Previous exam 2008

Question 0

List 2 cannulation strategies and associated methods by which you can give antegrade cerebral perfusion.

List nasopharyngeal temp you want and rates and pressure

Answer 0

Axillary cannulation

direct cannulation of the head vessels with special balloon catheters once the arch is open

Target temp is 15-20 degress

perfusion rate is 10-15ml/kg/min ( 700 to 1500ml/min) HCT 25%

cerebral perfusion pressure is measured via the radial arterial line

Question 1

intra-operative dissection occurs post ascending aortic aneurysm repair. List 3 immediate steps

Answer 1

Expose femoral vessel and cannulate the right common femoral artery. Change in-flow to the femoral cannula and go on bypass and cool to 20C.

DHCA to 20 degrees, pack head with ice, mannitol, circulatory arrest, trendulburg

Bring down distal anastomosis and expose aortic arch. Identify the intimal tear and resect. Bring together the intimal tear and the aortic wall with teflon felt and reconstitie the true lumen.

Recannulate with side arm the distal graft and retart CPB.

Trim and perform end to end graft.

Question 2

LVAD implant in a patient with cardiogenic shock who had a previous CABG. Now is Hep, ASA, and POD hypotension and CVP is 15 and flow in LVAD poor. List 3 causes and treatment

Answer 2

Tamponade: To OR for evaculation of clot
Hypovolemia: Needs volume resuscitation
RV failure: needs inotropic support and maybe RVAD

Question 3

List 3 tests you would perform for a patient with purulent pericarditis and 3 treatments

Answer 3

Fever
pericardial friction rub
elevated JVP
pulus paradoxus (> 10 mmHg decrease in systolic pressure on inspration
Kussmauls sign (increase in JVP in inspiration

Pericardiocentesis
Gram stain and culture
Echo

Draingage and anti-microbial

Question 4

Young CABG diabetic who plans for all arterial. No SVG. 90% LAD; 60% RCA; and 90% circumflex. what grafts

Answer 4

RIMA to LAD
left radial to circumlex
free LIMA to RCA

risk of mediastinitis 10% if IMA is pedicled and 2.2% if skeletonized

Question 5

7 day old baby who presents with failure, has systolic murmur, weak femoral pulses

Answer 5

Coarctation
hypoplastic arch
interrupted arch
severe AS/subaortic stenosis

treatment: 
IV PGEi
foley/fluid
intubation
treat metabolic acidisosis
surgical repair of lesion

Question 6

3VD with poor left ventricular function. List 5 independent predictors of increased mortality in this patient CABG surgery

Answer 6

urgency of operation 
number of previous surgeries? 
increasing age
Left ventricular ejection fraction 
% stenosis of leaf main
number of diseased vessels with > 70% stenosis

Question 7

BNP–List 3 things it does physiologically and when and where is it secreted

Answer 7

Brain natriuretic peptide

Mechanisms
Natriuesis/Diuresis/decrease myocardial fibrosis and remodeling
improve myocyte relaxation during diastole
inhibit renin-angiotensi system

some secreted in brain but most in ventricles.

higher levels in CHF, ACS, and pericarditis

Question 8

48 year old F with asymptomatic severe AI. List 4 echocardiographic features that would make you opearate

Answer 8

EF < 50%
LVESD > 55ml
LVEDD > 75
Dilated ascending aorta (>5 in marfa and > 5.5 in others

Question 9

Ebstein’s anomaly. List the 4 pathological findings with the tricuspod valve and annulus

Answer 9

Displacement of spetal and posterior leaflet towards the RV

arterialization of the RV segment between the true trucuspid annulus and the new position of the leaflet attachment

small RV

anterior leaflet that maybe large, sail like or restricted in motion

Question 10

List 3 alternatives to heparin for HIT

Answer 10

Argatroban
Bivalirudin
Leupirudin
Danaparoid
Fondaparinux

Question 11

Adult with undiagnosed PDA has eisenmengers syndrome now. What are 2 surgical options to treat this patient now

Answer 11

Heart lung transplant

Lung transplant

Question 12

REMATCH trial list the actuarial survival of the medical therapy group

Answer 12

1 year: medical 25% device 52%

2 year: medical 8% device 23%

Question 13

In ischemic MR list 3 beenfts of annuloplasty on the mitral valve

Answer 13

Prevents further annulus dilation and helps in LV remodelling
Reduces the size of the annulus allowing better copatation of the leaflets
relives tensions from the suture lines
Decrease MR
Prevent annular dilation
Restore leaflet coaptation

Question 14

What are types of endoleaks

Answer 14

This is Type 1.
Type 2: leak from flow outside the graft
Type 3: leak from graft tear or defect
Type 4: leak from porous graft
Type 5: leak from endotension

Question 15

What is intramurual hematoma

Answer 15

Accumulation of blood in the media of the aorta without the presence of any flow, resutling from bleeding of the vasa vasocrum into the media

1/3 develop into aortic dissection

ascending should be treated like type A dissection

decending treat medical

Question 16

List most common causes of death in transplant patients at 0-30 days; 31-1 year; and > 5 years

Answer 16

0-30–most common is acute graft failure

30-1 year: infection

> 5 years: chronic allograft vasculopathy

Question 17

List mechanisms of reperfusion injury

Answer 17

i) oxygen free radicals
ii) intracellular calcium overload
iii) endothelial & microvascular dysfunction
iv) altered myocardial metabolism
v) Platelet, neutrophil, & complement activation

Question 18

Question on Sano shunt vs. modified BT shunt in Norwood operation and when blood flow occurred in coronaries and pulmonary arteries in both shunt. Gave you a 2x2 table and had to fill in boxes. Options were diastole, systole, or both.

Answer 18

Coronaries PA
Sano Both Systole
Modified BT Both Both

Question 19

Cardiac resynchronization therapy question in patient with dilated cardiomyopathy. List 2 reasons why it would fail. Long question can’t remember all the details of the question.

Answer 19

Lead malpositioning
Lead fracture
Loss of capture
Cardiac perforation
Crosstalk
Oversensing
Battery end of life
Inadequate LV/RV synchronization

Question 20

Patient with dilated cardiomyopathy (EF<20%). Has been on “state of the art” meds. Now patient has NYHA class 3-4 failure. List 4 “state of the art” meds patient was on. List 4 non-medical treatment options for this patient.

Answer 20

beta blocker, ACEI, spironolactone, digoxin

CRT, CABG if pt has CAD, LVAD as destination therapy, transplant, ICD

Question 21

In patient with 3VD and poor LV fxn. List 5 independent predictors of increased mortality in this patient with CABG surgery

Answer 21

Old age
Poor LV function
Preop renal failure
Cardiogenic shock
Emergency status
COPD