Repair of descending aneurysm:
after proximal anastomosis, how should flow to the head and heart be re-instituted
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
Descending aortic dissection
% of patients with visceral malperfusion ?
what is the most common mechanism of malperfusion ?
21% of patients have visceral malperfusion
80% of these cases are dynamic branch compromise
Dynamic branch compromise
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
Static branch malperfusion
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
WHO Pulmonary Hypertension Classification
○ WHO Group I -
○ WHO Group I - Pulmonary arterial hypertension (PAH)
WHO Classification of pulmonary hypertension
○ WHO Group II -
○ WHO Group II - Pulmonary hypertension associated with left heart disease
WHO Pulmonary HTN Classification
○ WHO Group III -
○ WHO Group III - Pulmonary hypertension associated with lung diseases and/ or hypoxemia
WHO Classification of Pulmonary hypertension
○ WHO Group IV -
○ WHO Group IV - Pulmonary hypertension due to chronic thrombotic and/ or embolic disease
WHO Classification of pulmonary hypertension
○ WHO Group V
○ WHO Group V - Miscellaneous.
WHO Classification
Pulmonary arterial hypertension (PAH)
○ WHO Group I - Pulmonary arterial hypertension (PAH)
WHO Classification
Pulmonary hypertension associated with left heart disease
○ WHO Group II - Pulmonary hypertension associated with left heart disease
WHO Classification:
Pulmonary hypertension associated with lung diseases and/ or hypoxemia
○ WHO Group III - Pulmonary hypertension associated with lung diseases and/ or hypoxemia
WHO Classification
Pulmonary hypertension due to chronic thrombotic and/ or embolic disease
○ WHO Group IV - Pulmonary hypertension due to chronic thrombotic and/ or embolic disease
What is a non-restrictive VSD ?
Left and right ventricular pressures equalize
What are the major factors that impact the flow patterns across a VSD ?
- Chief factor: Pulmonary / Systemic resistance
- Size of the Defect
- Others
- HCT (viscosity)
- CO (velocity)
- HCT (viscosity)
- CO (velocity)
What determines the Qp/Qs in a non-restrictive VSD
Difference in the pulmonary - systemic vascular resistance
What determines the Qp/Qs in a restrictive VSD
(PVR + Gradient across the VSD) - SVR
How does VSD size impact the flow across it ?
As the size of the VSD --> 50% of the aortic annulus the flow becomes non-restrictive
General categories of VSD
- Inlet
- outlet
- Perimembranous
- Muscular t
A child with swiss cheese VSD
flow left to right
Qp/Qs > 2.1
approach ?
1. Pulmonary banding
2. most of the defects will close with time
Describe the conduction system with respect to a conal VSD
Conduction system is remote
Conduction system with respect to a d-looped perimembranous VSD
posterior and inferior to the defect
- place sutures on the RV side only
Conduction system with respect to a perimembranous defect with l-looped ventricles
anterior and superior to the defect
Conduction system with respect to an inlet VSD
apex of the triangle of koch
Infective endocarditis
- overall 6-month mortality
20-25%
Infective endocarditis
- perioperative mortality
10%
Infective endocarditis
The rate of re-infection of a prosthesis?
2%
Native valve endocarditis
Class I Indications for Surgery
(ACC/AHA 2006/2014/2017; ESC 2009, 2015)
Class I
- Heart Failure
- Evidence of LV dysfunction or PA HTN
- Abscess, Fistula, Pseudo-Aneurysm
- Fungal or highly resistant bacterial IE
- Persistent bacteremia after 1 week Ab Rx
Mnemonic:
F HEAP (Fungus, heart failure, EF(low), Abscess), Persistent Bacteremia)
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)
Prosthetic valve endocarditis
Class I Indications for surgery
