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List 4 advantages of TEVAR over open repair for traumatic rupture

avoidance of a thoracotomy
avoidance of the systemic effects of cardiopulmonary bypass
avodiance of spinal ischemia
avoidance of cross-clamping
avoidance of single lung ventilation
should result in decrease in perioperioative mortality and complications

page 1149 cohn


List 4 possible procedural challenges with TEVAR for traumatic tear repair

Adequate proximal landing zone (need 1.5cm for seal)
heavily calcified arch
small radius of curvature
access related complications--too large of graft delivery system

page 1151


70 year old patient with type B dissection

List 3 management principles

What is risk of death over the next 3 years if patient is discharged home

surgical management 50% mortality with 30% in medical

control the heart rate and blood pressure to decrease shear stress on aorta and limit expansion of the false lumen and propagation of dissection
Pain control
follow-up clinical assessment at 3 and 6 months

Medical management has a 1 year survival rate of 85% and a 5 year 71%

page 1015


patient post acute anterior MI can't wean off CPB--place an LVAD

patient become cyanotic (shunting), which is the most likely cause

List 3 intracardiac lesions to repair during LVAD insertion

Most likely cause is a PFO

Important anatomical abnormalities include
1. PFO
2. Aortic insufficiency
3. repair tricuspid valve
4. removal of LV thrombus to prevent systemic embolization

page 1364


Severe asymptomatic aortic stenosis

What is risk of mortality over the next year

What is likelihood of developing symptoms in the next year

In AS what is the rate of decrease in the valve area per year

symptomatic patients have a 10%/year sudden death average survival 3 years with symptoms

Asymptomatic have a less then 1% rate of sudden death per year

overall 7% of asymptomatic patients with AS experience death or AVR 1 year after diagnosis

The average decrease in AVA is 0.12cm2/year resulting in a average increase in transvavular gradient of 10 to 15mmh

page 696 cohn


Doing a study to look at risk factors for stroke after cardiac surgery. You create a receiver operator curve to test your model

What is on the x0axis and the y0axis of graph

What does the C-index mean

The C-index is 0.59, the assistant says that means it it is a good model.
Is this true or false
Explain your answer

X axis : false positive or 1- specificity
Y axis : true positive or sensibility

C index is area under the curve

It will vary between 0.5 to 1

An index over 0.7 mean an acceptable correlation


What determines the classification of double outlet right ventricle?

List the 4 types of DORV

DORV-50% rule, that a heart is termed DORV if in addition to the PA more then 50% of the aorta arises in the RV. No aorta-to-mitral valve continuity

The classic pathologic classification of DORV centers on location of VSD.

1. DORV with subaortic VSD
2.. DORV with subpulmonic VSD
3. Doubly committed
4. Non committed


53 year old pt, diabetic, want to do arterial revascularization, has previosuly had saphenous vein stripping (LAD 80%, RCA 60%, Circumflex 90%)

List conduits to use and where you would put them

Risk of mediastinitis in a diabetic patient

left internal thoracic artery

right internal thoracic arery

Low rates of sternal infection with BITA about 1.7% (if skeletonized...) overall about 2.6% in diabetics when skeletonized. A pedicle harvest is about 4.5%

Diabetic pts derive the greatest benefit as it was shown to be 10% in non skelentonized vs 2.2 in skeletonized

cohn book...


Questions about plavix...
What class of medication is plavix and list 2 other drugs in the same class

What is the mechanism of action of plavix, include the mechanism and receptor it acts on

List 3 ways to decrease blood loss due to plavix, either pre-operatively or intra-operatively

Plavix is an adenosine diphosphate (ADP)inhibitor . It blocks platelet ADP P2 Y12 receptors inhibiting platlete activation by prevetning ADP mediated responses, decreasing

Two other drugs in same class

Prasugrel (EFFIENT)
congrelor (intravenous)

page 336 cohn


Patient found in dumpster at -11 degrees. Patient is getting CPR and is cold

List 4 interventions to rewarm other than CPB

Give two cannulation and perfusion strategies to rewarm with CPB

Warm blanket
Warm IV fluid
Hot gastric lavage
Hot peritoneal lavage

Cannulation fem-fem, arteriovenous because CPR
Fem- jug, venovenous only if perfect hemodynamics


List 3 classes of drugs that are basis of transplant immunosuppression

Calcineurin inhibitors (cyclosporine and tacrolimus)--inhibit IL-2
Purine synthesis inhibitors (MMF, Azathoprine)
corticosteroids, which inhibit cytokines (IL1- TNF)
Monoclonal antibody that binds to CD3 receptor on T-lymphocytes (OKT3)


What is mechanism of action of factor VII

Two things that must be done before giving factor VII

Most likley complication

recombinant activated factor VII complexes with all avilable tissue factor to activate factor X directly and induced thrombin generation. Leads to formation of a tight and stable fibrin plug that is resistant to early fibrinolysis

most likely complication is thrombosis

two things that must be done?
2. correct acidosis

page 335


Patient 3 hours post transplant, swan shows low CI, CVP 25, wedge 6

List 2 ventilator strategies that will help this patient

List 3 classes of IV medications that are indicated in this patient

Phophodiesterase inhibitor
Inhaled nitric oxide

Correct hyoxia
avoid hypercapnia


70 year old pt with 16 year history of smoking, diabetes, presents with heart failure, ETT whos EF 25%, 2:1 block with variable 3rd degree block. Cath shows not revascularizable.

List 3 possible pacing modes for this patient

List 2 other intestigations that will help you decide on the best pacing mode for this patients

What pacing mode should be chosen for this patient

echo, ecg, viability


CANMED question: JW signed refusal of transfusion preop. Now needs transfusion to survive. When meeting the family what 2 CANMEDS roles could you provide and list 3 key elements for each



List 3 pathophysiological mechanims and an example for each that lead to secondary tricuspid regurgitation

annular dilation
rv infarction
primary PHTN


STEMI--mildy elevated trops, cath showing severe left main and 3VD. Don't want to PCI. Cannot operate now.

List 3 constructive things you can do to help this patient before going to OR

Insert IABP
Anticoagulation treatment
dual anti-platelet therapy


List 3 ideal indications for aortic valve repair (exam wording) and 3 most common aortic valve repair techniques

young age
normal leaflet tissue
no calcium, no fenestrations
No stenosis


List 4 characteristics of a patient that would most benefti from CRT based on randomized trials

QRS> 150
low EF 35%
no structural/IHD


Elderly pt with chronic arch aneursym
List 5 clinical findings that may lead you to operate on this patient

List radiological findings that would make you operate

Connective tissues disorder
family history- rupture/death

absolute size (5.5)
annular rate of growth (0.5cm.year)
ration (aortic crossectional area/BSA)


Patient with an ICD
List 3 most common reasons for inapporpriate shock and a managment stategy for each

atrial arrhythimia**
t wave oversensing
lead fracture


Apart from echo and LV angiogram list 4 clinical features that will differentia post infarct VSD from post MI Mitral regurgitation

Loud apical holosystolic murmur that radiates to axilla
frequently an inferior MI on ECG
unlikely to have a conduction abnormality (this is more a VSD)
Right heart cath shows elevated PA pressure with a V wave reaching 40mmHg
Mixed venous saturaton is <50%
Absecene of a an oxygen step-up in the pulmonary artery is a strong evidence against Post MI VSD
page 633 cohn


Apart from neoplasm, ischemia, and cardiac surgery, list 6 etiologies of constrictive pericarditis

Infection-viral (cocsackie/fungal/tuberculosis
Drugs (procainamide, hydralazine
tumor (mesotheioma)
Mediastinal radiotherapy (dose dependent)
previous cardiac surgery


patient with LVEF 60% with calcified aortic valve AVA 0.8 and gradient of 20mmhg. Compare to a patient of AVA 0.8 and a gradient of 40mmHg

List 2 ways they differ hemodynamically

List 2 ways they differ demographically

A patient with low gradient AS will do _____ with medical theraoy ______ with surgery

Hemodynamics : less LV compliance and reduce stroke volume
Demographics. : older, female, HBP

Worse with meds
Better with surgery


How do you see viability with

Contrast MRI



MRI: LGE. Gadolinium uptake greater then 50% there is no viability
PET: perfusion and metabolism evaluation. Perf + Met + is viable. Perf - met + is viable. Perf - met - is dead
SPECT: thallium injection. Capitation is viability. Uptake is directly related to viable myocardium. The more uptake then greater the viability.


List 4 indications for operation in prosthetic valve aortic endocarditis

Congestive heat failure
paravalvular abscess
recurrent systemic embolization
persistent sepsis despite appropriate antibiotics
acute valvular dysfunction
high risk infection (staph or fungus)


List 6 echocardiographic findings of ischemic mitral regurgitation

Hypocontractile segment
Systolic restriction of leaflet
Annular dilatation
Lateral displacement of papillary muscle
Ventricular dilatation
Centra jet
Coaptation below the annulus


What are the component of the CHADS2 score

What is recommended anticoagulation at CHADS 0, 1, 2, >2

Congestive Heart Failure
Age > could be 75*
Diabetic Mellitis
Prior stroke (CVA) x 2
0 = none or ASA
1 = ASA or warfarin
2 warfarin


Post op day 12 from transplant, biopsy on day 7 shown no rejection. Pt becomes hypertensive, nurse gives nifedipine, 2 hours later patient come sycope and hypotensive and 37.9

3 possible causes

what 3 investigations would you perform


Do sepsis work up, repeat biopsy and order echo


LVAD--increased velocity on echo at the inflow

What are 3 possible causes and briefly describe strategy for each cause



FFR-how its measured, how its reported, significant value

Is a measure of pressure proximally and distally to the lesion in question.

An FFR of 0.75/0.80 or less identifies a hemodynamically significant lesion.

Routine use of FFR to ensure the necessity of PCI reduces the risk of adverese events both immediately and at 1 year.

The ratio is calculated after the administration of adenosine.

page 471


List 4 lesions associated withe corrected transposition (L-TGA)

Congenitally corrected transposition involves discordance of the atrioventricular arterial connection and discordance of the ventricular arterial connection. So there is double discordannce

Most commonly associated with

pulmonary stenosis
dysplasia of the tricuspid valve
conduction abnormalities (heart block)
page 20003 sabiston


Newborn develops severe acidosis.

List 4 ductal dependant lesions that will require PGE1 for restoration systemic flow through the dectus

critical coarctation
hyposplastic left heart
interrupted arch
aortic stensosis


Air embolism on CPB

List 6 intra-operative strategies

List 2 post operative strategies to mitigate cerebral damage

Stop CPB
Clamp lines
Inform team
Tredelenburg position
Remove arterial cannula
Suck air from hole in aorta
Retrograde cerebral perfusion
Give steroid and mannitol
Go back to normal CPB and cool down to 20
Maintain high perfusion pressure
Oxygen 100% for 6 hours postop
Consider hyperbaric chamber


List 4 findings on echo that favour decision to operate on asymptomatic severe MR give thresholds

Ejection fraction < 60%
Left ventricular end systolic dimension of > 45
pulmonary hypertension---systolic pulmonary pressure at rest of > 50mmHg
Left atrial dilation (volume index >60 ml/m2 BSA
high likelihood of repair and flail leaflet


2 days post cardiac surgery with TEE...Fever subcuta air, mediastinal air, pleural effusion

what is likely diagnosis

3 immediate stops in treatment

esophageal perforation

Pleural drainage


LVAD implanted for post caridiotomy cardiogenic shock 5 days later and patient now has high bilirubin and jaundice. List 3 etiologies

RV dysfunction


Retrograde cerebral perfusion

List 3 advantages and 1 disadvantage

air embolism

negative: poor nutrient?


Axillary cannulation for aortic dissection
List 4 advantages and 3 disadvantages

antegrade cerebral perfusion
less manipulation
continuous flow

difficult dissection
assumption of intact COW


75 year old AVA 0.6, few comorbidities, List 5 general things you should discuss with the patient before surgery

prosthetic choice
expected post op course
alternative therapies
anticipated outcomes
answer all questions


List 3 possible negative side effects of HOC3 during CPR

increases CO2
exxacerbates acidosis

*in Chon chapter*


What are 4 classifications of TAPVR



Redo coronary surgery with patent LIMA-LAD, 3 vein grafts and 2 are disease

List 5 possible adverse events that you will discuss with the patient pre-op

Bleeding and transfusion
Renal failure and dialysis


List 4 indications for congenital VSD closure in adults

Congestive heart failure
Aortic insufficiency
Previous endocarditis


Compare Barlow vs FED valve (5 statements for each)

Younger patients
Long history of MR
entire valve is thickened and prolapsing/billowing
excess leaflet tissue
Chordae are elongated
Papillary muscles maybe elongated
Annulus is dilated and occasionally calcified
Generalized myxomatous degeneration

FED- thin, normal tissues, < 2 segments, thin, short history


What is Dagbitran

Venous thrombolsim post hip
prevention of stroke in nov-vavlular
Direct, oral thrombi inhibitor

(Re-align - Dabigtran)


Patient presents with low CI, and high CVP. You suspect right heart failure.

What is differential

Three intravenous drugs used to treat

Reduce RV afterload : IV milrinone
Increase coronary perfusion pressure: IV noradrenaline
Increase RV contractility: IV milrinone and adrenaline


4 treatments/medications to decrease elevated panel reactive antiobiotics (PRA) pre-transplant

Patients with elevated PRA levels---do a prospective cross match (to determine whether a donor-specific antibodies that threaten the allograft are present. Could do a virtual cross matching.

4 treatments
1. Plasmaphresis
2. Intravenous immunoglobulins
3. rituximab
4. mycophenolate mofetil
5 cyclophoshamide

page 1303 Cohn

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