Cardiac Flashcards

Question

Tell me about causes of RV failure

Answer 1

1. Intrinsic RV failure - Infarction - Cardiomyopathy 2. Increased RV afterload - Pulmonary hypertension (many causes) e.g. left heart disease, intrinsic lung disease - PE (acute vs. chronic) 3. RV volume overload - LV failure - Left-to-right shunt (ASD or VSD)

Answer 2

Peripheral oedema Ascites Raised JVP (should be <4cm height above sternal angle) Tender hepatomegaly Pansystolic tricuspic regurg murmur Loud P2 raised PA pressure 3rd heart sound

Answer 3

Increased RV:LV ratio Loss of crescent shape of RV Flattening of interventricular septum Tricuspid regurgitation

Answer 4

1. Treat underlying cause e.g. PCI for MI, thrombolysis/clot retrieval for PE 2. Reduce PVR - Correct acidosis - PaO2 / PaCO2 optimise - Pulmonary vasodilaters e.g. inhaled nitric, sildenafil, prostacyclin 3. Restore right coronary perfusion pressure - MAP >65 4. Improve contractility - Inotropes 5. Reduce RV pre-load with diuretics 6. Mechanical support - RVAD, ecmo

Answer 5

ANGINA DYSPNOEA ORTHOPNOEA / PND SYNCOPE PALPITATIONS EXERCISE LIMITATION

Answer 6

Canadian Cardiovascular Society Class I = angina with strenuous exercise Class II = angina causing slight limitation (e.g. >1 flight of stairs) Class III = angina causing marked limitation (e.g. 1 flight of stairs) Class IV = angina with ANY physical activity or rest

Answer 7

New York Heart Association classification of functional capacity I = no limitation of activity II = slight limitation in physical activity III = marked limitation in physical activity but comfortable at rest IV = discomfort at rest Combined with American Heart Association AHA objective assessment A = no evidence B = objective evidence of minimal disease C = objective evidence of moderate disease D = objective evidence of severe disease Duke Activity Status Index questionnaire 12 questions related to ability to perform tasks and exercise Relates to METs metabolic equivalent of tasks <4 METS = high risk of adverse outcomes

Answer 8

EuroSCORE Patient related e.g. age, sex, CKD, prev. cardiac sx. , critical pre-op state Cardiac related e.g. unstable angina, LV dsyfunction, pulmonary HTN, recent MI Operation related e.g. emergency sx, thoracic aorta, operation other than isolated CABG Parsonett Patient related Cardiac related Surgery related

Answer 9

Revised Cardiac Risk Index (6 things) - High risk surgery - Pre-op IHD - Pre-op CCF - Pre-op CVA - Pre-op elevated creatinine - Pre-op insulin use

Answer 10

Congenital heart disease refers to a STRUCTURAL abnormality of the heart which is present at brith and has potential functional significance. Excludes by convention cardiomyopathies and congenital arrythmias Spectrum of severity 90% of children with Cong HD survive to adulthood Prevalence is increasing

Answer 11

Adults have often had interventions therefore better classified according to complexity Compare with children who are classified according to structural features

Answer 12

Simple lesions - Repaired e.g. VSF - Unrepaired e.g. small ASD, isolated valve disease May require cardiology follow up Often can have surgery in non-specialist centres

Answer 13

Unrepaired: VSD with associated anomaly e.g. valve disease Moderate to severe pulmonary stenosis Unrepaired ductus arteriosus Repaired Tetralogy of fallot Patients require cardiology follow up, ongoing risk of complications and reduced life expectancy Should be discussed with specialist centres

Answer 14

Adult cyanotic heart disease Single-ventricle pathology Corrected Transposition of Great Arteries (TGA) Eisenmenger's syndrome Double-outlet ventricle High risk of significant complications High risk of perioperative deterioration, surgery performed in specialist centres

Answer 15

Associated non-cardiac disease Psychological factors Arrythmias and potential effect of arrythmias Potential effect of negatively inotropic / vasodilatory effects of anaesthetic agents Potential effect of ventilation strategies Thromboprophylaxis and antibiotic prophylaxis

Answer 16

During pregnancy - Increase in total blood volume, increase in cardiac output, increase HR and peripheral vasodilation During labour - Further increase in blood volume (autotransfusion), increased cardiac output, sympathetic surge

Answer 17

Discussion with specialist centre, likely will need referral Most likely approach for severe congenital cardiac disease will be - Combines spinal-epidural with cautious doses to avoid sudden haemodynamic changes - If high risk of deterioration consider general anaesthesia in cardiac theatres with bypass/ ecmo available If attempting normal labour - Early epidural to mitigate sympathetic response Anticoagulation must be considered

Answer 18

C = CHD (score 1) H = Hypertension (score 1) A = Age >75 (score 2) D = Diabetes (score 1) S = Stroke/TIA (score 2) V = Vascular disease or MI (score 1) A = Age 65-74 (score 1) Sc = Sex category female (score 1) Max score 9 Consider oral anticoagulants Males 1 Females 2

Answer 19

Duke's criteria 2 major 1 major and 3 minor 5 minor Major - 2x seperate BCs taken at different sites - CT/echo evidence of endocarditis e.g. vegetation Minor Risk factor Temp >38 Embolic phenomena e.g. janeway lesions, ischaemic limb Immunological phenomena e.g. roth spots, osler nodes, +ve RF Micro evidence that doesn't meet major criteria e.g. 1x positive sample

Answer 20

Cardiac vs. non-cardiac Cardiac - Valve prosthesis - Bicuspid AV - MV prolapse - Rheumatic heart disease - Indwelling cardiac devices Non-cardiac - Immunocompromised e.g. malignancy, DMARDs, steroids, diabetic - Indwelling lines e.g. dialysis line - IV drug use

Answer 21

Common - these are often culture +ve Streptococci (viridans, bovis) Staphylococcus (aureus + coag -ve staph) Enterococci Less common - HACEK: Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella Fungi: Candida, Aspergillus

Answer 22

Embolic event with large intracardiac vegetations (>10mm) Severe valvular dysfunction with large vegetation (>10mm) Very large vegetations which may obstruct outflow (>15mm) Aortic root abscess

Answer 23

Usually effects Right side of the heart causing 1. Pneumonia and empyema 2. Septic PE Causative organisms: Pseudomonas aeruginosa Staphylococcus aureus Fungal species

Answer 24

In addition to my usual anaesthetic pre-operative assessment I would focus on the following: 1. Aetiology of cardiac failure and date of transplant - Any systemic co-morbidities e.g. vasculopathy with atherosclerosis in ischaemic cardiomyopathy - Congenital abnormalities 2. Functional assessment - Indication of graft function and heart failure 3. Chest pain/angina - Evidence of allograft vasculopathy 4. Presence of pacemaker, when inserted, why 5. Current medication including immunosupressant and heart failure medication 6. Screen for evidence of active infection

Answer 25

Echocardiography - graft function ECG Exercise tolerance Coronary angiography - allograft vasculopathy Endomyocardial biopsy - graft rejection Bloods: Renal dysfunction Liver dysfunction Bone marrow suppression CXR

Answer 26

1. CMV - Re-activation of previous or primary CMV - Can effect LUNGS, GIT, retina - CMV-negative blood to be used in transfusion 2. Toxoplasma - Encephalitis, myocarditis, pneumonitis 3. PJP 4. Legionella 5. Candida albicans 6. HSV

Answer 27

Suture line from donor atria to recipient atria with no autonomic inervation to donor heart Resting HR maintained by donor SA node activity HR 90-100 Normal reflex changes with peritoneal stretching/laryngoscopy/awareness are lost No compensatory tachycardia in response to hypotension - Hypovolaemia poorly tolerated Exercise results in blunted increase in heart rate as entirely dependant on adrenal catecholamine release MI is 'silent' - no pain

Answer 28

Vagolytic drugs useless e.g. atropine/glyco INDIRECTLY acting sympathomimetics e.g. ephedrine have limited effects GTN no reflex tachy Digoxin retains +ve inotropy but no HR effects Sux and neostigmine have no bradycardic effects Autonomic denervation means upregulation of donor receptors Adenosine effects x4 Adrenaline use smaller doses

Answer 29

Peri-operative Senior support, cardiac centre ideally Careful positioning - fragile skin, steroids Monitoring - AAGBI, CO monitoring, CM5 if ischaemia risk Lines - 16G, CVC, art line Trained assistant Resus drugs all drawn up including vasopressor/inotrope infusions External pacemaker device available Steroid replacement with hydrocortisone and consider infusion Prohylactic antibiotics Induction - smooth, titrated, haemodynamically stable with art line placed before Airway oral over nasal (sinusitis risk), careful as gingival hypertrophy bleeding gums Maintanence - volatile low MAC, entropy monitoring Emergence - extubate vs. keep intubated, assess Post op Analgesia/disposition Likely HDU/ITU Lines kept in as brief as possible Caution NSAIDS Input with other teams re: restart immunosuppresants

Answer 30

Pre-eclampsia Eclampsia Premature delivery Gestational diabetes Allograft rejection

Answer 31

Chambers - size, function, wall motion abnormalities, thrombus presence Septum - thickening/thinning, motion abnormalities Valves - structural anatomy, thickening, cusp number, calcification, stenosis/regurg Measurements: - Chamber pressures - Aorta and pulmonary vasculature - Peak velocity across valves - Mean gradients - Ejection fraction

Answer 32

WHO CLASS IV stratification: Pregnancy contraindicated, termination should be discussed - Pulmonary hypertension of any cause - Severe systemic ventricular dysfunction (LVEF <30%, NYHA class III-IV) - Severe symptomatic MS and AS - Marfan's syndrome with aortic root dilation >45mm - Native severe COA

Answer 33

WHO CLASS III stratification: Increased risk of maternal mortality 25-50% Intensive specialist cardiac, obstetric monitoring needed throughout Mechanical valve Fontan circulation Unrepaired cyanotic heart disease Other complex congenital heart diseases Marfan syndrome with aortic room 40-45mm

Answer 34

Stable - Fixed stenosis Unstable - Plaque rupture - ACS Vasospastic - Inducible but vessel normal e.g. cocaine related - SUSTAINED vasospasm can still cause infarction

Answer 35

Non-Modifiable e.g. age, gender Modifiable e.g. smoking, HTN, high chol, T2DM etc

Answer 36

Exercise stress test - Ramped treadmill, stopped when BP dec or inducible ischaemia Dobutamine stress echo CPET Cardiac MRI

Answer 37

Transmitted via sympathetic cardiac branches Return to upper thoracic and lower cervical ganglia Left arm and shoulder synapse here hence 'referred pain'

Answer 38

A dynamic, non-invasive assessment of the cardiovascular system at rest and during exercise which aims to determine functional capacity

Answer 39

Expired gas analysis Pulmonary flow measurements Continuous 12-lead ECG SpO2 NIBP

Answer 40

Peak oxygen consumption (VO2 peak) - Maxium rate of O2 consumption during the test Anaerobic threshold (AT) The point at which O2 demand exceeds delivery producing Lactic acid, buffered by bicarb production, CO2 inc. in lungs Ventilatory efficiency for CO2 - measure of lungs ability to excrete CO2

Answer 41

It is frequently expressed in terms of the metabolic equivalent (MET), with 1 MET defined as an oxygen consumption of 3.5 ml kg−1 min−1 (based on the resting oxygen consumption of a 70 kg, 40-yr-old male).

Answer 42

1. By cause Ischaemic Hypertensive Valvular Myocardial disease Pericardial disease 2. Side of heart Right Left Right + Left (Congestive) 3. By EF HF with reduced EF (<40%) HF with mildly reduced EF (40-50%) HFpEF LVEF >50%

Answer 43

Crepitations on lung auscultation - pulmonary oedema Decreased basal breath sounds - pleural effusion S3 gallop on heart auscultation - Elevated LVEDP

Answer 44

Systemic hypertension causes an increase in cardiac AFTERLOAD In order to compensate and provide an adequate SV against increasing afterload, the myocardium thickens (concentric ventricular hypertrophy) This causes stiffening and impaired filling (diastolic failure) Over time, increases in afterload EXCEED the hearts ability compensate by hypertrophy Perforator arteries have to pass through greater muscle mass leading to impaired O2 supply Increased O2 demand e.g. exercise leads to increased O2 demand This mismatch leads to myocardial ischaemia Over time, SV decreases and LVEDV increases

Answer 45

NYHA class III or IV LVEF <35% Widened QRS or ventricular dyssynchrony on echo Maximal pharmacological therapy

Answer 46

VT Prev. VT/VF arrest Family hx with high risk sudden cardiac death (cong long QT, HOCM)

Answer 47

Overall, 4-6 x higher periop mortality than patients without heart failure Risk greater if acute OR associated with recent MI

Answer 48

In addition to usual anaesthetic pre-op assessment. Hx/Exam/Ix - Further details on heart failure symptoms, stability, cause - Quantify Exer Tol - ?4METS can you climb 2 sets stairs - Periop co-morbidities - Dhx, what taken when Exam - as described Ix - Blood tests, exclude anaemia, renal impairment, LFT derangement, coagulopathy - ECG - CXR - Echo if time Optimise with cardiologist.

Answer 49

Generally should be offered local or regional techniques for peripheral surgery monitoring - art +-cvc, IDC Guiding principles are 1. Maintaining CO 2. Ensuring balance between O2 supply and demand 1. Maintaining CO - Preload: minimise preop fasting period, maintain SR - Afterload: avoid excessive afterload, poorly tolerated - Contractility - be v. wary of cardiac depressant drugs in anaesthesia, use pressors 2. O2 supply/demand balance - Avoid tacyhycardia, pain, shivering - O2 targets - Hb

Answer 50

Analgesia - to prevent excessive O2 demand/supply issues HDU/ICU Careful fluid balance Reintroduction of meds Cardio input O2

Answer 51

2014 ACC/AHA guidelines

Answer 52

E, A, R, L, M, C Emergency --> proceed Active cardiac cond ---> refer Risk ---> use risk calculator If LOW 0-1 risk ---> proceed If >4 METS ---> proceed Will testing change mx Yes --> Cardiac testing No ---> Continue surgery

Answer 53

Autosomal dominant condition affected the fibrillin 1 gene on chromosome 15 Connective tissue disorder causing multi-system features

Answer 54

Respiratory - Emphysema - Spont pneumothorax CVS - Aortic pathology - dilatation, dissection, regurgitation - Mitral valve P - Tricuspic valve P Skeletal - Tall stature - Arachnodactyly (long fingers) - Scoliosis - Pectus excavatum - High arched palate - Hypermobility Ocular - Lens dislocation - Retinal detachment

Answer 55

Capillary pulsation in nail beds - quinke's Water hammer radial pulse Widened pulse pressure Laterally displaced apex Short rumbling diastolic murmur heard loudest 2nd intercostal space right sternal edge Lung creps

Answer 56

Regurgitant fraction % of SV returning to LV from aorta Mild = <30% Mild-Mod 30-39% Mod-Sev 40-49% Severe AR >50%

Answer 57

Arrythmias Bleeding Tamponade Pulmonary HTN

Answer 58

Airway - May be difficult - high arched palate, prognathism Resp - Risk of spont ptx, avoid high peak pressures CVS - Avoid precipitous inc. SVR if aortic root dilatation or AR - Usual haemodynamic principles for AR - Opioids, beta blockers Positioning - Joint hypermobility - High risk for ocular injury

Answer 59

Umbrella term for a group of connective tissue diseases characterised by synthesis or modification abnormalities of collagen Features - Skin hyperextensibility - Joint hypermobility - Poor wound healing - Resistance to local anaesthetic - Aortic dissection/regurg - Bleeding tendancy

Answer 60

Airway - TMJ dislocations, atlantoaxial instability - Avoid rpt laryngoscopy - High cuff pressures causing tracheal injury Circulation - Avoid HTN --> aortic dissection Haematological - TXA, cell salvage, ddavp - Use rotem Local anaesthetics - More resistance in type III EDS Neuraxial blockade - Anatomical difficulties, haematoma

Answer 61

It potentiates the effects of antithrombin III ATIII protease inhibitor irreversibly binds thrombin and factor Xa

Answer 62

May occur in 20% patients undergoing CPB Congenital - Autosomal dominant ATIII deficiency Acquired - Reduced synthesis e.g. warfarin or liver failure - Inc clearance e.g. nephrotic sx - DIC = consumption Treatment = FFP, recombinant ATIII

Answer 63

Ensure haemodynamic stability MAP >70 using fluids /pressors /inotropes Pacing wires if sig. bradycardia occurs Maintain communication with surgical team throughout Maintain temperature May require conversion to bypass

Answer 64

Variety of procedures that avoid midline sternotomy Examples - Mini sternotomy e.g. avr - VATS - thoracoscopic or mini thoracotomy CPB may still be required , can be peripheral or endoclamp cross clamp

Answer 65

Reduced postop pain Shorter stay and recovery Improved cosmetic appearance

Answer 66

Difficult Increased risk of stroke with peripheral CPB Risks of DLT Sternotomy conversion Cerebral hypoperfusion External vs. internal paddles Migration if using endoballoon so need 2 art lines Not suitable for all surgeries

Answer 67

Near infrared spectroscopy Method for detecting cerebral tissue oxygenation Predominantly used in cardiac surgery and during carotid endarterectomy

Answer 68

Adhesive sensors applied to forehead Sensory emit light at 2 wavelengths 760 and 850nm Light penetrates scalp and skull Absorption spectra for oxyhaemoglobin and deoxyhaemoglobin are different, properties determined by reflected light Physical principles underpinned by beer and lambert laws

Cardiac Flashcards

(93 cards)