Corey Prediction 2013 Exam Flashcards
Define Diastolic function
Limitation of the ventricle to fill to normal end-diastolic volume without an abnormal increase in end-diastolic pressure at rest or during exercise.
Loss of compliance/loss of relaxation with abnormal distensibility abnormal filling
What is mechanism of action of Dabigitran?
Name two other meds in this class with similar action?
What was study and outcome that was assessed with this drug?
Oral, direct competitive thrombin, inhibitor
Rivaroxaban and Apixaban
Re-Ly study showed in AF that 110 vs warfarin was equal and 150 vs warfarin resulted in less stroke 1.69 vs 1.11% with similar bleeding
Limitation was the time spent in therapeurtic range on warfarin was limited for pt. when pts were in therapeutic range greater >70%) of time there was no difference.
What are echo signs of Diastolic dysfunction
- Prolonged Transmitral E wave deceleration time (normally adults less than 220 ms)
- Prolonged Isovolumetric relaxation time (interval in the cardiac cycle, from the aortic component of the second heart sound, that is, closure of the aortic valve, to onset of filling by opening of the mitral valve, greater then 80)
- Reversal of transmitral E:A ratio (impaired relaxation (E:A reversal i.e. E is < A)
- Delayed ratio of transmitral A wave duration to pulmonary atrial reversal wave duration ( > 30)
- Blunting of systolic pulmonary vein flow to Diastolic ratio (systolic blunting, a decrease in the height of the S wave)
What are echo predictors of SAM post mitral valve repair
Septum > 15mm Small LV cavity Hyperdynamic LVEF 65% Aorto mitral angle < 120 (some say 130) Short coaptation-septal distance< 25 mm Too small annuloplasty ring Excessive height of posterior leaflet post repair (>15mm)
What are details of first generation LVAD
Pulsatile, volume displacement using a pusher plate system.
The pump senses when the chamber is full and activates the pusher plate. It has porcine xenograft valves.
35% device failure in 2 years;
Heartmate XVE
What are details of Second Generation LVAD
Continuous flow, rotary pump, smaller, eliminating the reservour chamber and valves that was needed for first generation.
Rotary blood pump is in axial blood flow path, with an internal rotor suspended on bearings.
Inflow at apex of LV and outflow in ascending aorta.
Risk of negative intraventricular pressure. INR 2.5- 2.5
Heart mate II
What are details of 3rd Generation LVAD
eliminated need for “bearings”
Using hydrodynamic or electromagnetic suspension of an impeller to reduce mechanical wear and trauma to blood cells
contact free rotation
List contraindications to LVAD
sepsis anuria CVP < 16 Revised Columbia score > 5 (mortality 47% if score > 5) likelihood of recovery low
What are features of Barlows mitral valve
young age, long history of symptoms myxoid infiltration Bulky, billowing and tall leaflets multi-segment prolapse Calcification of annulus atrialization of leaflets chordal thickening/elongation late SEM with mid click
What are features of Fibroelastic defiencey
older, usually sudden onset impaired connective tissue thin leaflets prolapse of single segment ruptured chord holosystolic murmur thickened and excess chord only at prolapsing segment
What are criteria for Brain Death
Unresponsive to central pain stimulus Absence of brain stem reflexes a. no occular movements b. no corneal reflex Apnea a. measure po2 and pco2 after 8 minutes of apnea b. if pco2 > 60 or 20 point increase normothermia, no toxins, two physicians, clinical evidence of cns event keeping with brain death
List features of Ebstein Anomaly
Dysplasia of Triscuspid valve resulting in
- fused perforated or absent leaflets and abnormal chordaie
- apical displacement of the septal and posterior leaflets into the body of the right ventricle
- thin atrialized right ventricle
- right ventricle dysfunction
- rhythm abnormalities (wpw)
- often severe TR
What are echo features of TR
- Vena contracta > 0.7cm
- systolic flow reversal in hepatic vins
- Effective Regurgitant volume > 45ml
- Effective regurgitant orifice area > 0.40cm2
List features of Carcinoid Heart
How do you test for it
50% develop valve disease
Primary lesion is located in the small intestine
Mainly right sided lesions
Usually TR or TS
plaques are on the downstream of the valves leading to adherence of the leaflet on the underlying structures
Regurgitation and may constrict the annulus leading to stenosis
Pulmonary valve replacement
*test urine of 5-HIAA serotonin
Describe atrial senning operation
Atrial switch concept was first successful accomplished Senning in 1959
Relocating the walls of the right atrium and the atrial septum
Pulmonary and systemic venous return rerouted by incising and realigning the atrial septum over the pulmonary veins and using the the right atrial wall to create a pulmonary venous baffle.
Describe ISHLT classification of rejection
Grade 0 No rejection
Grade 1A Focal, mild, no necrosis
Grade 1B Diffuse infiltrate, no necrosis
Grade 2 Focal, moderate, one focus of aggressive infiltration with myoctye damage
Grade 3A Multifocal aggressive infiltration
Grade 3B Diffuse–diffuse inflammatory, myocyte necrosis
Grade 4 Severe rejection,Hemorrhage, vasculitis, Diffuse aggressive, edema
List INTERMACS
Class 1: Critical cardiogenic shock Class 2: progressive decline Class 3: stable on inotropes Class 4: recurrent Advanced Heart failure Class 5: Exertion intolerant Class 6: Exertion limited Class 7: NYHA III
Describe HIT
What percentage of pts develop HITT type II and how many develops thrombosis
IgG antibody binds to complex of platelet factor 4 and heparin leading to the formation of an immune complex.
The immune complex binds to platelets via platelet Fc receptors producing intravascular platelet activation, thrombocytopenia, and thrombosis
1- 5% develop Type II HIT and 20% of those develop thrombosis
Contraindications to Ross
Pulmonary valve disease Marfan Autoimmune disorders Poor LV function/Anatomical issues aberrant coronary anatomy mismatch of PA and Aorta
Mechanism and dosing of Factor VIIa
Stimulates the coagulation cascade by activation of thrombin at the site of tissue injury by tissue factor dependent and independent mechanisms
Tissue dependent results in factor X activation and thrombin generation
Tissue factor independent mechanisms include activation, aggregation, recruitment and stabilization of platelets.
65 ug/kg to 100 ug/kg
What is Ticagrelor
Nonthienopyridine, oral pyrimidine derivative, direct-acting, and reversible antagonist of the ADP receptor P2Y12 with a plasma half-life of about 12 hours
More rapid, potent and consistent effect on platelet function compared with clopidogreal.
PLATO trial improved rates of MI/Death/Stent thrombosis
Who should get a PA band
Unbalanced AV canal
Multiple VSD “swiss cheese”
Contraindication to cardiopulmonary bypass “weight”
VSD with Coarctation
Late presentation TGA (3 weeks..then place for 1 week before doing switch)
List cancers associated with post transplant
Basal Cell Squamous Cell B cell lymphoma Cervical *rare Vulvar * Kaposi sarcoma *
What are 5 signs of positive exercise stress test
Abnormal symptoms (chest pain, syncope) Abnormal ECG (ST depression) Abnormal Blood pressure (drop in BP) Abnormal Heart rate Inability to achieve 6 mets
List 7 factors that a rate responsive pacemaker will respond
Body vibration Body temp respiratory rate shortened QT interval Acceleration in motion RV systolic pressure RV systolic volume
What are 2012 indications for CRT
EF < 35% Sinus rhythm LBBB with QRS > 150 msec NYHA II, III or IV on optimal medical therapy
List predictors for RVAD placement after LVAD
Cardiac index < 2.2 RV stroke work index < 0.25 Severe RV dysfunction Pre-operative increase in serum creatinine previous cardiac surgery Systolic blood pressure < 90 mmg
List causes of restrictive cardiomyopathy
Amyloid Endomyocardial post radiation Sarcoid Eosinophilic
What are features of Constrictive pericarditis
RVEDP> 1/3 RVSP RAP and LAP are equal and > 10 mmhg RVEDP = LVEDP (equalization within 5) atrial size is normal Ejection fraction is > 40% Square root sign on right ventricle tracing Pulmonary artery pressure is usually low
List health Edwards classification of Pulmonary artery hypertension
- medial hypertrophy without intimal hyperplasia
- media hypertrophy with intimal hyperplasia
- medial hypertrophy with fibrosis
- areas of vascular occlusion with fibrosis
- angiomatoid lesions
- necrotizing arteritis
What are causes of organic TR
Rheumatic Carcinoid Marfans Endocarditis Trauma Anorexectic drugs Whipples disease SLE
What are causes of functional TR
RV failure –ischemia
Pulmonary hypertension -mitral valve disease/left sided lesions
RVOT obstruction –Pulmonary embolism/chronic
Core Pulmonale– congenital disease/left to right shunting
How does Milrinone work
What is loading dose and typical infusion rate
Inhibitor of Phosphodiesterase enzyme, which normally converts cAMP to its inactive form of 5 -AMP. So by being a phosphodiesterase inhibitor it increase the cAMP and subsequently creates a greater influx of calcium into myocardial cells
loading dose is 50ug/kg and 0.5ug/kg/min
How to adrenergic drugs effect cardiac contractility
stimulate adnylate cyclase which catayses the conversion of ATP to cAMP.
increases the amount of calcium introduced to into the cell for contraction
What does DDAVP stimulate
Increase VIII and vWF
What are ideal indications for fontan procedure
- minimal age 4
- sinus rhythm
- normal caval drainage
- right atrium normal
- mean pulmonary pressure < 15 mmhg
- pulmonary artery resistance < 4
- no impairing effects of previous shunts
- competent atroventricular vavle
- normal ventricles
- pulmonary-artery-to aorta-diameter ratio of > 0.75
What is natural history of AS
Median survival of 2-3 years after symptoms
Progression of decrease 0-15 mmHg/year
angina = 5 years, syncope = 3 years; dyspnea 1-2 years
What is natural history of AI
Latent period of 3-10 years 6%/year develop symptoms 3-5% develop LV dysfunction 25% will develop symptoms if LV is dysfunction 10%/year die when symptoms develop
Describe steps of Norwood stage I operation
Stage I reconstruction is performed shortly after birth via median sternotomy and deep hypothermic circulatory arrest (DHCA)”
- atrial septectomy
- Construction of a neoaorta from the pulmonary valve by division of the PA at the bifurcation and anastomosis of the aorta to the proximal PA
- Placement of a systemic-to-pulmonary modified Blalock-Taussig shunt (mBTS) or RV to PA conduit
What is Natural History of VSD
80% close at birth
25% will close if not closed at 12 months
50% will develop pulmonary HTN at 20 years of age if left open
