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Flashcards in Previous exam 2011 Deck (66):

List 4 indications for CABG in stable

3vd (class 1)
left main (class 1)
2vd with proximal lad (class 1)
2vd without proximal LAD, with significant myocardial ischemia (IIa)
1vd with proximal LAD (IIa)
1 or more significant stenosis with unacceptable angina (I)


What are indications for MVR in chronic severe MR

Symptomatic patients with LVEF > 30% and LVESD < 55mm
Asymptomatic with LV dysfunction LVESD > 45mm and/or LVEF < 60%

Class IIa
Asymptomatic with preserved LV function and new onset AF or pulmonary hypertension (Systolic PA > 50mmgh)
asymptomatic pts with preserved LV function, high likelihood of durable repair, and LVESD > 40 mm


What are indications of surgery in an adult with Ebsteins anolmaly

Cardiothoracic index over 65
Desat under 90
Severe TR with symptoms
Stroke or TIA


Partner A

TAVI vs Surgery
Outcome – death from any cause 35 vs 33.9%
Stroke + TIA – increased with TAVR 11.2 vs 6.5% at 2 years
Increased major vasc complication at 2 years 11.6 vs 3.8%
More paravalvular leak in TAVR


Partner B

TAVI vs med thereapy
AVA 0.8, NYHA class II or more, inoperable
Inclusion = inoperable i.e. deemed inoperable by 2 surgeons/1 cardiologist (STS risk of morb/mort >50%,
Exclusion – Bicuspid valve, MI, 3+ MR, annulus <18 or >25, LVEF <20%, recent TIA stroke, sever CRF
Death from any cause = 43% vs 68%, rehosp 35.0 vs 72.5%
STS >15%, no difference in outcome (~ 50% vs 60%)
Class I or II 83.1% vs 42.5%


Describe the syntax 3 year results

1800 patients, 85 centers, LM or 3vd
Decreased MACCE with CABG (20.2 vs 28.0%)
Revasc 10.7 vs 19.7
MI 3.6 vs 7.1%
Cardiac death favors CABG 3.6 vs 6.0%
Composite safety (death/stroke/MI) 12.0 vs 14.1% no difference
Stroke 3.4 vs 2.0% (p=0.07)
LM – MACCE not different 22.3 vs 26.8%
3vd – MACCE favors CABG 18.8 vs 28.8%
MACCE increased with PCI in entire cohort and 3vd with sntax score >22, in LM with syntax >33
LIMITATIONS – inadequately powered to detect low frequency evetns (stroke, MI), short term followup for now, LM and 3vd not prespecified
Worse outcomes with 3vd, syntax >22


Describe the STITCH hypothesis II, limitations, end-points

1000 patients
CABG + med Rx vs CABG + SVR + med Rx
Followup = 48 months
Outcome – primary = Death from any cause and hospitalization for cardiac cause. 59% vs 58%
Limitations: inadequate volume reduction, selection bias (paients that were thought to benefit most were not randomized)


Describe the PREVENT IV results

Saphenous vein graft patency treated with edifoligide or not, at 12-18 months
Non-randomized comparison of ESVH vs Open
Decreased patency (46.7 vs 38.0%)
Increased MI, death, repeat revasc (20.2 vs 17.4%)
Increased Death or MI (9.3 vs 7.6%)
Increased death (7.4 vs 5.8%)


Describe the ROOBY trial endpoints

2203 patients, 18 VA medical centers
minimum 20 OPCAB per surgeon
Primary - Short term: composite death and complicaitons within 30 days (reop, new mechanical support, cardiac arrest, coma, stroke, renal failure)
Long term: at 1 year - Composite death, repeat revac, nonfatal MI,
Secondary – completeness of revasc, graft patency, neuropsy, use of major resources
Short term – no difference (7.0 vs 5.6 %)
Long term – against OPCAB 9.9 vs 7.4%, increased cardiac death
Decreased graft patency


List the classification of anti-arrhymtics and list one example of each

I. Inhibit sodium channel. Lidocaine
II. Inhibit beta receptor. Metoprolol
III. Inhibit potassium channel. Amiodarone
IV. Inhibit calcium channel. Verapamil


Name 2 antiepilpetic medications

Valproic acid (usually 250 to 750 mg)
Dilantin (Phenytoin)


List 3 methods of cerebral protection

Deep hypothermic circulatory arrest
Antegrade cerebral perfusion
Retrograde cerebral perfusion


Describe pathophysiology and treatment for vasoplegic syndrome post operatively

Activation inflammatory cell with CPB, release cytokines
Support: vaso, levo


Post op MRI is needed, what devices are compatible and what are not?

Coronary stents are all safe
Heart Valve prostheses are safe
Metal wires, medistinal clips, temporary pacer wires ok

ICD, and PPM are not safe.


CTA is needed pre-operatively. What hinders good visualization



What are contraindications to TEE

Recent oesophageal surgery
Oesophageal diseases ( neo,fistula, stricture, varices)
Upper GI bleeding
Cervical instability


FFR definition, mechanism, and condition used

Pressure distal to lesion divide by pressure before the lesion at maximal dilatation (adenosine)

Fame < .80. Defer < .75 for signification

For lesion with unclear severity


What are cellular and sub-cellular changes causing ventricular reverse remodeling after VAD

Reduce cellular length, diameter and mass
Increase beta 1 receptor density
Reduce inter acellular calcium


What are the most common malignant cardiac tumors? What are contraidicatoins to repair



What are contraindications of Ross Procedure

Connective tissue disorder
Pulmonary valve anomaly
Aberrant coronary artery over RVOT
Autoimmune disorder


What is classification and grading of DORV

Location of VSD

Double comitted


What are options for treatment of right sided heart failure after transplant

Optimize the fluid balance
decrease PC@ < 40 mmHg
treat acidosis
Increase RV contractility
Keep high perfusion pressure
Make need to have atrial kick (atrial pacing)
Pulmonary vasodiltor


Management of a TOF

< 3 months do a BT shunt if symptomatic
if Symptomatic and > 12 week you could do a primary repair
Asymptomatic do a primary repair at 6 to 12 months
If LAD cross RVOT do a BT shunt and then full repair between 3 to 5 years


What is surgical management of TOF

Median sternontomy
Trans atrial approach
Patch the VSD with avoiding the area of the conduction system
resection of the muscular bands and pulmonary valvotomy
possible RV to PA conduit/transannular patch


What is management of TOF tet spell

increase SCR

beta blockers are used for prevention


Post pump pancreatiis. What is Ransons criteria

Age > 55
WBC > 16 000
BG > 200
LDH > 350
AST > 250

at 48 hours

HCT fall > 10%
BUN > 8 increase
base excess
low arterial PO2
low serum ca
estimated fluid sequester > 600 cc


What are principles and management of post infarction septal rupture

Expeditious establishment of total CPB
mod hypothermia
meticulous myocardial protection
Trans infarvation approach to VSD
Trimming of LV margins of the infarct back to viable myocardium to prevent delayed rupture of the closer
conservative trimming of the RV
Inspection of the papillary muscle, possible replacement of MV
Closure of the VSD without tension
Closure of infarcetectomy with out tesnion and use prosthetic material
Buttress suture lines with pledgets or strips of felt to prevent from cutting through muscle.


4 year old with ASD, classifcaiton, work-up and why and when would you fix

Secendum ASD (80%)
Sinus venosus ASD (5-10%)
Coroanry sinus ( ASD)
Premmium ASD

ECG/CXR/ECHO/Cath-calculate shunt and assess other cardiac anomlaies

when to fix if 4 year old
ASD with symptoms
ASDY asymptomatic withe RV overload
QP:QS> 1.5
Associated PAPVD
Associated tricuspid or mitral valve disease


Benefits of ASD closure in child

Increase life expectancy
Increase exercise tolerance in future
Avoid late complications
A Fib
RV failure leading to cyanosis
pulmonary hypertension
paradoxical emboli
problems during pregnancy


What does surgery for Ebsteins Anomaly involve

Tricuspid valve repair or replacement
atrial septal defect closure
arrhythmia surgery
and likely CABG


Name adult congenital repairable lesions

Fotan Revision
Right Ventricular outflow tract reconstruction
Atrial Septal Defects
Ebsteins's Anomaly
Left ventricular outflow tract reconstruction
Arrhythmia surgery


“case scenario”: patient with multiple devices and prosthesis needs MRI for seizures? List the MRI - safe and MRI – unsafe prosthetics.



ECHO grades of diastolic LV dysfunction and findings for each grade

1)Impaired relaxation, E/A reversal
2) Pseudonormal – Elevated LAP, E/A normal but slope changed
3) Reversible restrictive – reversible with valsalva
4) fixd restrictive diastolic dysfunction


“case scenario: post op seizures ”: List 2 IV anticonvulsants and doses

Dilantin – 1g IV
Midazolam – 2 mg IV


List five oral anti-failure medications with mechanism of action

Loop diuretics
Spironolactone – aldosterone antagonist, inhibists sodium potas exhanige in dital convoluted tubule
Digoxin – inhibits sodium potassium ATPase thus increasing intracellular Ca


case scenario: malignant effusion” A- define Kaussmal sing / Pulses paradoxus B- six signs and symptoms of tamponade

Kussmaul – increased JVP with inspiration
Pulsus paradoxus – decrease of BP by 10mmhg with inspiration
Muffled heart sounds, hypotension, increased JVP, fatigue, dyspnea, decreased cardiac output


Epidemiology : test of significance/ meta-analysis limitations

Meta analysis limitations –
publication bias, more positive studies get published
Search bias, miss studies due to incomplete search of the literature
Selection bias, dependent upon person choosing which studies to include (should be more that one person)
Heterogenity of individual studies


Indications for OR in Ebsteins

Limited exercise capacity
increasing heart size (ratio >65%)
cyanosis (O2 sat <90%)
severe TR with symptoms


list 4 short term MCS / what is the best current long term MCS / name and design of trial (HM2 trial)

IABP, impella, tandem heart, ECMO (biomedicus)
Heartmate II LVAD had RCT and FDA approval
Heartmate II Trial design: RCT, 2:1 vs heartmate XVE (134 VS 66)
Improved survival free from disabling stroke, and reop to repair/replace device at 2 years
46% vs 11%
survival 58 vs 24%


Mechanism and histology of micro re-entry in a fib

shortened atrial refractory period, atrial tissue heterogeneity, electrical remodeling leads to micro reentry. Need trigger, substrate
histology – atrial fibrosis ,decreased muscle mass


case scenario: post op hemodynamics” SIRS/mechanism/markers/ treatment (three iv medications)

cytokine release, WBC activation, during CPB
markers = increased WBC, CRP, ESR
Meds to treat what? Levophed, methylene blue, inotropes?


List 8 steps to air embolism

Stop pump
Clamp lines
Steep trendelenberg
Aortic cannula in SVC with proximal clamp, at 300-500cc/min until no more air, start cooling
Aspirate air from aorta
Aortic cannula in aorta and cool to 18 degrees
Steroids, barbiturates
Complete cardiac intervention
Postop monitoring for seizures
Consider hyperbaric oxygen chamber
Discuss with family


Four energy sources for MAZE

RF (monopolar vs bipolar), Cryo, microwave, HIFU, laser


Milrinone; mechanism / receptor / secondary messenger

Inotrope, PDE-3 inhibitor, prevents cAMP degradation -> increased PKA -> increased Ca channel phosphorylation -> -> increased Ca influx -> increased myocardial contractility


What are indications for Ascending aorta surgery

>5.5 cm, asymptomatic
CTD 4.0-5.0
Growth >0.5 cm/yr
>4.5cm undergoing aortic valve surgery
symptomatic aneurysm


What is definition of threshold and options when failure to shock occur

Threshold = minimum amount of energy required to reliably depolarize the chamber being tested
Failure to shock – reposition, change vector (coil vs box), increase voltage, change algorithm


Class I indications for AICD

Following sudden cardiac death due to VF or HD instability with VT after excluding reversible causes
Structural heart disease and spontateous sustained VT
Syncope of unclear origin and inducible VF or VT on EPS
LVEF <35% due to MI, 40 days post MI, NYHA II-III
LVEF 30%, prior MI, NYHA class I
NSVT due to prior MI, LVEF <40%, , VF or VT on EPS


5 things to manage a borderline donor heart

Thyroxine, cortisol, , vasopressin, insulin, (dopamine) (sabiston, dopamine not listed)


Factors that influence CT angiogram

Heart rate, heart rhythm, calcification


Class I indications for Tricuspid valve surgery

Class I – Severe TR undergoing mitral surgery
IIa – severe symptomatic primary TR
Replace if severe secondary TR if valve abnormal not ameable to repair
IIb – less than severe TR undergoing mitral valve surery with PTHN or annular dilatation


What is Wilkins Score

Leaflet mobility, calcification, thickening, subvalvualr apartus thickening


List ways for cerebral protection during aortic surgery

ACP, RCP, steroids, barbiturates, packing with ICE, NIRS, BIS


A- Causes for culture negative endocarditis

B- indications for surgery in IE

a. antimicrobial therapy, fastidious organism, non-bacterial endocarditis

b. Severe AI/MR with CHF or increased LVEDP, Virulent organism, abcess/fistula/heart block, recurrent emboli, positive culture despite ABx, >10mm vegetation


Three hereditary connective tissue disorders associated with arch aneurysms

Marfan, Loez dietz, ehlers danlos


List VW classification and examples of each

Class I – Na channel blocker, prolongs AP, Lidocaine
Class II – BB, blocks beta adrenergic receptors, metoprolol
Class III – potassium channel blocker, amiodarone
Class IV – CCB, diltiazem, verapamil


Describe FFR

Ratio of pressure distal and proximal to a coronary lesion (FFR = prox/dist) with maximal vasodilation of the distal coronary bed, physiologic measurement of coronary stenosis after coronary stenosis to before
Indication – during coronary angio with stenosis of unclear significance

List the two studies and the ratios used

Defer = <0.75, Fame = <0.80


List 3 outcomes with TTD

Pulsatility index (measures resistance), Flow (ml/cm2), % diastolic flow


List complications with calcium removal from the annulus

VSD, heart block, mitral leaflet perforation, annular perforation, calcium embolism


“Case scenario : traumatic aortic tear” : TEVAR; Advantages & Limitations

Advantages: Shorter operative time, no CPB, decreased risk of bleeding with concomitant injuries, decreased paraplegia
Disadvantage: requires long-term followup long term outcomes unknown, limited availability


“case scenario” : Causes of RV dysfunction after Bentall procedure

Coronary button problem
Air embolism
Inadequate myocardial protection


Two features of the most common morphology of BAV

Left-right cusp fusion ?
1 raphe


4 types of vascular rings

Double arch
Right arch with aberrant left subclavian, left ligamentum
Left arch with aberrant right
Circumflex aorta
Pulmonary artery sling


“case scenario”: patient with multiple devices and prosthesis needs MRI for seizures? List the MRI - safe and MRI – unsafe prosthetics.

Starr-Edwards ball cage valve (although no report of complication
1 MRI safe PPM (Medtronic)


What are ways to deal with elevated PRA in transplant

Donor-recipient crossmatch


Indications for VSD closure in adults

Class I
1) ‘significant’ VSD (symptomatic; left ventricular [LV] volume overload; deteriorating ventricular function due to volume [left ventricle] or pressure [right ventricle] overload, pulmonary-to- systemic flow ratio [Qp:Qs] of at least 2:1; pulmonary artery systolic pressure greater than 50 mmHg). (Level B)
2) Sgifnicant RVOT obstruction
3) perimembranous or subarterial with more than mild AI
4) Severe pulmonary HTN

Class IIa
History of endocarditis, especially recurrent
To prevent paradoxical emboli with transvenous pacing


Indications for CABG in stable angina

left main stenosis
left equivalent (proximal LAD and proximal circumflex)
Three-vessel disease
Two-vessel disease with proximal LAD and EF < 50% or demonstrable ischemia
Disabling angina refractory to medical therapy
One or Two-vessel disease without proximal LAD but with a large territory at risk and high-risk criteria on noninvasive testing

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