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Flashcards in Previous exam 2006 Deck (46):

What are levels of evidence

Level of Evidence A: data derived from multiple randomized clinical trials of meta-analyses
Level of Evidence B: data from a single randomized trial, or nonrandomized studies
Level of Evidence C: only consensus opinion of experts, cases studies, or standard-of-care.


Female with right heart dysfunction now post op MVR with PA pressures 85/50. What are 4 specific interventions you would do

Optimize preload
Minimize afterload (particulary the RV)
4 specific interventions
Administer fluid for PCWP 15 to 20
Nitroglycerine/nitroprussed for afterload reduction
Mirinone for reduction of PAP, inotropy, lusitropy
Inhaled nitric oxide
optimize O2/pH/Co2


Patient with RCA infarction post CABG--cannot wean from RVAD. List 3 possible recovery pathways

Bridge to recovery

Long-term VAD

Bridge to transplant


What is a protocol for weaning off RVAD

Start to wean when CI > 2.9 and no increase in PCWP when flow rate dropped by 50%. Then drop 25% further and assess PCWP.


How do you calculate pulmonary vascular resistnace

Mean PA pressure - LA pressure divuded by CO

measures in Dynes.


What degree of PVR do you intervene

PVR > 80 do not repair
PVR 6 to 8 do vasodilatory challenge
PVR < 6 then it's ok


LVAD placement, output falls 12 hours after surgery: Give 4 possible cuases

Bleeding as a result of tamponade
RV failure
Device failure


4 clinical features of tamponade

Low urine output
cold peripheral


4 hemodynamic features of tamponade

increased filling pressures
equalization of filling pressures
pulsus paradoxus
low cardiac output
Right atrium and right ventricular
increased JVP
respiratory variation in TV/MV inflow
CVO tracing: attenuated y descent (reduced atrial filling) with or without prominent x


List 5 ways to assess athersclerosis of the aorta

chest x-ray
CT chest
Epiaortic echo


5 ways of dealing with porcelain aorta identified in the OR

cancel the case
Off pump LITA, RITA, with SVG with prximal contructed to LITA or innominate artery
Off pump beating assisted (cannulate femorial or axillary artery) and use off pump technique
Fibrillatory arrest--provided no AI
May perform only LIMA to LAD and do PCI to remainder
Replacing the ascending aorta under circulatory arrest and then do CABG


For off pump CABG lsit 3 things that are equivocal and list 5 things that are less with OPCABG

3 things that are equivocal
30 day mortality
stroke rate
myocardial infarction
5 things that are less with OPCABG
post op AF
red cell transfusion
less inotropes
length of stay
few distalas


3 advantages of bicaval anastomosis in transplant

Less TR and MR
Less atrial arrhythmias and conduction disturbance
shorter hospital stay
reduced postoperative dependence on diuretics
Less RV dysfunction


List 6 clinical bedside test

No response to pain
absecene of brain stem reflexes (doll's eyes, caloric reflex test, pupils dilated)
Bedside ECG
sensory evoked potentials
ensure no metabolic disturbances, pharmacologic agents, and hypothermia
cerebral angiography
radionuclide cortical blood flow studies


10 complications of open PDA ligation

recurrent laryngeal nerve damage
phrenic nerve injury
ligation of PA, aorta
residual flow


What is management of intra mural hematoma from LSCA to diaphragm;

IMH secondary to rupture of the vasa vasorum

Treat like type B dissection (BP control, operation for complication of type B such as contained rupture, malperfusion, progressive enlargement, persistent pain, and persistent hypetension


List 3 general physiologic derangements that can lead to tissue hypoxia and give an example of each

Low cardiac output (decrease deliver)
Anemia (decrease oxygen carrying capacity)
Hypoxemia: DO2 = Co x Hg x Sao2 + paO2


List 5 ways to repair the anterior leaflet of the mitral valve

triangular resection
chordal transfer
alfieri stitch
papillary muscle sliding or shortening
chordal transpositoin from posterior leaflet


What is Custodiol cardioplegia

Intra-cellular solution
Crystalloid cardioplegia that contains histidine, trptophan, and ketoglutarate
histidine has a strong buffer effect which can prevent acidosis in cardiac myocytes
Low acting (2.5 hours)
30cc/kg in a single dose


Left superior vena cava and mitral surgery

What structure does NOT involute with persistent LSVC

What can be absent with persisten LSVC

Where does it drain

List 2 ways to do venous cannulation

Does not involute---Left anterior cardinal vein

The innominate vein maybe absent

Drains into coronary sinus

Venous cannulation: LSVC, double cannulation on the right if no innominate, cannulate coronary sinus with big cannula and do vaccum assit


Redo CABG--retrograde ongoing for 2 minutes--heart still beating. retrograde pressure is 40 with a flow of 60ml/min. What are two problems and how to correct

Problem # 1: Heart is still beating
Problem # 2: retrograde pressure is too low...should be 200ml/min. Could represent coroanry sinus becoming distended or that the cannula has entered the coronary vein.

Ways to solve this problem
Pull Canula back, increase flow, check K+, isolate and clamp lita, cool to 25 degrees C.


Patient is post CAB. 4 different medication and rationale

ASA--benefit on graft occlusion--Mangaon NEJM 2002 (lower MI, mortality, lower stroke, lower renal failure, bowel infarction)
Cholesterol lowering agent: decrease risk of CV events at > 7 years "post CABG NEJM 1997)
Beta Blocker: significant decrease in AF
ACE: Apres, IMAGINE--lower incidence of CV events, angina, repeat revascularization


FInish implanting a DDD pacemaker--nurses notices pt HR is 120 upper limit of device. List 3 possible causes

Pts own sinus rate at 120 (and device is at its upper limit)
Pt is in SVT (AF or A flutter)
Pacemaker-mediated tachycardia


What is Pacemaker-mediated tachycardia

Occurs with DDD pacemakers--inadvertently cause a reentrant arrhythmia. retrograde conduction through the AV node, possibly triggered by a premature ventricular depolarization.

If pacemaker senses the resulting atrial depolarization and paces the ventricle, a recurring cycle us set up that could continue indefinetly at the upper rate limit of the pacemaker.


What is treatment of pacemaker pocket infection: list 3 steps in management

prompt extraction of the device and leads

course of IV antibiotics

Device implantation at another site during a separate surgical procedure


Antegrade List 2 advantages and disadvantages

Most physiologic efficient perfusion of the brain
Sequential perfusion of the cerebral arteries provides addtional safety to unilateral cerebral perfusion
improved cooling and oxygenation shown to decrease ischemic injury

Con: risk of dissection of the arterial wall--complex cannulation techniques
risk of embolism of atheromatous plaque material or air


What is advantage and disadvantage of retrograde cerebral perfusion

Accepted facts in a supplement cooling of the brain hemisphers
Possible expulsion of solid particles or gaseous bubbles from the arch arteries

distribution of retrograde flow is uneven, with a preferential distribution in the saggital sinus and hemisphere veins. The large steal of blood to the inferior venous territory is corroborated by the clinical finding of an extremely small proportion of perfused blood flowing out of the arch

Interstitial edema is another potential problem of retrograde perfusion, which can lead to cerebral edema and HTN, if [ressure gets over 25mmHg

No docuementd benefit over hypothermia alone


Patient is a previous CABG and needs MVR and possible redo graft to RCA.

List 2 surgical incisions through which the operation can be done.

List 2 atrial incisions to approach the mitral valve...and advantage and disadvantage of each.

Redo sternotomy
Right anterior thoracotomy *preferred approach is right throactotmy and transseptal atrial incision*

better for small LA size
increased suture line/greater risk of injury to arteries that supply SA node
Sondegaard grove: (left atrial incision)
less suture line
more difficult in small LA


What are 2 indications to use radial artery for conduit in bypass

Young patients that you plan for total arterial revascularization and longer graft patenty

Lack of conduits, contra-indications to bilateral ITA

*Need to source studies*


What are 3 contraindications to radial artery in general

Job restrictions
positive (poor Allens test)
Potential need for vasopressor (severe LV dysfunction)
renal failure needing fistual
Need for immediate high flow
Anatomical restrictions (not 70% stenosis on the left or > 90% on the right coronary systems)


What are contraindications to use the LITA

Previous surgical damage
subclavian stenosis
Mediastinal irradiation
Leriche syndrome


Benefits of skeletization

less pain
greater length
more flow
improved visualization
easier to construct composite grafts
more sternal perfusion
less sternal infection


Name trial which showed PCI vs CABG in diabetics

5 year survival was 65.5% among patients treated with DM who were assigned PCI compared with 80% who were CABG


What are important issues to consider for type A dissection

Location of tear: most common anterior aspect of the ascending aorta 3 -5 cm above the RCA ostium

Extent of resection:
Aortic valve replacement: if disease or severed by the dissection or BAV
Root: in case of tear into root, destructed annulus, connective tissue disorder


AVR replacement with mechanical prostheis; used ostial cannulation; now can't come off pump. List 3 possible problems

RV ischemia: RCA dissection; RCA embolic event (calcium/air)
LV ischemia: Left maim, LAD, or circumflex dissction or embolic event
LV stunning: inadquate protection (short LM with preferential perfusion of the LAD
RV stunning: inadequate protection (small RCA)


IVDU--what is most common valve, pathogen, and 4 surgical options

Most common valve is Tricusid
Most likely organism is S. Auerus
Surgical options are
Repair (vegetectomy and primary repair/debride bicuspidse/devega/
Valvectomy (remove it(


What are indications and work out for a patient with early prosthetic valve endocarditis. Pt will present with microhematurai and mild leukocytosis and fever/chills

Early prosthetic valve endocarditis

obtain Echo and blood culture

Criteria for diagnosis: positive blood cultures, echo, fever, embolic, immunlogic.

early surgery for mild heart failure, S.aureus,


Peri-infarct VF arrest with EF at 30%, revasculaize and EF returns to normal. What do you do about arrhythmia? What do you do if EF stays at 30%

2002 guidelines for implantation of AICD circulation

In revascularized patient with normal EF in who ventricular arrhythmia pre-op is attributable to an ischemic even , there is no indication for AICD

in patients with EF < 30% at least one month post MI or 3 months post CABG there is indication to implant AICD (IIa)


5 year old kid with L-R shunt on echo; Name 5 indications for surgical intervention

Pulmonary to systemic flow ratio (Qp:Qs) 1.5:1
Uncontrolled CHF...growth failure, recurrent respiratory infection
Large asymptomatic defects associated with elevated PA pressure (PAP > 40 mmHg)
If the shunt results in prolapse of an aortic valve cusp
Ventricular enlargement/RV dysfunction

if PVR is fixed at 8-12 then operation is contraindicated


Previous TOF repair with transannular patch. Name 5 late complications that would represent indications for surgical intervention.

Pulmonary valve regurgitation with fatigue and dyspnea/RV failure
Pulmonary valve regurgitation with ventricular arrhythmias
Pulmonary valve regurgitation with TR
persistent or recurrent RVOTO
residual or recurrent VSD
Large left to right shunt
aortic root dilation and aortic valve regurgitation > 55
Pseduo or aneursym of RVOT


What are risk factors for PA rupture from PA cathf

Pulmonary HTN
systemic anticoagulation
long term steroid use
age older then 60
Excessive cath manipulation
balloon hyperinflation
surgically induced hypothermia
cardiac manipulation during surgery
cardiac decompression

mortality near 70%


What is treatment for PA rupture

Trancatheter embolization
Urgent thoracotomy
hilar clmaping with direct arterial repair
PA ligation

Adjunctive: lateral decubits; IV fluids; reverse anticoaglation, PEEP,


List 4 indications for LV aneurysm repair

Ventricular arrhytmia
Rupture with or without development of pseudoaneurysm
Congenital aneurysms--due to presumed risk of rupture
Documented expanion


What drugs do you treat a type B dissection with

Sodium nitroprusside
direct arterial vasodilator and short onset and duration of action
ideal to rapidly achieve target SBP
Beta 1 selective with short half life
decreased inotropic state of myocardium and decreased heart rate
metoprolo, propanolo, and labetolo aer other options


What is SAM, pathophysiology and 2 ways to manage it.

Develops in patients with excess leaflet tissue and a posterior mitral leaflet heigh of more than 1.5 cm. After mitral valve repair, line of leaflet coaptation is displaced anteriorly by redundant PML. Venturi effect pulls AML and coaptation point toward vetricular septum during systole and causes LVOT obstruction

Give volume
avoid being hyperdyanmic
decreased inotropic
beta blocker
Back on bypass
Ensure annuloplasty band is of sufficient size and correct orientation
sliding posterior-leaflt valvuloplasty to move coatation point to a more posterior location
reduction of size of anterior leaflet by triagulat resection or plication
edge to edge repair of sewing A2 and P2, creating double orifice mitral valve
neochordal placement to pull posterior leaflet further


Describe levels of evidence and associated grades of recommendations based on those levels

Class I: conditions for which there is evidence and/or general agreement that a given procedure or treatment is beneficial, useful, and effective.
Class II: conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment
Class IIa--weight of evidence in favour of usefulness
Class IIb less well established

Class III--conditions for which there is evidence and an/or general agreement that a procedure is not useful/effective an in some cases may be harmful.

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