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LS CV Oral Review > 101-200 > Flashcards

101-200 Flashcards

(97 cards)

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1
Q

Repair of descending aneurysm:

after proximal anastomosis, how should flow to the head and heart be re-instituted

A

Arterial flow is re-instituted either through the axillary or a perfusion cannula into the graft.

Flow should be restarted slowly at 500-700cc.hr

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2
Q

Descending aortic dissection

% of patients with visceral malperfusion ?

what is the most common mechanism of malperfusion ?

A

21% of patients have visceral malperfusion

80% of these cases are dynamic branch compromise

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3
Q

Dynamic branch compromise

A

Most common type of malperfusion following repair of Type B dissection (80% of cases)

Due to narrowing or compression with the majority of flow through the false lumen compressing the osteal opening

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4
Q

Static branch malperfusion

A

Dissection flap or intimal tear extends into the branch leading to obstruction of flow from intimal intussusception

Maybe augmented by the presence of a thrombus

This may be treated percutaneously

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5
Q

WHO Pulmonary Hypertension Classification

○ WHO Group I -

A

_○ WHO Group I - Pulmonary *arterial* hypertension (PAH)_

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6
Q

WHO Classification of pulmonary hypertension

○ WHO Group II -

A

○ WHO Group II - Pulmonary hypertension associated with left heart disease

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7
Q

WHO Pulmonary HTN Classification

○ WHO Group III -

A

○ WHO Group III - Pulmonary hypertension associated with lung diseases and/ or hypoxemia

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8
Q

WHO Classification of Pulmonary hypertension

○ WHO Group IV -

A

○ WHO Group IV - Pulmonary hypertension due to chronic thrombotic and/ or embolic disease

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9
Q

WHO Classification of pulmonary hypertension

○ WHO Group V

A

○ WHO Group V - Miscellaneous.

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10
Q

WHO Classification

Pulmonary arterial hypertension (PAH)

A

○ WHO Group I - Pulmonary arterial hypertension (PAH)

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11
Q

WHO Classification

Pulmonary hypertension associated with left heart disease

A

○ WHO Group II - Pulmonary hypertension associated with left heart disease

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12
Q

WHO Classification:

Pulmonary hypertension associated with lung diseases and/ or hypoxemia

A

○ WHO Group III - Pulmonary hypertension associated with lung diseases and/ or hypoxemia

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13
Q

WHO Classification

Pulmonary hypertension due to chronic thrombotic and/ or embolic disease

A

○ WHO Group IV - Pulmonary hypertension due to chronic thrombotic and/ or embolic disease

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14
Q

What is a non-restrictive VSD ?

A

Left and right ventricular pressures equalize

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15
Q

What are the major factors that impact the flow patterns across a VSD ?

A
  1. Chief factor: Pulmonary / Systemic resistance
  2. Size of the Defect
  3. Others
    • HCT (viscosity)
    • CO (velocity)
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16
Q

What determines the Qp/Qs in a non-restrictive VSD

A

Difference in the pulmonary - systemic vascular resistance

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17
Q

What determines the Qp/Qs in a restrictive VSD

A

(PVR + Gradient across the VSD) - SVR

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18
Q

How does VSD size impact the flow across it ?

A

As the size of the VSD –> 50% of the aortic annulus the flow becomes non-restrictive

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19
Q

General categories of VSD

A
  1. Inlet
  2. outlet
  3. Perimembranous
  4. Muscular t
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20
Q

A child with swiss cheese VSD

flow left to right

Qp/Qs > 2.1

approach ?

A
  1. Pulmonary banding
  2. most of the defects will close with time
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21
Q

Describe the conduction system with respect to a conal VSD

A

Conduction system is remote

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22
Q

Conduction system with respect to a d-looped perimembranous VSD

A

posterior and inferior to the defect

  • place sutures on the RV side only
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23
Q

Conduction system with respect to a perimembranous defect with l-looped ventricles

A

anterior and superior to the defect

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24
Q

Conduction system with respect to an inlet VSD

A

apex of the triangle of koch

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25
Infective endocarditis - overall 6-month mortality
20-25%
26
Infective endocarditis - perioperative mortality
10%
27
Infective endocarditis The rate of re-infection of a prosthesis?
2%
28
Native valve endocarditis Class I Indications for Surgery (ACC/AHA 2006/2014/2017; ESC 2009, 2015)
**_Class I_** 1. Heart Failure 2. Evidence of LV dysfunction or PA HTN 3. Abscess, Fistula, Pseudo-Aneurysm 4. Fungal or highly resistant bacterial IE 5. Persistent bacteremia after 1 week Ab Rx Mnemonic: F HEAP (Fungus, heart failure, EF(low), Abscess), Persistent Bacteremia)
29
_Native Valve Endocarditis_ Class II Reccomendations (ACC/AHA 2006/2014/2017; ESC 2009, 2015)
_Class II Reccomendations_ Recurrent emboli and persistent vegetation despite appropriate AB Rx (IIa) Large ( \> 10mm) mobile vegetation, particularly on AMVL (IIb) Increase in vegetation size on AB Rx (IIb)
30
**_Prosthetic valve endocarditis_** Class I Indications for surgery
1. Heart Failure (IB) 2. Severe prosthetic valve dysfunction (IB) 3. Dehiscence, abscess, fistula, etc. (IB) 4. Fungal or highly resistant bacterial PVE (IC)
31
Prosthetic valve endocarditis Class II Endocarditis
**_CLASS II_** * Persistent bacteremia or recurrent emboli despite appropriate AB Rx (IIa, C) * Relapsing infection (IIa, C)
32
MRI findings for myocardial viability -
**_Lack of Viability of Myocardium_** * *Late gadolinium enhancement* (LGE) identifies the presence, location, distribution, and transmural extent of nonviable myocardium * \> 25% transmural distribution of LGE on CMR is bad sign * Extracellular volume (T1 mapping)
33
Echocardiographic signs of irreversible myocardium -
_Viability_ _of Myocardium:_ 1. Extensive thinning 2. Extensive akinesia or dyskinesia 3. No Contractile reserve on DSE _Suggestions of Longstanding Disease (*hence irreversible*)_ 1. Severely dilated left ventricle (LVEDD \> 70mm) 2. LVEF \< 25% 3. Moderate or Severe Right ventricular dysfunction
34
Pivotal Trial for HVAD for Bridge to Transplant Indication
ADVANCE (2012)
35
Pivotal Trial for HVAD for Destination Therapy
ENDUANCE | (2017)
36
Pivotal Trial for HeartMate 3 for Short Term and Long Term Use
MOMENTUM 3
37
Indications for surgical embolectomy
Surgical embolectomy Failed thrombolytic therapy Failed catheter embolectomy Insufficient time for effective thrombolytic therapy in critical patients
38
The procedure of choice for: Older patients (e.g., age \>50 years) with aortic root aneurysm and normal aortic annulus
Remodeling
39
Mutation associated with Marfan's Syndrome
Mutation of the FBN 1 Gene encoding for Fibrillin -1 10% will have a TGF-B receptor mutation
40
Marfan's Syndrome Histology phenotype
Fragmentation of the elastic lamellae Loss of smooth muscle cells
41
Loeys-Dietz Syndrome Mutation
TGF-B receptor 1 or II mutation
42
Loeys-Dietz Syndrome Phenotype
1. _Aggressive aortic disease_ * 98% develop aortic root aneurysm * High incidence of dissection 2. _arterial tortuosity_ 3. _Hypertelorism_ 4. _bifid uvula_ 5. _cleft palate_ 6. *Prominent facial features in kids correlate with pathology*
43
Ehlers-Danlos mutation
COL3A1 Gene mutation Encoding type III collagen
44
Phenotype of Ehlers-Danlos Syndrome
Easy bruisability Thin Skin Facial features Arterial, uterine, and intestinal rupture
45
Fundamental mechanisms of the two major valve preserving surgeries for the aortic root
Remodeling - Yacoub Reimplantation -David
46
DISSECT mnemonic for aortic dissections
mnemonic “DISSECT”: Duration, Intimal tear (location), Size (maximum diameter), Segmental Extent (ascending, descending, etc.), Complications, Thrombosis of the false lumen
47
T David II procedure
Same as the Yacoub I (remodeling) Yacoub - remodeling TDavid II and III are the same III adds a strip betwen the mitral trigones
48
Differences in the David Procedures
I : reimplantation (interupted around the base) II - is a Yacoub Remodeling ( scalloped sinus) III- is the same as a II but a synthetic strip between mitral trigones IV: is the same as a 1, but the graft is 4mm larger and distal plication V: same as a 1 but 6mm larger and proximal and distal plications
49
Mutation for: 1. Marfan's 2. Loeys-Dietz 3. Ehler's Danlos
Mutation for: 1. Marfan's : FBN 1 2. Loeys-Dietz : TGF-B 3. Ehler's Danlos : Type IV Callogen
50
AHA Class I guidelines for surgery on the ascending aorta
Isolated and asymptomatic - 5.5 cm Marfan 5.0 Growth rate \> 0.5cm/year Conominant valve opration = 4.5 cm Symptomatic
51
Normal root diameter male/female
Root (female) 3.50 to 3.72 Root (male) 3.63 to 3.91
52
Normal ascending aorta diameter -
2.86
53
The procedure of choice: Younger patients with inherited aortic root aneurysms such as in Marfan syndrome, Loyes-Dietz syndrome, familial aneurysm, and incompetent bicuspid aortic valve frequently have associated annuloaortic ectasia
These patients should have reimplantation of the aortic valve to permanently stabilize the aortic annulus.
54
Size indications for surgery on the aortic arch
5.5 cm
55
size guidelines for surveillance of aortic arch aneurysm
* \< 4cm: yearly * \> 4cm: q6 months
56
How does a persistent LSVC affect cardioprotection
Persistent LSVC: Blood returns to the LA via the coronary sinus 1. venous drainage issue 2. blood enters the CS to the LA and is warmer, so may impact on the cooling of the heart. 3. Difficult to administer retrograde cardioplegia
57
After unclamping the aorta during a case with retrograde cardioplegia you notice the myocardium is slow to regain electrical activity.
Make sure the retrograde balloon is down
58
Recommendations for aortic aneurysm intervention in Marfan's Syndrome
Surgical repair when the aorta reaches 5.0 cm _unless_ there is a family history of AoD at 5.0 cm, a rapidly expanding aneurysm or presence or significant aortic valve regurgitation
59
AHA recommendations for intervention for Loey's Dietz syndrome
Surgical repair recommended at an aortic diameter of 4.2 cm by TEE (internal diameter) or 4.4 to 4.6 cm by CT and/or MR (external diameter)
60
AHA recs for an aneurysm repair with bicuspid / marfans with concomitant valve disease
\> 4.0 cm
61
where is the David IV plicated
at the ST Junction
62
When pharmacologic maneuvers fail to rectify SAM- the fundamental issue is typically?
1. the residual **anterior** and **posterior** leaflet heights 2. the **_septal-lateral diamete_r** of the mitral annulus following *ring annuloplasty*
63
Physical signs of AI
water hammer pulse wide pulse pressure low diastolic blood pressure diastolic decreshendo murmur
64
% of patients with an atherosclerotic ascending aneurysm that also have a AAA?
10-20%
65
Marfan's Syndrome Key phenotypic features
1. Stature: tall, thin 2. Lax joints 3. Lentis ectopia 4. High arched palate
66
Loeys-Dietz syndrome key phenotypic
1. Blue sclerae 2. Hypotelorism 3. Bifid uvula 4. Malar flattening 5. Retrognathia 6. Translucent skin 7. Arachnodactaly
67
David method sizing dacron graft for aortic root reimplantation
Aortic annulus ~ 2/3 cusps height x 2 Dacron graft ~ 2/3 cusps height x 2 + 2xLVOT thickness Ideal STJ plus 4 to 6 mm
68
El-Khoury technique for determining graft size for aortic root repair
* Height of interleaflet triangle (between LCC and NCC)
69
Gender/body sized approach to determining the size of the graft for an aortic root replacement
* 28 mm women / 30 mm male * 30 mm woman / 32 mm male BAV
70
sizing of the graft for a biobental
the tube graft is usually 3-5mm larger than the valve chosen
71
how frequently should a root aneurysm be followed up postoperatively
CT scans should be performed at 1, 3, 6, 12 months then annually thereafter
72
TOF ## Footnote Tight RVOT RV trabeculations - BIG RV Overiding aorta
73
TET Cxr - Boot shaped heart
74
Indications for Palliative procedure for TET
\< 6kg and symptomatic \< 4 months and symptomatic Small pulmonary arteries Need for RV-PA conduit LAD from RCA Multiple cardiac abnormalities
75
Indication for primary repair of TET
\> 4-6 Months of age 6-12 months after shunt
76
Size of a BT shunt
shunt size = 1-2 x weight 3.5 - 4.0 mm most common
77
On what side should a BT shunt be performed?
The side opposite the arch so most commonly on the left
78
What type of VSD does TOF have?
he ventricular septal defect (VSD) in tetralogy of Fallot (TOF) is a perimembranous defect with extension into the subpulmonary region.
79
coronary concerns for TOF
LAD may arise from the RCA, thus coursing across or near the infundibulum
80
RV/PA pressure ratio following TOF repair
RV/PA ratio \> 0.7 correlates with worse outcome
81
Steps to TOF Repair
1. CPB w. moderate hypothermia 2. Check RV for coronary anomalies which may be of issue 3. Divide systemic to pulmonary shunts / PDA 4. Transect RVO obstructing muscles 5. Close the VSD with a PTFE patch 6. Close ASD (unless concern for RV dysfunction) 7. Probe pulmonary valve - annular enlargement if small
82
TOF Repair What to do if need for RVOT enlargement but coronary artery obstructing
RV to PA conduit RV ventriculotomy below the coronary
83
Operative survival and late survival of TOF
Operative: 95% Late : 0%
84
*An adult patient with TET repair in infancy* Indications for pulmonic valve replacement
1. PI 2. RV enlargement * EDVI \> 160 * ESVI \> 80 3. Worsening TR 4. Decreased exercise tolerance 5. QRS \> 180ms
85
smooth part of the right atrium
Sinus venarum
86
**European Society of Cardiology/ACCF/AHA/World Heart Federation** **_Universal Definition of Myocardial Infarction_**
1. new ST elevation at the J point in at least 2 contiguous leads of : 1. In Men: 2 mm (0.2 mV) in men 2. In Women: 1.5 mm (0.15 mV) in women in leads V2–V3 and/or of 1 mm (0.1mV) in other contiguous chest leads or the limb leads (7).
87
In the setting of a STEMI when should reprofusing therapy be administered
Reperfusion therapy is reasonable for patients with STEMI and symptom onset within the prior 12 to 24 hours who have clinical and/or ECG evidence of ongoing ischemia. Primary PCI is the preferred strategy in this population (81,94,95). (Level of Evidence: B)
88
P2Y12 therapy for adjunct with PCI for NSTEMI
A loading dose of a P2Y12 receptor inhibitor should be given as early as possible or at time of primary PCI to patients with STEMI. a. _Clopidogrel_ 600 mg b. _Prasugrel_ 60 mg c. _Ticagrelor_ 180 mg
89
Ticagrelor
Brilinta P2Y12
90
Class II Antiarrhythmic Agents
_Class II:_ * beta-blockade * Block sympathetic activity * reduce rate and conduction
91
Class III Antiarrhythmic Rx
Class III: potassium-channel blockade Delay repolarization (phase 3) and thereby increase action potential duration and effective refractory period.
92
Contraindication to AF ablation by PV isolation
Surgical ablation for symptomatic AF by pulmonary vein isolation alone is not recommended in the setting of: left atrial enlargement (\>4.5 cm) or more than moderate mitral regurgitation
93
Cox-Maze III
Cut and sew
94
Risk factors for pre-operative atrial fibrillation
hypertension obesity alcohol consumption diabetes mellitus structural heart * Mitral valve produces the most LA enlargement Atrial fibrosis (ischemia)
95
Indications for stand-alone Cox-Maze
The primary indication for ablation in stand-alone patients is the presence of symptomatic AF refractory to at least one class I or III antiarrhythmic drug. In
96
For stand-alone surgical ablation, what is the rate of? Mortality? Morbidity? Pacemaker?
Mortality: 0.74% Morbidity: 16.43 Pacemaker: 1.03%
97
What sutures should be used to repair an Apical VSD
1-0 Tevdek

LS CV Oral Review (6 decks)

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