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What are features of total anomlaous venous return

ASD must be present
The shunt is right to left
pulmonary venous obstruction is common.

PGE1 cannot be used to treat cyanosis


What are side effects of cylcosporine

elevated creatinine
elevated potassium


The best treatment for hyperhirosis



During CPB with hypothermia what happens to pH

Goes up


The full hammersmith dose of aprotinin is

240 mg


With a perimembranous VSD, the conduction system lies

posterior and inferior


The PDA is derived from

distal left 6th aortic arch


Nitric oxide does the following

causes vasodilation
inhibits PMNs
Inhibits smooth muscle proliferation
inhibits platelet aggregation


Stone heart is defined by

tetanic contraction after reperfusion


What is the action of reopro?

monoclonal antibody to the platelet receptor


What can result from untreated VSD?

Infundibular stenosis
*Not cyanosis*


List complications of untreated ASD

Paradoxical embolism
pulmonary vascular disease

*endocarditis* is not a feature of untreated ASD


All of the following are complications after fontane circulation

Pleural effusions
protein losing enteropathy


ECMO has the best results in

Meconium aspiration


List features of Shone complex

Parachute mitral valve
Subaortic stenosis
Supravalvular mitral membrane


All of the following are complications of Glenn shunt

SVC syndrome
AV fistula from right lower lobe
phrenic nerve damage


What are features of ARDS

Increase in A-a gradient
there is an increase in shunt fraction
the FRC is decreased


The best technique to diagnose post transplant coronary artery disease is



The aortic arch is derived from

4th arch


The nerve root most likely to be damaged during ductus is

Recurrent nerve


You have opened the chest of an infant and see a very large azygous vein. You think

Interrupted inferior vena cava


Most common vascular ring

Double aortic arch


Pulmonary vascular resistance is increased in

alph adrenergis


Propanolol decreases tet spells by

decreasing infundibular muscle tone


The Rastelli classification deals with

Anatomical description of complete AV canal defects


What are principles of cardioplegia arrest

Rapid diastolic arrest is achieved most effectively with potassium by blocking the inward sodium current, thereby preventing the initial phase of cellular depolarization.

By causing diastolic arrest, potassium preserves ATP and creatine phosphate stores for postischemic work.


What is purpose of glucose in cardioplegia

Substrate (i.e., glucose) should be provided to support anaerobic or aerobic energy production during aortic cross-clamping. However, the energy available is far greater if the cardioplegia solution contains oxygen (i.e., blood).


What are buffers in cardioplegia solution

buffer additives (sodium bicarbonate, tris-[hydroxymethyl]-aminoethane

Membrane stabilization with calcium supplementation or other additives is important.

Osmolarity and colloid osmotic pressure must be maintained to avoid producing myocardial edema iatrogenically during cardioplegia infusion


3 ways to determine coronary sinus cath is in correct place

1) observation of dark (deoxygenated) blood return following insertion (myocardial oxygen consumption is generally higher than peripheral oxygen consumption);
2) palpation of the tip at the base of the left atrial appendage; and
3) pressure monitoring during infusion.


What are physical signs of tricuspid disease

Tricuspid regurgitation features a high-pitched, blowing, holosystolic murmur.

Tricuspid stenosis a low-pitched, rumbling diastolic murmur with a presystolic crescendo if the patient is in normal sinus rhythm.

each is best heard at the lower sternal border and each increases in intensity during inspiration due to augmented right ventricular filling


What are different symptoms between TR and TS

Both are the consequence of systolic venous congestion, including ascites, peripheral edema, hepatomegaly, pulsations of the liver, and positive hepatojugular reflux (enhanced jugular venous pulse with liver compression).

Gross jaundice and cirrhosis do not generally occur with tricuspid regurgitation


What are rates of tricuspid valve thrombosis

thrombosis rate of mechanical valves in the tricuspid position is lowest with bileaflet valves.

thrombosis of a mechanical prosthesis in the tricuspid position may be insidious.

therapy is the initial treatment of choice but it may not be successful in all cases due to the chronicity of the process.

Calcification of bioprosthetic valves is less common in the tricuspid position than in the aortic or mitral position.


What are indications for functional tricuspid surgery

1) significant pulmonary hypertension, especially if it is long-standing or minimally reversible; 2) long-standing right ventricular dilation, especially with tricuspid annular enlargement;
3) tricuspid regurgitation that has been clinically significant and constant with persistent evidence of right heart failure.


What at features of hemolysis post valve repair

Unconjugated or indirect bilirubin is a reliable guide to the presence of increased heme catabolism and is elevated in patients with hemolysis.
The serum level of conjugated or direct bilirubin is normal unless the patient has associated hepatic or biliary dysfunction.
Jaundice is apparent if the serum bilirubin level is higher than 2mg/dL, but with hemolysis, unconjugated bilirubin never exceeds 5.0mg/dL.
Haptoglobin, which binds to hemoglobin, is low with intravascular hemolysis
Lactic dehydrogenase is often markedly elevated with hemolysis.


What is natural history of mitral valve replacment

durability of porcine valves is less in the mitral position than in the aortic position.

related to differences in the pressures the cusps are subjected to during the cardiac cycle.

aortic position, the diastolic pressure is the maximal closure pressure applied. In the mitral position, the higher left ventricular systolic pressure is applied at closure. Other shear and turbulent forces act upon the closed, high-profile bioprosthesis as blood is ejected through the left ventricular outflow tract in a tangential direction.


What influences durability of mitral valve replacment

directly proportional to the patient's age. Structural valve deterioration is extraordinarily rapid in children and young adults under age 40. In these cases, mechanical prostheses are better suited to avoid early reoperation. In patients with hypercalcemia related to hyperparathyroidism or chronic renal failure, the durability of bioprostheses is further shortened, and they generally are not recommended. Improved anti-calcification treatments applied to new generations of bioprostheses may change this.


What are rates of SVD for mitral valve

35 year old undergo bioprosthetic mitral valve replacement, the risk of required reoperation for structural valve deterioration is 50% at 10 years.

adult patient younger than 30 years this is approximately 75% at ten years


What at rates of valve related complications

incidence of thromboemboli whose anticoagulation is well managed is similar to patients with bioprosthetic valves without anticoagulation, which is 1.5-2% per patient-year.
The incidence of anticoagulant-related hemorrhage is related to patient age and to anticoagulation control.

INR maintenance between 2.5-3.5 this complication has an incidence of 1-2% per patient-year. In elderly patients (>70), the risk of bleeding approaches 10% per patient per year


Why place co2 in the surgical field

Nitrogen is the main component of ambient air (80%). Of the three components of interest (also oxygen and CO�) it is the least soluble in blood. Carbon dioxide is the most soluble and it is infused into the pericardial well in an effort to displace nitrogen and enhance clearance of intracardiac and intravascular gas after cardiotomy. The benefit of this approach is unproven but logical.

Air bubbles rise and as a result intracardiac air will tend to enter the right coronary artery and anteriorly placed aortocoronary bypass grafts.


What are predicts for post vsd mortality

preoperative hemodynamic instability, left main coronary artery disease, right heart failure, renal dysfunction, previous myocardial infarction, posterior defect location and age.


What is long term survival of post mi vsd pts

mortality is high, most survivors do well and many patients are NYHA Class I or II.

Additional procedures are not routinely required.

Long-term survival of operative survivors is limited by pre-existing coronary artery disease, postoperative renal failure and residual postoperative shunts.

60 to 80% survival in 5 years


What incidence of papillary muscle rupture

anterolateral papillary muscle has a dual blood supply (LAD and circumflex), while the posteromedial papillary muscle has a single source (posterior descending branch of the right coronary).

Papillary muscle rupture is a complication of about 1% of acute infarcts and involves the posteromedial papillary muscle most frequently.


What importance of true and false aneurysm

True ventricular aneurysms should be differentiated from false aneurysms because large false aneurysms are prone to rupture whereas true aneurysms are not.

True aneurysms which result from expansion of an infarct often have a broad or no neck.

False aneurysms that result from a contained ventricular rupture have a narrow neck.

The presence of a ventricular aneurysm is suggested by persistent ST elevation on the electrocardiogram despite the absence of pain.


What are post op,concerns for TMR

cardiac complications (myocardial infarction, low cardiac output, and ventricular arrhythmias) are the most common adverse events associated with TMLR (about 50%). Low cardiac output results from myocardial injury, either from ischemic areas that are not addressed or from additional myocardial damage from the laser therapy. There is a rise in CPK-MB and a 50% incidence of ischemic EKG changes in the first 48 hours after TMLR


What are outcomes pericardiectomy

Perioperative mortality has decreased to 5-10%, but long-term survival remains limited and has not improved greatly.

Five year survival for the idiopathic group is in the range of 85-90%; it approximates 66% for postcardiotomy patients and 30% for post-irradiation constriction.

In patients who survive, early symptomatic improvement can be expected in 90%.


How good is Epi aortic scanning

epi-aortic scanning detected atherosclerotic disease in 90% of patients compared to 76% by digital palpation.
Epi-aortic scanning is currently the most sensitive and accurate technique, and it represents the "gold standard" for assessing atherosclerotic aortic disease in the operating room.


Describe history and patterns of OHT rejection

Forty percent of cardiac transplant recipients will have a rejection episode within the first month, 60% within 6 months and 66% by one year.

The risk of rejection decreases after the first year to a constant low level.

Ninety-five percent of these rejection episodes are in the setting of hemodynamic stability.


What are risk factors for rejection

Female gender, younger age, African American heritage, cytomegalovirus infection, HLA-DR mismatch, previous serious infection, and prolonged ischemic time


What is PTLD

There is a higher incidence in children (13-26% vs. 10% in adults)


What are risk factors for PTLD development

associated with Epstein-Barr virus infection.

Other factors
the organ transplanted, type of immune suppression (anti-CD3 monoclonal antibody and tacrolimus) and its intensity , and CMV infection.

There is a higher incidence in children


What is treatment of PTLD

reduction or temporary cessation of immumsuooression.

Advanced stage disease has clear features of malignancy and is usually treated with combination chemotherapy. Anti-CD20, interferon alfa-2a and anti-viral drugs may be beneficial


What is penetrating atherosclerotic ulcer

ulcerations in the wall of the aorta secondary to rupture of an atherosclerotic plaque through the internal elastic lamina.

local disruption of the media occurs and aortic rupture may ensue.


Describe IMH

An intramural hematoma (IMH) is caused by a vaso vasorum rupture that creates a localized hemorrhage into the aortic media.


What is blood flow to spinal cord

the anterior spinal artery (fed by the vertebral arteries),

the lumbar arteries of the abdominal aorta and

segmental intercostal arteries from the descending thoracic aorta.

The artery of Adamkiewicz, originates from intercostal arteries from T8 to T12


How do you distinguish cp from rp

both conditions, right and left ventricular diastolic pressures are elevated.

In restriction, however, diastolic pressure in the left ventricle is higher than in the right ventricle at rest and during exercise, usually by at least 3-5mmHg.

pulmonary hypertension is common with restrictive cardiomyopathy but rare in constrictive pericarditis.

Marked right ventricular systolic hypertension (>60mmHg) usually indicates restrictive cardiomyopathy.


List the acynaotic lesion of heart disease



List the acyanotic obstructive left sided disorders

Aortic coartations
Congenital AS
Interruped arch
Congenital MS


List cyanotic lesions (right to left)

pulmonary stenosis
Tricupsid atresia
Ebstein's anomaly
Pulmonary atresia


List cynatic lesions with mixing

Truncus arteriosus


What is incidence of PDA

20 to 30% of pre-term infants
up to 75% incidence in 28 to 30 weeks GA


List ways that PDA contributes to morbidity

Renal failure
abnormal cerebral blood flow
respiratory distress
chronic lung disease


What are other complications from PDA

Infective endocarditis
ductal aneursym
Aortic aneursym
pulmonary artery aneurysm


List other lesions that are associated with PDA

Aortic stenosis
mitral stensosis
subaortic stenosis


How do adults with CoArc present

unexplained HTN
visual disturbances
exertional dyspnea
CVA, aortic rupture/Dissection/aneursym

34% mortality by age 40


Mechanism of HTN in CoArc

Renin-angiotensin system disruption
Abnormal endothelial function proximal to stenosis
increased stiffness of prestenotic aortic wall
abnormal baroreceptor function


What are 5 most common associated anomlaies in Interrupted aortic arch

AP window


List important features of DiGeorge Syndrome

Calcium metabolism
Immunologic abnormalities
learning difficulties


What is the management of Junctional ectopic tachycardia

Core Cooling to 34 to 35 degrees
Reduction in inotropes
Atrial pacing above JET
antiarrhythmic therapy--amio


What are Ransons Criteria for pancreatitis

Age > 55
WBC > 16 000
Blood glucose 200mg/dl
Serum LDH 350
AST > 250

During 48 hrs
HCT fall > 10%
BUN increase > 8
Serum ca
Arterial PO2; estimated fluid sequestration > 600 ccl BE


What are risk factors for AV groove disruption during mitral valve surgery

Non conservation of posterior leaflet and subvavular apparatus
Too aggressive decalcification of the annulus
Cutting the PM too close to the wall
Too much tension on tissues when excising the valve
Ancoring suture too deep in the muscle
malalignment of sutures not perpendicular
Too big or too small prosthetis
High profile valve
Damage with cardiotomy
HTN crisis


List side effects of cyclosporine A

Neurotoxicity (tremor/seizure)
Gingival hyperplasi
pericaridal effusion
abonormal hair growth


What are signs of traumatic aortic rupture of CXR

Large mediastinum > 8 mm
Abnormal aortic contour, larger (0.7cm)
Left main bronchus displaced in lower position
Trachea displaced to the right
increased angle between trachea and left main bronchus
narrowing of the left main bronchs
left pleaural cap
liquid on the chest
flail chest
right deviation of the NG tube


Going on bypass with retrograde carioplegia cath. Position is good but you have very low coronary sinus pressure. You think?

This indicates patent left superior vena cava.

elevated pressure from kinking, valve obstruction.

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