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Failure to arrest heart with antergrade cardioplegia

The problem is aortic insufficiency

Could stop, vent through the root and give again at high pressure

attempt placement of retrograde


Arterial line showing low pressure (24mmHg) ECG tracing asystole, PAP 2mmHg, retrograde has a pressure of 32 mmHg, arterial line pressure is 80mmHg.

This patient has hypotension from either vasodilation or hypovolemia

Increase pump flow
Add vasopressors
*increase fluid


Hemodynamics show a retrograde tracing of 32mmHg, and arterial line pressure of 260mmHg

Cardioplegi pressure is too high

possible etiologies
kinked line
catheter too far
clamp on line
cardioplegia not right?

rideout upper queens, kingston (straight...down and up hill. right


Patient with a coactation repair at age 5. Now with pseudoaneursym of 8 cm just distal to left subclavian

what is the method of repair at first operation?

List 4 methods to protect the spinal cord during the repair operation

Likely end to end

Cerebrospinal fluid drainage
maintain adeuqate perfusion pressure
distal perfusion support
minimize ischemic clamp time
preserve intercostals


What is the preferred method of repair of coarctation for



Neonate: extended end to end; subclavian flap

Adult: interposition graft; end to end; angioplasty/stent


List 5 complications of carctation repair

Recurrent laryngeal nerve injury
thoracic duct injury
paradoxical hypertension
late true aneurysm
intermittent visceral ischemic pain


CT scan showing transected aorta just distal to the left subclavian

discuss appropriateness of each of the following

Open repair
Delayed repair

Open repair: viable option for pt w/o life threatening instability or other severe life threatening injuries.

Stenting: when readily available with suitable anatomy, useful in pts with other major concomitant injuries. Becoming more common. Carries risk of endoleak, branch vessel occlusion, infection, hematoma, paraplegia, stroke

Delayed repair: when stenting not available and pt has other severe life threatening injuries.


Patient with moderate to severe secondary TR going for MV operation
What would you do? If the TR is secondary and moderate what findings sway you to no repairing

Tricuspid ring
Right ventricle is normal size
tricuspid annulus not dilated (<30mm)
Right ventricle functioning well
minimal pulmonary hypertension


Trauma pt with a large L pleural effusion, CT drained 2L of milky fluid

Likely diagnosis is chylothorax

3 tests are
TG > 1.1 mmol
Cell count: lymphocytes > 80%
Cell > 1000 microlitre

2 ways to treat medically are medium chain triglyceride diet; TPN

3 ways to treat surgically: tube thoracostomy; pleurodesis; duct ligation; pleuroperitonal drainage


List 4 post acute MI complications that are amenable to immediate surgical repair

Left ventricle perforation
rupture papillary muscle rupture
Ventricular septal defect
Cardiogenic shock secondary to heart failure


List 3 findings on a stress thallium scan that predict high likelihood of future cardiac events

Left ventricle dilation with stress
Increased pulmonary activity
Extensive reversible ischemia of multiple segments
reverse redistribution


Patient with 20% EF , LF and LAD disease, No angina, symptoms of CHF. What would you like to know about the myocardium? List 3 tests that can be used to predict benefit from revascularization


Stress thallium scan
PET scan
Sestamibi scan
Dobutamine echo


Uneventful MVR in a female. POD # 2 sudden arrest on ward. After chest compressions regains...EKG shows 1st degree AV block. What are 3 possible causes

Ventricular arrhythmia
vagal episode
AV conduction block (3rd degree)


Peri-infarct VT, VF arrest--now post op CABG X 3 month. Management is what?

If EF is restored to normal
EP study if positive AICD if negative continue post op medical management
If EF remained at 30%


List 5 echocardiographic findings of ischemic MR

displaced papillary muscle
annular dilation
restricted posterior leaflet motion
elongated papillary muscle
Rwma?(not sure what this is?)


Carpentier Classification of mitral valve pathology

I normal motion
II excessive motion
IIa restricted systolic and diastolic motion
IIb restricted systolic motion


Female patient with 21 mm aortic bioprosthesi. With respect to PPM and aortic root enlargement
1) under what indexed EFO do you expect PPM
2) What % of patients with PPM will experience residual symptoms
3) What % of these patients will experience improvement of 1-2 NHYA classes


37% will experience residual symptoms

90% will experience improvement of 1-2 NHYA class


List 3 most common benign non-myxomatous cardiac tumors

papillary fibroelastoma


With respect to aortic root enlargement procedures
1) Describe the incision of a Nicks aortoplasty
2) How is a Manougian difference
3) How much annular diameter would you expect to gain from these techniques

Nicks aortoplasty: incision made in the middle of non coronary sinus up to annulus

Manouguain: incision made between the non and left coronary cusp and onto anterior leaflet of mitral valve (close to roof of LA)

Can expect 2 mm (2 sizes with a Nicks) and 4 mm with a Manougian


5 cath findings of constrictive pericarditis

square root sign of right ventricle pressure tracing during diastole
inspiratory increase in right CVP
prominent y descent
decreased cardiac output
equal CVP/PAD/PCWP/RA/PV pressure


Patient with post operative atrial fibrillation. Cannot tolerate medical treatment List 3 options at restoring sinus rhythm

DC cardioversion
Pharmacologic cardioversion
AV node ablationand permanent pacing


Patient with chronic hypertension presents with acute back pain. CT shows intramural hematoma

What is the definition and etiology of IMH?

What is the natural history of this lesion?

How would you treat?

Presence of IMH without dissection of aortic layers--two etiologies
rupture of vasa vasorum
intimal disruption with contained hematoma and no dissection
Natural history is 1/3 aneursym, 1/3 improve and 1/3 remain the same

I would treat a surgical type A IMH with surgical managment


With regards to AV managment in ascending aortic dissection with moderate AI. What are 3 options

Resuspend aortic valve


Valve sparing aortic root replacement


Describe the mechanism of action and the role of spinal cord stimulation in the treatment of angina

Mechanism: produces a functional sympathectomy and alters pain perception

The role for this is in patients with non-revascularizable CAD who have ongoing angina


Five year old pt with ASD.List 4 situations that preclude percutaneous device closure

No Landing rim
primum AS
Large ASD (> 20mm)
Sinus venosus defect
pervious failed percutaneous repair


TOF repair. You open the pericardium and there is an anomalous vessel curing the RVOT from right to left
What is it?
List 3 options for dealing with this scenario

Anolmalous LAD from RCA

Repair TOF through a trans atrial approach only
Repair RVOT through combined atrial/transpulmonary approach
Transverse ventriculotomy beneath coronary to remove RV muscle bundles
Use of RV to PA conduit with intracoronary ventriculotomy


Patient comes to office post CABG surgery and list 4 classes of medication and rational for each

Beta blockers: Survival benefit in those who have had a MI
Statin: shown to have a positive impact on CAD with graft longevity
ACE: control hypertension and reduced future events especially in setting of previous MI
Aspirin: improves graft patency and reduction of events related to CAD


List 3 classes of anti-thormbotic mechanism used in the treatment of ACS

Antiplatelet agents---plavix, ASA
Anticoagulatnt: Heparin
Thrombolytics: TNK, streptokinase


Placement of chest tube into the colon. 5 management steps with Gen surg

Removal of CT and closure of mediastinal-peritoneal communication
Broad antibiotic coverage
Extensive irrigation
Repair of colonic laceration
placement of chest tube in remote location


List 5 absolute contraindications to the use of a donor heart

ABO mismatch
Prolonged CPR, hypoxia or hypotension
HIV infection, HCV, HBV
High inotropic requirements


List 5 indications for surgery fro severe, chronic MR

Low ejection fraction
New onset of atrial fibrillation
LV dilation (LVESD > 45mm)
Setting of concomitant procedure
Pulmonary hypertension (PAS > 50mmHg)


List 4 physiologicl changes that occur during pregnancy that can exacerbate an existing cardiac condition

Increased heart rate
increased circulating volume
decreased systemic vascular resistance


List 4 absolute contraindications to insertion of a TEE probe

Esophageal perforation
Esophageal stricture
Esphagleal diverticulum
Esophageal laceration
Espophageal spasm

relative: antlanto-axial instability associated with arthritis; large hiatus hernai; upper GI bleed; significant dysphagia, cervical arthritisi


With current Canadian standards for blood products what are the infection rates for

HIV 1 in 4 Million
HCV 1 in 3 Million
HBV 1 in 275 000
CJD 1 in 10 Million


Definitionas of type of Heart transplants

Orthotopic--replaces organ in the anatomic position
Classic Shumway--biatrial
Bicaval venous inflow anastomiss of patients SVC and IVC to transplant organ
complete: 2 separate pulmonary vein islands and SCV and IVC anastomosis

2) Heterotropic in a non anatomic position


List 2 options for implanting a permanent ventricular pacemaker in a patient with a mechanical tricuspid valve

Ventricular lead through the coronary sinus


List 3 mechanims of how LV aneurysms cause LV dysfuntion

Increase global LV wall tension thereby decreasing global subendocardial perfusion
Paradoixcal dyskinetic motion of LV aneursym reduces systolic efficiceny
Increased wall tension on normal myocardiaum leads to global remodeling with overal LV dilation with systolic and diastolic dysfunction


What are boundaries of the triable of koch

Coronary sinus
Tricuspid annulus corresponding to septal leaflet of tricuspid valve
Tendon of Todaro


Patient 1 week post OHT and has a biopsy showing grade 1A rejection

What is definition of 1A rejection? how would you manage it

Repeat shows grade IIIB, what would be managment

What are revised definition of of ISHLT

If grade 1A just manage with current medical management and make sure its optimized

Grade IIIb-- high dose iv steroids and switch maintenance drugs; repeat biopsy if still positive then consider repeat iv steroids or ATG

0---no rejection
1---mild lymphocytic infiltrates without myocytosis OR one focus of infiltration with myocytolisis
2----moderate, multifocal sites of infiltration and myocytolisis
3 ---- severe, generalized infiltration and mycocytolisis with edma and hemorrhage, vasculitis, and necrosis

treat grade 2 and 3


List 5 presentations of a left atrial myxoma

Congestive heart failure
Fevers, arthralgias, myalgias, malaise, constitutional symptoms
rhythm disturbances


What are the mechanisms of action for

Cyclosporin--Calcineurin inhibitor--results in IL-2 and subsequent lymphocyte inhibition

ATG--ployclonal antiobodies to thymocytes resulting in rapid T cell depletion

OKT3--Monoclonal antibody to thymocytes resulting in rapid T cell depletion

Azathoprine---anti-proliferative which inhibits lymphocyte proliferation by inhibiting de novo and salvage purine biosynthesis

Prednisone--inhibit lymphyocyte proliferation by inhibiting macrophage production of IL-1 and IL-6.


List 3 methods of cerebral protection in someone undergoing DHCA

Adequate hypothermia
antegrade cerebral perfusion
retrograde cerebral perfusion
topical cooling (pack head in ice)
pharmacoligcal (largely unproven)


78 year old female with low cardiac output post CABG

what is diastolic dysfunction?

What are risk factors for diastolic dysfunction?

List 4 treatments for diastolic dysfunction?

Impaired compliance of the ventricular myocardium with resultant increased stiffness ultimately leading to poor ventricular filling, decreased preload and decreased cardiac output

Risk factors for diastolic dysfunction: diabetes, hypertension, ischemia, cardiopulmonary bypass, female sex, elderly

treatments; ensure maximal preload, reduced afterload, cAMP dependent inotropy, intra-aortic balloon pump


Compare and contrast "bridge to transplant" to "bridge to recovery"

Both instance require use of mechanical assist device to support myocardial function

Bridge to transplant has goal of temporary support until a suitable organ becomes available for transplant versus bridge to recovery which may employ longer support to allow wean from device when pts own myocardium can support the circulation

Bridge to recovery is applied in scenarios where recovery is likely (viral or post cardiotomy stunning) whereas disease processes with no potential for recovery should not be managed this way


Define Crawford type I, II, III, and IV

Type I: above T6 to above renals
Type II: above T6 to below renals
Type III: below T6 to varying degree of abdominal aorta
Type IV: varying extent of abdominal aorta only from above renals but below diaphragm


4 potential advantages of skeletonization of ITA

increased length
preserve sternal vascularity
decreased parasthesia
associated with higher graft flows
associated with larger anastomotic diameters


Calculate shunt fraction when given right and left heart cath saturations



Define the following

Structural valve dysfunction: change in function of any operated valve related to intrinsic abnormality of the valve that causes stenosis or regurgitation

Non structural: Abnormality resulting in stenosis or regurgiation of the operated valve not intrinsic to the valve itself.

Valve thrombosis : any thrombus not related to endocarditis on or near the valve that occludes part of the path of flowof blood

Bleeding event: any episode of major internal or external bleeding that causes death, injury, requires hospitalization or transfusion

Embolism: any embolic event that occurs in the abscence of infection in the immediate postoperative period



IABP with an ischemic leg: List 3 options for mangement

Remove IABP


What are 5 indications for early operative surgery for type B dissections

Refractory hypertension--unresponsive to medical therapy
Refractory pain--unresponsive to medical therapy
End organ malperfusion symdome (visceral, renal, limb)
aneurysm formation
progressive dissection


Define pH stat and alpha stat and list 1 advantage of each

pH stat: active correction of alkalosis associated with cooling by adding CO2 while on CPB
increase ratio of cerebral blood flow to cerebral oxygen demand (
increases rate of cooling
alpha stat: no active correction of alkalosis associated with cooling
easy to accomplish
in adults may be preferable not to increase cerebral flow to minimize embolization while on CPB
preserves cerebral autoregulation at low blood pressure better then pH stat


60 year old female with chronic pulmonary thromboembolic disease

List 2 abnormalities or either ABG or PFT

What are 2 absolute contraindications for pulmonary thromboenartectomy

Reduced PO2 on ABG
Moderate reduction of DLCO

Type IV thromboembolic disease
no upper limit of PVR precluding surgery
Significant and severe parenchymal disease
Severe PVD (relative)
other send stage terminal illness


55 year old undergoing 3rd time sternotomy and during opening dark blood. List 5 steps for management

administer full dose heparin, volume, and RBC as necessary
compress/pack sternum with cell saver suction recovery of blood
cannulate femoral vessels
initiate cardiopulmonary bypass with cooling and use of pump suckers
carry on with careful dissection


List 4 mechanisms of neurologic injury for a patient on CPB

altered cerebral blood flow
cerebral ischemia/reperfusion injury
whole body inflammatory repsonses


Cath Lab with an LAD dissection. Patient is stable but on UFH ad received plavix. What is management

Discontinue plavix and stay on UFH

If stable its ok to wait?


Pertaining to AS

Normal AVA - 2-4 cm2
Mild AS 1.5 to 2 cm2
Moderate AS < 1.5 cm2
Severe AS < 1cm
Congenital is all based on pressure.


Pertaining to rate responsive pacemakers. What are 5 variable that they can sense?

What are the basic components of rate responsive pacemakers

Respiratory movement
temperature with dedicated lead
QT interval
RV stroke volume through impedance
RV pressure with dedicated lead

pacing leads
response algorithm


25 year old with IVDU and fever: What tests? What valve most likely inovolved? 5 indications for TV endocarditits? 4 surgical options? most common organisms?

Blood cultures and TTE required


Heart failure/uncontrolled sepsis/antiobiotic reistance/type of organism/large vegetation/multiple emboli/abscess/intracardiac fistula

Valve repair/valve replacement/valvectomy

Most common organisms are staph aureus/gram negative/candida

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