Advanced Cardiac Diagnostics and Therapies Flashcards
1
Q
What are the 6 contraindications for cardiac catheterization?
A
- severe peripheral vascular disease
- untreated infection
- endocarditis
- renal failure
- severe uncontrolled HTN
- bleeding disorder/anticoagulant use
2
Q
What are 9 possible complications of catheterization?
A
- irregularity arrhythmias
- allergic reaction to contrast
- cardiac tamponade
- MI
- injury to coronary artery
- injury to blood vessel being used for catheterization
- blood clots
- infection of insertion site
- kidney damage
3
Q
What are the 4 main uses for catheterization?
A
- repair heart defects
- open stenotic valve
- open blocked arteries or grafts
- biopsy collection
4
Q
What is the best detection method of finding atherosclerotic disease?
A
coronary angiography
5
Q
What are the 5 main uses for angiography?
A
- locate blockages in pts whose ECG shows NSTEMIs with ischemia and/or heart failure, STEMIs
- r/o stenosis
- define possible treatments
- determine prognosis
- follow up after invasive procedures or medical therapy
6
Q
Which 10 factors make angiography a risky undertaking?
A
- decompensated CHF
- severe HTN
- GI bleed
- CVA
- refractory arrhythmia
- pregnancy
- uncooperative patient
- renal failure
- contrast dye allergy
- active infection
7
Q
What are 6 main complications of angiography?
A
- death
- emergency CABG
- vascular access site complications
- contrast agent nephropathy
- MI
- stroke
8
Q
What is the main purpose of angioplasty?
A
open blocked arteries
9
Q
Which class in the ACC/AHA classification system indicates unanimous agreement for a treatment?
A
Class I
10
Q
Which class in the ACC/AHA classification system indicates treatment is not needed/safe
A
Class III
11
Q
Which class in the ACC/AHA classification system indicates weight of evidence/opinion generally points towards going forward with a treatment?
A
Class IIa
12
Q
Which class in the ACC/AHA classification system indicates less evidence that one should go forward with a treatment?
A
Class IIb
13
Q
Describe the 3 steps and eventual result of the stenting process.
A
- Perform angiogram to map out the arteries
- Dr. will inflate balloon to expand the stent until the stent touches the artery wall.
- The balloon and catheter are taken out of the artery, leaving the stent behind in the artery.
- Eventually, the cells will integrate the stent into the artery wall
14
Q
What is the procedure where a drill grinds away a blockage called?
A
rotational atherectomy
15
Q
According to evidence, how much does intracoronary radiation reduce renarrowing?
A
70%
16
Q
How long following angioplasty should a patient avoid hard labour/exercise?
A
4 weeks
17
Q
How long will ASA and/or clopidogrel be taken following angioplasty?
A
Up to a month
18
Q
If you see scalloped dipping in the right atrium, what arrhythmia can you suspect?
A
atrial fibrillation
19
Q
Which view would be best for detecting aortic dissection?
A
Suprasternal view (atop the suprasternal notch)
20
Q
On the echo image, what could an abnormally large right ventricle or a “D”-shaped left ventricle signify?
A
right ventricular strain/hypertrophy
21
Q
Describe the angioplasty procedure.
A
- A needle-tipped catheter with an attached balloon is fed through the femoral artery to the aorta
- The guide wire inside the catheter is pulled out.
- A fluoroscope is injected, which highlights the coronary arteries and identifies blockages.
- The balloon on the catheter is repeatedly pumped and deflated to slowly expand the lumen.
- The catheter and balloon are taken out.
- A pressure bandage is applied to the insertion site to prevent bleeding out.
- The patient lays on their back for some time.
22
Q
What is the basic pathway for coronary circulation?
A
aorta –> coronary arteries –> coronary veins–> great cardiac vein –> coronary sinus
23
Q
What are the 9 major coronary arteries (including the two mains)?
A
RCA-> SaNA, RMA/AMA, PDA/PIvA, AvNA, LCA –> LADA/AIvA, LMA, LCxA
24
Q
Which coronary artery branches off of what’s known as the dominant coronary artery (RCA or LCA)?
A
posterior descending artery
25
Which two insertion points are used to thread a catheter into the coronary circulation?
either the back of the hand or the groin/inner thigh
26
Which 3 vessels can be used in a CABG (1 vein, two arteries)?
vein from the leg, wrist artery, chest wall artery/left titty artery
27
Describe the on-pump CABG procedure.
- jewelry and clothing will be removed
- pt will be asked to pee
- IV will be placed in arm
- catheters will be placed in neck and wrist for blood samples
- pt layed on back
- anesthesiologist will monitor vitals and blood oxygen
- breathing tube will be put inside trachea, with one end of the tube attached to HLM
- urinary catheter will be inserted
Stage 1 - Taking pipes out
- vessel taken from elsewhere in the body (either mammary artery, superficial greater saphenous vein)
- breastbone split open
Stage 2
- HLM connected to heart
Stage 3
- heart will be injected with cold solution to cease its movement
- vessel piece connected to aorta and to portion of affected coronary arteries after the occlusion
- doctor will check to make sure the grafts are good
- chest will be closed again and sewn together
- drainage tubes will be inserted into the tubes
- tube will be inserted into patient's mouth/nose to drain gastric material
- blood in HLM funneled back into heart
- heart will be restarted
- pacemaker may be used temporarily
28
When was off-pump/beating-heart surgery (alternatives to invasive open-heart surgery) invented?
1990s
29
What are 5 benefits to the endoscope method of vein harvesting?
- shorter recovery time
- less visible scarring
- less invasive
- lower risk of infection (since the area isn't actually being opened up)
- less post-op pain
30
What are 4 things that need to be addressed before undergoing a CABG?
- stop smoking ASAP before procedure
- clotting time will be checked
- Dr should know if pt has a pacemaker
- pt must tell HCPs if pregnant
31
What 7 structures can you best see with the PLA view (2 chambers, 2 tracts, 2 myocardial walls, 1 valve)?
- right ventricular outflow tract
- left atrium
- septum
- mitral valve
- left ventricle
- inferoposterior wall
- left ventricular outflow tract
32
When is TEE preferred over TTE?
- in obese patients (extra fat distorts the sonic waves)
- suspected mass (either a thrombus or tumour)
- COPD (extra air distorts the sonic waves)
33
Under what circumstances should a pharmacological stress test be chosen over a traditional stress test?
- left bundle branch block
- pt is using beta-blockers
- if pt just had an MI
- if pt's ventricular heart rhythm is being controlled with a pacemaker
34
Where is the transducer aimed in the parasternal short axis view (PSA)?
left shoulder
35
What 9 structures can you best see with the A4C view (4 chambers, 3 valves, 2 myocardial walls)?
- right atrium
- tricuspid valve
- right ventricle
- septum
- left atrium
- mitral valve
- left ventricle
- apex
- aortic valve
36
Where is the transducer aimed in the parasternal long axis view (PLA)?
right shoulder
37
Where is the transducer aimed in the A4C view?
left shoulder
38
What 7 structures can you best see with the PSA view (2 chambers, 3 valves, 1 artery, 1 tract)?
- right atrium
- tricuspid valve
- right ventricular outflow tract
- pulmonary valve
- pulmonary artery
- left atrium
- aortic valve
39
What are the main four types of data you can get from an echo?
- chamber sizes
- quality of pumping action
- quality of valve function
- volume measurements
40
What can a M-mode echo do?
- find issues with the valves (i.e. timing of valve movements)
- find issues with myocardium's shape and function (i.e. wall thickness, chamber diameter)
41
Which cardiac structure does the short axis run roughly parallel to?
- AV junction
42
What are the 6 reasons that exercise stress tests are generally better than pharmacological stress tests?
- can replicate symptoms more reliably
- can see how well angina is controlled with a medical regimen
- can see how well pt tolerates activity
- can see stress-induced arrhythmias
- can see how the heart responds to exercise
- can see how blood pressure changes with exercise
43
What are the main 4 types of data you can get from an echo?
- chamber sizes
- quality of pumping action
- quality of valve function
- volume measurements
44
Which view do you get first in an echo study?
PLA view
45
Which view gives a bird's eye view (aka from the top looking down) of the heart?
PSA view
46
What 9 structures can you best see in the subcostal 4-chamber (S4C) view (4 chambers, 2 valves, 1 artery, 2 walls)?
- right atrium
- tricuspid valve
- right ventricle
- septum
- left atrium
- mitral valve
- left ventricle
- abdominal aorta
- pericardium
47
Where do you aim the transducer in the S4C view?
left shoulder
48
Where do you aim the transducer in the A2C view?
left side of neck
49
Which transducer positions gives an upside-down view of the heart?
apical (upside-down and straight vertical)
| subcostal (upside-down and diagonal to pt's left)
50
Where do you aim the transducer in suprasternal view?
left jaw (have pt turn head slightly to their left)
51
What structure will you see in the suprasternal view
aortic arch
52
Which transducer approaches gives an upside-down view of the heart?
apical (upside-down and straight vertical)
subcostal (upside-down and diagonal to pt's left)
* Incidentally, both approaches use the 4CAP, thereby with these two approaches, you get to see each chamber, as the 4CAP splits the heart into front and back.
53
Which plane splits the heart into top and bottom?
SAP
54
Which plane splits the heart into left and right?
LAP
55
What are 2 other names used to describe the position of the transducer?
- approach
| - window
56
What does the A5C view add to the echocardiogram?
left ventricular outflow tract
57
What does Doppler add to the 2D?
- assessment of blood flow (direction and speed) means one can see
- where murmurs are coming from
- which phase of the cardiac cycle problems are happening in
- pressure gradients in the heart and great vessels
- how well a CABG is working
58
Which structures are best seen in the continuous wave Doppler imaging mode?
aorta, the CW imaging mode sees the whole range of speed of blood flow
59
What does the A5C view add to the echocardiogram image (as opposed to an A4C view)?
left ventricular outflow tract
60
What are the three main steps of conducting a stress echo?
1. Do a resting echo with 4 images.
2. Do the stress test until patient reaches 85% of MHR.
3. Get another set of echo images within 30s of ending the stress test.
61
In a pharmacological stress test, _ minutes should elapse before switching over from _ to _ at _mg/min.
15, dobutamine, atropine, 0.25
62
What conditions indicate a need for CABG as the first solution to try?
- blockage of the left main artery (aka before bifurcation)
- blockage of the three mains at the same time
- pt has already had multiple stents
63
When is an off-pump/beating-heart surgery an appropriate option?
When the blockage is on the anterior surface of the heart, so that the still-working heart doesn't need to be taken out of the chest.
64
Who is involved in a bypass surgery?
- surgeon
- anesthesiologist
- nurses
- incision team
- heart-lung perfusionist
65
Which medication is given immediately prior to attaching the great vessels to the heart-lung machine?
heparin
66
In a heart transplant, which structure is only partially replaced?
left atrium
67
What order is the new heart sewn on in?
First atria sewn in by the venae cavae, then the pulmonary artery and aorta
68
What are some possible side effects of anti-rejection medications?
- development of cancer
- damage to kidneys, liver, etc
- increased risk of infections
69
Where is the bypass graft connected to in a CABG procedure?
The bypass graft is connected between the aorta and the coronary artery being replaced below the stenosis area.
70
What factors are taken into consideration when deciding if a cardiac rehab outpatient can exercise independently?
1. Presence of cardiac symptoms
2. Willingness to continue exercise without supervision
3. How HR, BP, and heart rhythm responds to exercise
4. How much patient knows of proper exercise principles and what an abnormal symptom would be.
71
Which inotropic agents are used in a pharmacological stress test?
The inotropic medications used in a pharmacological stress test are dobutamine and arbutamine.
72
Which coronary vasodilators are used in a pharmacological stress test?
The coronary vasodilator medications used in a pharmacological stress test are dipyridamole and adenosine.
73
When doing a pharmacological stress test, how often do you increase the infusion rate of dobutamine?
You increase the dobutamine infusion rate every 4min
74
When can you start administering atropine during the pharmacological stress test, and at what rate?
You start infusing atropine at the 15-minute mark, at 0.25 µg/kg/min.
75
Who is not eligible for tilt table testing (6-7 conditions)?
1. Patients who refuse to partake
2. Morbidly obese people
3. People who can't stand for too long d/t pain
4. Pregnant people
5. People who've had an MI/stroke/TIA within the past 6 months
6. People who have a history of severe stenosis anywhere in their vessels.
7. In people who have atrial fibrillation, they may be able to have a tilt table test, but the BP may vary from beat to beat.
76
What are the 6 endpoints for a tilt table test?
1. SBP falls quickly or falls below 80 mmHg (positive test, therefore no need to continue further)
2. HR falls quickly or falls below 50 bpm (positive test, therefore no need to continue further)
3. Heart rate rises above 170 bpm
4. Arrhythmias start developing
5. Patient is feeling uncomfortable
6. Patient hyperventilates enough to have end-tidal CO2 of less than 20 mmHg, and patient can't control it
77
What does "cardio-inhibitory type A"/"cardio-inhibition without asystole" mean?
These are terms used to describe a type of positive result of tilt-table testing. It means that the patient's heart rate fell below 40 bpm for longer than 10s, but there wasn't a ventricular pause longer than 3s.
78
What type of disorder is likely when a tilt table test results in an excessive heart rate increase, followed by syncope?
POTS
79
What are the 8 steps in a heart transplant?
1. Connect patient to cardiopulmonary bypass machine.
2. Tie off the vena cavae.
3. Tie off the aorta.
4. Remove the old heart (specifically, everything but a piece the left atrium containing the pulmonary veins).
5. Trim the donor heart to fit the patient's own left atrium and the patient's own great vessels.
6. Put the donor heart in the cavity left behind.
7. Sew the atria on.
8. Sew the aorta and pulmonary arteries on.
