TSRA Clinical Scenarios - Adult Cardiac Surgery Flashcards
(370 cards)
1
Q
Heparin dose for CPB?
A
400 units/kg
2
Q
ACT required for initiation of CPB?
A
400-480
3
Q
5 min after cross clamp is released when coming off CPB, the heart begins to distend w/o contraction. What is the next move?
A
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.
4
Q
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?
A
Hemoconcentrate. IV insulin with glucose. Lasix or bicarb can also help.
5
Q
A patient fibrillates when coming off CPB. How do you defibrillate?
A
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.
6
Q
If heart is distending when coming of CPB, what amount of AI requires consideration for replacement?
A
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.
7
Q
Explain CPB components.
A
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.
8
Q
Attempt CPB, but perfusionist says high aortic line pressure. What is differential?
A
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
9
Q
What is your differential for inadequate venous drainage on CPB?
A
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?
10
Q
Attempting CPB flows, but MAP not rising above 40. Pt has hx of ACE use.
A
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.
11
Q
You place retrograde cardioplegia line in coronary sinus, but pressures are low. How do you troubleshoot?
A
Check for rupture of the sinus - inspect inferior aspect of the heart
Check position of cannula
Check if balloon is ruptured
Persistent L SVC
12
Q
When giving retrograde cardioplegia, you find a L SVC. How do you manage?
A
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.
13
Q
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?
A
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.
14
Q
If patient has previous CABG and is requiring CPB, how do you manage an open LIMA?
A
Can clamp vs cold bypass flow
15
Q
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?
A
Axillary cannulation may be needed to make room for an aortic cross clamp.
16
Q
In a patient w/ CABG w/ open LIMA, what is the problem with antegrade cardioplegia?
A
Antegrade will perfuse the OM and PDA territories, but not the LAD.
Retrograde will perfuse all.
17
Q
In the setting of aortic insufficiency, discuss options for CPB.
A
Retrograde cardioplegia would ensure delivery. Antegrade would likely require direct delivery of cardioplegia.
18
Q
How could you incompletely deliver cardioplegia if using retrograde cardioplegia assuming no L SCV? What can you do?
A
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).
19
Q
What can make retrograde cardioplegia delivery riskier in a redo operation (previous CABG)?
A
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.
20
Q
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?
A
Aortic insufficiency.
Switch to retrograde cardioplegia and turn on the aortic root vent vs an LV vent to decompress the heart.
21
Q
How do you ensure adequacy of retrograde cardioplegia catheter delivery?
A
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.
22
Q
What is a concern with retrograde cannula placement even if it works well to arrest the heart?
A
Myocardial edema. This is why the balloons on the cannula are not usually 100% occlusive.
23
Q
Where does a persistent L SCV usually drain?
A
Into the coronary sinus, may partially drain via innominate V.
24
Q
You attempt to infuse antegrade cardioplegia. The perfusionist notes high line pressure. How do you manage?
A
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.
25
After a cardiac surgery pump case w/ retrograde cardioplegia, the myocardium is slow to regain activity. What should you check?
Check retrograde catheter and/or that the balloon is down, in order to allow for adequate coronary sinus flow.
26
When sewing a CABG, you notice bleeding from the arteriotomy. What does this mean?
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.
27
How do you manage a perforation of the coronary sinus after placement of a retrograde cardioplegia catheter?
CPB, clamp, and arrest with antegrade. Repair the hole directly with prolene or a pericardial patch.
28
What are the three broad categories for etiology of persistent electrocardial activity (problem with initiating plegia in CPB)?
Access - cannula placement
Collateral - clamp, drainage, L SVC, vents/suckers; hypothermia?
Myocardial mass - hypertrophy may require hypothermia
29
Redo sternotomy, and there is a significant amount of dark blood from the sternomanubrial jct. What was injured?
Innominate vein
30
Redo mitral w/ innominate vein injury during sternotomy. How do you manage?
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.
31
Redo case. You attempt to dissect SVC for cannulation, but make a large hole before pursestring is in. How do you manage?
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.
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?
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.
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?
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.
34
SVC is ruptured during balloon dilation for SVC syndrome. How do you manage?
```
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.
```
35
Bicaval cannulation in an old lady, and the IVC tears below the diaphragm. How do you manage?
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.
36
Cath lab creates and RV puncture and places a pericardial drain w/ bloody drainage. Manage.
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.
37
There is a small R PA injury noticed after an aortic surgery when coming off bypass. Manage.
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.
38
You puncture the opposite side of the aorta during arterial cannulation. Manage.
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.
39
What symptoms represent unstable angina?
chest pain at rest, exertional angina not relieved by rest, and new onset of chest pain
40
What symptoms represent stable ischemic heart disease
exertional angina - predictable, improves with rest
41
What is included in guideline-directed medical therapy?
lifestyle modification, statin therapy (LDL goal 70-100), beta-blockade, aspirin, and ACE inhibition (if LV dysfunction, DM, or CKD)
42
What are hemodynamically significant coronary lesions on left heart cath?
Left main >50%
| non-LM >70%
43
What FFR is hemodynamically significant? When is FFR used?
< 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.
44
What is the SYNTAX score?
16 segments in the coronary tree.
Lesions in this tree are scored.
The sum of these scores is the overall SYNTAX score.
45
What are the cutoffs for the SYNTAX score?
>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.
46
What is a non-invasive option for imaging the coronary arteries?
Gated cardiac CT
47
What did a secondary analysis of the STITCH trial reveal concerning myocardial viability studies?
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.
48
How do you decide who needs coronary revascularization in patients with stable ischemic heart disease?
Activity limiting symptoms despite maximal medical therapy.
Active patients who want PCI for better QoL compared to med therapy.
Anatomy with proven survival benefit.
49
After deciding on revascularization, how do you decide who needs CABG?
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.
50
Management of significant CAD in 1 vessel w/ refractory angina despite medical therapy and PCI.
CABG.
51
Management of significant CAD in 1 vessel after sudden cardiac arrest from ischemic ventricular arrhythmia.
CABG.
52
Management of CAD at 50% in 1 vessel in patients undergoing valve or aortic surgery?
Concurrent CABG.
53
What is the ideal graft for the LAD?
IMA. Left preferred. Right is second choice.
54
In a patient undergoing CABG for 3 vessels without excessive risk of sternal complications or other organ failure, what are the ideal grafts?
BIMA and radial.
55
What can be done technically to reduce the risk of sternal complications in a patient getting BIMA grafts?
Skeletonized.
56
Known risks of sternal infection and malunion in cardiac surgery?
Nonelective procedure, age, uncontrolled DM (HbA1c >7), BMI >40, female, COPD, preop hospitalization >3 days, smoking, immunosuppression regimen, radiation mediastinal injury
57
When should CABG patients receive aspirin?
Preoperatively when they discover CAD is ideal.
Within 6 hrs postop after CABG.
Continued indefinitely.
58
A patient comes in for elective CABG but has not stopped taking plavix. What do you do?
Cancel the case.
| Plavix and ticagrelor (Brilinta) need to be stopped for 5 days preop.
59
A patient requires an urgent CABG but is taking plavix. What do you do?
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.
60
Why are beta blockers reinstituted after CABG (as long as no contraindications)?
reduce incidence and sequela of atrial fibrillation
61
What is the target for statin therapy in patients undergoing CABG?
reduce LDL <100 and achieve at least 30% dec in LDL
62
Which postop CABG patients require ACE or ARB?
LVEF <40, HTN, DM, CKD. Unless otherwise contraindicated.
63
What is the continuous IV insulin target in postop CABG?
blood glucose concentration <180
64
When anatomically and clinically suitable, what is the RIMA often used for?
L Cx or RCA usually if critically stenosed and perfusing LV myocardium - can improve survival and decrease reintervention
65
RIMA patency is directly related to what?
Degree of proximal stenosis of the target vessel. Ie how much competitive flow is there?
66
When is a radial artery recommended? What is patency of the RA prone to?
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.
67
Who is the ideal patient who gets complete arterial revascularization?
<60, with few comorbidities, severe L sided stenosis, and critical R sided stenosis. Skeletonize.
68
What are inferior leads?
II, III, aVF
69
What EKG findings suggests RV or RCA ischemia (or L dominant PDA disease)?
Inferior leads: II, III, aVF.
| Or posterior findings: reciprocal V1-2.
70
What EKG changes suggest LV or LAD/LCx territory ischemia?
Anteroseptal: V1-V2.
Anteroapical: V3-4.
Anterolateral: V5-6, I, aVL.
71
What is diagnostic for STEMI?
Angina symptoms for 20 min w/ ST elevation 2+mm in 2 contiguous leads or new LBBB. Greater risk for transmural ischemia.
72
What is the diagnostic criteria for NSTEMI?
```
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.
```
73
When can IABP be useful in the setting of MI?
refractory shock despite initial medical management; post-infarct VSD; acute papillary muscle rupture
74
What are contraindications for IABP?
Severe AI and PVD precluding placement.
75
What is the first line reperfusion strategy for STEMI?
PCI. Door to balloon time of 90 min.
76
What is the role for CABG in STEMI?
Failure of PCI + coronary anatomy suitable + persistent ischemia.
OR MI complication - papillary muscle rupture, post-infarct VSD, LV rupture
77
What coronary disease is left-main equivalent?
>70% in LAD and L Cx
78
A patient presents w/ NSTEMI, stable, meets indication for CABG. How do you manage?
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.
79
A patient is resuscitated from witnessed cardiac arrest. Coronary angiography shows 3V disease. What's the revascularization strategy?
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
80
Manage pt w/ inferior infarction and RV involvement. PCI failed.
CABG.
| Consider delaying until RV is optimized w/ inotropes, diuretics, or even mechanical support.
81
A patient w/ previous coronary stent undergoes CABG. How do you manage this vessel?
If it is wide open, no reason to bypass as it will likely fail 2/2 competitive flow.
82
A patient requires CABG and is found to have a porcelain aorta. How does this affect planning?
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.
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?
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.
84
Redo CABG has higher risk than primary revascularization w/ mortality of 7-11% mostly 2/2 what cause?
perioperative MI - can be 2/2 incomplete revascularization, atheromatous emboli, damaged grafts, hypoperfusion through new grafts, or early graft occlusion
85
In a redo CABG, what is the general principle in regard to handling previous venous bypass grafts?
No touch technique - avoid embolization of debri
86
What is your myocardial protection strategy for redo CABG?
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.
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)?
sequencing vein grafts
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?
Grafts to that area on TEE should be reconstructed immediately.
89
During redo CABG, there is no room on the aorta for proximal anastomoses. What options are there?
End-to-side to patent arterial grafts.
| Use RIMA in situ if possible.
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?
Suspect coronary/graft injury.
Heparinize and obtain femoral bypass.
Can attempt repair once injury is exposed vs coronary perfusion catheter.
Complete the operation.
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?
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.
92
What are the important diagnostic studies for post-infarct VSD?
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.
93
Post-infarct VSD mortality?
Poor - 25% within 24 hrs, increasing with time up to 97% in 1 year.
This is an indication for urgent surgery.
94
Manage a post-infarct VSD preop.
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.
95
How do you do an anterior septal rupture repair (pt w/ post-infarct VSD)?
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.
96
How do you do apical VSD repair (postinfarct VSD)?
Incision through infarcted apex.
Debride necrotic tissue (may include LV, RV, septum).
Reapproximate w/ interrupted mattress through felt (use felt b/w each layer).
97
How do you do posteroinferior VSD repair (postinfarct VSD)?
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).
98
When is delayed repair for post-infarct VSD acceptable?
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.
99
What is the greatest predictor of post-operative mortality in pts w/ postinfarct VSD?
Time in cardiogenic shock
100
Is asymptomatic severe aortic stenosis an indication for surgery?
No
101
How can you "unmask" asymptomatic severe aortic stenosis to objectively confirm a patient is without impairment?
exercise stress test (treadmill) - positive if…
- Symptoms.
- SBP dec by >10 mm Hg.
- Dysrhythmias.
- ST changes.
102
What is the peak gradient equation (in the context of aortic stenosis)?
How is it obtained?
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.
103
In what scenario may a patient with severe aortic stenosis have a low gradient?
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.
104
How can a low flow/low gradient AS be confirmed in a patient w/ normal EF (>50)?
Stroke volume index <35% ml/min/m^2.
105
How can a low flow/low gradient AS be confirmed if the patient has a low EF (<50%)?
Dobutamine stress echo - if gradient increases while AVA remains the same, AS is confirmed.
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?
pseudo-AS
107
In the workup of AS, a significant subvalvular gradient and asymmetric septal hypertrophy is found, what treatment may be required?
Septal myectomy and possible mitral valve surgery
108
If the diagnosis of AS is uncertain by echo, including dobutamine stress testing, what else can be done?
Cardiac cath to cross the valve and obtain a hemodynamic AV study.
Can directly measure gradients.
109
In a potential TAVR candidate for AS, what imaging needs to be obtained?
TAVR CT scan - valve morphology (TTE unreliable), AV annulus and LVOT sizing, coronary height and orientation, and sinus height and width sizing.
110
What are the diagnostic criteria for severe AS?
```
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.
```
111
How do you decide on SAVR vs TAVR for symptomatic, severe AS?
Anatomy.
Age and medical conditions affecting long-term prognosis.
Preference.
112
What STS risk score is prohibitive for SAVR for symptomatic severe AS?
STS >15%. TAVR shows survival benefit in these patients.
113
Compare likely complications for TAVR vs SAVR.
TAVR - perivalvular leak, ppm.
| SAVR - bleeding, re-hospitalization, atrial fibrillation.
114
What are the benefits of a mechanical aortic valve compared to bioprosthetic?
Lower reintervention rate in <60 yrs old.
| Superior survival at 15 yrs if b/w 50-70 yrs.
115
What complication of a surgical bioprosthetic aortic valve placement will likely reduce benefit from a valve-in-valve procedure?
patient-prosthesis mismatch
116
An AS patient undergoes TAVR CT showing bicuspid aortic valve. The valve is functional, and the patient is low risk. Discuss TAVR use.
TAVR is not approved for use in this population.
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?
4.5 cm
118
What is the EOAI and why is it useful for aortic valve placement?
Effective orifice area (obtained by sizing valve and finding the corresponding EOA published by the manufacturer)/BSA.
Used to predict PPM.
119
An aortic valve's EOAI is < 0.85. What does this mean?
Predictive of PPM. 0.65-0.85 is predictive of moderate PPM. <0.65 is severe.
120
Is EOAI <0.85 a contraindication for aortic valve surgery?
No. In a comorbid elderly patient w/ symptomatic severe AS, a risk of moderate PPM is preferred over cross-clamp time and surgical risk.
121
During workup for CABG, moderate AS is found. How do you manage?
Class IIa indication for replacement at time of surgery.
122
You are doing surgery for AS, but the heart is not arresting well. How do you manage?
```
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.
```
123
Intraop TEE during AVR for AS shows moderate perivalvular leak. How do you mange?
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).
124
What can you do if a patient's EOAI is <0.85 during AVR for AS, and this is unacceptable?
consider root enlargement or total root replacement
125
What can make an asymptomatic severe AS a surgical candidate?
```
Low gradient w/ <50% EF.
Critical AS (>5m/s velocity).
Severe LVH.
Concomitant cardiac operation.
Severe calcification.
```
126
A patient with aortic regurgitation gets an echo. What are you looking for?
Confirm diagnosis and severity, assess for etiology, valve morphology, LV assessments, aortic root size.
127
In workup for AR, a bicuspid valve morphology tells you what about the future procedure?
More amenable to repair, especially with more normal sized roots. Jet direction is critical.
128
Which AR patients need a heart cath?
Need: significant risk factors for CAD or those older than 40 in whom AVR is considered.
129
In workup of AR, what test can be done to confirm diagnosis if echo is inconclusive or discordant w/ physical findings?
cardiac cath w/ root angiography and measurement of LV pressures
130
Severe AR is defined by what echo/angio parameters?
```
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+
```
131
Diagnosis of chronic severe AR requires evidence of what?
LV dilation
132
2017 guidelines indications for surgery for chronic AR?
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)
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?
Prior to bypass, you should be ready for distention - have retrograde cardioplegia access.
Arrest immediately.
Create the aortotomy, then give direct cardioplegia.
134
When trying to establish retrograde cardioplegia for an AR case, you have difficulty, and the position is questionable. What can be done?
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).
135
During AR case, what if you injure the coronary sinus and/or retrograde cardioplegia becomes unreliable?
Initiate CPB, clamp, give ostial cardioplegia.
136
During AR case, TEE and direct visualization shows a tricuspid valve w/ prolapse of the R cusp. What are the surgical options?
Replacement is safest.
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?
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.
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?
Use a bovine or autologous pericardial patch to ensure no tension on the suture line.
139
You complete an AVR, but there is periprosthetic regurgitation. What do you do?
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.
140
Symptomatic acute aortic regurgitation should be taken care of expeditiously. Why?
The ventricle has not had time to develop any adaptation to overcome the increased volume which can lead to rapid deterioration.
141
In non-surgical candidates w/ AR, what are some of the operative considerations for TAVR?
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.
142
Describe the benefits of aortic valve repair in AR surgery?
Similar results for AVR w/o need for anticoagulation as opposed to mechanical implants and possibly improved durability compared to bioprosthetics
143
How do stented pericardial aortic valves tend to fail?
By aortic stenosis of the biologic prosthesis, but tend to last longer than porcine valve.
144
What type of aortic valve is generally favored in younger (<55) patients?
Mechanical valves, though they do limit lifestyle d/t need for anticoagulation, and they limit future TAVR options.
145
What tests should you obtain before a redo AVR?
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
146
Compared to TAVR, redo AVR is associated with what risk profile?
Lower vascular complications and perivalvular leak.
| Higher short-term stroke rate, atrial fib rate, AKI, bleeding.
147
How do you decide b/w valve in valve TAVR vs redo SAVR?
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.
148
In considering valve-in-valve TAVR, what would be considered a small in place prosthetic valve?
<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.
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?
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.
150
A previous AVR fails d/t AI (as opposed to AS). What are the considerations for procedural management?
There needs to be a compelling reason to NOT do redo SAVR.
| Most current TAVRs are designed for AS, not AI.
151
In what situations should a ViV TAVR be more strongly considered as opposed to a redo AVR?
>75-80 yrs, prior CABG w/ LIMA (esp if near sternum), HFrEF, poor condition, calcified ascending, renal failure.
152
ViV TAVR self-expanding vs balloon expandable discussion.
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).
153
For a younger patient at low surgical risk w/ severe structural bioprosthetic aortic valve deterioration, what is the ideal procedure?
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.
154
Discuss cannulation strategy for redo AVR.
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.
155
Discuss myocardial protection in a redo AVR w/ AI.
Retrograde cardioplegia +/- antegrade and ostial.
| LV vent.
156
What are the considerations for the conduction system in redo AVRs?
Higher risk of heart block. Make sure you have reliable wires and consider a-wires.
157
Discuss prevention and management of fibrillation during initial dissection of a redo AVR w/ moderate AI.
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)
158
Discuss operative plan for redo AVR w/ previous CABG.
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.
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?
Transect aorta.
160
During redo AVR, you tear the aorta/outflow tract when removing the old valve. How do you fix this?
Patch.
| May need homograft recon if necessary.
161
During redo AVR, you injure R coronary ostia while removing the valve. How do you manage?
Preparation: have legs prepped so vein can be taken.
| Look at cath to ensure you are distal to disease during bypass.
162
Coming off bypass from redo AVR, and there is RV dysfunction. Assessment and plan?
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.
163
How can you be sure coronary ostia are open after redo AVR?
Before closing aortotomy, visualize the ostia.
| Give retrograde plegia and look for blood return from the os.
164
After redo AVR, you cannot close the aortotomy d/t tension on the aorta.
In redo settings, the aorta can be less compliant. Use a patch, and try not to "oversize" the aorta.
165
77yr pt w/ mechanical AVR has failed w/ AS to the point of requiring intervention, and there is MR. Assessment and plan?
Likely functional MR 2/2 AS.
| Safest: redo SAVR and monitor MR as outpt for need for MitraClip.
166
What critical diagnoses need to be considered in the differential for patients with a failed AVR being considered for re-intervention?
PPM - look for evidence of high gradients postop => may need enlargement and SAVR
Endocarditis - echo and cultures in right clinical setting => no ViV TAVR
167
What critical diagnoses need to be considered in the differential for patients with a failed AVR being considered for re-intervention?
PPM - look for evidence of high gradients postop => may need enlargement and SAVR
Endocarditis - echo and cultures in right clinical setting => no ViV TAVR
168
In terms of valve sizing, what info can be obtained before AVR to ensure no PPM?
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.
169
Primary mitral regurgitation is generally caused by what?
primary leaflet abnormalities - usually result of degenerative disease
170
Secondary MR is generally caused by what?
structurally normal valve leaflets are unable to coapt completely - owing to a distortion of either the annulus or the subvalvular apparatus
171
LV dysfunction and secondary MR prognosis compared to either abnormality in isolation?
much worse; controversial whether revascularization alone is helpful; controversial whether addressing MR will be of value
172
Carpentier's Type 1 MR?
normal leaflet motion - results from LV enlargement and annular dilation (functional MR)
can also be from perforation in leaflet
173
Carpentier's Type II MR?
leaflet prolapse - can be degenerative, acute papillary rupture after MI
174
Carpentier's Type IIIa MR?
leaflet restriction, systole and diastole - rheumatic
175
Carpentier's Type IIIb MR?
restriction during systole alone - chronic ischemic disease
176
Dilated cardiomyopathy is likely to cause what type of MR?
type 1 - normal leaflet motion
| pts may have severely depressed LV fct
177
Ischemic MR tends to cause what type of MR?
| What is mechanism?
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
178
What is the study of choice to clarify the mechanism of MR?
| What is a problem with this study?
TEE - however, MR may be lower intraoperatively d/t anes and ventricular unloading
179
At the time of CABG for severe ischemic MR, what is the preferred surgery for the mitral valve?
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
180
What is an Alfieri stitch and when is it appropriate?
At the time of apical incision such as LVAD for Type I (nl leaflet motion) secondary MR
181
In CABG MVR, why do you do distal anastomoses first before valve?
avoids excess manipulation of heart that predisposes to AV groove dissociation
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?
LVAD. Consider Alfieri stuure after apical coring.
183
A patient who requires CABG is found to have moderate ischemic MR. What do you do for the MR?
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.
184
Pt w/ severe symptomatic secondary mitral regurgitation and EF <50%. Pt sx are persistent despite GDMT. What is recommended for mitral valve?
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)
185
What is often the mechanism for acute mitral regurgitation 2-7 days after MI?
How do you manage?
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.
186
How does the jet in primary mitral regurgitation predict leaflet affected?
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
187
Vena contracta for severe mitral regurgitation?
0.7 cm
188
Regurgitant volume for severe MR?
60 ml
189
Regurgitant fraction for severe MR?
50%
190
Central jet for severe MR?
40% LA or holosystolic eccentric jet
191
In primary mitral regurgitation, which patients should get an operation? Do they have to have severe findings?
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
192
If doing a mitral valve repair, what is a necessary adjunct to reinforce most repair techniques?
Ring or band annuloplasty
193
During mitral repair, what is at risk when placing stitches near posteromedial commissure?
Near right trigone - conduction tissue
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?
Aortic valve (L/non commissure) - look for aortic insufficiency that wasn't there preop.
195
During mitral repair, what is at risk if you place deep sutures at P1?
Circumflex artery - look for WMA on the lateral wall.
| Avoid by angling the needle toward the ventricle (away from the atrium).
196
While doing a mitral repair, what is at risk if placing deep retraction stitches outside the annulus of the P3 scallop?
Coronary sinus
197
What is likely the ideal repair in patients w/ mitral regurg 2/2 mitral valve prolapse 2/2 fibroelastic deficiency?
In fibroelastic deficiency, there is a paucity of tissue. Neochords are often the best repair, or a very limited triangular resection.
198
In MVR w/ Barlow's valve, what is often the best repair?
There is excess tissue in almost all scallops.
| Perform quadrangular resection w/ sliding plasty.
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?
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.
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?
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.
201
In acute MR, acute chordal rupture from degenerative etiology needs to be differentiated from papillary muscle rupture d/t ischemia. Why?
The treatment is different.
Papillary muscle rupture often warrants replacement (they may also need a CABG).
Ruptured chords can be repaired.
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?
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.
203
For MV approach, when might L atriotomy be best approach?
| How is it done?
Most common approach.
Incision of choice for robotic and mini-thoracotomy.
Approach via R side through Sondergaard's groove (Waterston's).
204
For MV approach, when might vertical transseptal be best approach?
How is this done?
Any advantages?
Feasible w/ large LA in setting of chronic MR.
Via fossa ovalis.
Reduces risk of PPM, easier to close.
205
For MV approach, when might extended superior transseptal (Guiraudon) be best approach?
How is this done?
DIsadvantages?
Any advantages?
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).
206
For MV approach, when might horizontal transseptal (Dubost) be best approach?
Any advantages/disadvantages?
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.
207
For MV approach, when might transaortic be best approach?
How is this done?
Any advantages?
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.
208
For MV approach, when might left atrial appendage be best approach?
How is this done?
Any advantages?
Very uncommon.
Left thoracotomy.
Alternative approach after multiple previous re-operations.
209
For MV approach, when might transventricular be best approach?
When is this done?
Can be utilized if entering the LV for another reason (ventricular aneurysmectomy or LVAD).
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?
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).
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?
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.
212
Describe the pathophysiology of SAM after mitral surgery?
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.
213
What increases the risk of SAM in mitral surgery?
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.
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?
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
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?
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.
216
During mitral surgery, the left atrium is opened, and there is blood. You cannot see anything.
What is your checklist?
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.
217
A patient has an indication for re-operative mitral valve replacement. What workup should be considered?
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
218
Can a mitral valve be re-repaired?
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.
219
How close is the circumflex to the PL mitral annulus?
| When would you suspect injury?
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.
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?
Complete heart block 2/2 AV node damage 2/2 deep/wide posteromedial mitral commissure stitch during MVR or ring annuloplasty.
221
What are the differences between early and late prosthetic valve endocarditis in terms of timing, causative bacteria, and mortality?
Early: within 2 mo, Staph, higher mortality
Late: Strep, lower mortality
222
Discuss the difference in PVE of bio vs mechanical valve infection anatomy?
Mechanical valve: infection localized to sewing ring -> abscess and dehiscence.
Bio: leaflets -> vegetations, leaflet perforation
223
A pt is undergoing redo bio MVR. She asks if she will need a 3rd reoperation. What do you say?
Freedom from reoperation at 15 yrs is 80% w/ bio valves in mitral position.
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?
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.
225
During MV replacement, what is the ideal management of the chords and leaflets?
Try to spare them - improved outcomes. But do not compromise outflow.
226
Define severe symptomatic mitral stenosis.
What are measurements/echo findings?
What are associated symptoms?
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
227
A pregnant female presents with new symptoms from known severe mitral stenosis. What should you do?
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.
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?
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
229
A pt w/ rheumatic mitral stenosis has severe (<1.5 cm) findings. What are the best options for treatment?
Commissurotomy - either percutaneous or open.
230
What is the population of patients with rheumatic MS that should get surgical commissurotomy?
Severe (<1.5 cm MVA) +
Symptomatic (dyspnea on exertion/dec exercise tolerance +
Not candidate for PMBC (valve not pliable, clot, >2 MR) _
Surgical candidate.
231
Which rheumatic MS patients should get intervention if they are asymptomatic.
```
Severe findings (<1.5 cm MVA) +
PMBC candidate (pliable valve, no clot, <2+ MR) +
New onset AF OR PASP >50 mm Hg.
```
232
Is someone with progressive MS (>1.5 cm MVA) a candidate for MV intervention?
Yes. IF...
Exertional symptoms, stress test shows hemodynamically significant MS, and PMBC candidate (pliable valve, no clot, <2+ MR). ONLY PMBC offered.
233
A patient has severe MS and has severe symptoms. The junior fellow wants to do surgery. What should you tell them?
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.
234
A patient with severe symptomatic mitral stenosis also has AS, TVR, and CAD that requires surgery. How do you proceed?
```
Distal coronaries.
Aortic valve is excised - break it down.
MVR.
TVR.
AVR.
Proximal coronaries.
```
235
How do you manage mitral annular calcification?
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.
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?
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.
237
How can you cause conduction block during mitral surgery?
Sutures too deep near the posterior commissure and right trigone - AV node and budle of his.
238
After mitral surgery, what would cause increased gradients across the LVOT?
What do you do?
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.
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?
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.
240
After mitral replacement, there is perivalvular leak on postop echo. How do you manage?
Small leaks stop after protamine.
| Significant leaks require reimplantation or repair.
241
What are important postoperative parameters after MVR for MS?
Respiratory status - Many patients require aggressive diuresis.
Pulmonary pressures - Inotropy and pulmonary vasodilation may be required.
"High and dry."
242
What is the INR goal for mechanical MVR?
2.5-3.5.
This is higher than AC goal for atrial fibrillation, so it still increases risk in patients already on AC.
243
What complication will occur in mitral surgery if there is aggressive debridement or retraction/lifting of the heart?
AV groove disruption/rupture
244
What are the three principal goals of surgical intervention for AF?
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
245
When can stand alone surgery be done for AF?
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).
246
During Cox Maze, you are dissecting the transverse sinus when you see dark blood beginning to pool. What is the likely injury?
R PA.
247
A patient with ascending aorta aneurysm is undergoing aortic valve or CABG surgery. What is cutoff to add aorta intervention?
4.5 cm end-diastolic diameter.
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?
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.
249
A pt has peri-mitral flutter after mitral repair w/ CMIV and LAA ligation. What is the cause and what can be done?
Conduction across the LA isthmus d/t incomplete lesion line involving the MV annulus.
EP can do catheter intervention to complete the ablation line.
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)?
```
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.
251
While performing CMIV, you notice a cryolesion across the pericardial surface of the RA. What complication can you expect?
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).
252
What are the principles of ensuring a CMIV doesn't fail?
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.
253
In CMIV surgery, can char on the RFA clamp affect outcome?
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.
254
What is the ligament of marshall?
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.
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?
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.
256
You perform a CMIV w/ LAA clip placement. TEE shows a small pouch with clot in the appendage. What happened?
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.
257
In CMIV, what is an alternative to LAA clip?
| What are some risks with this?
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.
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?
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).
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?
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.
260
What patients may be candidates for a stand alone CMIV?
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.
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.
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
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.
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.
263
A patient is undergoing minimally invasive PVI, but thrombus is discovered on TEE. What should you do?
Convert to open.
264
A patient s/p Cox Maze decades ago cannot develop sinus tachycardia during exercise. What happened?
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%).
265
Where is Bachmann's bundle (CMIV surgery)?
Medial and superior to the roof lesion - transecting this will delay the arrival of a sinus impulse from the RA to the LA.
266
What is the "flutter line" and "isthmus lesion"? Why should it be avoided during CMIV surgery?
It is across the cavo-tricuspid isthmus (CTI) - damage results in the inability to develop appropriate bradycardia when asleep.
267
Define severe TR?
| What will symptoms be?
```
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.
268
Which patients with progressive TR (stage B) can get surgical intervention?
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.
269
What are indications for surgery for severe TR?
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.
270
During TV surgery, where will the AV node be?
Triangle of Koch: coronary sinus, septal annulus, tendon of Todaro
271
How does the tricuspid annulus dilate?
Septal is fixed. Will dilate posteriorly more than anteriorly.
272
How should the tricuspid valve be addressed if taking to the OR for a L valve?
Do L side lesions first.
| Tricuspid can be addressed with the heart beating (PFO must be closed before unclamping).
273
Describe a tricuspid ring annuloplasty.
Interrupted mattress sutures with a gap a Koch's triangle (1cm from anterospetal commissure to midpoint on septal leaflet).
274
During tricuspid annuloplasty, what can be injured when placing sutures near the anteropostero commisure?
RCA.
275
How do you select ring size for tricuspid annuloplasty?
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.
276
What are the major principles for tricuspid replacement?
Preserve native leaflets, similar to mitral (unless infected).
When placing sutures near the AV, place them through the septal leaflet instead.
277
What are the principles of the surgery for tricuspid endocarditis?
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).
278
Benefits of tricuspid bioprosthesis over mechanical?
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.
279
When coming off pump following TV replacement, the RV dilates, CVP is high, and PAP decreases. How do you manage?
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).
280
Manage RV dysfunction postop TV repair?
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.
281
When should a tricuspid valve be done in a reoperative patient?
```
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.
```
282
Coming off CPB from TV surgery, the patient has complete heart block.
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.
283
What are options for pacemaker placement after tricuspid surgery?
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.
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?
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.
285
In carcinoid valvular disease, what is the management of an affected TV?
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.
286
What's the best study for tricuspid valve?
Preoperative TTE. This is where you will make your decisions.
287
Before performing TV repair with a beating heart, what anatomic pathology must be ruled out?
PFO.
| Otherwise air gets into the L side.
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?
70% any lesion.
| 50% LM.
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?
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.
290
Sequence of surgery for CABG/MVR/AVR in pt w/ AF?
Distals, aortotomy w/ AV resection, CMIV, MVR, AVR, proximals.
291
You are finish an AVR/MVR when TEE shows lateral WMA. What do you do?
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.
292
What complications could oversizing the mitral valve cause?
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.
293
A patient has severe AS and sever MR. He is induced and subsequently arrests. What happened?
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.
294
What important structure is behind p2-p3 of the mitral valve?
Circumflex
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?)
Do NOT lift the heart. This is likely AV dissociation. Go back on bypass first, then repair.
296
What is the conduct of an AVR/MVR?
Open aorta, excise leaflets and debride annulus, explore mitral and do NOT oversize if requiring replacement, size aortic valve, replace aortic valve.
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?
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.
298
A pt undergoes AVR/MVR. You come off bypass, and TEE shows the following, with increased gradient across the LVOT. What happened?
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.
299
In pt with significant multivessel CAD and significant carotid disease, how do you decide which to approach first?
Most symptomatic should go first with a 4-6 waiting period before second surgery. If both are symptomatic, can do synchronous procedure.
300
After a combined CEA and CABG, the patient has neuro deficits associated with operative CEA. What do you do?
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.
301
After a combined CEA and CABG, the pt develops a large neck hematoma with tracheal deviation. What do you do?
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.
302
What are the major Duke criteria for endocarditis?
| Positive is 2 major, 1 major and 3 minor, or 5 minor.
Major: microbio (atypical requires time b/w 2+ cxs or 3/4+ cxs); endocardial involvement (new regurg, abscess, vegetation, dehiscence of prosthetic).
303
What are the MINOR Duke Criteria?
| Are there minor echocardiographic criteria?
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.
304
How can the diagnosis of infective endocarditis be rejected (4 scenarios)?
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.
305
What are the positive echocardiographic findings for infective endocarditis?
(and thus fulfill a major Duke criteria)
- 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.
306
What are the principles of empiric antibiotic therapy in suspected infective endocarditis?
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.
307
What should empiric antibiotic therapy cover in IE?
In general, empiric therapy should cover staphylococci (methicillin-susceptible and methicillin-resistant), streptococci, and enterococci.
308
When should a TTE or TEE be repeated in treatment of infective endocarditis?
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.
309
What is the role for ASA or antithrombotic therapy for infective endocarditis?
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)
310
In pts w/ IE, what atrial fibrillation pts require anticoagulation no matter the CHA2DS2-VASc score?
mitral stenosis
311
What IE pts need to be screened with dental evaluation?
IE due to common oral organisms. All active sources of oral infection should be eradicated.
312
What further screening is needed if IE is due to group D streptococci?
colonoscopy is warranted - association w/ cancer
313
When should IE on R side valves receive surgery?
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.
314
When should early valve surgery be performed for L side IE?
* 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.
315
For neuro symptoms associated with IE (in pt w/ indication for surgery), should surgery be delayed?
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.
316
In the setting of active infection in a pt w/ IE and a surgical indication, is repair or replacement preferred?
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.
317
How does a prosthetic valve affect the decision for surgery for IE?
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).
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?
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.
319
You are doing surgery for IE on mitral valve. Only a part of P2 is involved. What should be done?
Excise and repair. Avoiding placement of prosthesis i preferred in an infected setting.
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?
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.
321
Common causes of culture negative endocarditis?
HACEK: Hameophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella).
Also fungal organisms.
Consult ID.
322
Discuss the timing for intervention in L side endocarditis in patient with stroke.
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.
323
Describe management for R side valve endocarditis.
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
324
What is the INR goal for tricuspid mechanical valve?
| no additional risk factors, not high-risk valve
3.0. Same as mitral.
| Ball-in-cage and tilting disc valves (other than Medtronic) requiring 3.5 in the mitral or tricuspid position.
325
A non-adherent IVDU patient has second recurrence of tricuspid endocarditis with a surgical indication. What other options are there?
valve excision without replacement - if pulmonary pressures and pulmonary vascular resistance are not elevated and good RV and LV fct
326
Describe considerations in management for prosthetic valve endocarditis.
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.
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?
permanent atrial and ventricular epicardial pacing leads are less likely to become infected than transvalvular leads
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?
Probably coronary artery injury. Use vein and bypass the injured coronary.
329
A patient is stabbed and taken to the OR. After sternotomy, you find a RA injury. How do you manage?
Use clamps and sew. No need for CPB.
330
You discover a large ventricular injury in penetrating trauma. How do you manage?
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.
331
There is penetrating injury to the coronary sinus in a sick trauma patient. How do you manage?
Ligate it.
| Patch can be considered if the patient and heart are not friable.
332
When can you ligate a traumatic coronary injury?
If it is distal, and there is not reversible ventricular dysfunction.
333
What is the major mechanical force (pathology) that leads to aortic dissection?
Hypertension.
Other risk factors: connective tissue disease, fam hx of aneurysm or dissection, aortic valve dz, pregnancy, recent open or catheter aortic manipulation, stimulants.
334
Where are you likely to find the dissection tear in type A?
right anterior aspect of ascending aorta, spiraling around the arch into the descending
335
What are the causes of mortality in typa A aortic dissection?
aortic rupture, pericardial tamponade, acute AI and CHF, acute MI, stroke
336
What is the ideal study for a type A dissection?
CT angio from neck through femoral vessels, EKG-gated
337
What study can be done to diagnose type A aortic dissection in an unstable patient?
If suspicion is high, get TEE on-table in OR.
338
What is your exam and workup for possible type A dissection?
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.
339
What d-dimer level makes type A dissection less likely?
<500 ng/dL
340
What are the initial goals of management for type A dissection?
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.
341
What are the cannulation strategies for a type A dissection undergoing surgery?
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.
342
CTA shows type A aortic dissection with arch vessel involvement. What surgery should be done?
Hemiarch is often sufficient to completely resect the tear and exclude the false lumen to re-establish arch vessel perfusion.
343
In type A dissection what would necessitate more extensive arch surgery?
Arch rupture.
| >5.5 cm arch aneurysm.
344
In type A dissection, what are the options if the aortic root is involved?
Bentall, David.
345
Type A dissection found in pt under 40 yrs. What should be included in eval?
CTD - Marfan, Loeys-Dietz, Turner (female)
346
In type A dissection, future reinterventions are most frequently due to failure to do what?
failure to replace the whole root, failure to replace the entire ascending aorta, or aneurysm of the aortic wall at the coronary artery button
347
How do you manage intramural hematoma in the ascending aorta?
Treat like ascending dissection.
| IMH hallmarks: absence of intimal tear, absence of false lumen flow (differentiates from penetrating aortic ulcer).
348
In type A dissection, how do you manage dissection of coronary ostia?
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.
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?
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.
350
In a type A dissection, SMA occlusion is found. How do you manage?
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.
351
If there is ileofemoral malperfusion during a type A dissection, what should be considered for intervention?
ax-fem or fem-fem bypass; may also require fasciotomies
352
How do you manage a chronic type A aortic dissection?
>90 days.
| Surgery is indicated for complications or symptoms.
353
How do you manage a type B dissection?
Medical.
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?
This is an aortic dissection.
Adventitial hematoma could be the cause, but the high line pressure makes this dx less likely.
Confirm w/ TEE.
355
How will an iatrogenic (intraop) ascending aortic dissection manifest? What should you assess?
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.
356
Manage an iatrogenic ascending aortic dissection.
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.
357
During surgery, you cause an iatrogenic ascending aortic dissection. The LV begins to distend. What does this mean?
Valve incompetence.
| Place an LV vent or open the aorta.
358
How can aortic dissection occur at the end of the case?
| What do you do?
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.
359
How do you manage acute AI in the setting of iatrogenic ascending aortic dissection?
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.
360
S/p CABG, a pt develops signs of MI and hemodynamic instability in the ICU. What is your workup?
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.
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?
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.
362
What are the indications for repairing a TAA?
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).
363
How does bicuspid aortic valve affect indication for surgical repair in aortic root aneurysm?
Normally 5.5 cm.
| If BAV, then 5 cm is cutoff.
364
In pt w/ aortic root aneurysm requiring surgery, how do you manage the valve operatively?
If valve is normal, a valve sparing procedure can be performed - David.
If <40 yrs old, consider Ross.
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?
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.
366
You do a valve sparing root replacement and are coming off bypass. There is 3+ AI. What do you do?
Go back on, resect the valve, and replace it.
367
When coming off CPB after root surgery, there is persistent blood coming from behind the proximal anastomosis. What happened?
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.
368
How do you follow aortic root patients after replacement?
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.
369
How are pts w/ aortic root dilation that don't meet surgical criteria treated?
Control HTN. Optimize lipid profile. Smoking cessation. Reduce risk factors for atherosclerosis.
370
You are doing a redo aortic root replacement, but cannot safely dissect the tissue around the aortic root posteriorly. What are your options?
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.
