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Flashcards in Previous exam 2000 Deck (37):

How do you calculate aortic and mitral valve effective orifice areas

generally 2 possible ways

Invasive hemodynamics

Echocardiographic findings.


What is Gorlin formula

Based on Cath data
works for stenotic valves only (need to have a stenosis to detect a gradient)
Basic principle is that flow = area x velocity
Velocity = square toot of change of pressure x constatn
Not valid in the presence of AI

AVA = AVF/44.3 (c) square root of pressure gradient

valve area = cardiac output/square root of pressure gradient.


What is continuity equation

determined echocardiographic
tends to underestimate valve area compared to Gorlin equation'

AVA = stroke volume
*eT (85) Vmean

Et = ejection time
Vmean= mean flow velocity just distal to valve


List 3 indications for retrograde carioplegia

severe proximal coronary artery disease (unable to administer adequate antegrade plegia)

re-op situation with patent arterial grafts and proximally occluded native vessels

re-op coronary surgery to avoid thromboemboli down disease vein grafts

complex mitral valve surgery

aortic valve/root surgery--theory that retrograde cardioplegia provides better perfusion to subendocardium in LVH than antegrade cardioplegia

Aortic insufficieny


List 6 complications of a child with untreated VSD

Bacterial endocarditis
RV outflow tract obstruction secondary to infundibular muscular hypertrophy (RV muscle bundles)
Aortic insufficiency
Pulmonary hypertenion/TR/RVH/Right heart failure/Eisenmengers' complex
failure to thrive
congestive heart failure


Indications for surgery in acute type B dissection

Failure of medical management
refractory pain
refractory hypertension
proximal extension of dissection
Visceral compromise
Aneurysmal size greater then 6.5 cm


List 5 predisposing factors for type A dissection

Connective tissue disorder
Bicuspid or unicuspid aortic valve
coarctation of the aorta


Intra-operative risk factors for AV groove separation in MVR

non preservation of the posterior apparatus
over sizing the valve
excessive traction on annular sutures
dislocation of the heart to inspect grafts post MVR
excessive traction on the papillary muscles
misplacing post of bioprosthesis (into the the posterior wall of LV)


What is angiographic grading of AI

0 = No AI
1+ dye does not fully opacity entire LV, clears with each systole
2+ fully opacifies LV but clear with each systole
3 + as dark as aorta does not clear with each systole
4 + darker than aorta does not clear with each systole


Angiographic grading of MR

0 = NO MR
1+ does not fill LA, clears with each systole
2+ fills LA less opacity then LV does not clear with 1 systole
3+ fills LA as dark as LV
4+ fills LA darker than LV increased with each systole (pulmonary veins also fill)


List mechanism of FK506 and ATGAM

FK506 (tracro) inhibits calcineurin which blocks transcription of IL2 which is needed for T cell activation

ATGAm--anitthymocyte gobulin that is introduced into humans and directly blocks t cells.


What is classification of vascular rings

Complete ring
double aortic arch
right dominant aortic arch with left ligamentum
Incomplete ring
inominate artery compressure syndrome
pulmonary artery slight (RPA from LPA behind the traches
abberant right subclavian.


List reasons why you cannot ventilate a patient after a CABG

ETT disconnected
ETT blocked
ETT moved
collpased lung
compressed lung
pulmonary edema


What is predictability of biventricular repair in PA/IVS

depends on two factors
presence of a right ventricular depenent coroanary circulation (which prohibits biventricular repair)
The ability of the RV to provide adequate pulmonary blood flow at normal filling pressures. Must decompress RV with RVOT procedures (patch or valvotomy) to encourage growth of RV.

TV size is a good measure of RV volume.


What are tricuspid valve z scores that will allow biventricular repair to occur for PA/IVS

1. TV (Z = 0 to 2) perform RVOT procedure alone. No increased mortality. The need for subsequent shunt is low (RV can provide adequate pulmonary blood flow)

2. TV (Z = -2 to -2) the chance of biventricular repair decreases as tricuspid annuls diameter decreases. Suggest RVOT procedure+ shunt (low chance of mortality and subsequent procedure). Good pulmonary blood flow, Right ventricle growth, Shunt can be taken down percutaneously

3. TV (Z < 3. Shunt alone. Less mortality then if an RVOT procedure was attempted. in CHSS data, no patient withe Z score < 3 survivied biventricular repair.


List features of scimitar syndrome

1. right pulmonary veins draining entire right lung connecting into IVC
CXR: veritically ortiented crescent-shaped density, adjacent to right heart border (looks like a turkish sword
Angio-"fir tree" appearance due to its many tributaries
2 pulmonary parenchyma and brochi
3. Anomlaous pulmonary artery supply
4. ASD


What are steps for air embolism

Stop CPB
Immediately clamp arterial and venous lines
Tell anesthiology, place head down, occlude carotid, pack head with ice.
location and confirm source of air
aspirate air from arterial cannula
purge the arterial line
Insert the arterial cannula into the SVC and perform retrograde cerebral perfusion
give volume into the venous system to fill the heart
Remove cross clamp (if it's on)
start direct cardiac massage
ventilate the lungs
administer vasopressors to raise perfusion pressure
Remove arterial cannula from SVC and place back into aorta and start CPB
Anesthiology can give steroids, mannitol , pack head with ice
Complete operation
Inform family
consider hyerbaric oxygen treatment when back in ICU


What are options for a patient with 90% left main and calcified aorta

1 alternative cannulation sites
2 Cross clamp alternatives
hypothermic fibrillatory arrest, beating heart pump support
3 alternative for proximals (pedicled, off innominate)
4 Off pump
4 cannulation, DHCA, replace aorta and do proximals off dacron.


What are clinical and cath findings for constrictive pericarditis

1. increased JVP
2. prominent x and y descents
3. small or normal size heart
4. pulmonary and hepatic congestion
5. no ventricular dilation
6. normal ventricular systolic function


opening pericardium in TOF, vessel noted across teh RVOT. Which vessel. 3 options

Vessel is likley LAD from the right coronary artery

RV- to PA conduit

palliative shunt and forget it...

transverse incision in the infundibulum before coronary artery to close CSD and resect of infundibular stensosis

dissecting the coronary artery off the outflow that's risky!!!


Patient has a VVI pacer and list 2 mechansism why CO may be low

Pacemaker syndrome
loss of coordinated contraction of the atria and the ventricles
unpleasant symptoms due to atrial contraction agains a closed TR
Oversensing with low ventricle escape rhythm
Absecne of normal chronotropic response toexercise
(no increase in heart rate with exercise)
Need to be in VVI-R


List 3 situations where a VVI PM is bad

Sick sinus syndrome
increase risk of atrial fibrillation, embolic events
Heart block with atrial arrhythmia
Patient with compromised cardiac systooic function or diastolic function


HOCM ---list 4 treatment options

Medical therapy
beta blockers
calcium channel
DDD pacemaker
Septal ablation
Mitral valve repair/replacement
Heart transplantation


List 4 mechanisms of ischemic reperfusion injuries

Intracellular calcium influx
production of oxygen free radicals--disrupts membrane integrity
activation of leukocyte--source of oxygen free radical and other substance
complement activation


List 4 viability studies

1. SPECT imaging
2. PET imaging
3. Dobutamine echo
4. Contrast echo
5. Dobutamine MRI


Pt with refractory AF. list 4 treatments

Electrical cardioversion
DDD paacing
AV node ablation with pacemaker insertion
Maze procedure
Ablation of the triggers causing AF


What are mechanism of SVG occlusion over different times

Early (hours to weeks)
technical complications
Intermediate (< 1 year)
intimal hyperplasia
intimal hyperplasia


List contraindications for bilateral ITA

poorly controled diabetics


List 5 complications of senning mustard

atrial dysarhythmias (> 50% in 10 years)
Late RV systemic failure
TR with RV dilation
significant TR
RV failreu
late caval obstruction
pulmonary venous obstruction
dynamic subvavluar pulmonary stenosis
residual shunts at atrial level


Risk factors for post op low cardiac output

poor Left ventricle function
prolonged CPB
poor myocardial protection
ischemia time


List 3 options to pace a patient who has AV block with a mechanical TV in place

permanent transthoracic pacing (epicardial leads)
pass the leads between the sutures and the annulus and the valve ring
coronary sinus lead placement for ventricular pacing


Define autograf, alllograft, heterograft, xengraft transplant



Describe CCS classification



Complications of IABP



How does IABP help failing heart

afterload reduction
decrease SBP by 20%
decrease LV wall stressed and MVo2
increase diastolic pressure by 30%
increase CO by 20%
decrease in PCWP
increase coronary flow


What are alternative to protamine

platlete factor IV
recombinant platlete factor IV
Heparin binding filters
Hexadimethrine bromide


Carpentier classification of mitral valve pathology

Type 1: normal leaflet motion
Type 2: excessive leaflet motion
Type 3: restrictive leaflet motion
a. in diastole
b. in systole

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