cardiology surgery incorrects

Question 1

patient with a heart attack undergoes cardiac catheterization. sudden onset hypotension, tahcycardia, flat neck veins and back pain

diagnosis?

1st line investigation?

management?

Answer 1

retroperitoneal hematoma

CT scan of abdomen and pelvis with contrast!!!!

bed rest, monitoring, IV fluids

Question 2

in ACUTE mitral regurgitation, what is the atrial size? LV size? left ventricular ejection fraction?

Answer 2

left atrial and lv are normal as there is no time for dilation. as result the pressure transmitted to lungs causing pulmonary edema -> crackles.
lv ejection fraction is normal or increased

Question 3

pregnant woman experiencing palpitations. midsysolic murmur at upper left sternal border. echo shows a dilated right ventricle

most likely cause?

Answer 3

atrial septal defect - left to right shunting via atriums cause RIGHT sided volume overload. (risk of right sided heart failure.
(as atriums on top and ventricles below). atrial stretching -> a fib.
echo shoes dilated atrium and ventricle

NOT a VSD or PDA as these are distal to atrioventricular valves. left to right shunt as well, but it just means that more blood is pumped from right ventricle to lungs -> LEFT SIDED volume overload

Question 4

patient was undergoing a laparascopic cholecystectomy and immediately the needle was placed in the peritoneal space, patient developed severe bradycardia, and AV block.

most likely cause?

Answer 4

peritoneal stretching!!!

laparascopic surgery requires insufflation of CO2 in to abdomen. intraabdominal pressure -> stretch receptors on abdomen -> increase in vagal tone -> bradycardia, av block, sometimes asystole

Question 5

patient after a fall, CXR shows widened mediastinum. severe chest pain. most likely diagnosis?

other findings in this situation?

what investigation confirms the diagnosis??

Answer 5

blunt aortic injury

pseudocoarctation - upper extremity HTN and lower extremity hypotension

hoarse voice - left recurrent laryngeal nerve compression

CT angiography!!

Question 6

patient just had heart surgery.

clicking when he bends over, on palpation of sternum, there is rocking and clicking.

most likely diagnosis?

management?

Answer 6

sternal dehiscence

may also be diagnosed via displaced sternal wire on radiography.

Question 7

abdominal pain, fever and leukocytosis shortly after abdominal aortic aneurysm repair. most likely diagnosis?

Question 8

3 months of fatigue, low grade fevers and palpitations. now has acute left sided weakness.

brain imaging reveals multiple small, acute infarcts.

echo shows a mass in left atrium.

most likely diagnosis?

Answer 8

intracardiac tumour!! - aka myxoma!!

embolization of tumour fragments -> stroke, acute limb ischemia

valve obstruction -> murmur, dyspnea, syncope

constitutional symptoms - fever, weight loss

not infective endocarditis - as echo would show valvular vegetations not a mass

not rhuematic heart disease as mitral stenosis develops yearss after intial event

Question 9

multiple embolic strokes due to endocarditis investigations?

Answer 9

investigation for malignancy -> CT scan of chest and abdomen, colonoscopy

hypercoagulability work-up

Question 10

patient with chronic back pain, intermittent bilateral heel pain. impaired spinal mobility and limited chest expansion

exertional shortness of breath and apical impulse diplaced to left

most likely diagnosis?

Answer 10

aortic regurgitation!!!

complication of ankylosing spondylitis!!!!

Question 11

Revised cardiac risk index
for cardio surgery.
learn it, especially when no further testing is needed

Question 12

following cardiothoracic surgery. signs of infection of the sternum. Condition is called?

diagnosis and management?

Answer 12

acute postoperative mediastinitis

chest and sternal imaging!!!

INTRAVENOUS antibiotics and surgical debridement

Question 13

expected hemodynamic alterations in mitral stenosis -> elevated pulmonary artery pressures and normal LV pressure

Question 14

surgery is indicated in patients with severe MR both symptomatic and ASYMPTOMATIC if LVEF is </= ?

Answer 14

60%

Question 15

how does a left ventricular aneurysm present months after a myocardial infarction?

ECG findings?

echo findings

Answer 15

HEART failure!!!! most common -> raised jvp, bibasilar crackles.. heart failure because the aneurysm has distorted the ventricle wall and reduced the ejection fraction

less commonly- ventricular arrhythmia, systemic embolization, chest pain

ECG - persistent ST elevation and deep Q waves!!!!

echo = thin and diskinetic ventricular wall

Question 16

patient with a mechanical heart valve undergoing routine colonoscopy?

what antibiotic prophylaxis is needed?

Answer 16

none!!!!

as this is a GI/GU procedure not taking place in setting of active infection

also dont need for c sections/vaginal deliveries

you need for gingival work, respiratory mucosa incision etc.

Question 17

first step in management of acute limb ischemia?

Answer 17

IV heparin

later = CT angiography

Question 18

Prosthetic valve dysfunction (murmur over a mechanical heart valve) -> prompt evaluation with echo.

Question 19

damage to tricupsid valve during pacemaker insertion can cause T regurgitation -> right sided HF

Question 20

acute limb ischemia in the setting of pre existing PAD = due to atherosclerotic plaque disruption

sudden onset acute limb ishcemia = an embolism

Question 21

in addition to rate control/rhythm control. what is important in management of atrial flutter/atrial fibrillation?

Answer 21

anticoagulation

Question 22

Cardiac tamponade is a complication of heart surgery eg CABG

Signs

First step in management?

Answer 22

Hypotension
Signs of shock eg reduced urine output
Elevated heart pressure eg in right atrium , right ventricle

ECHO!!

Question 23

Learn the complications of aortic dissection. In a patient with hypotension and fluid In pleural space, most likely complication?

Answer 23

Hemothorax

Question 24

Post cardiac surgery pleural effusions managed conservatively if?

Answer 24

Early onset 1-2 days post surgery
Small and not enlarging
No resp symptoms

Question 25

abdominal pain, fever and leukocytosis shortly after abdominal aortic aneurysm repair. most likely diagnosis?

Question 26

And ABPI of what is diagnostic of PAD?

Answer 26

<0.9

Question 27

Patient with 2 weeks of worsening dyspnea. Enlarged heart/ cardiac silhouette on CXR. Clear lung fields. History of lung necancer. Most likely diagnosis? Best next step in management? Treatment ?

Answer 27

Malignant pericardial effusion Echo Pericardiocentesis

Question 28

What happens to cardiac index in cardiac tamponade?

Answer 28

Decreases as restricted filling of heart chambers Cardiac index is cardiac output per body surface area SVR increases

Question 29

To gain informed consent you must discuss risks of not undergoing procedure

Question 30

Blunt chest trauma if stable you do what ix first?

Answer 30

CXR and ECG If abnormal move to ct chest

Question 31

MI complications and how they present 1. Papillary muscle rupture? 2. Left ventricular free wall rupture? 3. Iterventricukar septum rupture? 4. Left ventricular aneurysm

Answer 31

1. MR 2. Pericardial effusion with tamponade -> shock and cardiac arrest 3. Left to right ventricular shunt and murmur 4. Heart failure, arrhythmia, thin dyskinetic heart wall

Question 32

How does post cardiac injury syndrome present Causes? Mechanism? Treatment?

Answer 32

Acute pericarditis plus fever leukocytosis, pericardial effusion MI = dressers Cardiac injury or surgery PCI Immune mediated inflammation NSAIDs and colchicine

Question 33

Woman with mitral stenosis want to become pregnant. Management?

Answer 33

Surgery before pregnancy

Question 34

Complications of cardiac catheterisation Via femoral artery? How do they present

Answer 34

AVF = continuous murmur, palpable thrill. Swelling tenderness - can cause lim edema , limb ischemia, high output heart failure Pseudoaneurysm = pulsatile mass and systolic mass rather than continuous Femoral artery dissection = acute lower extremity ischemia = pain and pallor Peripheral nerve = injury = paresthesia Hematoma = mass, expands to retroperitoneum = flank pain and hypotension

Question 35

Persistent tachycardia and arrhythmia eg premature ventricular contractions are concerning for? Further management?

Answer 35

Blunt cardiac injury Echo

Question 36

Long term management of malignant pleural effusion following pericardiocentesis?

Answer 36

Pericardial window!! Or prolonged catheter drainage

Question 37

In a patient with HOCM undergoing surgery, most important thing to ensure?

Answer 37

Adequate intravenous hydration

Question 38

Mechanism that results in tricuspid valve regurgitation?

Answer 38

Dilatation of the tricuspid valve annulus

Question 39

Pancreatic surgery receives red blood cells. Now low bp, high hr, hig(resp rate, bibasal crackles. Low spo2. Low cardiac index and raises PCWP. Most likely diagnosis?

Answer 39

MI! Perioperative MI that has caused shock. Risk factors = intraoperative haemorrhage requiring blood transfusion Classic chest pain not typically present. Impaired cardiac contractility causes low CI and high PCWP Not trali as LVF won’t be impaired thus CI and PCWP normal

Question 40

Indications for surgery in infective endocarditis?

Answer 40

Acute HF = aortic or mitral valve regurgitation Extension of infection = abscess, fistula, heart block. Difficult to eradicate organism = fungus, Mdr pathogen Persistent bacteremia on antibiotics Large vegetation, persistent septic emboli

Question 41

74 YO man, persistent back pain. Smoking history. Pain from epigastric to supraumbilicus region. X ray normal except prevertebral calcifications. Next step in evaluation?

Answer 41

Ct abdomen! Signs of AAA Abdominal flank or groin pain depending on lesion site , flank echymosis, limb ischemia If hemodynamically unstable = USS if diagnostic uncertain

Question 42

Erectile dysfunction, pain in hip, gluteal and thigh muscles. Next step in management?

Answer 42

ABPI Leriche syndrome - blood flow through iliac arteries limited. Diminished femoral pulses may also occur

Question 43

Fevers, chills, leukocytosis, moderate chest pain and moderate pericardial effusion. Arrthymias eg atrial fibrillation and tachycardia, after antibiotics next step in management?

Answer 43

Pericardiocentesis This is purulent pericarditis Urgent pericardiocentesis needed not echo. So u can confirm and treat Risk factors = chronic hemodyalisis, cardiothoracic surgery,

Question 44

Short stature, amen Orr he’s = turners = aortic dissection risk

Question 45

indication for aortic valve replacement?

Answer 45

aortic velocity of 4 m/s, Or transvalvular a mean pressure gradien of ≥40 mmHg, Usually aortic valve area (AVA) of ≤1 cm2 but not required So the above = severe AS Plus one of symptoms, LVEF <50%, undergoing other cardiac surgery eg CABG

Question 46

Man with aortic stenosis, no symptoms but transvalvular gradient consistent with severe AS. Ejection fraction is 45%. Next step in management?

Answer 46

Surgical replacement

Question 47

Both ASD and pulmonary stenosis has splitting of S2, but in pulmonary stenosis, the splitting varies with respiratory cycle Also PS is an ejection click then crescendo decree endo systolic murmur ASD is a mid systolic murmur