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Severe aortic stenosis

Risk of mortality over the next year
Likelihood of developing symptoms in the next year
33% at 2 yr, 14% at 1 yr
In aortic stenosis, what is the rate of decrease in valve area per year
0,1 cm2
7 mmHg (mean)
0,3 m/s


What is classification of Ebsteins

A: Little S-P leaflet displacement, Ant leaflet N, small atrialized chamber, RV N
B: Moderate S-P leaflet displacement, Ant leaflet N but chord aN, large atrialized chamber with reduced contractility, reduce size RV
C: Severe S-P displacement, restricted Ant leaflet, large atrialized chamber with low contractility, small and hypocontractile RV
D: Sac, no ant leaflet mobility, infundibular RV


Secondary tricuspid regurg
List 3 pathophysiologic mechanisms and an example for each

Annular dilatation (dilatated CMP)
PHT (left lesion)
Leaflet restriction (ischemia)


What are indications for endocarditis prophalaxis

Prosthetic valve or material for repair
Previous infectious endocarditis
Cyanotic unrepaired or palliated
Repair congenital anomaly 6 months postop
Repair with residual defect close to prosthetic material
Transplanted patient with valvulopathy


What is outcome of FREEDOM

Primary endpoint is composite of death all cause, MI and stroke
26,6% in PCI and 18,7% in CABG


List 3 negative of hco3 in CPR

Metabolic alkalosis
Intracellular acidosis
Large osmotic load


PCI in SYNTAX 5Y (increase, decrease or same) vs CABG

MACCE : inc
Mortality : same
Stroke : same
MI : inc
Repeat revasc : inc
Cardiac mortality : inc
MACCE LM : same in SYNTAX <33, inc SYNTAX >33
MACCE 3VD : same in SYNTAX <22, inc SYNTAX >22


Mechanism and histology of micro re-entry in a fib

Mechanism: shortened atrial refractory period, atrial tissue heterogeneity, electrical remodeling leads to micro reentry.
histology : atrial fibrosis ,decreased muscle mass, inflammation


Class I indication of CABG to improve survival

3VD with or without prox LAD
2VD with prox LAD
Survivor of sudden death with presumed ischemia mediated VT


Ischemic MR: recent literature states certain subgroups benefits with reverse LV remodeling.
List 4 preoperative pedictors that suggest improved remodeling after CABG + IMR repair

LVEDD < 65
LVESD < 51
Systolic sphericity index below 0.72
Wall motion score index score below 1.59


5 predictors for developing symptoms or adverse outcomes in AS

Advance age
CAD risk factors
Peak jet velocity
Excessive LV hypertrophy
Symptoms on exercise testing
Increased natriuretic peptides


Spinal cord protection in thoracoabdominal

Partial or complete bypass
avoidance of hypotension/maintenance of MAP
avoidance of hyperglycemia
partial hypothermia
Reanastomosis of intercostals T7-T12
CSF drain


5 predictors of recurrent MR after ischemic MR repair

Posterior leaflet angle >45
Anterior leaflet angle >25
Tenting area >2,5 cm2
Coaptation distance >10mm
End systolic interpapillary muscle distance >20mm
Systolic shericity index >7


5 year freedom from death, symptoms and surgery in asymptomatic severe MR



Sano shunt vs. modified BT shunt in Norwood operation
When blood flow occurred in coronaries and pulmonary arteries in both shunt.

Sano: coronaries in diastole and PA in systole
BT shunt: coronaries in diastole and PA in both


What are predictors of early SVG

Age <40
Renal insufficiency


What are predictors of RVAD placement after LVAD

Preop vasopressors
Preop ventilation support
Increased bilirubin
Increased creatinine
Increased BUN
Decreased RV stroke work index
Increased CVP/Wedge ratio
Increased CVP


Patient with dilated cardiomyopathy (EF<20%). Has been on “state of the art” meds. Now patient has NYHA class 3-4 failure. List 4 “state of the art” meds patient was on. List 4 non-medical treatment options for this patient.

Beta blocker, ACEI, spironolactone, digoxin or lasix???
CRT, LVAD, transplant, ICD??


Patient with LVEF 60%, with calcified aortic valve, AVA of 0.8 and gradient of 20mmHg. Compared to patient of AVA 0.8 and gradient of 40mmHg

List 2 ways these patients differ demographically
older age
female gender
concomitant presence of systemic arterial hypertension
2 ways they differ hemodynamically
Reduced LV compliance
Reduced stroke volume

A patient with low gradient AS will do ____ better/worse/equivalent with medical therapy. _____Better/worse/equivalent with surgery


What is drug, half life, and time to wait before surgery

Prasugrel: Thienopyridines, P2Y12 ADP inhibitor, 4hr, 7d
Clopidogrel: Thienopyridines, P2Y12 ADP inhibitor, 8hr, 5d
Ticagrelor: Cyclopentyltriazolopyrimidine, P2Y12 ADP inhibitor, 12hr, 5d
Abciximab: Gp IIb/IIIa inhibitor, 30min, 12hr
Tirofiban: Gp IIb/IIIa inhibitor, 2.2hr, 2-4hr
Dabigatran: Direct thrombin inhibitor, 12hr, normal renal fct 2d, abnormal renal fct 4d

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