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LS CV Oral Review > 1-100 > Flashcards

1-100 Flashcards

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1
Q

what makes an aortic dissection “Complicated”

A

Complicated dissection is those with:

  • persistent pain
  • thoracoabdominal mal perfusion
  • impending rupture
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2
Q

sizing of the graft for a valve-sparing root

  1. Estimated annulus
  2. Dacron graft size
A

Aortic annulus ~ 2/3 cusps height x 2
Dacron graft ~ 2/3 cusps height x 2 + LVOT thickness

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3
Q

DeBakey type 1 aneurysm

A

Ascending and descending aorta

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4
Q

Signs of mitral stenosis

A
  1. Low volume pulse pressure
  2. Irregular pulse
  3. Tapping non-displaced apex beat
  4. Loud S1 heart sound
  5. Opening snap Mid diastolic rumbling heart loudest at the apex
  6. Pulmonary HTN
    1. Mitral facies : Rosy cheeks while the rest of the face is cyanotic
    2. Central cyanosis
    3. Loud P2 heart sound
    4. TR – pan systolic murmur at right sternal edge
    5. Pulmonary Regurgitation: Grahm Steel early systolic murmur on inspiration
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5
Q

Social history questions for aortic dissection

physical exam

A

Query the use of amphetamines or coccaine

Physical:

Skeletal to diagnose CT disease

Vascular exam should be documented

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6
Q

Medical treatment of a type B dissection

A

a. Beta - blocker ( esmolol or labetolol)
b. vasodilator (nipride)

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7
Q

what territory does ECG lead I represent

A

anterolateral

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8
Q

Severe mitral regurgitation in an asymptomatic patient direction

of treatment

A
  1. if LVEF > 60, LVESD < 40 and liklihood of repair > 95% with expected mortality < 1% –> Repair
  2. if new onset afib or PASP > 50 and liklihood of repair > 95% and expected mortality < 1% –> Repair
  3. if LVEF 30-60% or LVESD > 40 –>“mitral surgery”

Per Boling:

LVEF < 60%, PAP > 50, LVESD > 40, AF

If > 95% repair, <1%, mortality

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9
Q

MVA for Moderate MS

A

MS (mitral valve area 1.6 cm2 to 2.0 cm2)

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10
Q

the direction of the jet with a restricted leaflet

A

jet will be toward the restricted leaflet

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11
Q

Ghent criteria

Minor Skeletal Criteria

A
  1. Pectus excavatum of moderate severity
  2. Joint hypermobility
  3. Highly arched palate with crowding of teeth
  4. Facial appearance:
    • dolichocephaly
    • malar hypoplasia
    • enophthalmos
    • retrognathia
    • down-slating palpebral fissures
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12
Q

Low Risk Pulmonary Embolism

A

Embolism without the presence of :

  1. shock
  2. hypotension
  3. RV dysfunction
  4. Myocardial injury
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13
Q

Diagnostic criteria for STEMI

A

Angina sx for > 20 min

with

ST elevation > 1mm in 2 contigous leads

or

LBBB

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14
Q

Method of selecting a tricuspid ring size

A
  1. Using a sizer:

septal leaflet and the surface area of leaflet tissue from the anterior pap muscle

  1. Approximately

30-32 for a female

32-34 for a male

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15
Q

Reccomendation

Mitral stenosis patient

symptomatic

MVA < 1.5cm2

Wilkins < 8

No LA thrombus

No MR

A

Class 1: PMBC

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16
Q

Anteroseptal ECG leads

A

V1 and V2

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17
Q

IIb/IIIa inhibitors

when should they be discontinued

A
  1. Eptifibatide (integrillin) - IIb/IIIa Inhibitor - 2-4 hr
  2. Tirofiban ( Aggrastat) - IIb/IIIa inhibitor -2 -4 hours
  3. Abciximab (Repro) - IIb/IIIa inhibitor -12 hours

EAT !

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18
Q

Crawford Type IV aneurysm

A

Extends from the diaphragm to below the renal arteries

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19
Q

what territory does V6 represent?

A

anterolateral

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20
Q

Ghent Criteria

Pulmonary minor criteria

A

Spontaneous PTx

Apical Blebs

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21
Q

Type B aortic dissection -

Medical vs Surgical management

what is the rate of surgical reintervention

A

Equivalent

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22
Q

Fondaparinux trade name

A

Arixtra

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23
Q

Ghent criteria

minor skin criteria

A
  1. Strech marks not associated with weight changes
  2. Recurrent incisional hernia
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24
Q

Ghent Criteria:

Major family history Criteria

A
  1. Having a first-degree relative (parent, child, or sibling) who meets these diagnostic criteria independently
  2. Presence of a mutation in FBN1 known to cause the Marfan syndrome
  3. Presence of a haplotype around FBN1, inherited by descent, known to be associated with unequivocally diagnosed Marfan syndrome in the family
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25
Posterior medial papillary muscle blood supply
PM pap muscle is more vulnerable because of its single blood supply: RCA for right dominant cx for left dominant
26
DeBakey IIIa aneurysm
Confined to the thoracic descending aorta alone
27
"theme" of fibroelastic defficiency mitral repair
No resection or limited resection
28
which ECG lead is the ground?
Right Leg
29
Ghent Criteria Minor CV Criteria
1. Mitral valve prolapse with or without mitral valve regurgitation 2. Dilatation of the main pulmonary artery, in the absence of valvular or peripheral pulmonic stenosis or any other obvious cause in patients age \< 40 years 3. Calcification of the mitral annulus in patients age \< 40 years 4. Dilatation of dissection of the descending thoracic or abdominal aorta in patients age \< 50 years
30
"theme" to Barlow's repair
Barlow's - remove tissue Tissue dissection and leaflet displacement
31
General criteria for Marfan's Diagnosis by Ghent
_Positive family history_ * at least 2 systems (skeletal, cardiovascular, ocular) * and the presence of at least 1 major criterion (eg, ascending aortic aneurysm, ectopia lentis) _negative family_ _history / unknown__,_ major criteria in 2 systems and have involvement of at least 1 other system (skeletal, cardiovascular, ocular).
32
Ghent Criteria Major Skeletal Diagnostic Criteria
Presence of at least 4 : 1. Pectus carinatum 2. Pectus excavatum requiring surgery 3. Reduced upper-to-lower segment ratio or arm span-to-height ratio greater than 1.05 4. Wrist and thumb signs 5. Scoliosis \> 20 degrees or spondylolisthesis 6. reduced extensions at the elbows (\< 170 degrees) Medial displacement of the medial malleolus causing pes planus 7. Protrusio acetabulare of any degree (ascertained on radiographs) (femoral head is medial to the ileoischeal line)
33
The goal of a medical therapy for a type B dissection
Reduction of the Systolic bp Reduction of the mean bp Reduction of the dp/pt
34
how long should a BMS be on plavix
30 days
35
What is the Crawford Extent: Descending aorta from near the left subclavian to the abdominal vessels but not the renal arteries
Type I
36
Anterio apical ECG leads
V3 - V4
37
In repairing a descending aneurysm what should be done with intercostal arteries above T7? Why?
Oversew Eliminate steal of blood from the spinal cord
38
ECG of PE Lead 3 findings
1. q-wave 2. inverted t-wave
39
Factors which make a patient more susceptible to recurrent MR
1. larger MV annular diameter (\>3.7cm) 2. High tethering area 3. greater MR severity (3.5+)
40
anterolateral ECG leads
V5-V6, I, avL
41
duration of symptoms for STEMI
20 minutes
42
Evaluation of IMR - features to note on the evaluation of the angiogram
1. look for an occluded vessel with an inferior wall motion abnormality 2. Clarify right vs left dominance 3. Viability may be of help
43
The phenotype of fMR with normal mitral leaflets
1. Pronounced global LV dilation (typically have \< 30% EF) 2.Ischemic MR - frm caused by *asymmetric* LV remodeling disruption of the subvalvular apparatus (of the posterior medial papillary muscle leading to leaflet tethering)
44
what territory does ECG lead V4 represent?
anteroapical
45
what territory does ECG lead V3 represent
anteropical
46
**_Wilkins Score_**
Wilkins Score: 1. Components: 1. Leaflet mobility 2. Thickenening 3. leaflet calcification 4. subvalvular thickening 2. Each scores between 0-4 - (score between 0-16) 1. \> 9 – unlikely to be amenable to PMBV
47
Crawford type II aneurysm
Descending aneurysm that Begins: near the subclavian Extends: below the renal arteries
48
how long should a DES be on plavix
1 year
49
Diastolic pressure half time for mitral stenosis
\> 150ms (severe) \> 220 ms (very severe)
50
The primary goals of repairing a type B dissection
To replace only a short segment of aorta To redirect flow into the true lumen To stay above T7 and avoid reimplant of intercostal arteries
51
what territory does ECG lead III represent
Inferior
52
what territory does ECG lead aVL represent
anterolateral
53
Defect associated with Ehlers-Danlos syndrome
Defective type III Callogen the hallmark of this disease is Aortic Dissection, not an aneurysm
54
What leads suggest right ischemia
II, III, aVF +/- reciprical changein V1 V2
55
DeBakey Type 2 aneurysm
Ascending alone
56
Intermediate risk pulmonary embolism
Embolus in the RV +/- evidence of myocardial injury shock or hypotension
57
DeBakey IIIb aneurysm
Thoracic aorta and abdominal aorta
58
Rx for low risk PE
LMWH or Fondaparinux
59
Fondaparinux dosing
weight based 50-100Kg --\> 7.5, \>100kg: 10mg give sc x 5-9 days --\> overlap with coumadin Dc with INR 2-3 hold if plt \< 100,000
60
Rx for intermediate risk pe
Heparin / Fondaparinux and long-term A/C
61
ECG leads indicative of inferior wall damage
II, III, aVf
62
what territory does V5 represent
anterolateral
63
Class IIa reccomendations for percutaneous balloon mitral commisurotomy
_Class IIa_ 1. asymptomatic patients 2. very severe MS (mitral valve area ≤1.0 cm2, stage C) 3. favorable valve morphology 4. the absence of left atrial thrombus or moderate-to-severe MR
64
Mitral Regurgitation Recommendation directly for repair
_IIa:_ * Severe MR on echo * Asymptomatic with either: * LVEF \>60% and LVESD \< 40mm * *or* * new AF or PASP \> 50 mmHg * with the likelihood of: * successful repair \> 95% * *and* * expected mortality \< 1%
65
what territory does lead aVf represent
inferior
66
ECG of PE lead 1 findings
S-wave
67
ECG changes indicative of posterior wall infarct
reciprocal changes in V1 and V2
68
what separates a chronic and acute dissection
14 days
69
Ghent Criteria major ocular criteria
Ectopia lentis
70
Type B Dissection 30 day mortality for Medical vs Surgical management
Type B 30 day mortality: Medical management: 9- 16% Surgical managment: 27-32%
71
Anticoagulation reccomended for mitral stenosis
_Class I Evidence:_ 1) MS and AF (paroxysmal, persistent, or permanent) 2) MS and a prior embolic event 3) MS and a left atrial thrombus
72
gastrointestinal bleeding from angiodysplasia in the presence of aortic stenosis.
**_Heyde's syndrome_** is a syndrome of gastrointestinal bleeding from angiodysplasia in the presence of aortic stenosis.
73
what territory does ECG lead II represent
inferior
74
Crawford Type III aneurysm
Begins at T6, and extends to the abdominal aorta
75
what are the class 1 recomendations to perform MVR for MS as concominant surgery
Concominant mitral valve surgery with severe MS (MVA \< 1.5cm2) and underoing surgery for other indications.
76
Ghent Criteria Minor Occular Criteria
Abnormally flat cornea (as measured by keratometry) Increased axial length of globe (as measured by ultrasound)
77
Ghent Criteria for Marfan's Major cardiovascular criteria
Dilatation of the ascending aorta with or without aortic regurgitation and involving at least the sinuses of Valsalva or dissection of the ascending aorta
78
Ghent Criteria for Marfan's Major Dural Criteria
_Lumbarsacral_ dural _ectasia_ as demonstrated by CT or MRI
79
Diagnosis with nSTEMI
Chest pain at least 10 minutes elevated biomarkers or ST of 0.5 or 1mm or ST depression \> 0.5 or TWI greater than 1mm
80
Crawford Extent Begins near the origin of the left subclavian Extends to below the renal arteries
Type II
81
MVA for severe Mitral stenosis
\< 1.5 cm2 (severe) \<1.0cm2 (very severe)
82
Ghent Criteria what systems have major criteria
1. Genetics 2. Skeletal 3. Occular 4. CV 5. Dura
83
DeBakey Type III aneurysm
Descending alone
84
Imaging studies pre CPB
1. if the history of a stroke: head CT 2. Carotid duplex: if a stroke or bruit or LM 3. ABI 4. PFT 5. Chest CT for any patient with calcification on CT
85
what territory does V2 represent
Either: Antero septal or reciprocal changes represent posterior
86
pH Stat or alpha-stat for DHCA
dependent upon the age of the patient: pH-stat in the paediatric (P in the P) alpha-stat in the adult patient. (a for the a)
87
_Class 1 Reccomendations_ for **Percutaneous mitral balloon commissurotomy**
_Class 1 Recommendation:_ 1. symptomatic 2. severe MS (mitral valve area ≤1.5 cm2, stage D) 3. favorable valve morphology 4. the absence of left atrial thrombus 5. absence moderate-to-severe MRs )
88
Class IIb Reccomendations for percutaneous balloon mitral commisurotomy
_Class IIb_ 1. asymptomatic patients 1. severe MS (mitral valve area ≤1.5 cm2, stage C) 2. favorable valve morphology 3. absence of left atrial thrombus or moderate-to-severe MR 2. asymptomatic patients 1. who have new onset of AF. 3. Symptomatic 1. mitral valve area greater than 1.5 cm2 2. evidence of hemodynamically significant MS 1. pulmonary artery wedge pressure greater than 25 mm Hg or 2. mean mitral valve gradient greater than 15 mm Hg during exercise 4. Severely symptomatic (NYHA class III to IV) 1. severe MS (mitral valve area ≤1.5 cm2, stage D) 2. have a suboptimal valve anatomy and who are not candidates for surgery or at high risk for surgery.
89
Pre CPB Review of systems (6)
1. Stroke 2. Renal disease 3. Respiratory problems 4. Bleeding Disorders 5. Peripheral vascular Disease 6. Intestinal angina
90
5-year survival after repair of: 1. Ascending 2. Arch 3. Descending 4. Thoracoabdominal 5. Marfans
5-year survival after repair of: 1. Ascending: 70% 2. Arch: 80% 3. Descending: 60% 4. Thoracoabdominal: 60% 5. Marfans: 85%
91
Reccomendation for Mitral Stenosis patient severely symptomatic (NYHA III to IV) MVA \< 1.5cm2 prior failed PMBC
Class 1 Recomendations are to perform surgery
92
DeBakey classifications including the ascending aorta
Type I and Type II
93
Labs to order pre CPB
1. CBC 2. BMP 3. Coags 4. LFT's
94
EKG of Pulmonary Embolism
S1Q3T3
95
Type B Aortic Dissection: Factors which would advocate for endovascular treatment
Endovascular - * Older * Poor operative risk 1. Renal failure 2. COPD 3. Poor cardiac function 4. Acidotic from mal perfusion * Favorable anatomy
96
what territory does V1 represent
Either: Antero septal or reciprocal changes represent posterior
97
MOA of Fondaparinux
chemically related to LMW heparin
98
Crawford extent I aneurysm
**_Descending aorta_** from near the _left subclavian_ to the _abdominal vessels_ but the **renal arteries** are *excluded*.
99
Crawford Extent Does Type III include the renal arteries
Type III : From T6 to below the renal arteries.
100
how do differentiate on physical exam an acute VSD from an MR
MR is best heard at the apex VSD a the left sternal border and has a thrill
101
Ghent Score consistent with Marfans
\>= 7

LS CV Oral Review (6 decks)

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