Random Lecture Notes Flashcards
What are the guidelines for primary prevention of CVD?
Assess risk (10 yr ASCVD risk)
>5%-7.5% (borderline) may require statin.
7.5%-20% (intermediate) if risk and enhancers favor statin, add mod-intensity.
>20% (high risk) requires high-intensity statin.
Emphasize adherence to healthy lifestyle.
High-intensity statin if LDL >190.
Moderate-intensity statin if DM and >40 yrs old.
When assessing CVD risk, what score is the best test in predicting CAD event?
Coronary artery calcium score.
>100 increases risk.
Can modify risk upward for borderline patients who want to avoid statin.
Calcium score >100, what med should be added (other than statin after risk assessment)?
Aspirin.
Benefit more pronounced if calcium score >400.
If a patient is getting risk assessed for coronary disease, and their calcium score is 0, what does that do to their risk classification?
Modifies risk downward.
Best test to predict low risk.
Venous cannula is kinked. What immediate complication occurs?
Low volume in the venous reservoir.
On CPB. Kink in the centrifugal pump. What does this cause?
Low BP
The venous line of dual stage cannula is chattering. What is happening?
What do you do?
It’s hypovolemic - the wall of the vein/atria is collapsing and flapping around it.
Turn down the venous suction.
“Make a fast change.”
Can also try repositioning.
Which cannula in the CPB machine is only one way?
Pump suckers.
Arterial can go both ways, venous can go both ways.
What is the purpose of a L side vent on CPB?
Drain the pulmonic circulation.
Prevent distention of the heart.
What cause of high arterial line pressure can be diagnosed by cerebral oximetry - different readings on left and right?
Cannulation of an aortic arch vessel.
The perfusionist asks if you want to RAP. What will it do to the pump prime volume?
Decrease it.
If BP is ok and not ischemic, you can use blood to displace the crystalloid prime from the pump.
Femoral arterial pressure is usually higher than radial artery pressure when (during CPB run)?
Rewarming.
The further down the arterial tree you go, the more muscular and less capacitance. Normally, BP is higher at the extremities.
What factors determine oxygen delivery while on CPB?
Hgb level, cardiac index, FiO2 on MV.
Pink or red tinge in urine is a consequence of what on CPB?
Cardiotomy suction, shear stress on RBCs, air-blood contact, time of exposure to CPB machine
Trace a RBC’s path through the CPB machine.
Patient, venous line, venous reservoir, centrifugal head/pump, oxygenator, filter, arterial line, patient.
Coming off bypass checklist?
Temperature.
Rhythm and rate: shock if needed, speed up if slow; best to worst is NSR, atrial paced, AV paced, then V paced.
Vascular tone.
Lytes, Hgb, ABG should look ok.
SVG patency at 10 years?
50%
How can you expose a lateral OM for a distal anastomosis?
Retracting the heart to the right, place sponges on the lateral heart, twisting the heart, using a positioning or suction device.
When placing a coronary sinus catheter for retrograde plegia (not directly), how can you confirm you’re in place?
The catheter faces the L shoulder and doesn’t move side to side.
There’s ventricularized pressure of dark blood returning.
Palpate the back of the heart.
TEE.
What is the tradeoff in mechanical vs bioprosthetic valves?
Mechanical - bleeding and drug interactions w/ warfarin. Ticking. ESRD pts probably shouldn’t get mech valve.
Bioprosthetic - reoperation.
What are some indications for short term percutaneous non-IABP MCS?
- Very high-risk PCI w/ a large territory and EF <35.
- Acute MI c/b acute MR or VSD w/ cardiogenic shock.
- Advanced RHF or LHF during stabilization of critical pts while making decisions about longer-term support - “bridge-to-a-bridge.”
- High risk perc valve procedures if needing support.
- Support for pts undergoing EP procedures w/ severe LV dysfx and who may not tolerate sustained VT/VF.
- Medically refractory arrhythmias assd w/ ischemia.
- Acute heart txp failure or RV failure.
What pathologies (cardiac or otherwise) may be preclude patients from MCS?
AR Metallic aortic valve Aortic aneurysm or dissection Severe PAD LV or LA thrombus Bleeding diathesis Uncontrolled sepsis
Explain the role of SVI in the evaluation of AS.
What scenario would this come up?
What must be controlled before making this measurement?
Used to diagnose severe low-gradient AS. OR paradoxical low-flow severe AS.
The scenario would be a patient who presents with exertional dyspnea/decreased exercise tolerance and is found to have an AVA <1cm or AVAi <0.6.
BUT the gradients aren’t severe (mean <40, V <4), AND they have EF >50.
The suspicion arises when the LV wall is thick, or the chamber is small, or there is restrictive diastolic filling. These patients have a normal EF, but the stroke volume is too low to generate a gradient/velocity. Use the SVI to identify this group.
Make sure BP is <140.
In the workup of AS, who would be considered prohibitive for SAVR, but good for TAVR?
Prohibitive for SAVR: STS ≥8%, ≥2 frailty measures, ≥2 organ system failure, procedure specific impediment.
Good for TAVR: Life expectancy w/ acceptable QoL >1 yr, suitable anatomy after workup.
