Post Cath / post AICD complications

Question 1

sudden onset of back pain and hypotension post cardiac cath

Answer 1

RP bleed with arterial puncture above inguinal ligament may result in bleeding. bleeding doesn’t stop with manual compression.

Question 2

Presentation and labs of RP bleed

Answer 2

drop in hgb and BP and high HR see flank or bakc pain.

Question 3

Diagnosis of RP bleed

Answer 3

CT abd pelvis without contrast

Question 4

Superior vena cava syndrome definition

Answer 4

See compression of superior venous cava vein so blood backs up

resulting in facial edema and plethora or headache or syncope with squatting;

body tries to offset the high venous pressure by creatining venous collaterals and central venous pressure remains high and causes symptoms

Question 5

Common causes of SVC syndrome

Answer 5

tumor compression of vein

scarring and stenosis by endothelial damage wiht insertion of transvenous AICD placement.

Can also happen in thrombophilic state, and infections

Question 6

when do symptoms of SVC syndrome start to happen

Answer 6

1-15 months after procedure.

Question 7

symptoms of SVC syndrome

Answer 7

dyspnea, head fullness, facial arm swelling chest wall edema that worsens with bending or lying down or episode syncope or presyncope

Question 8

Diagnosis of SVC syndrome

Answer 8

bilateral upper extremity venography and contrast enhanced CT scan can be done first to show extent of venous bloackage and visualize collaterals and identify the caustive factor

Question 9

therapy of SVC syndrome

Answer 9

long term anticoagulation extensive clot burden and severe symptoms may need thrombolysis and stent implantation and bypass surgery or extraction of leads and re implantation

Question 10

horner’s syndrome and hand weakness or muscle atrophy - consider

Answer 10

pancoast tumor - invades the brachial plexus and parietal pelural and surrounding fascia and ribs and vertebral bodies. See shoulder pain and weakness

Question 11

Shoulder pain and smoker

Answer 11

make sure you get a CXR to rule out pancoast tumor.

Question 12

what is this condition?

worsening peripheral edema and or anasarca and extreme fatigability with response to exertion. See JVD and pulses pardoxus and Kussmal’s sign and pericardial knock

Answer 12

Constrictive pericarditis

Question 13

What is subclavian steal syndrome?

Answer 13

atherosclerotic narrowing of proximal subclavian artery which results in flow reversal in ipsilateral vertebral artery and this happens on left side though pts are asymptomatic. May see exercise induced fatigue, pain, numbness and coolness and fatigue. pts have vertebral basilar insufficiency (dizziness and vertigo and disequilibrium and drop attacks)

Question 14

within first 24 hrs of MI what are the complications?

Answer 14

arrhythmias (VT, VF, accelerated idioventricular rhythm, afib)

Question 15

when does acute pericarditis or Dressler syndrome or immune mediated percarditis occur?

Answer 15

2-4 days 2-10 weeks for Dressler syndrome Presents with chest pain worse with inspiration and sitting upright. See STE diffisuely and PR depression on EKG

Question 16

when would you see a left ventricular aneurysm occur post MI

Answer 16

weeks to months

Question 17

presentation of a left ventricular aneurysm?

Answer 17

no symptoms. See persistent STE without troponin elevation

Question 18

When does left ventricular free wall rupture occur after a MI and how does it present?

Answer 18

3-5 days post MI and see sudden decompensation and death with acute cardiac tamponade on TTE

Question 19

when does mitral valve regurgitation present post MI?

Answer 19

2-7 days and see hypotension, pulmonary edema and holosystolic murmur with wide spread radiation and thrill. -

Question 20

When does VSD happen post MI?

Answer 20

3-5 days see new HDS and new onset heart fialure and holosystolic murmur at left lower sternal border. Reverse blood flow at interventricular septum

Question 21

painful tender mass near puncture site below the inguinal ligament after a endovascular intervention

Answer 21

hematoma and possible pseudoaneurysm formation.

Question 22

possible differentials for post cath complicaitons

Answer 22

RP hemorrhage, arterial dissection, arterial thrombosis and pseudoaneurysm and formation of AV fistula

Question 23

to rule out hematoma or pseudoaneurysm formation post cath with symptoms, need to order a

Answer 23

doppler ultrasound.

Question 24

what is an arterial pseudoaneurysm?

Answer 24

hematoma that remains in continuity with arterial lumen with blood flow into and out of hematoma cavity. Usually has a pulsatile mass with systolic bruit over the mass.

Question 25

why do we worry about pseudoaneurysms?

Answer 25

risk for expansion and rupture and catastrophic bleeding . Need to be treated with ultrasound guided compression or a ultrasound guided thrombin injection in to the pseudoaneurysm cavity

Question 26

if there's a infection of ICD must

Answer 26

remove the entire device generator and leads Any evidence of valve or lead vegetation or TTE positive blood cultures with an organism with high propensity for causing infective endocarditis (staph, strept, candida spp) evidence of pocket infection need to remove it (including localized pain/tenderness, erythema, swelling, purulent drainage or skin erosion)

Question 27

people who have AICD and infection with suspected endocardial invovlement with pain, swelling and purulent drainage should get treatment for infective endocarditis:

Answer 27

6 weeks of therapy

Question 28

pocket infection with AICD tx

Answer 28

needs to have removal of ACID and blood cultures if negative, blood cultures and unremarkable TTE need 2 weeks of antibiotics following removal.

Question 29

after a pocket infection AICD how do you treat the infection?

Answer 29

reimplant new AICD on the contralateral side of chest once there's source control

Question 30

VSD post MI

Answer 30

see new onset of hypotension CHF (prodominantly of R heart failure) hear a harsh loud holosystolic murmur with radiation best heard at left lower sternal border.

Question 31

timeline of post MI conditions when do you see MR as a complication of an inferior MI?

Answer 31

Can see **acute mitral regurgitation** due to papillary muscle rupture at _2-7 days_ after MI. See this due to rupture of _posteromedial papillary muscle_ supplied by RCA or dominant left circumflex. More common than anterolateral papillary muscle since that has dual supply from LAD and left circumflex. see acute onset of cardiogenic shock and pulmonary edema, systolic murmur and hyperdynamic precordium. Can see equalization of left atrial and left ventricular pressures. Diagnosis is via TTE or TEE.

Question 32

rupture of left ventricular free wall

Answer 32

catastrophic complication of MI. seen **days to 2 weeks after MI**. see hemopericardium and cardiac tamponade and presents with sudden onset chest pain and profound shock and rapid progression to PEA and death.

Question 33

sudden onset of chest pain after having nausea and diarrhea for two days. Two weeks ago had a inferior MI and had a bare metal stent placed. EKG has sinus bradycardia and STE in II, III, AVF what happened?

Answer 33

Pt has a **stent thrombosis**; this happens within the 1st month most commonly but can happen at any time. Most often due to result of premature discontinuation of DAPT; if someone wasn't able to eat due to gastroenteritis.

Question 34

long term side effects of left ventricular aneurysm

Answer 34

scarred myocardium due to prior MI and can cause progressive left ventricular enlargement leading to heart failure, angina, arrhythmias or mural thrombus embolization.