10 Heart Flashcards
(111 cards)
1
Q
Heart patients are classified according to how sick they are as determined by the following systems:
A
- New York Heart Association (NYHA) Heart Failure Classification
- System AHA/ACC stages
2
Q
Per the NYHA, a Class I patient…
A
has cardiac disease but without limitations of physical activity
3
Q
Per the NYHA, a Class II patient…
A
has slight limitations of physical activity that will resolve with rest
4
Q
Per the NYHA, a Class III patient…
A
has marked limitations of physical activity but is usually comfortable at rest
5
Q
Per the NYHA, a Class IV patient…
A
has an inability to carry on any physical activity without symptoms, even at rest
6
Q
Per the AHA/ACC, a Stage A patient…
A
is at risk for Heart failure but has not developed structural heart changes
7
Q
Per the AHA/ACC, a Stage B patient…
A
has structural heart disease without symptoms
8
Q
Per the AHA/ACC, a Stage C patient…
A
has structural abnormalities with symptoms of heart failure
9
Q
Per the AHA/ACC, a Stage D patient…
A
has end-stage, refractory heart failure
10
Q
Indications for heart transplant include…
A
- End stage heart disease unresponsive to conventional therapy
- Ventricular arrhythmias despite medications or ablation
- Re-transplantation or graft failure
- Declining functional status – (NYHA Class 3 or 4, or CHF with poor prognosis < 2- year survival)
- All other medical and surgical options exhausted
11
Q
Common diagnoses that could lead to heart transplant include…
A
- Cardiomyopathy
- Valvular Heart Disease
- Myocarditis
- Cardiac Tumors
- Congenital heart disease
- Metabolic disorders
- Toxins
- Systemic Diseases
12
Q
Absolute contraindications to heart transplant include…
A
- Significant peripheral vascular disease
- Cerebrovascular disease
- Active infection (except for LVAD patients)
- Irreversible pulmonary hypertension (4-6 wood units or TPG >12)
- Significant primary lung disease
- Recent pulmonary embolus (within 6 wks of transplant)
- Irreversible end organ function or failure (renal/hepatic)
- Recent cancer (within 5 years)
- Life threatening illness- survival < 5 years
- Severe neurologic injury or impairment
- Active AIDS
- Active alcohol, smoking or drugs
13
Q
Heart failure generally begins with the…
A
left side, specifically the left ventricle
14
Q
With left sided heart failure, the patient may experience the following symptoms:
A
- Cough
- crackles
- wheezing
- confusion
- cyanosis
- blood tinged sputum
- shortness of breath
- exertional dyspnea
- orthopnea
- tachycardia
- elevated pulmonary capillary wedge pressure
- paroxysmal nocturnal dyspnea
15
Q
With right sided heart failure, the patient may experience the following symptoms:
A
- Fatigue
- Ascites
- Anorexia/GI symptoms
- swelling in hands/fingers
- Edema
- Increased peripheral venous pressure
- Enlarged liver and spleen
- Distended jugular veins
16
Q
With right sided heart failure, patients can also develop…
A
pulmonary hypertension (PHTN)
17
Q
Cardiac diagnostic tests include…
A
- ECG
- Right and left heart cath (check PVRi)
- Echocardiogram (Low EF indicating poor function)
- Cardiopulmonary Stress Test - Vo2 max < 14ml/kg/min (50% predicted, major limitation of activity)
- Thallium stress test-nuclear imaging method that shows how well blood flows into the heart muscle, both at rest and during activity.
- Pacemaker/defibrillator analysis (EF < 35%)
- Holter monitor
- Cardiac MRI
18
Q
The normal range for cardiac output is…
A
4-8L/min
19
Q
The normal range for cardiac index is…
A
2.5-4L/min/m2
20
Q
The normal range for pulmonary artery pressure is…
A
12-16mmHg
21
Q
Normal BNP is…
A
<100pg/ml
22
Q
Normal NT-Pro BNP is…
A
<125 pg/ml
23
Q
Normal Troponin is…
A
0-0.4
24
Q
Per OPTN listing criteria, a Status 1 patient includes someone…
A
- VA ECMO
- Non-dischargeable, surgically implanted, non-endovascular biventricular support device
- MCSD with life-threatening ventricular arrhythmia
25
Per OPTN listing criteria, a Status 2 patient includes someone…
* Non-dischargeable, surgically implanted, non-endovascular LVAD
* IABP
* V-tach / V-fib, mechanical support not required
* MCSD with device malfunction/mechanical failure
* TAH, BiVAD, RVAD, or VAD for single ventricle patients
* Percutaneous endovascular MCSD
26
Per OPTN listing criteria, a Status 3 patient includes someone…
* Dischargeable LVAD for discretionary 30 days
* Multiple inotropes or single high-dose inotrope with continuous hemodynamic monitoring
* VA ECMO after 7 days; percutaneous endovascular circulatory support device or IABP after 14 days
* Non-dischargeable, surgically implanted, non-endovascular LVAD after 14 days
* MCSD with one of the following:
* device infection
* hemolysis
* pump thrombosis
* right heart failure
* mucosal bleeding
* aortic insufficiency
27
Per OPTN listing criteria, a Status 4 patient includes someone…
* Dischargeable LVAD without discretionary 30 days
* Inotropes without hemodynamic monitoring
* Re-transplant
* Diagnosis of one of the following:
* congenital heart disease (CHD)
* ischemic heart disease with intractable angina
* hypertrophic cardiomyopathy
* restrictive cardiomyopathy
* amyloidosis
28
Per OPTN listing criteria, a Status 5 patient includes someone…
On the waitlist for at least one other organ at the same hospital
29
Per OPTN listing criteria, a Status 6 patient includes someone…
All remaining active candidates
30
An adolescent donor is defined as…
11 years of age or older, but less than 18 years of age
31
Per OPTN listing criteria for pediatric patients, a Status 1A is someone on a …
* ventilator
* mechanical assistance
* ductal dependent pulmonary or systemic circulation maintained by stent or prostaglandins
* CHD on inotropes in the hospital
32
Per OPTN listing criteria for pediatric patients, a Status 1B is someone on …
* high dose inotropes
* restrictive or hypertrophic cardiomyopathy \< 1 yr at time of listing
33
Per OPTN listing criteria for pediatric patients, a Status 2 is someone on …
Active listing, not meeting above criteria
34
Per OPTN listing criteria for pediatric patients, a Status 7 is someone …
temporarily unsuitable for transplant
35
ABO incompatible blood products can be used in pediatric patients that are…
typically, but not exclusively, Infants less than 12months of age to up to 2nd birthday
36
The geographic area for allocation of hearts includes circles of …
nautical miles from donor hospital up to 2500 based on level of matching
37
While waiting of the list, patients may be medically managed to maintain optimal hemodynamics through the following:
* Diuretics
* ACE inhibitors/ARB
* Beta-blockade
* Hydral/Nitrates
* Aldosterone blockers
* Digoxin
* Angiotensin Receptor Neprilysin Inhibitors (ARNI)
* Inotropic support Anti-coagulation
38
An AICD (automatic implantable cardiovascular defibrillator) is used...
to prevent sudden cardiac death
39
Indications for an AICD include…
* cardiac arrest
* recurrent VT
* prior MI with LVEF \<35% WITH documented VT
* prior MI with LVEF \<30%
40
CRT (cardiac resynchronization therapy) is used to…
synchronize ventricular contractions
41
The indications for CRT include…
* Moderate to severe HF: (NYHA class III or IV) EF \< 35%
* Wide QRS (duration \> 120 ms)
* Remains symptomatic despite stable, optimal heart failure drug therapy
42
An Intra Aortic Balloon Pump (IABP) increases…
* myocardial oxygen perfusion while increasing cardiac output
* oxygen supply increases/coronary blood flow increases
43
The first steps in choosing mechanical support for heart failure patient takes into consideration…
* Size of patient
* Anatomy of patient
* Urgency
* Goal of Support/Device
44
A VAD (ventricular assist device) is a…
* mechanical blood pump used to support a failing ventricle
* it is implanted and contained completely within the pericardial space
45
Bridge to Recovery is the use of a device to…
provide time for native heart function to return
46
Bridge to Transplant is the use of a device to…
provide normal hemodynamics until a donor heart becomes available
47
Bridge to Bridge/Candidacy is the use of a device until…
adequate assessment of the patient can be made
48
Destination therapy is the use of a device to…
provide normal hemodynamics in a patient who is not a candidate for transplant
49
The universal comorbidities associated with cardiac assist devices include…
* Stroke
* Bleeding
* Infection
* device malfunction
50
ECMO (Extracorporeal Membrane Oxygenation) is support for patients whose…
* heart and lungs are severely diseased or damaged
* blood is oxygenated outside the body
* very invasive
* not long-term
51
A device used in an infant/small child/small adult to maintain blood flow through a pump is called a…
Berlin Heart
52
A native heart is removed except for the atria when using this type of cardiac assist device:
Total Artificial Heart (TAH)
53
For a heart transplant, specific donor criteria includes…
* Age \< 70 years old
* Size - height and weight
* Blood group
* EF \> 50 (prefer \> 60)
* EKG – no Q waves (s/s of MI)
* No pressors (epi, vasopressin)
* No trauma to heart
54
For a heart transplant, specific donor exclusion criteria includes…
* Cardiac abnormalities (lab, EKG, echo, and usually left heart catheterization if \>40 years old)
* Increased pressor support
* Chest trauma (cardiac contusion)
* Increased risk patient (drugs, multiple sexual partners, prison) – although can accept a high-risk donor if center is willing and recipient consents
* Pre-existing disease (HIV, hepatitis)
* Cancer
55
If a patient presents for heart transplant, with IV inotropes when they arrive to ICU…
continue until surgery. They will be removed in OR.
56
The most common surgical technique used with heart transplantation is…
Bi-Caval technique
57
The 5 anastomoses for Bi-Caval surgery include…
* 2 venous (SVC and IVC)
* Aorta
* Pulmonary Artery
* Left arterial cuff (pulm veins)
58
The advantages of Bi-Caval technique includes…
* less dysrhythmias
* tricuspid valve more competent
59
The disadvantages of Bi-Caval technique includes…
* increased ischemic time
* caval stenosis
60
The surgical technique that sews the donor and recipient's atrial cuffs together is called…
Bi-Atrial technique
61
With a Bi-Atrial technique the EKG findings might show…
2 P-waves
62
The preferred ischemic time for heart transplantation is...
less than 5 hours
63
Atropine will not work for bradycardia after heart transplant due to…
denervation during transplant
64
Denervation means…
no autonomic nervous system control
65
The leading cause of early post heart transplant morbidity is due to…
Right Ventricle Dysfunction
66
Signs and symptoms of right ventricle dysfunction include…
* Hypotension
* Tachycardia
* Elevated CVP
* Decreased CO
67
Interventions for right ventricle dysfunction include…
* Optimize preload, decrease RV afterload and PVR
* Inhaled Nitric Oxide, sildenafil
* Decease PA pressure
* IV medications such as nitro, nipride, dobutamine, milrinone, nitric oxide
* Mechanical support LVAD, IABP
* With proper interventions, CVP should decrease, CO increase, PVR decrease, hypotension resolved
68
Left ventricular failure can be caused by…
* Ischemic injury
* Reperfusion Injury
* Damage to graft
* Poor reserve
69
Signs and symptoms of left ventricular failure include…
* Decreased in CO, CI, SV
* Decreased EF ≤ to 30% or \< 25% less than baseline
* Decreased tissue perfusion
* Increased creatinine and LFT’s
* HF symptoms
70
Interventions for left ventricular failure include…
* Agents to increase CO and SVR
* Milrinone, epi, norepi, dobutamine
* Pacing - atrial
* Prepare for: IABP ECMO LVAD
71
The most common telemetry rhythm after heart transplant is…
Junctional rhythm
72
Many patients come out of surgery with a temporary pacemaker. An ideal HR immediate post surgery is…
100-120
73
Bleeding can be caused by…
* Liver dysfunction
* Hypothermia
* Heparin product
* Bypass – destruction of cells
* Trauma
74
Signs and symptoms of bleeding after heart transplant include…
* Increased chest tube drainage
* Decreased Hgb and Hct
* Increased heart rate and O2 need
* Decreased Cardiac Output/Cardiac Index
* SVO2 \<65
* Hypotension
75
Interventions for bleeding can include…
* Administration of blood
* Protamine (reverse effects of heparin)
* Return to the OR
76
Cardiac tamponade is caused by…
* Blood accumulating in the pericardium resulting in slow or rapid compression of the heart.
* Chest trauma, surgery, aortic dissection
77
Signs and symptoms of cardiac tamponade include…
* Increased SOB, anxiety
* Arm/chest pain
* Decreased CT drainage
* Increased CVP, wedge pressure
* Decreased CO/CI,
* decreased urine
* Hypotension, narrow pulse pressure
* Distant heart sounds
78
Infections seen early post transplant can include:
* Pneumonia – gram negative
* Wounds – gram negative and staph
* Skin –HSV
* Foley catheter – UTI’s
* Line care/discontinue lines & catheters ASAP
79
Infections that can present early or late in heart transplant recipients include…
* Bacterial
* Viral
* Fungal
* Parasitic
80
Bacterial infections common to heart transplant recipients include…
* Staph
* C. Diff
* Salmonella
* Pseudomonas
* Listeria
* Legionella
* mycobacterium
81
Viral infections common to heart transplant recipients include…
* influenza
* herpes
* EBV
* Varicella
* CMV
82
Fungal infections common to heart transplant recipients include…
* candida
* aspergillus
* PCP
* histoplasma
83
Parasitic infections common to heart transplant recipient include…
* toxoplasma
* cryptosporidium
84
Prophylaxis prevention for viral infections may include…
* ganciclovir IV or oral valganciclovir
85
Prophylaxis prevention for bacterial infections may include…
Bactrim
86
Prophylaxis prevention for fungal infections may include…
Fluconazole/Nystatin
87
The type of antibody mediated rejection that occurs immediately post heart transplant is…
Hyperacute
88
The main cause of hyperacute rejection post heart transplant is due to..
Cytotoxic antibodies from recipient
89
The risk factors for hyperacute rejection post heart transplant include…
* Blood group mismatch
* Pre-existing antibody to donor cells
* Pre-sensitization (high PRA’s) (not looking at specificities)
90
Signs and symptoms of hyperacute rejection include…
* Similar to cardiogenic shock:
* Decreased BP
* Decreased CO/CI
* Increased CVP, wedge, SVR
* Pulmonary congestion
* Peripheral edema
* S3/S4 heard
91
Interventions for hyperacute rejection include…
* Mechanical circulatory support (ECMO/LVAD)
* Relist
92
Rejection is common and is treatable if…
caught early
93
Acute cellular rejection can be associated with..
severe hemodynamic compromise
94
Acute cellular rejection post heart transplant can be caused by…
* the infiltrates of T lymphocytes and macrophages in heart
* Severe cases cause cell accumulation and necrosis
* Medication used to prevent T cell response on target (organ)
* Suppress cytotoxin production through steroids and calcineurin inhibitors
* Prevent expansion of lymphocytes (cellcept and azathioprine)
95
Signs and symptoms of acute cellular rejection post heart transplant include…
* Flu like symptoms (fever, malaise, fatigue, nausea, vomiting, diarrhea)
* JVD
* Edema, increased weight
* SOB, crackles/wheezes
* Third heart sound, pericardial effusion
96
The most common approach for an endomyocardial biopsy is via the…
internal jugular vein
97
Treatment for Cellular Rejection: Grade 0R & 1R includes…
* No treatment, adjust medication to therapeutic levels and re-biopsy according to schedule and/or patient condition
98
Treatment for Cellular Rejection: Grade 2R includes…
* IV or oral steroids
* Hospitalization based on patient condition
99
Treatment for Cellular Rejection: Grade 3R includes…
* IV steroids
* Possible use of Cytotoxic Agents (Thymoglobulin)
* Plasmapheresis (DSA involvement)
* Mechanical support as indicated
100
According to the ISHLT 2004 biopsy grading scale, grade 0 will indicate…
No acute cellular rejection
101
According to the ISHLT 2004 biopsy grading scale, grade 1R will indicate…
Mild, low grade acute cellular rejection. Interstitial and/or perivascular infiltrate w/up to one focus of myocyte damage
102
According to the ISHLT 2004 biopsy grading scale, grade 2R will indicate…
Moderate, intermediate grade acute cellular rejection – two or more foci of infiltrate w/associated myocyte damage
103
According to the ISHLT 2004 biopsy grading scale, grade 3R will indicate…
Severe, high grade, acute cellular rejection – diffuse infiltrate with multifocal myocyte damage ± edema, ± hemorrhage, ± vasculitis
104
Antibody-mediated rejection is caused by…
B cell antibodies that cause vascular inflammation and damage
105
Ongoing treatment for AMR may take…
* weeks to months
* require ongoing ECHO and DSA surveillance
* include assessment for CAV
106
Treatment for AMR may include…
* Pheresis
* Rituximab
* IVIG
* Thymoglobulin
* Cytoxan
* Bortezomib
* Eculizumab
107
Chronic rejection manifests as…
Coronary Artery Vasculopathy: CAV
108
Signs and Symptoms of CAV include…
* Angina/Chest pain RARE due to denervated allograft
* Increased fatigue
* Dyspnea on exertion or at rest
* Increased LV filling pressures
109
Diagnosis of Chronic Rejection includes…
* Noninvasive testing is not always reliable:
* Nuclear stress test
* Exercise EKG
* Left heart catheterization
* IVUS (intravascular ultrasound)
* assess the diameter
* Wall morphology
* Quantifies stenosis
110
Treatment for chronic rejection may include…
* Percutaneous transluminal coronary angioplasty (PTCA) or bypass may be limited due to nature of the disease (post stenting there is 50-60% restenosis)
* Progression may be slowed by adjusting immunosuppression (adding sirolimus), treating DM and hypertension
* Only real treatment is re-transplant
111
Long-term complications common to heart transplant include…
* Diabetes
* Hypertension
* Hyperlipidemia
* Kidney Disease
* GI problems
* Osteoporosis
* Infection
* Neoplasms – skin cancers, lymphomas
