Cardiovascular

Question 1

AAA ruptured Mx

Answer 1

1. Standard resus measures
2. urgent surgical repair (EVAR), or open if anatomy unsuitable

with perioperative Abx (braod spec to cover G+ and G- e.g. doxycycline, azithromycin)

Question 2

AAA symptomatic not ruptured Mx

Answer 2

Repair indicated regardless of diameter (EVAR)
With pre-op CV risk reduction (low dose aspirin continued during peri-op period) and ongoing hypertensive management.
Plus periop Abx (doxy/azithromycin)

Question 3

AAA asymptomatic large diameter specifications

Answer 3

(>5.5cm, OR >4cm and increased by >1cm in 12m)

Question 4

AAA asymptomatic large diameter Mx

Answer 4

1. Elective repair confers survival advantage. Open and EVAR are equal in survival advantage but EVAR has more secondary interventions. Fenestrated EVAR is an option for patients with juxtarenal/suprarenal AAA or those with short infrarenal aortic neck.
   
   2. Address modifiable RF, low dose aspirin continued in peri-op period, HTN control. Statin at least 1m before surgery and cont. indefinitely. Consider beta-blockade 1 month pre-op in pts w/IHD or MI
      Peri-op Abx (doxy/azithromycin)

Question 5

AAA asymptomatic small

Answer 5

1. Surveillance: annually if 3-4.4cm, 3mo if 4.5-5.4cm
   
   2. Lifestyle mod. (smoking offer medication, exercise programmes)
   3. Low dose aspirin continued during peri-op. HTN control. Statin

Question 6

Cx of AAA repair

Answer 6

MI
Arrythmia
Bleeding
Injury to bowel 
DVT
Graft infection
DEATH!

Question 7

Cx of non-surgically Mx AAA

Answer 7

Rupture!
Increase in size
Peripheral arterial disease

Question 8

Prognosis of AAA

Answer 8

Ruptured: NO treatment = 100% mortality, 50% with open surgery
Unruptured: rate increases with size, <5% annually if <5cm. Elective surgery confers survival advantage but mortality still slightly higher than general pop and at risk of CVD.

Question 9

EVAR types

Answer 9

1. Percutaneous (standard): stent inserted through femoral arteries under x-ray guidance. Stent extends from above AAA into common iliac arteries.
   
   2. Fenestrated: Used when juxtarenal repair needed, fenestrations in graft allow renal blood supply.
      TEVAR: stent inserted into thoracic aneurysm

Question 10

Open repair of AAA

Answer 10

Laparotomy approach, involves dissecting through to visualise aorta, clamping above and below AAA. Before opening the AAA and inserting a stent graft into lumen extending to just above iliac bifurcation.

Question 11

AAA repair indications

Answer 11

1. Rupture
2. Symptomatic
3. > 5.5cm
4. > 4cm and >1cm increase in last 12m

Question 12

Aortic dissection management (acute)

Answer 12

Acute: Hb unstable suspected dissection
1. ALS with H/d support: (including fluids and oxygen)
Noradrenaline 0.5-1 microgram/min IV initially and titrate up usual dose 2-12mcg/min max of 30mcg/min AND/OR
dobutamine 0.5-1mcg/kg adjust up usual dose 2-20mcg/kg max 40 mcg/kg

Question 13

aortic dissection management (confirmed A, or B with complications)

Answer 13

Open surgery or endovascular stent-graft repair

- Type A: open removal and replacement of ascending aorta with tube graft +/- repair/replacement of aortic valve depending on retrograde extension
- Complicated type B: resect/cover tear and restablish blood flow. Endovascular repair is becoming preferred option if presenting with fewer Cx

Question 14

Complicated type B aortic dissection features

Answer 14

rupture, visceral/limb ischaemia, expansion, persistent pain

Question 15

type B aortic dissection Management (uncomplicated)

Answer 15

• Endovascular stent graft repair: usually Mx medically with BP and pain control during acure phase (less than 14d).
  However growing evidence that early intervention improves survival:
  TEVAR to promote false lumen thrombosis and prevent aneuyrsmal degeneration is an option for management

Question 16

Type B chronic aortic dissection management

Answer 16

• Use of TEVAR becoming more common but can also be Mx medicaclly with BP control (long term) and pain relief

Question 17

after d/c management of aortic dissection

Answer 17

• Antihypertensives:
  ○ Metoprolol 25-100mg PO modified release OD AND/OR enalapril 5-40mg OD PO
  Can add CCB, diuretic if nec.

Question 18

Complications of aortic dissection

Answer 18

• Visceral ischaemia: ALS and repair of dissection
  
  • Stroke (ischaemic)
  • Renal failure/AKI: surgery +/- dialysis
  • Acute aortic regurgitation
  • Hypovolaemic shock: ALS, vasopressors, blood transfusion
  • Retrograde type A after type B repair (reduced with TEVAR)
  • Lower limb ischaemia after surgery

Question 19

Prognosis of aortic dissection

Answer 19

Type A: without treatment is almost always fatal. 50% die before reaching specialist centre. Patients treated with surgery have a high survival rate (90%). 60% 5year survival
B: 5 year survival 50-80% . 30% chance of forming aneuyrsm.

Question 20

Aortic regurgitation severity

Answer 20

Determined by valvular anatomy (calcification, biscupid, rheumatic changes). Valve haemodynamics (jet width, flow reversal). Haemodynamic consequences (EF, and LV ESD/EDD). Symptoms (only present in severe - exertional dyspnoea or angina or HF sx)

Question 21

AR management acute

Answer 21

Inotropes (dopamine 2-5mcg/kg/min titrate to max of 20) AND
Vasodilator (nitroprusside 0.3-0.5mcg/kg/min titrate to max of 10mcg/kg/min) AND
Aortic valve replacement

Usually reserved for severe cases (presssure halftime of <200ms) or with severe symptoms (chest pain, SOB, palpitation)
Prosthetic valve replacement pts need anti-coag

Question 22

AR management Chronic mild-mod

Answer 22

1. Asymptomatic with normal LV function: (>50%)
   DO NOT require treatment can be reassured
   2. Symtomatic or LV dysfunction:
      Investigate cause e.g. htn, CAD or cardiomyopathy

Question 23

AR Mx severe asymptomatic w/EF>50%

Answer 23

a. Compensated Dx: reassurance (provided no LV dilation)
b. Transitional Dx (LV 60-70mm EDD or 45-50mm ESD) - perform exercise test
i. Negative: reassure
ii. Positive (based on haemodynamic response): nifedipine 30-60mg OD
c. Decompensated: (LV EDD>70mm or ESD >50mm) - surgery
i. Mechanical or biological valve. If high risk consider TAVI (off label) (replacement patients will need anticoagulation)
Non-surgical candidate: Nifedipine 30-60md OD (or hydralazine 10-25mg 2-4/day) or enalapril 5-20mg BD

Question 24

AR Mx asymptomatic w Ef<50%

Answer 24

a. Mechanical or biological valve replacement with ongoing anticoagulation. (TAVI off label if high risk)
b. Non-surgical candidate: nifedipine 30-60mg OD (or hydralazine 10-25mg 2-4/day) or enalapril 5-20mg BD

Question 25

AR Mx severe symptomatic

Answer 25

1. Surgery: indicated regardless of LV function or dilation a. Mechanical or biological valve. TAVI if high risk pt. While awaiting surgery consider nifedipine 30-60mg OD or hydralazine 10-25mg 2-4/day 2. Non-surgical: nifedipine 30-60mg OD or hydralazine 10-25mg 2-4/day

Question 26

AR Cx

Answer 26

Thrombus -> stroke: anticoagulation (especially after valve replacement) Infective endocarditis: monitor for signs and treat with (vancomycin and aminoglycoside PLUS rifampicin if prosthetic valve!) Anticoag related bleeding; monitoring of INR Heart failure: managed with optimal AR therapy

Question 27

AR prognosis

Answer 27

Acute: operative risk higher than in chronic because usually involves v severe disease or Cx such as IE or dissecting aneuyrsm Chronic: prognosis good. LV dysunction likely reversible if detected early If patients enter heart failure prognosis is much poorer (Class III HF without surgery has 30% 4 year survival)

Question 28

AS Mx clinically unstable

Answer 28

1. Medical therapy (vasodilator eg nifedipine +/- beta blocker stopped on day of surgery) or balloon valvuloplasty to stabilise prior to surgery or TAVR

Question 29

AS Mx clinically stable symptomatic risk calculation

Answer 29

STS-PROM (mortality risk calculator) used alongside clinical picture to determine risk. Older patients wirh low-flow low-gradient AS most at risk

Question 30

AS Mx clinically stable low risk

Answer 30

1. Surgical aortic valve replacement a. PLUS long term IE prophylaxis before dental procedures PLUS long term anticoag. w/vitamin K antagonist in prosthetic valve. NOT required in bioprosthetic valve unless there is AF. 2. TAVR (preferred in less fit patients) awaiting long term data on durability, mortality a. PLUS long term IE prophylaxis before dental procedure PLUS long term anticoag. w/vit K antag. If prosthetic vlave (NOT bioprosthetic unless AF

Question 31

AS Mx clinically stable intermediate risk

Answer 31

1. Surgical aortic valve replacement a. PLUS long term IE prophylaxis before dental procedures b. PLUS long term anticoag. w/vitamin K antagonist in prosthetic valve. NOT required in bioprosthetic valve unless there is AF. 2. TAVR (preferred in less fit patients) a. PLUS long term IE prophylaxis before dental procedure PLUS long term anticoag. w/vit K antag. If prosthetic vlave (NOT bioprosthetic unless AF

Question 32

AS Mx clinically stable high risk

Answer 32

1. REFERRAL for AV replacement (will offer sig. survival benefit so important to consider). Dobutamine stress test will show ability to improve EF and SV - will do better than patients without contractile reserve. a. PLUS long term IE prophylaxis before dental procedures b. PLUS long term anticoag. w/vitamin K antagonist in prosthetic valve. NOT required in bioprosthetic valve unless there is AF. 1. TAVR a. PLUS long term IE prophylaxis before dental procedure PLUS long term anticoag. w/vit K antag. If prosthetic vlave (NOT bioprosthetic unless AF

Question 33

AS non surgical candidate

Answer 33

1. TAVR a. PLUS long term IE prophylaxis before dental procedure b. PLUS long term anticoag. w/vit K antag. If prosthetic vlave (NOT bioprosthetic unless AF 2. Medical therapy (patients with terminal illness or siginificant co-morbidity who may not benefit from from replacement) a. Target comorbs. CAD, lipids, htn, HF i. Vasodilators (nifedipine), ACEi, diuretics - but beware risk of syncope and hypotension Balloon valvuloplasty (reasonable palliative option for highly symptomatic)

Question 34

AS clinically stable Asymptomatic

Answer 34

Severe: (based on pressure gradient, flow status (and its reversibility) 1. Clinical and echo follow up or referral to surgery a. Surgery indicated if: LVEF <50%, undergoing another cardiac surgery e.g. CABG or other valvular. b. If not surgery repeat echo 6-12mly and r/v clincally Non-severe: Clinical FU and echo (every 3-5yrs, 1-2 if mod. stenosis)

Question 35

AS Cx

Answer 35

``` Sudden death - valve surgery HF: resultng from LVH and resultant diastolic dysfunction pHTN leading to SOB and eventual RHF Infective endocarditis Stroke from calcific emboli - anticoag Hypotension and syncope ```

Question 36

AS prognosis

Answer 36

Older patients with raised CV RFs are a/w more rapid haemodynamic regression Doppler aortic jet velocity is best marker of progression Prognosis excellent with replacement Without AVR median survival is 1-3 years after Sx onset

Question 37

Arterial Ulcer management

Answer 37

Any patient with critical limb ischaemia (ie ulcers) should receive urgent vascular review. Conservative: Lifestyle (smoking, weight loss, exercise, diabetes control) Medical: Statin (simvastatin 40mg), antiplatelet (aspirin 75mg, clopi) and optimisation of BP and glucose. Analgesia for ischaemic pain Surgical: angioplasty (+/- stenting) or bypass grafting for more severe disease. Any non healing ulcer despite good blood supply may be offered skin reconstruction with graft

Question 38

Arterial ulcer Cx

Answer 38

Infection: flucloxacillin 0.5-1g QDS PO or 1-2g IV every 6hrs Can become cellulitus/erysipelas issue necrosis if untreated - will require IV and ?amputation Worsening of ulcer: Management as listed +/- amputation

Question 39

Arterial ulcer prognosis

Answer 39

Left untreated can expect serious complications, and eventually amputation is likely Treatment will improve blood flow to the area meaning that further worsening becomes less severe. Outlook depends on patients ability to modify CV RFs and effectiveness of meds and surgery Patients with arterial ulcers indicate severe arterial disease and are therefore a/w higher mortality than general population. And signficant morbidity a/w impact of ulcer.