RV failure.
168
What is first-line in tx for patients with peri-op R HF s/p OHT?
Catecholamines - epi, isoproterenol, dobutamine.
Selective pulm vasodilators can also be used and are effective at reducing PVR w/o causing systemic vasodilation (infrequently used).
RVAD and ECMO should be considered early if cannot wean off CPB.
169
In acute AR, what happens to LV EDP, pulm venous P, and SV?
Inc LVEDP, pulm vein P, and SV.
Ie pressures behind aorta and forward flow from aorta inc.
Dyspnea, pulm edema, and heart failure can ensue.
170
What imaging is often best to evaluate the tricuspid valve?
TTE
171
Pt has severe aortic stenosis and moderate tricuspid regurgitation with RV enlargement/dysfunction. She is a low risk surgical pt. What is management?
Aortic valve replacement and tricuspid annuloplasty.
Tricuspid regurgitation does not reliably respond to correction of L side defects alone.
Tricuspid REPLACEMENT is likely NOT necessary for functional tricuspid disease.
TAVR is only for high and intermediate risk pts w/ symptomatic severe stenosis.
172
Asymptomatic adult pt s/p TOF as a child now has moderate pulmonic regurgitation. What would create indication to operate?
Pulmonic valve replacement if any TWO of following:
- mild or mod ventricular (R or L) dysfunction
- severe RV dilation
- elevated RV systolic P >2/3 systemic P
- progressive reduction in exercise tolerance (should be measured w/ cardiopulm exercise test)
173
An adult has pulmonic regurgitation and stenosis after balloon plasty for stenosis as a toddler. He has no symptoms, exercise capacity is stable, and echo is otherwise normal. What is next step?
Serial follow up.
Pulmonic valve replacement would be surgery if indicated.
174
Massive air embolism occurs during a case. How do you manage?
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Stop perfusion and clamp artery and venous lines.
Remove air in circuit by recirculation.
Trendelenburg.
Deep hypothermia.
Retrograde cerebral perfusion via SVC.
Aspiration of the arch via root vent.
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Adjuncts: hyperbaric oxygen, induce coma, steroids.
175
How can you tell if your septal myectomy is complete?
| What do you do if it is not?
Need to know if there is a resolution of the LVOT obstruction - TEE and gradient measurement.
A provoked gradient (holding Valsalva on vent) >25 requires resumption of bypass and additional resection. Ie complete the operation.
Do not just give volume, reduce HR, and remeasure.
