Previous exam 2007 Flashcards Preview

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Flashcards in Previous exam 2007 Deck (36):
1

6 anatomical layers cross with axillary artery cannulation

Skin
subcutaneous tissue/fat
pec major
Clavico-pectoral fascia
pec minor
axillary sheath
wall of artery (adventitia)

2 ways to cannulate are 1) Direct 2) through an end to side Dacron graft (8 or 10 mm)

2

4 possible advantages of axial flow pumps and 1 disadvantage

Minimal aticoagulation
Quiet
Small size
Less power consumption
durability

Disadvantage
Hemolysis/shear forces
non-pulsatile
Potential for negative ventricular pressure (air embolism, device thrombosis)

3

What is difference between dilated cardiomyopathy and hypertrophic cardiomyopathy

LVEF (reduced, normal)
LVEDV (increased, reduced)
LVESV (increased, reduced)
LV mass (increased, increased)
LV mass/volume (decreased, increased)
LV chamber thickness (deceased, increased)
Wall tension (increased, normal/increased)

4

What is Vo2 max effect on survival

if < 10 (50% die in one year)
if 10 to 18 (65-80% survival in one year)
if > 18 then (>95% survival in one year)

5

List factors that make SAM worse

Inotropes
Decrease in afterload
decrease in preload
tachycardia

6

What are risk factors for SAM

increase height of posterior leaflet of mitral valve
small left ventricle
narrow angle between mitro-aortic angle
Hypertrophic septum

7

What is JVP tracing in patient with AF...Draw it

No a wave, small x descent, large v wave, prominent y descent

8

What is the relevance of Intravascular ultrasound

Mean lumen diameter of 4.0 mm2 has been assessed as being a the cutoff threshold for intervention.

9

What are 5 complications from Fontan physiology

Protein losing enteropathy
Arrhythmias
cyanosis
Conduit obstruction
failing fontan circulation (higher PVR, single ventricle failing)
exercise intolerance
Thromboembolic
Hepatic dysfunction

10

Strategies to reduce the risk of neuro dysfunction on pump CABG

hypothermia
slow rewarming
epiaortic scanning
minimal manipulation of aorta
higher perfusion pressures
lower CPB times
anti-inflammatory strategies
Avoid cardiotomy suction

11

Describe approach to a root abscess under left main

Adequate debridement, closure of abscess cavity, assessment of anterior leaflet of mitral valve, assessment of left main coronary artery involvement. Reconstruction of the root with dacron or pericardial patch, new valve implantation, protect LM from emboli, retrograde cardioplegia

12

Name 3 possible substitues for aortic valve in the case of annular abscess

Homograft
Stented bioprosthesis
stentless aortic valve
mechanical aortic valve

13

What are 6 causes of tricuspid valve regurgitation in a 71 year old female with normal coronary arteries

Primary
myxomatous/degenerative changes, rheumatic, carcinoid, infectious
Seconday
Myxoma, high pulmonary vascular resistance, mitral regurgitation, right ventricle/annulus dilation

14

Name 2 most common malignant carid tumors and survival time. Name 1 clinical and 1 anatomical feature prior to planning a surgery

Angiosarcoma--50% death at 6 months
Rhadomyosarcoma--50% at 6 months

Angiosarcoma – if not resected 90% die within 1 yr.
Rhabdomyosarcoma – < 12months even with resection
???feature: local disease that is resectable with no evidence of metastasis

15

Transplant with hypertension given 10mg of nifedipine, 1 hour later BP 70/30, HR 110 T 37.9
List 4 possible causes

3 tests necessary

3 immunosuppression agent all transplant patient will taking

Hypovolemia
Sepsis
Rejection
Pericardial effusion

Echo
Biopsy
Septic work

Calcineurin inhibitor
Antimetabolites
Steroid

16

Name 3 studies that compare CABG vs multivessel PCI

What is freedom from re-intervention for PCI and CABG at 2 years

Syntax, freedom, sos


At 5 year in syntax, repeat revasc in PCI was 26 % and 13% in CABG
At 1 year in freedom, repeat revasc in PCI was 17 % and 5% in CABG

17

List 5 advantages of stent graft, main disadvantage, how much oversizing, how long proximal landing zone

Over sizing 20%
Landing zones 1.5 to 2 cm

Less invasive
No CPB
No or few heparin
Faster
Less paraplegia
Less renal insufficiency
Less bleeding

Irradiation
Long term unknown
Not always available
Anatomical restriction

18

Patient with end stage cardiomyopathy and EF of < 25%

Name 4 medications he should be on

name 4 other options/interventions that could be considered for this pt

What are results of rematch trial at 2 years

Bb
Acei
Aldactone
Lasix or digoxin

CRT
VAD
Transplantation
ICD


Rematch at 2 year, survival VAD 23% vs med 8%

19

interpret pulmonary function test in a patient with severe dyspnea

3 ways to assess respiratory reserve



What are the cut offs for FEV1 and FVC
FEV1<65% OF VC OR <1-1.5L

20

Patient with CHF and COPD at ER

1 peptide that can help differentiate between decompensation of COPD and decompensated Heart failure?

Why does it react so fast?

What are physiological side effects (3)

BNP

Respond to ventricular stretch

Vasodilatation
Diuresis
Natriuresis
Inhibition RAAS




21

Intra-operative hemorrhage is ongoing and all blood products are given.

Anesthiology suggests one off label solution?

What is this drug?

What is dosage?

What is physiological mechanism of action?

What is evidence for its use?

Recombinant factor VII

40-90 mg/kg

Used in hemophilia, trauma and rescue in cardiac surgery

Multiple case reports and series that have demonstrated its efficacy in non-hemophilic cases
In a multi-institutional study by McLaren et al: off label use in pts (92%) demonstrated efficacy in selected groups (those with pH>7.20)
2008 meta-analysis of 22 randomized controlled trials of rFVIIa in 3184 patients without hemophilia in which 15 percent died and 7.8 percent had thromboembolic events. Results included:

22

What is mechanism of Dobutamine, side effects

Has predominately B1 effect, increasing the force of contraction and heart rate
Mild B2 and Alpha effect. Will cause decrease in pulmonary and systemic vascular resistance
Side effects: Tachycardia, ectopic beats


Side effects : tachycardia, arrhythmia, hypotension

23

What is mechanism of action of milrinone, side effect and 3 physiological effects

Phosphodiesterase III inhibitor
Intotropy, vasodilatation systemic and pulmonary

Side effects: hypotension, arrhythmia

24

What are 3 indications for pacemaker in a patient with sick sinus syndrome

Symptomatic brady
Chronotropic incompetence
Syncope with unknown etiology

25

Patient with A. flutter, has received ami bolus, still remains in AF. Atrial wires remain. What are options

Electric cardioversion
Overpacing
Bb

26

VF post op in a pt with AF and on amio.

What is most probable diagnosis on ECG

What part of ECG is abnormal before VF

Normal value of this part of ECG?

Torsades
QT interval
Normal value QTc <440

27

What are aspects of antegrade cerebral perfusion

How do you monitor pressure--what is optimal

What is optimal flow?

Temperature, normally at 18
Right radial monitoring, usually 50-70 mmHg
10 cc/kg/min

28

IMH in ascending aorta.

What anomalies of aorta lead to this condition?

What is management?

Ruspure of vasavasorum
Treat as dissection

29

5 things you must explain to a patient before surgery to ensure he gives informed consent?

Disease with natural evolution
Treatment options, indications
Surgery
Risks
Answer questions

30

Previous AVR mechanial and now with MS and TR

How to do a redo for MVR.

1 thing that will complicate surgery on top of difficult sternal reentry

4 heart incisions to access MV and TV

MVR with aortic prosthesis in place

LA
Transseptal standard
Extended transseptal (Guiraudon)
Vertical transseptal (Dubost)

31

Pt is 2 vessel disease and doing off pump. At 1/4 through anastomosis on LAD you develop ST changes and hyoptension.

What are 2 options.

Shunt
Change position
Ballon pump
CPB

32

Associated anomalies with TOF

1) ASD
2) PDA
3) Rt Aortic arch
4) Multiple VSD
5) Persistence LSVC
6) AVSD

33

List 5 cardiac abnormalities associated with TOF

PDA
ASD
MAPCAS
PA stenosis
Aberrant coronary anatomy
Additional VSD

34

What are risk factors for PA rupture

1) PHTN
2) Anti-coagulation
3) Overinflation of the balloon
4) Inflation of the balloon with fluid rather than air
5) very distal balloon positioning
6) Anti-coagulation

35

What is managment of PA rupture

b. management
1) maintain airway
2) Isolate bad lung with double lumen ETT or ET with bronchial occluder
3) keep pt in lateral position with bad lung down
4) brochoscope to identify the site of bleeding
5) reverse anti-coagulation
6) If not resolving with conservative Mx will need pulmonary angiogram and embolization
7) If embolization fails, thoracotomy with resection of the effected segment

c. mortality
40-70%

36

The day after on pump CABG, with TEE monitoring, patient develops resp failure, leukocytosis, fever and pleural effusion. pH of pleural fluid is 7.2

What is diagnosis
Initial management
Surgical managment

Esophageal perforation

Chest tube, NPO, NG, Barium swallow, Broad spectrum Abx, CT thorax

Thoracic surgery consult, debridement of esophageal tear, primary closure of mucosa, sub mucosa, adventitia

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