TSRA Clinical Scenarios - Adult Cardiac Surgery

Question 1

Heparin dose for CPB?

Answer 1

400 units/kg

Question 2

ACT required for initiation of CPB?

Answer 2

400-480

Question 3

5 min after cross clamp is released when coming off CPB, the heart begins to distend w/o contraction. What is the next move?

Answer 3

Two possible problems:
1) valve leak
2) heart is not ejecting
Squeeze the heart. Pace the heart. If this does not resolve quickly, cross clamp again.
Talk to anesthesia and perfusion to see if they can help determine a cause on echo or via labs.

Question 4

Coming off CPB, you attempt to pace, but have no capture. Leads are well placed. Perfusion says K is 7. UOP is minimal. You cross clamp and vent the heart. How do you manage K?

Answer 4

Hemoconcentrate. IV insulin with glucose. Lasix or bicarb can also help.

Question 5

A patient fibrillates when coming off CPB. How do you defibrillate?

Answer 5

Internal paddles set to 10-20 joules and gradually increased.
If not working, give IV lidocaine and amiodarone 150 and try again.

If distended, manually squeeze the heart and empty with CPB, place vents if needed, then cardiovert.

Vent air, inc perfusion pressures to 75 (coronary perfusion and to flush out embolized air), optimize oxygenation, lytes, and temp. Check Echo for AI.

Question 6

If heart is distending when coming of CPB, what amount of AI requires consideration for replacement?

Answer 6

AI greater than 1+/moderate-severe may require exploration and replacement of the aorta.
Should be higher on differential after a mitral surgery - damage to noncoronary leaflet w/ placement of the mitral stitches.

Question 7

Explain CPB components.

Answer 7

Venous cannulas drain to reservoir by gravity or vacuum, pumped into the oxygenator/heat exchanger, then continues to arterial air filter and to the arterial cannula in the patient.

Question 8

Attempt CPB, but perfusionist says high aortic line pressure. What is differential?

Answer 8

Obstruction - kink or clamp
Malposition - in one of the aortic branches
Cannula too small - 21-24 Fr should be adequate (18-20 used at USC)
Aortic dissection - systemic P low w/ abnormal ascending aorta

Question 9

What is your differential for inadequate venous drainage on CPB?

Answer 9

Air lock
Cannula malposition
Add suction
Increase cannula size
Reduce flows if flow is high
Make sure no other avenues of blood flow into the heart - AI needs a vent, azygous vein needs adjustment to snares, L SVC needs snare or cannulation depending on situation (cannula if NO innominate).
Retroperitoneal or peritoneal hemorrhage?

Question 10

Attempting CPB flows, but MAP not rising above 40. Pt has hx of ACE use.

Answer 10

Rule out other problems. Could be vasoplegia.
Give pressors - phenylephrine, norepi, vasopressin. Methylene blue can be used as well.

This can occur postop as well.

Question 11

You place retrograde cardioplegia line in coronary sinus, but pressures are low. How do you troubleshoot?

Answer 11

Check for rupture of the sinus - inspect inferior aspect of the heart
Check position of cannula
Check if balloon is ruptured

Persistent L SVC

Question 12

When giving retrograde cardioplegia, you find a L SVC. How do you manage?

Answer 12

Check if there is an innominate.
Present - can snare to include it below the innominate.
Not present - cannulate the L SVC and add it to venous drainage.

Question 13

Coming off CPB from a mitral surgery. BP drops, ST elevation on EKG, and RV distends. You suspect air in the coronary. How do you manage?

Answer 13

R coronary ostium is anterior and susceptible to air embolism.
Re-institute CPB w/ high perfusion pressure to help support cardiac fct and push air through coronary into venous circulation.
Add a root vent to prevent further air migration into the coronary arteries.
A needle in the apex of the heart can be added to remove air if too much in the apex.

Question 14

If patient has previous CABG and is requiring CPB, how do you manage an open LIMA?

Answer 14

Can clamp vs cold bypass flow

Question 15

If patient has open SVGs after CABG and needs CPB, but the grafts are high on the aorta, what is an option to make room for cross clamp?

Answer 15

Axillary cannulation may be needed to make room for an aortic cross clamp.

Question 16

In a patient w/ CABG w/ open LIMA, what is the problem with antegrade cardioplegia?

Answer 16

Antegrade will perfuse the OM and PDA territories, but not the LAD.
Retrograde will perfuse all.

Question 17

In the setting of aortic insufficiency, discuss options for CPB.

Answer 17

Retrograde cardioplegia would ensure delivery. Antegrade would likely require direct delivery of cardioplegia.

Question 18

How could you incompletely deliver cardioplegia if using retrograde cardioplegia assuming no L SCV? What can you do?

Answer 18

Tip of the retrograde cannula is distal to the middle cardiac vein. Direct retrograde insertion can help (bicaval cannulation, snare cavas, and open R atrium).

Question 19

What can make retrograde cardioplegia delivery riskier in a redo operation (previous CABG)?

Answer 19

If you perforate the sinus, the posterior heart may be stuck, making dissecting in a bloody field more difficult. On the other dissection on the front end may damage CABGs.

Question 20

After cross clamping, 500 ml of antegrade cardioplegia is delivered, but there is poor distention of the aortic root, incomplete arrest, and LV distention. What is happening and how do you manage?

Answer 20

Aortic insufficiency.

Switch to retrograde cardioplegia and turn on the aortic root vent vs an LV vent to decompress the heart.

Question 21

How do you ensure adequacy of retrograde cardioplegia catheter delivery?

Answer 21

Cessation of electrical and myocardial activity. Appropriate pressure in cannula is around 40 mmHg. Observe flow through coronary veins and arteries. Can also check coronary ostia through aortotomy for backflow. Finally, heart should be cooling.

Question 22

What is a concern with retrograde cannula placement even if it works well to arrest the heart?

Answer 22

Myocardial edema. This is why the balloons on the cannula are not usually 100% occlusive.

Question 23

Where does a persistent L SCV usually drain?

Answer 23

Into the coronary sinus, may partially drain via innominate V.

Question 24

You attempt to infuse antegrade cardioplegia. The perfusionist notes high line pressure. How do you manage?

Answer 24

Stop flow. Look for kinks or clamps to r/o obstruction. Ensure pressure monitoring line is connected.
If all above ruled out, concern for dissection. Visualize the root and ask anes to look at aorta.
If dissection, cool with original aorta cannula distal to the clamp and prepare for dissection repair.

Question 25

After a cardiac surgery pump case w/ retrograde cardioplegia, the myocardium is slow to regain activity. What should you check?

Answer 25

Check retrograde catheter and/or that the balloon is down, in order to allow for adequate coronary sinus flow.

Question 26

When sewing a CABG, you notice bleeding from the arteriotomy. What does this mean?

Answer 26

Arrested myocardium is getting perfusion. Check the cross clamp and that the root vent is on.
There could be collaterals.
If unable to ID cause, monitor for electrical activity, and consider cold topical saline, cooling the patient to mild hypothermia (32 C), reducing flows as tolerated, or increasing frequency of cardioplegia administration.

Can deliver some plegia if vein graft once suturing complete.

Question 27

How do you manage a perforation of the coronary sinus after placement of a retrograde cardioplegia catheter?

Answer 27

CPB, clamp, and arrest with antegrade. Repair the hole directly with prolene or a pericardial patch.

Question 28

What are the three broad categories for etiology of persistent electrocardial activity (problem with initiating plegia in CPB)?

Answer 28

Access - cannula placement
Collateral - clamp, drainage, L SVC, vents/suckers; hypothermia?
Myocardial mass - hypertrophy may require hypothermia

Question 29

Redo sternotomy, and there is a significant amount of dark blood from the sternomanubrial jct. What was injured?

Answer 29

Innominate vein

Question 30

Redo mitral w/ innominate vein injury during sternotomy. How do you manage?

Answer 30

Pack the area and close the sternum with penetrating towel clamps.
Peripheral CPB. Put pump suckers in the injured field.
Reopen and dissect vein to length for closure w/o tension. Primary vs pericardial patch repair.
If cannot repair, divide and oversew.
If too lateral, may need trapdoor to expose - above clavicle and at 3rd rib space.

Question 31

Redo case. You attempt to dissect SVC for cannulation, but make a large hole before pursestring is in. How do you manage?

Answer 31

Tamponade it.
Attempt IVC and aortic cannulation for CPB. Need vacuum venous drainage to prevent air lock.
Pump suckers near SVC to clear the field.
May be possible to cannulate through the injury.
Consider placing pump sucker into azygous vs ligating azygous if you can’t see.
May need to dissect more proximal and place a Rummel tourniquet.
Once controlled, may need primary vs pericardial patch.

Question 32

You are called to cath lab during a lead extraction after the patient arrested w/ hypotension. What injury is likely? How do you manage?

Answer 32

Venous injury, often in the SVC.
Cannulate the groins and start CPB vs open to relieve tamponade and compress SVC while achieving CPB.
Open and decompress the heart. Identify the injury, dissect proximal and distal, control it, and repair primarily vs w/ patch.

Question 33

A redo cardiac surgery patient is femorally cannulated with difficulty during the venous cannulation. The venous line has return, but the patient continues to become hypotensive after CPB is started. How do you manage?

Answer 33

Goals: identify injury, cannulate beyond repair.
Venogram if available.
This hx is concerning for iliac vein injury.
If chest is open, can centrally cannulate, otherwise, may need access in contralateral femoral vein.
If the injury is above the iliacs, can use fluoro get wire and cannula above and go on, then open the abdomen and repair the injury.

Question 34

SVC is ruptured during balloon dilation for SVC syndrome. How do you manage?

Answer 34

Give heparin.
Emergency median sternotomy.
Bicaval cannulate - for the SVC, enter the RA and traverse cannula through injury. 
Empty the heart.
Primary vx pericardial patch closure.

Question 35

Bicaval cannulation in an old lady, and the IVC tears below the diaphragm. How do you manage?

Answer 35

Get venous access and go on CPB.
If possible, traverse the cannula through the injury from above.
Place a Rummel clamp if possible below the injury.
May need patch for tension free repair.

If unable, may need to go on w/ SVC cannula and suckers. Get femoral access.
Can attempt incising the diaphragm through sternotomy to get exposure.
If all else fails, extend sternotomy inferiorly and convert to RUQ subcostal incision.

Question 36

Cath lab creates and RV puncture and places a pericardial drain w/ bloody drainage. Manage.

Answer 36

Heparin and sternotomy.
CPB and arrest the heart.
Wide patch repair even if small.
Bypass the coronary lesion if during a cath case for coronary disease.

Question 37

There is a small R PA injury noticed after an aortic surgery when coming off bypass. Manage.

Answer 37

If small, a figure of 8 will fix.
If large or uncontrolled, go back on bypass (if you had axillary, can do end to end of previous graft).
Decompress the heart, and the PA will decompress.
Mobilize the R PA. May need pericardial patch.

Question 38

You puncture the opposite side of the aorta during arterial cannulation. Manage.

Answer 38

May need circulatory arrest.
Can cool with the existing cannula if forward flow is okay.
May need to establish axillary access.
Small aortotomy and local repair.

Question 39

What symptoms represent unstable angina?

Answer 39

chest pain at rest, exertional angina not relieved by rest, and new onset of chest pain

Question 40

What symptoms represent stable ischemic heart disease

Answer 40

exertional angina - predictable, improves with rest

Question 41

What is included in guideline-directed medical therapy?

Answer 41

lifestyle modification, statin therapy (LDL goal 70-100), beta-blockade, aspirin, and ACE inhibition (if LV dysfunction, DM, or CKD)

Question 42

What are hemodynamically significant coronary lesions on left heart cath?

Answer 42

Left main >50%

non-LM >70%

Question 43

What FFR is hemodynamically significant? When is FFR used?

Answer 43

< 0.80.
Determines hemodynamic significance of the cumulative effect of proximal stenosis.
Used to guide revasc in angiographically intermediate coronary stenosis in patients w/ stable angina.

Question 44

What is the SYNTAX score?

Answer 44

16 segments in the coronary tree.
Lesions in this tree are scored.
The sum of these scores is the overall SYNTAX score.

Question 45

What are the cutoffs for the SYNTAX score?

Answer 45

> 22 is intermediate complexity.
32 is high complexity.
The results of the SYNTAX trial revealed that patients with 3-vessel or L main disease benefited from CABG over PCI.

Question 46

What is a non-invasive option for imaging the coronary arteries?

Answer 46

Gated cardiac CT

Question 47

What did a secondary analysis of the STITCH trial reveal concerning myocardial viability studies?

Answer 47

They are obtained in preop CABG pts w/ EF <35%. They can predict an improvement in EF postoperatively, but this did not translate into a survival benefit. IE it should not be used as a way to rule out low EF patients for CABG over medical therapy.

Question 48

How do you decide who needs coronary revascularization in patients with stable ischemic heart disease?

Answer 48

Activity limiting symptoms despite maximal medical therapy.
Active patients who want PCI for better QoL compared to med therapy.
Anatomy with proven survival benefit.

Question 49

After deciding on revascularization, how do you decide who needs CABG?

Answer 49

1) 3-vessel disease, especially w/ syntax >22 (mod) and low surgical risk.
2) Significant L main disease (50%).
3) Multivessel (>1) w/ proximal LAD disease.

Europe guidelines add:
Multivessel (2+) w/ EF <40.
Multivessel (2+) w/ >10% ischemic territory.

Question 50

Management of significant CAD in 1 vessel w/ refractory angina despite medical therapy and PCI.

Answer 50

CABG.

Question 51

Management of significant CAD in 1 vessel after sudden cardiac arrest from ischemic ventricular arrhythmia.

Answer 51

CABG.

Question 52

Management of CAD at 50% in 1 vessel in patients undergoing valve or aortic surgery?

Answer 52

Concurrent CABG.

Question 53

What is the ideal graft for the LAD?

Answer 53

IMA. Left preferred. Right is second choice.

Question 54

In a patient undergoing CABG for 3 vessels without excessive risk of sternal complications or other organ failure, what are the ideal grafts?

Answer 54

BIMA and radial.

Question 55

What can be done technically to reduce the risk of sternal complications in a patient getting BIMA grafts?

Answer 55

Skeletonized.

Question 56

Known risks of sternal infection and malunion in cardiac surgery?

Answer 56

Nonelective procedure, age, uncontrolled DM (HbA1c >7), BMI >40, female, COPD, preop hospitalization >3 days, smoking, immunosuppression regimen, radiation mediastinal injury

Question 57

When should CABG patients receive aspirin?

Answer 57

Preoperatively when they discover CAD is ideal.
Within 6 hrs postop after CABG.
Continued indefinitely.

Question 58

A patient comes in for elective CABG but has not stopped taking plavix. What do you do?

Answer 58

Cancel the case.

Plavix and ticagrelor (Brilinta) need to be stopped for 5 days preop.

Question 59

A patient requires an urgent CABG but is taking plavix. What do you do?

Answer 59

Plavix and ticagrelor (Brilinta) should be stopped 24 hrs preop to reduce major bleeding.
Short acting IV antiplatelets (eptifibatide [Integrillin] or tirofiban [Aggrastat]; both gpIIb/IIIa inh) should stopped 2-4 hrs preop.
Abciximab (reopro) should be stopped 12 hrs preop.

Question 60

Why are beta blockers reinstituted after CABG (as long as no contraindications)?

Answer 60

reduce incidence and sequela of atrial fibrillation

Question 61

What is the target for statin therapy in patients undergoing CABG?

Answer 61

reduce LDL <100 and achieve at least 30% dec in LDL

Question 62

Which postop CABG patients require ACE or ARB?

Answer 62

LVEF <40, HTN, DM, CKD. Unless otherwise contraindicated.

Question 63

What is the continuous IV insulin target in postop CABG?

Answer 63

blood glucose concentration <180

Question 64

When anatomically and clinically suitable, what is the RIMA often used for?

Answer 64

L Cx or RCA usually if critically stenosed and perfusing LV myocardium - can improve survival and decrease reintervention

Question 65

RIMA patency is directly related to what?

Answer 65

Degree of proximal stenosis of the target vessel. Ie how much competitive flow is there?

Question 66

When is a radial artery recommended? What is patency of the RA prone to?

Answer 66

Prone to spasm in periop period and sensitive to competitive flow.
Only use for L side lesions >70% (severe) or R side lesions >90% (critical) - same for gastroepiploic arteries.
Give ca channel blocker postop.

Question 67

Who is the ideal patient who gets complete arterial revascularization?

Answer 67

<60, with few comorbidities, severe L sided stenosis, and critical R sided stenosis. Skeletonize.

Question 68

What are inferior leads?

Answer 68

II, III, aVF

Question 69

What EKG findings suggests RV or RCA ischemia (or L dominant PDA disease)?

Answer 69

Inferior leads: II, III, aVF.

Or posterior findings: reciprocal V1-2.

Question 70

What EKG changes suggest LV or LAD/LCx territory ischemia?

Answer 70

Anteroseptal: V1-V2.
Anteroapical: V3-4.
Anterolateral: V5-6, I, aVL.

Question 71

What is diagnostic for STEMI?

Answer 71

Angina symptoms for 20 min w/ ST elevation 2+mm in 2 contiguous leads or new LBBB. Greater risk for transmural ischemia.

Question 72

What is the diagnostic criteria for NSTEMI?

Answer 72

Angina symptoms >10 mins.
Elevated cardiac biomarkers.
ST elevation of 0.5-1mm 
 - or ST depression >0.5 mm 
 - or T wave inversion >1mm
More likely to have subendocardial ischemia.

Question 73

When can IABP be useful in the setting of MI?

Answer 73

refractory shock despite initial medical management; post-infarct VSD; acute papillary muscle rupture

Question 74

What are contraindications for IABP?

Answer 74

Severe AI and PVD precluding placement.

Question 75

What is the first line reperfusion strategy for STEMI?

Answer 75

PCI. Door to balloon time of 90 min.

Question 76

What is the role for CABG in STEMI?

Answer 76

Failure of PCI + coronary anatomy suitable + persistent ischemia.
OR MI complication - papillary muscle rupture, post-infarct VSD, LV rupture

Question 77

What coronary disease is left-main equivalent?

Answer 77

> 70% in LAD and L Cx

Question 78

A patient presents w/ NSTEMI, stable, meets indication for CABG. How do you manage?

Answer 78

Maximize medical mgmt: heparin, ASA, O2 if needed, IABP if refractory angina or low EF.
Urgent CABG (plavix should be stopped 24 hrs).
The patient should not be DC home.

Question 79

A patient is resuscitated from witnessed cardiac arrest. Coronary angiography shows 3V disease. What’s the revascularization strategy?

Answer 79

PCI of the INFARCT artery. THEN assess if cardiogenic shock…

• If stable w/ low complexity - PCI of non-culprit arteries.
• If cardiogenic shock - DON’T revasc non-culprit arteries. DEFER this… and determine at-risk myocardium.

Non-culprit supplies large area of myocardium?
No -> GDMT and heart team discussion.
Yes -> Complex/multivessel?
- No -> staged PCI.
- Yes -> heart team: GDMT w/ staged PCIs vs CABG

Question 80

Manage pt w/ inferior infarction and RV involvement. PCI failed.

Answer 80

CABG.

Consider delaying until RV is optimized w/ inotropes, diuretics, or even mechanical support.

Question 81

A patient w/ previous coronary stent undergoes CABG. How do you manage this vessel?

Answer 81

If it is wide open, no reason to bypass as it will likely fail 2/2 competitive flow.

Question 82

A patient requires CABG and is found to have a porcelain aorta. How does this affect planning?

Answer 82

Preop: evaluate groins and axilla w/ CT.
Consider beating heart CABG - may need fluids, pressors, and shunt.
If needed, peripheral cannulation: axillary or femoral.
Try to use all arterials, and Y off the LIMA if needed.
SVG may be anastomosed to innominate, carotid, SCA, R axillary artery, or descending aorta.
Be ready to circ arrest.

Question 83

A CABG patient has porcelain aorta and AI. They are getting AVR. How do you make sure the heart doesn’t distend too much?
How do you do proximal anastomoses?
What uf you cant find a safe place to clamp?

Answer 83

LV vent via R SPV or LV apex.
The patient will need ascending aortic replacement in order to place proximal anastomoses.
The patient may need circulatory arrest if you cannot find a safe place to clamp.

Question 84

Redo CABG has higher risk than primary revascularization w/ mortality of 7-11% mostly 2/2 what cause?

Answer 84

perioperative MI - can be 2/2 incomplete revascularization, atheromatous emboli, damaged grafts, hypoperfusion through new grafts, or early graft occlusion

Question 85

In a redo CABG, what is the general principle in regard to handling previous venous bypass grafts?

Answer 85

No touch technique - avoid embolization of debri

Question 86

What is your myocardial protection strategy for redo CABG?

Answer 86

Antegrade alone may not protect areas supplied by patent pedicled IMAs and may dislodge debri in SVG.
Retrograde allows washout of coronary debris and access to myocardial areas of occluded arterial grafts.
Clamping of patent arterial grafts ensures uniform cooling. Do NOT do difficult dissection of open LIMA-LAD if risk injuring it.
Consider cooling pt to 28-30 if keeping LIMA patent.

Question 87

During redo CABG, what strategy can be utilized in order to minimize the number of proximal anastomoses (ie the proximal sites on aorta are limited d/t prior grafts)?

Answer 87

sequencing vein grafts

Question 88

During redo CABG, patient fails to wean from bypass. Doppler is done once all other causes ruled out, and poor flow is found with associated regional abnormality on TEE. What do you do?

Answer 88

Grafts to that area on TEE should be reconstructed immediately.

Question 89

During redo CABG, there is no room on the aorta for proximal anastomoses. What options are there?

Answer 89

End-to-side to patent arterial grafts.

Use RIMA in situ if possible.

Question 90

During redo CABG sternotomy, there is bright red blood encountered before sternum is completely open. There are EKG changes. What do you expect, and what do you do?

Answer 90

Suspect coronary/graft injury.
Heparinize and obtain femoral bypass.
Can attempt repair once injury is exposed vs coronary perfusion catheter.
Complete the operation.

Question 91

During redo CABG, you are trying to dissect the LIMA-LAD proximally and injure it. There are hemodynamic, EKG, and wall motion abnormalities. How do you manage?

Answer 91

Get on bypass. Clamp and arrest the heart. Try to repair the injured mammary.
*Before dissection of the mammary, you need to be ready to clamp and arrest - heparinized w/ high ACT, cannulated, dissected ascending aorta.

Question 92

What are the important diagnostic studies for post-infarct VSD?

Answer 92

EKG - rule out ongoing ischemia and arrhythmia.
Echo diagnostic - color flow Doppler shows size and location of VSD (also valves, R side pressures, PA, tamponade).
RHC - step-up in oxygenation b/w RA and PA is diagnostic >9%; can also see elevated pulm-to-systemic flow ratio (1.4:1 to 8:1).
LHC - can determine if need for revasc.

Question 93

Post-infarct VSD mortality?

Answer 93

Poor - 25% within 24 hrs, increasing with time up to 97% in 1 year.
This is an indication for urgent surgery.

Question 94

Manage a post-infarct VSD preop.

Answer 94

Reduce afterload to decrease L-to-R shunt (nitroprusside).
Maintain cardiac output and perfusion (milrinone).
Increase coronary perfusion pressure.

IABP and inotropes. Milrinone.
ECMO or biventricular support can be used for temporary salvage before more definitive surgery can be performed.

Question 95

How do you do an anterior septal rupture repair (pt w/ post-infarct VSD)?

Answer 95

No PA catheter.
Conduit harvest if needed.
Bicaval cannulation. Antegrade cardioplegia. LV vent in R SPV.
Cool to 25 C.
LV transinfarct incision and infarctectomy including septum.
Patch with horizontal mattress sutures, felt strip, and Dacron patch.
Deair, wean CPB, TEE to assess residual VSD/shunt/LV fct/MR.
+/- IABP.

Question 96

How do you do apical VSD repair (postinfarct VSD)?

Answer 96

Incision through infarcted apex.
Debride necrotic tissue (may include LV, RV, septum).
Reapproximate w/ interrupted mattress through felt (use felt b/w each layer).

Question 97

How do you do posteroinferior VSD repair (postinfarct VSD)?

Answer 97

CPB and arrest.
The heart needs to be retracted (like for PDA bypass).
LV transinfarct incision w/ 1 cm of space lateral to PDA.
Debride necrotic tissue.
Inspect mitral for papillary infarct.
Inspect posterior septum - can re-approximate using double layer buttress.
Large defects require patch (must be tension free).

Question 98

When is delayed repair for post-infarct VSD acceptable?

Answer 98

Severe end-organ damage unable to undergo operative repair.
May need LVAD to improve end organ dysfunction and allow for maturation of the infarcted tissue.
Biventricular assist device may be needed if LVAD worsens R-to-L shunt.

Question 99

What is the greatest predictor of post-operative mortality in pts w/ postinfarct VSD?

Answer 99

Time in cardiogenic shock

Question 100

Is asymptomatic severe aortic stenosis an indication for surgery?

Answer 100

No

Question 101

How can you “unmask” asymptomatic severe aortic stenosis to objectively confirm a patient is without impairment?

Answer 101

exercise stress test (treadmill) - positive if…

• Symptoms.
• SBP dec by >10 mm Hg.
• Dysrhythmias.
• ST changes.

Question 102

What is the peak gradient equation (in the context of aortic stenosis)?
How is it obtained?

Answer 102

Peak gradient = 4(velocity)^2.
Maximum gradient present when central aortic pressure is subtracted from LV systolic pressure.
Obtained by echo w/ continuous wave doppler.

Question 103

In what scenario may a patient with severe aortic stenosis have a low gradient?

Answer 103

In a patient with low cardiac output. Velocity, and thus gradient (4[velocity]^2), is affected by CO. This is a low gradient/low flow AS.

Question 104

How can a low flow/low gradient AS be confirmed in a patient w/ normal EF (>50)?

Answer 104

Stroke volume index <35% ml/min/m^2.

Question 105

How can a low flow/low gradient AS be confirmed if the patient has a low EF (<50%)?

Answer 105

Dobutamine stress echo - if gradient increases while AVA remains the same, AS is confirmed.

Question 106

If low flow/low gradient AS is suspected in a patient w/ low EF (<50%), and dobutamine stress echo shows NO change in gradient w/ AVA increase >0.3cm^2 (or if AVA reaches 1cm^2), what is the diagnosis?

Answer 106

pseudo-AS

Question 107

In the workup of AS, a significant subvalvular gradient and asymmetric septal hypertrophy is found, what treatment may be required?

Answer 107

Septal myectomy and possible mitral valve surgery

Question 108

If the diagnosis of AS is uncertain by echo, including dobutamine stress testing, what else can be done?

Answer 108

Cardiac cath to cross the valve and obtain a hemodynamic AV study.

Can directly measure gradients.

Question 109

In a potential TAVR candidate for AS, what imaging needs to be obtained?

Answer 109

TAVR CT scan - valve morphology (TTE unreliable), AV annulus and LVOT sizing, coronary height and orientation, and sinus height and width sizing.

Question 110

What are the diagnostic criteria for severe AS?

Answer 110

Any of the following: 
- mean AV gradient >40
- peak velocity across AV >4 m/s
- AVA <1 or indexed <0.6
- dimensionless index <0.25 
Always confirm. Always r/o CAD, aneurysm, and MV disease.

Question 111

How do you decide on SAVR vs TAVR for symptomatic, severe AS?

Answer 111

Anatomy.
Age and medical conditions affecting long-term prognosis.
Preference.

Question 112

What STS risk score is prohibitive for SAVR for symptomatic severe AS?

Answer 112

STS >15%. TAVR shows survival benefit in these patients.

Question 113

Compare likely complications for TAVR vs SAVR.

Answer 113

TAVR - perivalvular leak, ppm.

SAVR - bleeding, re-hospitalization, atrial fibrillation.

Question 114

What are the benefits of a mechanical aortic valve compared to bioprosthetic?

Answer 114

Lower reintervention rate in <60 yrs old.

Superior survival at 15 yrs if b/w 50-70 yrs.

Question 115

What complication of a surgical bioprosthetic aortic valve placement will likely reduce benefit from a valve-in-valve procedure?

Answer 115

patient-prosthesis mismatch

Question 116

An AS patient undergoes TAVR CT showing bicuspid aortic valve. The valve is functional, and the patient is low risk. Discuss TAVR use.

Answer 116

TAVR is not approved for use in this population.

Question 117

A patient w/ AS and intermediate surgical risk has an associated ascending aortic aneurysm. At what size is there a strong indication for aorta surgery?

Answer 117

4.5 cm

Question 118

What is the EOAI and why is it useful for aortic valve placement?

Answer 118

Effective orifice area (obtained by sizing valve and finding the corresponding EOA published by the manufacturer)/BSA.
Used to predict PPM.

Question 119

An aortic valve’s EOAI is < 0.85. What does this mean?

Answer 119

Predictive of PPM. 0.65-0.85 is predictive of moderate PPM. <0.65 is severe.

Question 120

Is EOAI <0.85 a contraindication for aortic valve surgery?

Answer 120

No. In a comorbid elderly patient w/ symptomatic severe AS, a risk of moderate PPM is preferred over cross-clamp time and surgical risk.

Question 121

During workup for CABG, moderate AS is found. How do you manage?

Answer 121

Class IIa indication for replacement at time of surgery.

Question 122

You are doing surgery for AS, but the heart is not arresting well. How do you manage?

Answer 122

May just be slow d/t hypertrophy. 
Check crossclamp.
Check drainage. 
Add LV vent in R SPV. 
Open aorta and give direct cardioplegia.
Cool patient.

Question 123

Intraop TEE during AVR for AS shows moderate perivalvular leak. How do you mange?

Answer 123

Clamp, arrest, open aorta, and reassess.
If visible defect, place a stitch.
If not, remove valve and start over.
Ensure decalcification of entire annulus (retained Ca can lead to improper seating).

Question 124

What can you do if a patient’s EOAI is <0.85 during AVR for AS, and this is unacceptable?

Answer 124

consider root enlargement or total root replacement

Question 125

What can make an asymptomatic severe AS a surgical candidate?

Answer 125

Low gradient w/ <50% EF.
Critical AS (>5m/s velocity).
Severe LVH.
Concomitant cardiac operation.
Severe calcification.

Question 126

A patient with aortic regurgitation gets an echo. What are you looking for?

Answer 126

Confirm diagnosis and severity, assess for etiology, valve morphology, LV assessments, aortic root size.

Question 127

In workup for AR, a bicuspid valve morphology tells you what about the future procedure?

Answer 127

More amenable to repair, especially with more normal sized roots. Jet direction is critical.

Question 128

Which AR patients need a heart cath?

Answer 128

Need: significant risk factors for CAD or those older than 40 in whom AVR is considered.

Question 129

In workup of AR, what test can be done to confirm diagnosis if echo is inconclusive or discordant w/ physical findings?

Answer 129

cardiac cath w/ root angiography and measurement of LV pressures

Question 130

Severe AR is defined by what echo/angio parameters?

Answer 130

jet width >65% of LVOT
vena contracta >0.6 cm
holodiastolic flow reversal in the prox abdominal aorta
regurgitant volume >60 ml/beat
regurgitant fraction >50% 
effective regurgitant orifice >0.3 cm2
angio grade 3+ or 4+

Question 131

Diagnosis of chronic severe AR requires evidence of what?

Answer 131

LV dilation

Question 132

2017 guidelines indications for surgery for chronic AR?

Answer 132

symptoms and severe
other cardiac surgery and severe (moderate is IIb)
asymptomatic, severe, and LVEF <50
asymptomatic with severe LV dilation - LVEDD >75mm or ESD >55mm
asymptomatic with LV ESD >65 and normal EF (IIb)

Question 133

You are doing surgery in a patient w/ AR. CPB is initiated, and the heart continues to eject, and begins to distend. What do you do?

Answer 133

Prior to bypass, you should be ready for distention - have retrograde cardioplegia access.
Arrest immediately.
Create the aortotomy, then give direct cardioplegia.

Question 134

When trying to establish retrograde cardioplegia for an AR case, you have difficulty, and the position is questionable. What can be done?

Answer 134

Bicaval cannulation.
Make room for the cross clamp, and ID the aortotomy site.
Initiate CPB.
Place the LV vent, clamp, aortotomy, then give direct cardioplegia.
Once arrested, snare the SVC/IVC.
R atriotomy and place direct retrograde catheter for cardioplegia (just past opening to ensure middle vein gets plegia).

Question 135

During AR case, what if you injure the coronary sinus and/or retrograde cardioplegia becomes unreliable?

Answer 135

Initiate CPB, clamp, give ostial cardioplegia.

Question 136

During AR case, TEE and direct visualization shows a tricuspid valve w/ prolapse of the R cusp. What are the surgical options?

Answer 136

Replacement is safest.

Question 137

During AR surgery, a patient fibrillates and arrests while cannulating the RA. The heart dilates, and defibrillation fails. He is unable to be converted back to sinus. What do you do?

Answer 137

Institute CPB, empty the heart, and defibrillate again.
If unable to empty the heart d/t severe AI, cross clamp and open the aorta.
Decompress the heart with a sucker through the aortic valve and localize the coronary ostia to give antegrade cardioplegia w/ an ostial cannula.

Question 138

You complete an AVR, but are unable to close the aortotomy d/t the large prosthesis putting tension on the aortotomy suture line. What do you do?

Answer 138

Use a bovine or autologous pericardial patch to ensure no tension on the suture line.

Question 139

You complete an AVR, but there is periprosthetic regurgitation. What do you do?

Answer 139

Quantify and localize the leak. Differentiate between prosthetic vs periprosthetic.
You may have to remove the prosthetic to fix the problem.
Leaks from the non-coronary sinus are most amenable to direct suture repair.

Question 140

Symptomatic acute aortic regurgitation should be taken care of expeditiously. Why?

Answer 140

The ventricle has not had time to develop any adaptation to overcome the increased volume which can lead to rapid deterioration.

Question 141

In non-surgical candidates w/ AR, what are some of the operative considerations for TAVR?

Answer 141

The lack of calcification and larger annulus size may mean a self-expanding prosthesis would be more successful. The 30-day mortality for TAVR for AR is higher compared to TAVR for AS.

Question 142

Describe the benefits of aortic valve repair in AR surgery?

Answer 142

Similar results for AVR w/o need for anticoagulation as opposed to mechanical implants and possibly improved durability compared to bioprosthetics

Question 143

How do stented pericardial aortic valves tend to fail?

Answer 143

By aortic stenosis of the biologic prosthesis, but tend to last longer than porcine valve.

Question 144

What type of aortic valve is generally favored in younger (<55) patients?

Answer 144

Mechanical valves, though they do limit lifestyle d/t need for anticoagulation, and they limit future TAVR options.

Question 145

What tests should you obtain before a redo AVR?

Answer 145

Echo (consider TEE if concern for endocarditis).
Coronary imaging.
CTA C/A/P to eval for transcatheter options, root size, SJ width, coronary heights; access options.
Carotid duplex
PFTs if hx of pulm disease
Vein mapping if previous CABG
Prev op note: when, what was last valve, other procedures (root enlargement, ascending aorta), CABG conduits and if crossing midline

Question 146

Compared to TAVR, redo AVR is associated with what risk profile?

Answer 146

Lower vascular complications and perivalvular leak.

Higher short-term stroke rate, atrial fib rate, AKI, bleeding.

Question 147

How do you decide b/w valve in valve TAVR vs redo SAVR?

Answer 147

Early complication rates are lower for ViV TAVR. Durability is unknown.
Endocarditis is a contraindication.
Mechanical valves preclude TAVR.

Eval for risk of patient-prosthesis mismatch: What were the gradients postop? If they are high, the original valve may already be small => redo SAVR +/- root enlargement.
Eval for risk of coronary obstruction: coronary height needs to be >10mm.

Question 148

In considering valve-in-valve TAVR, what would be considered a small in place prosthetic valve?

Answer 148

<23 mm may require the smallest TAVR inside or require fracturing of the surgical valve via high pressure balloon dilation.
At <23 mm, there should be a compelling reason not to do redo SAVR.
Similar issues: narrow STJ, small root.

Question 149

In terms of a valve-in-valve TAVR, what measurement/diameter must be known in terms of the TAVR placement?
How can this number be confirmed?

Answer 149

The internal diameter of the previous surgical valve.
Look up product guide to find the internal diameter, and confirm w/ CTA or TEE.

When evaluating for SAVR, the external diameter of the valve matters as it must fit in place of the native valve annulus.

Question 150

A previous AVR fails d/t AI (as opposed to AS). What are the considerations for procedural management?

Answer 150

There needs to be a compelling reason to NOT do redo SAVR.

Most current TAVRs are designed for AS, not AI.

Question 151

In what situations should a ViV TAVR be more strongly considered as opposed to a redo AVR?

Answer 151

> 75-80 yrs, prior CABG w/ LIMA (esp if near sternum), HFrEF, poor condition, calcified ascending, renal failure.

Question 152

ViV TAVR self-expanding vs balloon expandable discussion.

Answer 152

Self-expanding:
Better gradients (important since valve area is being reduced more d/t ViV).
Higher pacemaker risk (lessened by previous valve “protecting” conduction system).
Less traumatic in setting of calcified aorta.
Do not require rapid pacing (important if HF/sick ventricle 2/2 recurrent AS).

Question 153

For a younger patient at low surgical risk w/ severe structural bioprosthetic aortic valve deterioration, what is the ideal procedure?

Answer 153

Redo AVR.

Especially if AR.
Especially if small valve (<23 mm), narrow STJ, or small root. Clue would be if initial postop gradients from previous SAVR are high.
Especially if high risk for coronary obstruction (eg surgical valve has leaflets outside the frame, effaced sinuses, low coronary height [<10 mm]).
Especially if concomitant surgical pathology.

Question 154

Discuss cannulation strategy for redo AVR.

Answer 154

Be prepared for anything - have preop imaging; axilla, femorals, and legs prepped (vein if coronary injury). Consider placing femoral sheaths (4-5 Fr).
Consider bypass prior to opening in following situations - aorta close to sternum, high PA pressures w/ RV close to sternum, critical bypass grafts under sternum, calcified aorta.

Question 155

Discuss myocardial protection in a redo AVR w/ AI.

Answer 155

Retrograde cardioplegia +/- antegrade and ostial.

LV vent.

Question 156

What are the considerations for the conduction system in redo AVRs?

Answer 156

Higher risk of heart block. Make sure you have reliable wires and consider a-wires.

Question 157

Discuss prevention and management of fibrillation during initial dissection of a redo AVR w/ moderate AI.

Answer 157

Can be caused by CPB w/ an incompetent valve or bovie near the LV during dissection (keep cautery <45).
Have external pads, so you can shock prior to heart being dissected out (100-200 joules).
Having heart dissected out before CPB allows you to shock w/ paddles in case of fib during CPB.
Instability - cannulate and go on pump immediately.
Heart distends - LV vent (ideally R SPV; LV apex if exposed; or clamp aorta and aortotomy w/ ostial plegia)

Question 158

Discuss operative plan for redo AVR w/ previous CABG.

Answer 158

Need preop cardiac cath and study of previous op note.
LIMA patent - frequent plegia and cool to 30 vs clamp LIMA (must be easy dissection, don’t risk injury)
- can clamp across all tissue w/ vascular clamp,
- if dissecting LIMA, be ready to clamp and arrest because injury will require immediate CPB and plegia
May need to mobilize grafts for aortotomy vs transect and rebypass w/ ligation of the old graft.

Question 159

During redo AVR, you are unable to access the root and get exposure of the valve via aortotomy, what can be done next for exposure?

Answer 159

Transect aorta.

Question 160

During redo AVR, you tear the aorta/outflow tract when removing the old valve. How do you fix this?

Answer 160

Patch.

May need homograft recon if necessary.

Question 161

During redo AVR, you injure R coronary ostia while removing the valve. How do you manage?

Answer 161

Preparation: have legs prepped so vein can be taken.

Look at cath to ensure you are distal to disease during bypass.

Question 162

Coming off bypass from redo AVR, and there is RV dysfunction. Assessment and plan?

Answer 162

Always assume regional functional issues are coronary problems.
Rule out air in the coronary system.
Assume new valve obstructed R coronary ostia - go back on pump, and graft R coronary system.

DO NOT reopen aorta and redo valve. You should have made sure you could see coronary ostia before closing aortotomy.

Question 163

How can you be sure coronary ostia are open after redo AVR?

Answer 163

Before closing aortotomy, visualize the ostia.

Give retrograde plegia and look for blood return from the os.

Question 164

After redo AVR, you cannot close the aortotomy d/t tension on the aorta.

Answer 164

In redo settings, the aorta can be less compliant. Use a patch, and try not to “oversize” the aorta.

Question 165

77yr pt w/ mechanical AVR has failed w/ AS to the point of requiring intervention, and there is MR. Assessment and plan?

Answer 165

Likely functional MR 2/2 AS.

Safest: redo SAVR and monitor MR as outpt for need for MitraClip.

Question 166

What critical diagnoses need to be considered in the differential for patients with a failed AVR being considered for re-intervention?

Answer 166

PPM - look for evidence of high gradients postop => may need enlargement and SAVR
Endocarditis - echo and cultures in right clinical setting => no ViV TAVR

Question 167

What critical diagnoses need to be considered in the differential for patients with a failed AVR being considered for re-intervention?

Answer 167

PPM - look for evidence of high gradients postop => may need enlargement and SAVR
Endocarditis - echo and cultures in right clinical setting => no ViV TAVR

Question 168

In terms of valve sizing, what info can be obtained before AVR to ensure no PPM?

Answer 168

Check BSA and CTA. If the required size is unlikely to fit the patient’s anatomy, be prepared for a root enlargement.
EOA (obtained via manufacturer) of valve / BSA should be > 0.80 to prevent PPM.

Question 169

Primary mitral regurgitation is generally caused by what?

Answer 169

primary leaflet abnormalities - usually result of degenerative disease

Question 170

Secondary MR is generally caused by what?

Answer 170

structurally normal valve leaflets are unable to coapt completely - owing to a distortion of either the annulus or the subvalvular apparatus

Question 171

LV dysfunction and secondary MR prognosis compared to either abnormality in isolation?

Answer 171

much worse; controversial whether revascularization alone is helpful; controversial whether addressing MR will be of value

Question 172

Carpentier’s Type 1 MR?

Answer 172

normal leaflet motion - results from LV enlargement and annular dilation (functional MR)
can also be from perforation in leaflet

Question 173

Carpentier’s Type II MR?

Answer 173

leaflet prolapse - can be degenerative, acute papillary rupture after MI

Question 174

Carpentier’s Type IIIa MR?

Answer 174

leaflet restriction, systole and diastole - rheumatic

Question 175

Carpentier’s Type IIIb MR?

Answer 175

restriction during systole alone - chronic ischemic disease

Question 176

Dilated cardiomyopathy is likely to cause what type of MR?

Answer 176

type 1 - normal leaflet motion

pts may have severely depressed LV fct

Question 177

Ischemic MR tends to cause what type of MR?

What is mechanism?

Answer 177

type IIIb - systolic restriction
chronic ischemia can cause asymmetric ventricular remodeling => mostly affects inferior and lateral LV wall => disruption of the subvalvular apparatus => downward and lateral (apical) displacement of the PM papillary muscle => leaflet tethering

Question 178

What is the study of choice to clarify the mechanism of MR?

What is a problem with this study?

Answer 178

TEE - however, MR may be lower intraoperatively d/t anes and ventricular unloading

Question 179

At the time of CABG for severe ischemic MR, what is the preferred surgery for the mitral valve?

Answer 179

mitral valve REPLACEMENT, chordal sparing - bio valve is probably best since poor prognosis long-term

• remember GDMT, as this is secondary MR
• stage D - RVol >60ml, RF >50%, ERO >0.4 cm2
• 2a evidence
• either way, 2 yr survival is 20-25% - why bio valve is likely best

Question 180

What is an Alfieri stitch and when is it appropriate?

Answer 180

At the time of apical incision such as LVAD for Type I (nl leaflet motion) secondary MR

Question 181

In CABG MVR, why do you do distal anastomoses first before valve?

Answer 181

avoids excess manipulation of heart that predisposes to AV groove dissociation

Question 182

An old pt w/ diffuse CAD and poor targets has dilated cardiomyopathy w/ secondary severe MR and EF of 15%. What should you plan for?

Answer 182

LVAD. Consider Alfieri stuure after apical coring.

Question 183

A patient who requires CABG is found to have moderate ischemic MR. What do you do for the MR?

Answer 183

Nothing. Concomitant MVr resulted in longer OR time, longer hospitalization, higher rates of a-fib, higher rates of stroke.
MitraClip may be better option down the road.

Question 184

Pt w/ severe symptomatic secondary mitral regurgitation and EF <50%. Pt sx are persistent despite GDMT. What is recommended for mitral valve?

Answer 184

Eval for transcatheter edge-to-edge MV repair (2a)

• LVEF 20-50
• LVESD <70mm
• PASP <70 mmHg

If anatomy not good, then consider surgery (2b)

Question 185

What is often the mechanism for acute mitral regurgitation 2-7 days after MI?
How do you manage?

Answer 185

Single blood supply to posteromedial papillary muscle - either RCA or L Cx depending on dominance.
Anterolateral has dual blood supply (LAD and L Cx).
Acute inferior STEMI -> Papillary muscle rupture -> flail leaflet -> apical holosystolic murmur, pulmonary edema -> dyspnea.
DO NOT increase afterload or cause volume overload. Give milrinone for inotropy and nitroprusside for vasodilation.
IABP should be considered.
ECMO may be needed.
Surgery: mitral replacement w/ chordal preservation.

Question 186

How does the jet in primary mitral regurgitation predict leaflet affected?

Answer 186

anterior directed jet is from posterior leaflet prolapse and vice versa; when planning repair, need to know if pt can tolerate second pump run if repair fails

Question 187

Vena contracta for severe mitral regurgitation?

Answer 187

0.7 cm

Question 188

Regurgitant volume for severe MR?

Answer 188

60 ml

Question 189

Regurgitant fraction for severe MR?

Answer 189

50%

Question 190

Central jet for severe MR?

Answer 190

40% LA or holosystolic eccentric jet

Question 191

In primary mitral regurgitation, which patients should get an operation? Do they have to have severe findings?

Answer 191

There are two conditions.
They have to be SEVERE AND have either…
- symptoms
- signs of systolic dysfx: EF <60, ESD >40
- progressive inc LV size or dec in LV fct x3 studies

• a center of excellence

Question 192

If doing a mitral valve repair, what is a necessary adjunct to reinforce most repair techniques?

Answer 192

Ring or band annuloplasty

Question 193

During mitral repair, what is at risk when placing stitches near posteromedial commissure?

Answer 193

Near right trigone - conduction tissue

Question 194

During mitral repair, what is at risk if you place deep stitches at the anterior leaflet while moving from the right to left trigone?

Answer 194

Aortic valve (L/non commissure) - look for aortic insufficiency that wasn’t there preop.

Question 195

During mitral repair, what is at risk if you place deep sutures at P1?

Answer 195

Circumflex artery - look for WMA on the lateral wall.

Avoid by angling the needle toward the ventricle (away from the atrium).

Question 196

While doing a mitral repair, what is at risk if placing deep retraction stitches outside the annulus of the P3 scallop?

Answer 196

Coronary sinus

Question 197

What is likely the ideal repair in patients w/ mitral regurg 2/2 mitral valve prolapse 2/2 fibroelastic deficiency?

Answer 197

In fibroelastic deficiency, there is a paucity of tissue. Neochords are often the best repair, or a very limited triangular resection.

Question 198

In MVR w/ Barlow’s valve, what is often the best repair?

Answer 198

There is excess tissue in almost all scallops.

Perform quadrangular resection w/ sliding plasty.

Question 199

A pt with severe MR (vena contracta >0.7 cm, regurg volume >60, regurg fraction >50%, ERO >40%, presents to your clinic. She is asx w/ normal EF (>60%).
When does she get surgery?

Answer 199

ESD >40.
Mortality <1% and >95% of successful and durable repair.
Progressive increase in LV size or decrease in LVEF >3 studies.

…Or if symptomatic or EF <60.

Question 200

56F w/ heart murmur presents to ED w/ worse dyspnea and hemoptysis. She was doing intense physical work when she experienced severe precordial chest pain.
She tachycardic w/ elevated JVP. She has a pansystolic murmur.
CXR shows BL pleural effusions.
What happened?
What are risk factors?
What is tx?

Answer 200

Exercise induced acute chordal rupture resulting in severe MR w/ heart failure.
The previous murmur suggests an underlying structural problem - MVP puts pts at inc risk for rupture.
Other predisposing factors: rheumatic heart disease and infectious disease.
Blunt chest trauma is a rare cause.
OR for urgent mitral valve repair.

Question 201

In acute MR, acute chordal rupture from degenerative etiology needs to be differentiated from papillary muscle rupture d/t ischemia. Why?

Answer 201

The treatment is different.
Papillary muscle rupture often warrants replacement (they may also need a CABG).
Ruptured chords can be repaired.

Question 202

59M admitted w/ acute SoB and systolic murmur. CXR shows effusions BL w/ R lung opacification and leukocytosis. EKG and troponin normal.
What study should be done next?

Answer 202

Get echo - can show severe MR 2/2 flail leaflet.

Do NOT misdiagnose PNA and start abx. The murmur means you need to determine if this is MR, or pt will decompensate.

Question 203

For MV approach, when might L atriotomy be best approach?

How is it done?

Answer 203

Most common approach.
Incision of choice for robotic and mini-thoracotomy.
Approach via R side through Sondergaard’s groove (Waterston’s).

Question 204

For MV approach, when might vertical transseptal be best approach?
How is this done?
Any advantages?

Answer 204

Feasible w/ large LA in setting of chronic MR.
Via fossa ovalis.
Reduces risk of PPM, easier to close.

Question 205

For MV approach, when might extended superior transseptal (Guiraudon) be best approach?
How is this done?
DIsadvantages?
Any advantages?

Answer 205

Vertical transseptal incision is extended superiorly onto the dome of the LA.
Risk of damaging SA nodal artery (increased risk of PPM).
May provide better exposure for a deep chest anatomy/wide AP diameter.

Approach of choice in the setting of previous AVR or aortic root placement.
Can be easily extended and connected with an aortotomy incision for a Commando operation (endocarditis and raidation).

Question 206

For MV approach, when might horizontal transseptal (Dubost) be best approach?
Any advantages/disadvantages?

Answer 206

Uncommon.
Can be considered in the setting of a hostile anatomy b/w the aortic root and LA dome (presence of calcified aortic homograft).
Difficult closure, risk of narrowing R superior pulmonary vein, risk of transseptal incision progressing/tearing AV node -> high risk of PPM.

Question 207

For MV approach, when might transaortic be best approach?
How is this done?
Any advantages?

Answer 207

Aortotomy is extended onto the dome of the LA.
Useful in in endocarditis when both aortic and mitral valves need to be replaced (transaortic Commando).
Exposure can be challenging, in which case the incision can be connected to the extended transseptal incision.

Question 208

For MV approach, when might left atrial appendage be best approach?
How is this done?
Any advantages?

Answer 208

Very uncommon.
Left thoracotomy.
Alternative approach after multiple previous re-operations.

Question 209

For MV approach, when might transventricular be best approach?
When is this done?

Answer 209

Can be utilized if entering the LV for another reason (ventricular aneurysmectomy or LVAD).

Question 210

Your patient is being evaluated for a mitral repair. They have a previous AVR complicated by a postop bleed requiring takeback then mediastinitis and sternal wound infection eventually requiring flap closure. How would you approach the mitral?
How do you get on bypass?
How do you arrest?

Answer 210

R anterolateral thoracotomy via 4th intercostal space centered at the anterior axillary line.
Cannulate through femorals.
Fibrillatory arrest under moderate hypothermia (requires competent AV).
Endoballoon (requires competent AV).

Question 211

A patient s/p mitral repair surgery is coming off pump. The patient becomes hypotensive, and 3+ MR is noted with encroachment of the anterior leaflet onto the LVOT.
What is the diagnosis and management?
What would the effect of nipride be in this setting (eg before coming off pump, anesthesia tries to “make room for volume”)?
What else could make this worse?

Answer 211

The patient has SAM. Wait for volume and consider adding beta-blocker to ensure not simply underfilled. Then aim to reduce the posterior leaflet height - folding valvuloplasty, revise triangular repair to quadrangular w/ sliding annuloplasty. Placement of a larger ring.
If all fails, replace the valve.
If the patient is too frail to replace, do an Alfieri stitch.

Nipride would accentuate the problem by underfilling the ventricle thus increasing ventricular systolic contraction.
Inotropic support and reduced afterload could make things worse.

Question 212

Describe the pathophysiology of SAM after mitral surgery?

Answer 212

Mitral surgery changes the line of coaptation to displace it more anteriorly towards the LVOT.
The Venturi effect causes the anterior leaflet to get sucked into the LVOT during systole.
At the same time, the posterior leaflet prolapses towards the atrium, creating an anteriorly directed jet.
SAM thus causes both mitral regurgitation and LVOT gradient.

Question 213

What increases the risk of SAM in mitral surgery?

Answer 213

Posterior leaflet is >1.5 cm in height after repair (ie it is tall).
Small hyperdynamic ventricle.
Ring is UNDERsized too much - causes line of coaptation to bulge anteriorly.
AL:PL ratio <1.3
Aorto-mitral plane angle <120 degrees
Coapt/septum distance <25 mm
IVS thickness >15 mm
Anterior displacement of prosthetic ring.

Question 214

After MV replacement, bright red blood is welling up behind the heart after the cross clamp is released?
What is the likely diagnosis?
What is the cause?
What is the management?

Answer 214

AV dissociation after mitral valve replacement/ AV groove disruption.
Can happens up to hours after the procedure and is signaled by massive intrapericardial hemorrhage.
Rupture occurs in the LV near the AV groove posteriorly.
Tends to occur in women w/ small LVs.
The cause is technical:
- too much traction on the annulus during excision of the valve or insertion of the prosthesis
- lifting the heart after valve replacement, tearing the annulus
- stitching through the posterior AV groove
- perforation from papillary muscle excision
- perforation of the AV groove during calcium debridement
Management: go back on pump and re-arrest. Open the LA. Remove the prosthesis. Pericardial patch. Reimplant the valve.
- if caused during repair, replace the valve and use the PL to buttress the patch repair and reduce tension on the suture

Question 215

Coming off pump from mitral surgery, ST changes are noted along the lateral leads and the patient becomes hypotensive.
What happened?
What is the management?

Answer 215

Differential includes postcardiotomy syndrome and cardiogenic shock from reperfusion or poor protection.
Most likely is damage to the circumflex.
Management: back on pump, harvest vein, bypass to distal OM.

Question 216

During mitral surgery, the left atrium is opened, and there is blood. You cannot see anything.
What is your checklist?

Answer 216

Make sure there is a working sucker in the RSVP.
Check the aortic cross clamp - ensure it is all the way across and occluding flow.
Explore the septum for an ASD - can be evaluated from LA, but may require RA incision to repair.

Question 217

A patient has an indication for re-operative mitral valve replacement. What workup should be considered?

Answer 217

EKG - rule out AF
CXR - count sternal wires
CT - assess distance b/w sternum and RV/aorta/innominate vein, aortic Ca
CTA - if previous CABG, need to know course and distance of vessels
CT abd/pelvis - assess femorals
Preop TEE - mitral pathology (especially for re-repair)
Cath - figure out CAD
RHC - if LV or RV dysfunction
Carotid duplex - older pts, vascular disease, coronary disease, neuro sx
PFTs - if COPD
***Op note - what was done to valve, valve manufacturer/size/material if replacement prev, how was it exposed

Question 218

Can a mitral valve be re-repaired?

Answer 218

Yes.
Re-repair is associated with lower mortality compared to replacement at reoperation.
Severe calcification (leaflets, annulus, subvalvular apparatus) and extensive leaflet destruction (eg endocarditis) can prevent this.
You will not be faulted for replacement in redo setting.

Question 219

How close is the circumflex to the PL mitral annulus?

When would you suspect injury?

Answer 219

2-4 mm.
Suspect injury: high-dose pressors when weaning. Pressor requirement persists. TTE shows lateral wall motion abnormality. EKG correlates w/ V5-V6 or 1 and AVL.

*
Right leads, V1-V2: Interventricular septum and right ventricle.
Anterior leads, V3-V4: Anterior wall of the Left ventricle.
Low lateral leads V5-V6: Low lateral wall.
High lateral leads I and AVL: High lateral wall.
Inferior leads II, III and AVF: Inferior wall.

Question 220

Redo mitral surgery is unable to be weaned from CPB w/o V-pacing. Monitor shows complete dissociation between atria and ventricles.
What is diagnosis? What happened?

Answer 220

Complete heart block 2/2 AV node damage 2/2 deep/wide posteromedial mitral commissure stitch during MVR or ring annuloplasty.

Question 221

What are the differences between early and late prosthetic valve endocarditis in terms of timing, causative bacteria, and mortality?

Answer 221

Early: within 2 mo, Staph, higher mortality
Late: Strep, lower mortality

Question 222

Discuss the difference in PVE of bio vs mechanical valve infection anatomy?

Answer 222

Mechanical valve: infection localized to sewing ring -> abscess and dehiscence.
Bio: leaflets -> vegetations, leaflet perforation

Question 223

A pt is undergoing redo bio MVR. She asks if she will need a 3rd reoperation. What do you say?

Answer 223

Freedom from reoperation at 15 yrs is 80% w/ bio valves in mitral position.

Question 224

What are the hemodynamic differences in bio mitral vs aortic valves in terms of their degeneration?
Are there other considerations in bio valve choice for young patients?

Answer 224

Mitral valves are exposed to increased hemodynamic stress during systole, so deteriorate faster.

Valve design has improved, and transcatheter valve-in-valve is an option to avoid re-operation.

Question 225

During MV replacement, what is the ideal management of the chords and leaflets?

Answer 225

Try to spare them - improved outcomes. But do not compromise outflow.

Question 226

Define severe symptomatic mitral stenosis.
What are measurements/echo findings?
What are associated symptoms?

Answer 226

Mitral valve area ≤1.5 cm2
Diastolic pressure half-time ≥150 ms
Severe LA enlargement
Elevated PASP >50 mm Hg

Decreased exercise tolerance
Exertional dyspnea

Question 227

A pregnant female presents with new symptoms from known severe mitral stenosis. What should you do?

Answer 227

1st: medical therapy.
2nd: PMBV.

Best management would have been to counsel a pt of childbearing age that they should have their MS treated first.

Question 228

A pt w/ rheumatic mitral stenosis has severe (<1.5 cm) findings but is asymptomatic.
What workup do they need?
What should they have done?

Answer 228

Figure out PASP and get EKG. If PASP >50 mm Hg or New AF ->
Ensure no clot, valve pliable and not much MR (<2+) ->
PMBC - perc mitral balloon commissurotomy

Question 229

A pt w/ rheumatic mitral stenosis has severe (<1.5 cm) findings. What are the best options for treatment?

Answer 229

Commissurotomy - either percutaneous or open.

Question 230

What is the population of patients with rheumatic MS that should get surgical commissurotomy?

Answer 230

Severe (<1.5 cm MVA) +
Symptomatic (dyspnea on exertion/dec exercise tolerance +
Not candidate for PMBC (valve not pliable, clot, >2 MR) _
Surgical candidate.

Question 231

Which rheumatic MS patients should get intervention if they are asymptomatic.

Answer 231

Severe findings (<1.5 cm MVA) +
PMBC candidate (pliable valve, no clot, <2+ MR) +
New onset AF OR PASP >50 mm Hg.

Question 232

Is someone with progressive MS (>1.5 cm MVA) a candidate for MV intervention?

Answer 232

Yes. IF…
Exertional symptoms, stress test shows hemodynamically significant MS, and PMBC candidate (pliable valve, no clot, <2+ MR). ONLY PMBC offered.

Question 233

A patient has severe MS and has severe symptoms. The junior fellow wants to do surgery. What should you tell them?

Answer 233

There needs to be a reason not to do PMBC.
Figure out if… valve is not pliable, clot is present, or MR is >2+.
Then they have to be surgical candidate.

Question 234

A patient with severe symptomatic mitral stenosis also has AS, TVR, and CAD that requires surgery. How do you proceed?

Answer 234

Distal coronaries.
Aortic valve is excised - break it down.
MVR.
TVR.
AVR.
Proximal coronaries.

Question 235

How do you manage mitral annular calcification?

Answer 235

Usually old, frail, debilitated patients.
DELAY intervention until severely limiting symptoms unable to be managed w/ diuresis and HR control.
Some catheter-based strategies are being developed.
Surgery may require radical debridement of the annulus down to pericardial fat, reconstruction with pericardial patch that saddles/sandwiches the annulus, then valve placement with sutures from LV to patch to LA to sewing ring.

Question 236

A mitral valve surgery is completed, and the cross clamp is removed. The LV distends. What should be done to evaluate? What is the likely diagnosis? What should be done if this diagnosis is confirmed?

Answer 236

TEE. Aortic insufficiency 2/2 anterior annular mitral stitches in the non-coronary or L cusp.
Rearrest, open the aorta and LEFT atrium, and remove suture or redo the mitral surgery. Repair the aortic cusp or replace it.

Question 237

How can you cause conduction block during mitral surgery?

Answer 237

Sutures too deep near the posterior commissure and right trigone - AV node and budle of his.

Question 238

After mitral surgery, what would cause increased gradients across the LVOT?
What do you do?

Answer 238

Prosthesis problem: high-profile mechanical valve, large stented bio valve posts, poorly seated valves.
Diagnose on TEE, and may need to replace the valve w/ lower profile.
Could also be SAM.

Question 239

What is a risk in mitral surgery if you leave the anterior leaflet unresected in a patient with septal hypertrophy?
What do you do?

Answer 239

SAM.
Stop inotropes, load, add betablocker, and add vasopressors - inc afterload and preload while reducing contractility.
You may need to do an aortotomy and do a transaortic excision of the offending subaortic mitral tissue +/- myectomy.

Question 240

After mitral replacement, there is perivalvular leak on postop echo. How do you manage?

Answer 240

Small leaks stop after protamine.

Significant leaks require reimplantation or repair.

Question 241

What are important postoperative parameters after MVR for MS?

Answer 241

Respiratory status - Many patients require aggressive diuresis.
Pulmonary pressures - Inotropy and pulmonary vasodilation may be required.

“High and dry.”

Question 242

What is the INR goal for mechanical MVR?

Answer 242

2.5-3.5.

This is higher than AC goal for atrial fibrillation, so it still increases risk in patients already on AC.

Question 243

What complication will occur in mitral surgery if there is aggressive debridement or retraction/lifting of the heart?

Answer 243

AV groove disruption/rupture

Question 244

What are the three principal goals of surgical intervention for AF?

Answer 244

1) conduction block of all micro and macro re-entrant circuits
2) reestablishment or maintenance of electrical AV synchrony
3) restoration of atrial mechanical function in order to improve diastolic filling

Question 245

When can stand alone surgery be done for AF?

Answer 245

According to The Society of Thoracic Surgeons (STS) 2017 Clinical Practice Guidelines for the Surgical Treatment of Atrial Fibrillation, primary stand-alone SA is a reasonable procedure for symptomatic AF in the absence of structural heart disease that is refractory to class I/III AADs and/or catheter-based therapy (class IIA, level of evidence [LOE] B-R).

Question 246

During Cox Maze, you are dissecting the transverse sinus when you see dark blood beginning to pool. What is the likely injury?

Answer 246

R PA.

Question 247

A patient with ascending aorta aneurysm is undergoing aortic valve or CABG surgery. What is cutoff to add aorta intervention?

Answer 247

4.5 cm end-diastolic diameter.

Question 248

A pt w/ mitral regurg and atrial fibrillation undergoes mitral repair and Cox Maze IV w/ LAA. 2 wks postop, she has palpitations w/ a-flutter in 160s. What is happening?

Answer 248

Peri-mitral flutter.
Failure to interrupt conduction across the LA isthmus allows for this. It is the most common mode of failure of surgery for AF.

Question 249

A pt has peri-mitral flutter after mitral repair w/ CMIV and LAA ligation. What is the cause and what can be done?

Answer 249

Conduction across the LA isthmus d/t incomplete lesion line involving the MV annulus.
EP can do catheter intervention to complete the ablation line.

Question 250

For AF, a large macro-reentrant circuit develops just above the mitral valve annulus. Which lesions must be completed in regards to preventing ongoing flutter (peri-mitral flutter)?

Answer 250

Mitral line (prevent conduction across the atrial myocardium). 
Coronary sinus lesion (prevent conduction across the coronary sinus; collapse the CS during cryoablation so a circumferential lesion can be assured; should connect to the level of the mitral annulus).

Place both lesions in the same plane. Transmural ablation (epicardium and endocardium) is key.

Question 251

While performing CMIV, you notice a cryolesion across the pericardial surface of the RA. What complication can you expect?

Answer 251

Hemidiaphragm paralysis from damage to the R phrenic. This is usually temporary.
Make sure the handle of the probe is not in contact with the phrenics (R or L).

Question 252

What are the principles of ensuring a CMIV doesn’t fail?

Answer 252

A single break in the line can preserve a macro reentry circuit. These waves will find the weakness. Make the lesions uniformly transmural and contiguous. Ensure that there is minimal tissue folding.

Question 253

In CMIV surgery, can char on the RFA clamp affect outcome?

Answer 253

Yes. The RF clamp relies on perfect contact b/w the tissue and electrodes. Char isolates and disrupts this contact, which can affect tissue from heating, breaking the line, and allowing macro-reentrant circuits through.
It is recommended to clean the clamp after every 3 ablations.

Question 254

What is the ligament of marshall?

Answer 254

It’s an epicardial vestigial fold that marks the location of the embryologic LEFT SVC. It contains the nerve, vein (vein of Marshall), and muscle tracts.
It is located on the epicardium between the left atrial appendage and the left pulmonary veins. The corresponding endocardial structure is the LA ridge.
It is a source of paroxysmal AF.

Question 255

In CMIV procedure, you cannulate, place the pt on bypass, and place an LV vent. You are exposing the L heart for LPV isolation. You divide the ligament of Marshall, then notice a device protruding through the LAA. What happened?

Answer 255

Rare. You may have compromised the position of the LV vent.

It is still necessary to divide the LoM to access behind the L pulmonary antrum for L PV isolatin.

Question 256

You perform a CMIV w/ LAA clip placement. TEE shows a small pouch with clot in the appendage. What happened?

Answer 256

The clip was not placed at the base of the appendage.

It should be placed under direct visualization, otherwise a small pouch can be a source of thrombus.

Question 257

In CMIV, what is an alternative to LAA clip?

What are some risks with this?

Answer 257

LAA amputation.
This will not remove macro-reentry circuits at the base. If this is done, you must anchor the base to the L PV isolation.
Can cause bleeding through the suture line or from tributaries at the AV groove near the coronary sinus.

Question 258

During CMIV procedure, after securing atriclip or amputation of the LAA, the patient is noted to have EKG changes with T wave inversions in the lateral leads. What are you concerned about?

Answer 258

Injury to L circumflex coronary artery causing MI at the time of LAA isolation.
This occurs if the LAA orifice is unusually low (normally at level of frenulum b/w L PV several cm away from MV annulus), and the L Cx is unusually high (normally in the AV groove slightly below the coronary sinus).

Question 259

During CMIV, after completion of the RA appendage line, you come off CP bypass and notice the pt in complete heart block. What happened?

Answer 259

Damage to the AV node - cryoprobe too posterior.
Damage to the SA node - prevent by placing the final RA lesion from the distal end of the vertical atriotomy to the tip of the RA appendage. Go as far anteriorly as possible to avoid the pacemaker complex.

Question 260

What patients may be candidates for a stand alone CMIV?

Answer 260

In patients who have failed or are intolerant to antiarrhythmic drug therapy, have failed catheter ablation in the EP laboratory, and in whom a minimally invasive approach is feasible, it is reasonable to attempt this procedure.

Question 261

A patient w/ MR requiring open surgery (TV is nl) has AF as well. Discuss the evidence for PVI (L side only) vs full CMIV.

Answer 261

In a series of 305 patients, there was an equal efficacy of a left-only approach, but a higher pacemaker implantation in those who underwent a biatrial lesion set. Both of these findings were confirmed on a meta-analysis of 2225 patients from 10 studies. The equivalent sinus restoration is supported by a randomized subgroup analysis of mitral valve patients that compared patients undergoing biatrial Mazes with pulmonary vein isolation alone.

There

Question 262

A patient w/ MR requiring open surgery (TV is nl) has AF as well. Discuss the evidence for PVI (L side only) vs full CMIV.

Answer 262

In a series of 305 patients, there was an equal efficacy of a left-only approach, but a higher pacemaker implantation in those who underwent a biatrial lesion set. Both of these findings were confirmed on a meta-analysis of 2225 patients from 10 studies. The equivalent sinus restoration is supported by a randomized subgroup analysis of mitral valve patients that compared patients undergoing biatrial Mazes with pulmonary vein isolation alone.

However, in a 2008 analysis of 1723 patients, absence of a biatrial lesion set was a predictor of failure at 48 months. This finding was also supported by a 2006 meta-analysis of 5885 patients in 69 studies. It is currently unknown which patients do better with a biatrial set.

Overall, many surgeons suggest PVI alone for pts w/ comorbidities who cannot tolerate a lengthier operation (especially if it is an isolated mitral) and full CMIV for those with persistent or recurrent AF.

Question 263

A patient is undergoing minimally invasive PVI, but thrombus is discovered on TEE. What should you do?

Answer 263

Convert to open.

Question 264

A patient s/p Cox Maze decades ago cannot develop sinus tachycardia during exercise. What happened?

Answer 264

One should avoid placing an ablation line through the “sinus tachycardia line” at the right atrium. This can lead to an inability to generate an appropriate response to normal exercise. This was a common complication with CMI (30%).

Question 265

Where is Bachmann’s bundle (CMIV surgery)?

Answer 265

Medial and superior to the roof lesion - transecting this will delay the arrival of a sinus impulse from the RA to the LA.

Question 266

What is the “flutter line” and “isthmus lesion”? Why should it be avoided during CMIV surgery?

Answer 266

It is across the cavo-tricuspid isthmus (CTI) - damage results in the inability to develop appropriate bradycardia when asleep.

Question 267

Define severe TR?

What will symptoms be?

Answer 267

Vena contracta width ≥0.7 cm.
Regurgitant volume ≥45 mL.
Central jet ≥50% RA.
ERO ≥0.40 cm2.
Dense continuous wave signal with triangular shape.
Hepatic vein systolic flow reversal.

These pts develop Dilated RV and RA w/ elevated RA with “c-V” wave. Symptoms include dyspnea on exertion, fatigue, ascites, edema.

Question 268

Which patients with progressive TR (stage B) can get surgical intervention?

Answer 268

Stage B: Central jet <50% RA, Vena contracta width <0.7 cm, ERO <0.40 cm2, Regurgitant volume <45 mL.
MUST be during L side valve procedure.
AND have annular dilation >4.0 cm OR prior RHF.

TV surgery for this pt has a 2a indication.

Question 269

What are indications for surgery for severe TR?

Answer 269

Only level 1 indication is during L side valve surgery.
If RHF (symptomatic; stage D):
- primary TR has 2a indication.
- secondary requires poor GDMT response AND annular dilation WITHOUT inc PAP for 2a indication.
- prior L side valve surgeryWITHOUT PH or severe RV dysfx has 2b indication.
If asymptomatic (stage C): primary TR w/ progressive RV dilation or sys dysfx has 2b indication.

Severe TR: Central jet ≥50% RA, Vena contracta width ≥0.7 cm, ERO ≥0.40 cm2, Regurgitant volume ≥45 mL, Dense continuous wave signal with triangular shape, Hepatic vein systolic flow reversal.

Question 270

During TV surgery, where will the AV node be?

Answer 270

Triangle of Koch: coronary sinus, septal annulus, tendon of Todaro

Question 271

How does the tricuspid annulus dilate?

Answer 271

Septal is fixed. Will dilate posteriorly more than anteriorly.

Question 272

How should the tricuspid valve be addressed if taking to the OR for a L valve?

Answer 272

Do L side lesions first.

Tricuspid can be addressed with the heart beating (PFO must be closed before unclamping).

Question 273

Describe a tricuspid ring annuloplasty.

Answer 273

Interrupted mattress sutures with a gap a Koch’s triangle (1cm from anterospetal commissure to midpoint on septal leaflet).

Question 274

During tricuspid annuloplasty, what can be injured when placing sutures near the anteropostero commisure?

Answer 274

RCA.

Question 275

How do you select ring size for tricuspid annuloplasty?

Answer 275

Measure the septal leaflet and surface area of leaflet tissue arising from the anterior papillary muscle.
Usually 30-32 mm for female, or 32-34 mm for male.

Question 276

What are the major principles for tricuspid replacement?

Answer 276

Preserve native leaflets, similar to mitral (unless infected).
When placing sutures near the AV, place them through the septal leaflet instead.

Question 277

What are the principles of the surgery for tricuspid endocarditis?

Answer 277

Excise vegetations to healthy tissue. Close gaps primarily or with a patch.
Consider annuloplasty if valve incompetence is in question.
Replace the valve if extensive destruction.
2-stage replacement can be considered in IVDU with normal RV fct and PAP (fallen out of favor).

Question 278

Benefits of tricuspid bioprosthesis over mechanical?

Answer 278

No anticoagulation.
Less structural valve deterioration than those in mitral position.
Does not limit transvalvular PM leads in the future.
Does rule out Swan use postop.

Question 279

When coming off pump following TV replacement, the RV dilates, CVP is high, and PAP decreases. How do you manage?

Answer 279

Rule out metabolic and air emboli.
TEE for assessment.
Eval RVOT for obstruction: eg, anterior leaflet tissue billowing -> central portion can be excised while maintaining chordal attachments.
Eval for ST changes from RCA occlusion (inferior leads) -> bypass RCA w/ vein.
Make sure there’s a Swan-Ganz that’s surgeon directed after this procedure (cannot do if mechanical).

Question 280

Manage RV dysfunction postop TV repair?

Answer 280

Epi and milrinone.
Restrict fluids. Diurese.
Can add nitric to vent or HFNC to unload some more.
Can use IABP to unload even more and improve RCA perfusion.

Question 281

When should a tricuspid valve be done in a reoperative patient?

Answer 281

Stage D (Central jet ≥50% RA, Vena contracta width ≥0.7 cm, ERO ≥0.40 cm2, Regurgitant volume ≥45 mL, 
Dense continuous wave signal with triangular shape, Hepatic vein systolic flow reversal; AND RHF symptoms). 
No PH or RV systolic dysfunction.

Question 282

Coming off CPB from TV surgery, the patient has complete heart block.

Answer 282

Sutures near the anteroseptal-septal commissure can easily damage the AV node.
Radial force from a prosthetic valve (or dual prosthetics in the MV and TV position).
2 sets of V pacing wires would not be overkill; in addition to external pacing pads before PPM placement.

Question 283

What are options for pacemaker placement after tricuspid surgery?

Answer 283

Endocardial - percutaneous into atrium, then coronary sinus.
- if unable to get into coronary sinus, can traverse repaired valve.
Epicardial - avoids foreign object through repair/replacement. Only option for mechanical valve.

Question 284

Pt w/ TV endocarditis (+ cultures, and vegetations) has previous PPM, and has an indication for mitral surgery. How do you handle the pacer leads?

Answer 284

Remove the initial wires in setting of bacteremia and endocarditis. New epicardial leads on the RV can be placed (tunneled through the L intercostal away from the mammary and out to a subcutaneous pocket). Transvenous atrial wires can be placed later if needed or if bacterial burden is too high on initial surgery.

Question 285

In carcinoid valvular disease, what is the management of an affected TV?

Answer 285

Grossly, you will see white fibrous tissue deposits/plaques on the endocardium of valve cusps on the ventricular side, causing adherence to the RV wall.
TV replacement required. Check pulmonic valve - may need to be replaced as well.
L heart valves are not affected d/t inactivation by MAO as it passes through the lungs.

Question 286

What’s the best study for tricuspid valve?

Answer 286

Preoperative TTE. This is where you will make your decisions.

Question 287

Before performing TV repair with a beating heart, what anatomic pathology must be ruled out?

Answer 287

PFO.

Otherwise air gets into the L side.

Question 288

A patient who is undergoing left side valve surgery gets a LHC preop. What is your cut off to bypass a lesion? What about LM lesions?

Answer 288

70% any lesion.

50% LM.

Question 289

You are coming off bypass from an AVR CABG w/ a 2 hr cross-clamp time. CI is 1.7. What do you do to assess? What do you do if no technical problems?

Answer 289

Look at the heart and the EKG. TEE to eval for MWAs. Assess grafts with flow probe.
Determine if there were issues with cardioplegia - if all above ruled out, it could be cardiogenic shock from poor protection. Rest the heart on full flow with the heart completely decompressed for 10-15 min. May require IABP. If the pt worsens over the next 12 hrs, consider catheterization to assess grafts.

Question 290

Sequence of surgery for CABG/MVR/AVR in pt w/ AF?

Answer 290

Distals, aortotomy w/ AV resection, CMIV, MVR, AVR, proximals.

Question 291

You are finish an AVR/MVR when TEE shows lateral WMA. What do you do?

Answer 291

You’ve injured the circumflex.
Re-heparinize and go back on bypass. Take vein, and bypass the circumflex.
Keep in mind that you have a new mitral that could be easily dislodged, or you could cause an AV groove disruption when exposing the lateral wall.

Question 292

What complications could oversizing the mitral valve cause?

Answer 292

LV rupture when the heart is contracting after coming off CPB.
Higher risk of block requiring PPM.
If concurrent with AVR, then oversizing MV can cause downsizing of the aortic valve -> pt prosthesis mismatch.

Question 293

A patient has severe AS and sever MR. He is induced and subsequently arrests. What happened?

Answer 293

SVR drops, venous return decreasing, coronary flow decreases, ventricles fail. The incidence of arrest on induction is higher than for isolated severe AS.

Secure the airway. Ventilate. Begin CPR/ACLS. Heparinize. Prep/drape/scrub. Emergency sternotomy and quick cannulation. Initiate CPB. Proceed with AVR/MVR.

Question 294

What important structure is behind p2-p3 of the mitral valve?

Answer 294

Circumflex

Question 295

After an AVR/MVR, you are coming off bypass and see bright red blood coming from behind the heart. What do you do?
(What do you NOT do?)

Answer 295

Do NOT lift the heart. This is likely AV dissociation. Go back on bypass first, then repair.

Question 296

What is the conduct of an AVR/MVR?

Answer 296

Open aorta, excise leaflets and debride annulus, explore mitral and do NOT oversize if requiring replacement, size aortic valve, replace aortic valve.

Question 297

During AVR/MVR, what structure is near mitral lateral A3 and the membranous septum of the aortic valve near the R and non-coronary cusps?

Answer 297

Conduction system.
Don’t oversize valves - can compress this system.
Place A and V wires on all double L valve cases.
PPM risk is 5% for single valve. It’s 15% for >1 valve.

Question 298

A pt undergoes AVR/MVR. You come off bypass, and TEE shows the following, with increased gradient across the LVOT. What happened?

Answer 298

MV strut is directed into the LVOT. Re-replacement of the valve should be done. This is more likely with bioprosthetic valves. These valves usually have markings for their struts that allow the surgeon to orient the valve in such a way that the space between the struts is over the LVOT.

Question 299

In pt with significant multivessel CAD and significant carotid disease, how do you decide which to approach first?

Answer 299

Most symptomatic should go first with a 4-6 waiting period before second surgery. If both are symptomatic, can do synchronous procedure.

Question 300

After a combined CEA and CABG, the patient has neuro deficits associated with operative CEA. What do you do?

Answer 300

If immediately postop, would get bedside ultrasound evaluation of flow and return to the OR if flap or technical problem is found. If out of PACU, would get head CT and carotid duplex.

Question 301

After a combined CEA and CABG, the pt develops a large neck hematoma with tracheal deviation. What do you do?

Answer 301

If time permits, the patient should go to the OR, prep and drape, intubate, then reopen.
If not, open at bedside and be ready to hold pressure while you get to OR and intubate.

Question 302

What are the major Duke criteria for endocarditis?

Positive is 2 major, 1 major and 3 minor, or 5 minor.

Answer 302

Major: microbio (atypical requires time b/w 2+ cxs or 3/4+ cxs); endocardial involvement (new regurg, abscess, vegetation, dehiscence of prosthetic).

Question 303

What are the MINOR Duke Criteria?

Are there minor echocardiographic criteria?

Answer 303

Predisposition – Intravenous drug use or presence of a predisposing heart condition (prosthetic heart valve or a valve lesion associated with significant regurgitation or turbulence of blood flow).
Fever – Temperature ≥38.0°C (100.4°F).
Vascular phenomena – Major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages, or Janeway lesions.
Immunologic phenomena – Glomerulonephritis, Osler nodes, Roth spots, or rheumatoid factor.
Microbiologic evidence – Positive blood cultures that do not meet major criteria, OR serologic evidence of active infection with organism consistent with IE.

*There are no echocardiographic minor criteria.

Question 304

How can the diagnosis of infective endocarditis be rejected (4 scenarios)?

Answer 304

A firm alternate diagnosis is made.
Resolution of clinical manifestations occurs after ≤4 days of antibiotic therapy.
No pathological evidence of infective endocarditis is found at surgery or autopsy after antibiotic therapy for four days or less.
Clinical criteria for possible or definite infective endocarditis is not met.

Question 305

What are the positive echocardiographic findings for infective endocarditis?
(and thus fulfill a major Duke criteria)

Answer 305

• Vegetation (oscillating intracardiac mass on a valve or on supporting structures, in the path of regurgitant jets, or on implanted material, in the absence of an alternative anatomic explanation), OR
• Abscess, OR
• New partial dehiscence of prosthetic valve

Also new valvular regurgitation is also evidence of endocardial involvement.

Question 306

What are the principles of empiric antibiotic therapy in suspected infective endocarditis?

Answer 306

For patients with suspected IE who present without acute symptoms, empiric therapy is not always necessary, and can be deferred until blood culture results are available, particularly since accurate microbiologic diagnosis is a critical first step in planning the treatment strategy.

For acutely ill patients with signs and symptoms strongly suggestive of IE, empiric therapy may be necessary. Such empiric therapy should be administered only after at least two (preferably three) sets of blood cultures have been obtained from separate venipunctures and ideally spaced over 30 to 60 minutes.

Question 307

What should empiric antibiotic therapy cover in IE?

Answer 307

In general, empiric therapy should cover staphylococci (methicillin-susceptible and methicillin-resistant), streptococci, and enterococci.

Question 308

When should a TTE or TEE be repeated in treatment of infective endocarditis?

Answer 308

Clinical indications for repeat TTE and/or TEE include new murmur, embolic complications, new or progressive heart failure, and development of atrioventricular block. In addition, patients with persistent fever or persistent bacteremia (eg, longer than five to seven days) warrant repeat echocardiography to evaluate for abscess.

Question 309

What is the role for ASA or antithrombotic therapy for infective endocarditis?

Answer 309

neither anticoagulant therapy nor aspirin reduces the risk of embolism in patients with IE; remember that pts w/ IE are also at increased risk for bleeding complications (particularly intracerebral)

Question 310

In pts w/ IE, what atrial fibrillation pts require anticoagulation no matter the CHA2DS2-VASc score?

Answer 310

mitral stenosis

Question 311

What IE pts need to be screened with dental evaluation?

Answer 311

IE due to common oral organisms. All active sources of oral infection should be eradicated.

Question 312

What further screening is needed if IE is due to group D streptococci?

Answer 312

colonoscopy is warranted - association w/ cancer

Question 313

When should IE on R side valves receive surgery?

Answer 313

Indications for surgery in right-sided NVE include very large vegetations (≥20 mm in diameter), recurrent septic pulmonary emboli, highly resistant organisms, or persistent bacteremia.

Question 314

When should early valve surgery be performed for L side IE?

Answer 314

• Heart failure (HF) symptoms - benefits of surgery appear to be greatest among patients with severe valve dysfunction causing HF, surgery should be undertaken as soon as signs and symptoms of HF appear and before hemodynamic instability occurs.
• Complicated infection - paravalvular extension of infection with development of annular or aortic abscess, destructive penetrating lesion (eg, fistula), and/or heart block
• Difficult-to-treat pathogens - include fungi and multidrug-resistant organisms (eg, Pseudomonas aeruginosa and vancomycin-resistant Enterococcus). NOT S. aureus.
• Persistent infection - bacteremia or fever lasting >7 days after initiation of appropriate antibiotic therapy.

Question 315

For neuro symptoms associated with IE (in pt w/ indication for surgery), should surgery be delayed?

Answer 315

No delay in valve surgery is required for silent microembolism, transient ischemic attack, cerebral abscess, or ischemic stroke with no hemorrhagic conversion and without severe neurological impairment or decreased level of consciousness.

For patients with major ischemic stroke (ie, with severe neurologic deficit or altered consciousness) or intracranial hemorrhage, we typically delay surgery for ≥4 weeks.

Question 316

In the setting of active infection in a pt w/ IE and a surgical indication, is repair or replacement preferred?

Answer 316

Valve REPAIR is preferable to valve replacement when feasible; valve replacement is associated with a small risk of infection of prosthetic materials. Valve repair may be possible when a leaflet perforation occurs in the absence of extensive leaflet destruction or annular involvement.
Also, there is no increased reinfection risk b/w mechanical and bioprosthetic valve installed after IE.

Question 317

How does a prosthetic valve affect the decision for surgery for IE?

Answer 317

Early surgery for prosthetic valve endocarditis is indicated for IE complications SIMILAR to native valve endocarditis (eg, HF due to prosthetic valve dysfunction, paravalvular regurgitation, or intracardiac fistula; annular abscess, difficult-to-treat pathogen, persistent infection).

Question 318

You are doing preop work for IE and find an annular abscess at the R/non-con commissure. What do you do?
What complications should you watch for?

Answer 318

Completely unroof the abscess and debride grossly infected tissue.
Patch the defect w/ autologous or bovine pericardium.
Involvement of a large part of the annulus may require replacement w/ homograft/xenograft (muscular portion may fill in tissue defect after extensive debridement).

The R/non-con is the site of the membranous septum, so VSD can occur w/ aggressive debridement.
Inc risk for conduction disturbance and PPM need.

Question 319

You are doing surgery for IE on mitral valve. Only a part of P2 is involved. What should be done?

Answer 319

Excise and repair. Avoiding placement of prosthesis i preferred in an infected setting.

Question 320

You are doing surgery for IE on mitral valve. The entire posterior annulus is involved with abscess.
What should be done?
What should you do?

Answer 320

Careful debridement of all tissue. If enough tissue remaining, reinforce the posterior annulus w/ interrupted figure of 8 sutures from LA to LV, creating a fold of tissue which can be used to secure the prosthetic valve.

Question 321

Common causes of culture negative endocarditis?

Answer 321

HACEK: Hameophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella).
Also fungal organisms.
Consult ID.

Question 322

Discuss the timing for intervention in L side endocarditis in patient with stroke.

Answer 322

Depends on patient risk factors and whether it is embolic or hemorrhagic. Controversial timing.
For hemorrhagic stroke, most agree that operation should be delayed. The duration requires judgment and balancing risks of cardiac vs neurologic complications. Reasonable to delay 3 to 4 weeks after the stroke.
If there is a significant decline in cardiac function, recurrent stroke/systemic embolism, or persistent sepsis, a delay of less than 4 weeks may be necessary.
With embolic CVA in the absence of bleeding, an operation may be safe in 3 to 5 days.

Question 323

Describe management for R side valve endocarditis.

Answer 323

Initial tx is abx. S aureus 70%. Strep and enterococci are next most common.

Surgery indications:

• 2cm vegetation
• recurrent PE
• highly resistant organism
• RHF 2/2 severe TR
• heart block
• paravalvular abscess

Question 324

What is the INR goal for tricuspid mechanical valve?

no additional risk factors, not high-risk valve

Answer 324

3.0. Same as mitral.

Ball-in-cage and tilting disc valves (other than Medtronic) requiring 3.5 in the mitral or tricuspid position.

Question 325

A non-adherent IVDU patient has second recurrence of tricuspid endocarditis with a surgical indication. What other options are there?

Answer 325

valve excision without replacement - if pulmonary pressures and pulmonary vascular resistance are not elevated and good RV and LV fct

Question 326

Describe considerations in management for prosthetic valve endocarditis.

Answer 326

Is it early or late? <2 mo after surgery is often aggressive and requires intervention within 1-2 weeks. If late PVE (>2 mo), treat like native valve endocarditis.

Is there valve dehiscence or paravalvular leak? Requires intervention within 24-48 hrs.

Question 327

A pt w/ AV endocarditis and paravalvular abscess requires a homograft. The pt is in complete heart block after weaning from CPB. What is the ideal management?

Answer 327

permanent atrial and ventricular epicardial pacing leads are less likely to become infected than transvalvular leads

Question 328

You do an emergency ED thoracotomy for a pt who was stabbed. You place pledgeted sutures. Coming of CPB, there is localized wall motion abnormality and corresponding ST elevation. What do you do?

Answer 328

Probably coronary artery injury. Use vein and bypass the injured coronary.

Question 329

A patient is stabbed and taken to the OR. After sternotomy, you find a RA injury. How do you manage?

Answer 329

Use clamps and sew. No need for CPB.

Question 330

You discover a large ventricular injury in penetrating trauma. How do you manage?

Answer 330

Larger defects may require a patch. Otherwise pledgeted horizontal mattress sutures often work. Make sure septal injury and valve injury are ruled out with echo if dealing with large defects or multiple chamber defects.

Question 331

There is penetrating injury to the coronary sinus in a sick trauma patient. How do you manage?

Answer 331

Ligate it.

Patch can be considered if the patient and heart are not friable.

Question 332

When can you ligate a traumatic coronary injury?

Answer 332

If it is distal, and there is not reversible ventricular dysfunction.

Question 333

What is the major mechanical force (pathology) that leads to aortic dissection?

Answer 333

Hypertension.
Other risk factors: connective tissue disease, fam hx of aneurysm or dissection, aortic valve dz, pregnancy, recent open or catheter aortic manipulation, stimulants.

Question 334

Where are you likely to find the dissection tear in type A?

Answer 334

right anterior aspect of ascending aorta, spiraling around the arch into the descending

Question 335

What are the causes of mortality in typa A aortic dissection?

Answer 335

aortic rupture, pericardial tamponade, acute AI and CHF, acute MI, stroke

Question 336

What is the ideal study for a type A dissection?

Answer 336

CT angio from neck through femoral vessels, EKG-gated

Question 337

What study can be done to diagnose type A aortic dissection in an unstable patient?

Answer 337

If suspicion is high, get TEE on-table in OR.

Question 338

What is your exam and workup for possible type A dissection?

Answer 338

Vascular history.
Palpate pulses x4 extremities and carotids. BP in BUE to eval diff.
Neuro exam.
EKG, D-dimer, CBC, lytes, LDH, cardiac markers, coags, type/cross.
CXR - widened mediastinum, single side effusion
CTA EKG gated vs MRA. TEE if cross sectional imaging contraindicated or not available.

Question 339

What d-dimer level makes type A dissection less likely?

Answer 339

<500 ng/dL

Question 340

What are the initial goals of management for type A dissection?

Answer 340

Access and monitoring.
HR <60 and BP 100-120 systolic.
Esmolol w/ loading dose 250-500 mcg/kg, then 25-50 mcg/kg/min.
Can add nitroprusside at 0.25-0.50 mcg/kg/min if esmolol controls HR, but BP needs control.
Pain control.
Foley.

Question 341

What are the cannulation strategies for a type A dissection undergoing surgery?

Answer 341

Ensure good CT review to know where dissection is and isn’t. Know what extent of dissection is to know how much of arch needs to be done.

R axillary artery w/ graft.
Direct cannulation of ascending aorta: Seldinger w/ TEE guidance vs samurai.
Femoral artery.
Venous cannulation: usually dual stage, but bicaval can be done if retrograde cerebral perfusion needed.

Question 342

CTA shows type A aortic dissection with arch vessel involvement. What surgery should be done?

Answer 342

Hemiarch is often sufficient to completely resect the tear and exclude the false lumen to re-establish arch vessel perfusion.

Question 343

In type A dissection what would necessitate more extensive arch surgery?

Answer 343

Arch rupture.

>5.5 cm arch aneurysm.

Question 344

In type A dissection, what are the options if the aortic root is involved?

Answer 344

Bentall, David.

Question 345

Type A dissection found in pt under 40 yrs. What should be included in eval?

Answer 345

CTD - Marfan, Loeys-Dietz, Turner (female)

Question 346

In type A dissection, future reinterventions are most frequently due to failure to do what?

Answer 346

failure to replace the whole root, failure to replace the entire ascending aorta, or aneurysm of the aortic wall at the coronary artery button

Question 347

How do you manage intramural hematoma in the ascending aorta?

Answer 347

Treat like ascending dissection.

IMH hallmarks: absence of intimal tear, absence of false lumen flow (differentiates from penetrating aortic ulcer).

Question 348

In type A dissection, how do you manage dissection of coronary ostia?

Answer 348

RCA is more frequent than left, but both need to be evaluated.
May need retrograde cardioplegia.
Mobilize the buttons and reapproximate the dissected layers.
If the coronary is dissected and not amenable to repair, bypass or interposition with saphenous vein is performed.

Question 349

A type A dissection patient is going on bypass. The femoral arterial line shows a decrease in pressure. What happened? What do you do?

Answer 349

False lumen compression.
Most likely the femoral art line or the arterial bypass cannula is in the false lumen.
Check a radial pressure. If it’s normal, then the femoral is either malperfused (possibly re-entry tear) or the femoral line is in the false lumen.
If radial pressure is dampened too, then recannulate.

Question 350

In a type A dissection, SMA occlusion is found. How do you manage?

Answer 350

Often, re-establishing true lumen flow at the type A will be enough. If there is a question about bowel integrity, then do a laparotomy and assess.
Stenting, fenestration, or bypass may be needed.

Question 351

If there is ileofemoral malperfusion during a type A dissection, what should be considered for intervention?

Answer 351

ax-fem or fem-fem bypass; may also require fasciotomies

Question 352

How do you manage a chronic type A aortic dissection?

Answer 352

> 90 days.

Surgery is indicated for complications or symptoms.

Question 353

How do you manage a type B dissection?

Answer 353

Medical.

Question 354

You are starting a CABG, and the arterial cannula is placed. There is high line pressure, and the aorta develops an enlarged purple hematoma. What happened? How do you confirm?

Answer 354

This is an aortic dissection.
Adventitial hematoma could be the cause, but the high line pressure makes this dx less likely.
Confirm w/ TEE.

Question 355

How will an iatrogenic (intraop) ascending aortic dissection manifest? What should you assess?

Answer 355

Increase in line pressure after arterial cannula placement. Purple hematoma involving the ascending aorta. MAPs drop.
TEE to confirm via a flap in the ascending aorta.
Eval EKG for ST changes. Eval pericardial well for blood.

Question 356

Manage an iatrogenic ascending aortic dissection.

Answer 356

Stop perfusing through the cannula.
Treat hypotension w/ volume and pressors.
Hypotension, if it occurs, in this setting is likely 2/2 myocardial ischemia or acute AI. There is no tamponade w/ the pericardium open, and rupture should be visualized.
Cannulate the axillary or femoral artery.

Question 357

During surgery, you cause an iatrogenic ascending aortic dissection. The LV begins to distend. What does this mean?

Answer 357

Valve incompetence.

Place an LV vent or open the aorta.

Question 358

How can aortic dissection occur at the end of the case?

What do you do?

Answer 358

Removal of the cross clamp under pressure. Make sure “flows way down” before removing clamp.
If this occurs, re-heparinize, and obtain axillary or femoral cannulation.

Question 359

How do you manage acute AI in the setting of iatrogenic ascending aortic dissection?

Answer 359

Evaluate the leaflets. If they are intact, repair the aortic dissection and resuspend the aortic valves as long as anatomy allows you to realign you with the center of coaptation.
Reevaluate the valve w/ TEE before leaving the OR.

Question 360

S/p CABG, a pt develops signs of MI and hemodynamic instability in the ICU. What is your workup?

Answer 360

EKG to eval for ST changes in specific anatomy.
CXR to eval for bleeding.
TTE to eval for WMA and possibly dissection.

If likely coronary problem, proceed to angio.
If likely aortic dissection, get gated CTA if stable or TEE in OR.

Question 361

You are attempting a mini-thoracotomy cardiac surgery requiring bypass. You cannulate the femoral, but resistance is noted. What is the next step, and what are you worried about? What if the dx is confirmed?

Answer 361

If concerned, can do an angio to eval for dissection.
If type B dissection is confirmed, check TEE to eval for ascending. Abort the procedure, do CTA to confirm extent. Medically manage for 4-6 wks and return to OR later. Cannulate a different site.

Question 362

What are the indications for repairing a TAA?

Answer 362

Symptomatic or ruptured.
End-diastolic diameter 5.5 cm.
Aortic size index 2.75 cm/m2.
Aortic area over height ratio 10 cm2/m.
If undergoing AV surgery or CABG, then EDD 4.5 cm.
If getting surveillance, expansion ≥5 mm per year for aneurysms <5 cm in diameter.
If bicuspid aortic valve, 5 cm.
Genetic factors also affect size cutoffs (image).

Question 363

How does bicuspid aortic valve affect indication for surgical repair in aortic root aneurysm?

Answer 363

Normally 5.5 cm.

If BAV, then 5 cm is cutoff.

Question 364

In pt w/ aortic root aneurysm requiring surgery, how do you manage the valve operatively?

Answer 364

If valve is normal, a valve sparing procedure can be performed - David.
If <40 yrs old, consider Ross.

Question 365

You finish replacing the aortic root and are deairing. There is 11mm ST elevation in the inferior leads (II, III, AVF). How do you manage? How do you prevent this?

Answer 365

Consider technical problem with the RCA button. The change in orientation can cause kinking, stretching, or compression.
Bypass the RCA.
Prevent this by sizing and placing the button with the heart engorged.
Can also manifest as difficulty coming off bypass, new WMA, arrhythmias, new EKG changes, or unexplained RV failure.
DDx is poor myocardial protection, air embolism, protamine reaction.

Question 366

You do a valve sparing root replacement and are coming off bypass. There is 3+ AI. What do you do?

Answer 366

Go back on, resect the valve, and replace it.

Question 367

When coming off CPB after root surgery, there is persistent blood coming from behind the proximal anastomosis. What happened?

Answer 367

Probably bleeding from the root vs LCA suture line.
Pack it and use topical agents. Stop the rest of the bleeding in the surgical field. If the bleeding persists, you may need to go back on CPB and place the stitch after the heart is arrested and emptied.
If the pt cannot tolerate another pump run, pack the chest open, resuscitate, and go back.

Question 368

How do you follow aortic root patients after replacement?

Answer 368

BP control and anticoag mgmt (if valve surgery done). Postop CT is needed to assess growth of non-replaced aorta and to eval for aneurysm formation.

Question 369

How are pts w/ aortic root dilation that don’t meet surgical criteria treated?

Answer 369

Control HTN. Optimize lipid profile. Smoking cessation. Reduce risk factors for atherosclerosis.

Question 370

You are doing a redo aortic root replacement, but cannot safely dissect the tissue around the aortic root posteriorly. What are your options?

Answer 370

The implication is the coronary arteries will be difficult/dangerous to mobilize.
Cabrol technique - coronary reimplantation by placing an interposition tube graft to the open coronary ostium then doing a side-to-side anastomosis to the main aortic graft.
Hemi-Cabrol - direct implantation of the RC button (usually easer to mobilize) and reimplant of LC artery w/ interposition graft on LC ostium and aortic graft.