TSRA Clinical Scenarios - Adult Cardiac Surgery Flashcards

Question

After a cardiac surgery pump case w/ retrograde cardioplegia, the myocardium is slow to regain activity. What should you check?

Answer 1

Check retrograde catheter and/or that the balloon is down, in order to allow for adequate coronary sinus flow.

Answer 2

Arrested myocardium is getting perfusion. Check the cross clamp and that the root vent is on. There could be collaterals. If unable to ID cause, monitor for electrical activity, and consider cold topical saline, cooling the patient to mild hypothermia (32 C), reducing flows as tolerated, or increasing frequency of cardioplegia administration. Can deliver some plegia through vein graft once suturing complete.

Answer 3

CPB, clamp, and arrest with antegrade if possible or direct if retrograde was because of inability to do antegrade. Repair the hole directly with Prolene or a pericardial patch.

Answer 4

Access - plegia cannula placement, kinking Collateral - clamp not across, drainage poor, L SVC, vents/suckers; hypothermia? Myocardial mass - hypertrophy may require more plegia or more hypothermia

Answer 5

Innominate vein.

Answer 6

Pack the area and close the sternum with penetrating towel clamps. Peripheral CPB. Put pump suckers in the injured field. Reopen and dissect vein length for assessment and attempt at closure w/o tension. Primary vs pericardial patch repair. If cannot repair, divide and oversew. If too lateral, may need trapdoor to expose - above clavicle and at 3rd rib space.

Answer 7

Tamponade it. Attempt IVC and aortic cannulation for CPB. Need vacuum venous drainage to prevent air lock. Pump suckers near SVC to clear the field. May be possible to cannulate through the injury. Consider placing pump sucker into azygous vs ligating azygous if you can't see. May need to dissect more proximal and place a Rummel tourniquet vs vascular clamps. Once controlled, may need primary vs pericardial patch. Be prepared for phrenic nerve injury with all the dissection around the SVC.

Answer 8

Venous injury, often in the SVC. Cannulate the groins and start CPB vs open to relieve tamponade and compress SVC while achieving CPB. Open and decompress the heart. Identify the injury, dissect proximal and distal, control it, and repair primarily vs w/ patch.

Answer 9

Femoral venous injury - could be retroperitoneal (likely iliac) or intra-abdominal. Goals: identify injury, cannulate beyond repair. Venogram if available. Chest is open: can centrally cannulate, otherwise, may need access in contralateral femoral vein. Injury is above iliacs: use fluoro to get wire and cannula above and go on, then open the abdomen and repair the injury.

Answer 10

Give heparin. Emergency median sternotomy. Bicaval cannulate - for the SVC, enter the RA and traverse cannula through injury - will have to use a malleable cannula, not a right angle. Empty the heart. Primary pericardial patch closure.

Answer 11

Initial goals: get venous access and go on CPB. If possible, traverse the IVC cannula through the injury from above. May need a malleable cannula for this. Next goal: get control below the injury or reduce blood flow to the injury. Try to place a Rummel clamp below the injury. If unable - SVC cannula for everything above, suckers to control bleeding in the pericardial well. Get femoral vein to control bleeding from below. Be careful with distance of femoral cannula is to not worsen the injury. Can attempt incising the diaphragm through sternotomy to get exposure. If unable - extend sternotomy inferiorly and convert to RUQ subcostal incision.

Answer 12

Heparin and sternotomy. CPB and arrest the heart. Wide patch repair even if small. Bypass the coronary lesion if during a cath case for coronary disease.

Answer 13

If small, a figure of 8 will fix. If large or uncontrolled, go back on bypass (if you had axillary, can do end to end of previous graft). Decompress the heart, and the PA will decompress. Mobilize the R PA. May need pericardial patch.

Answer 14

May need circulatory arrest. Can cool with the existing cannula if forward flow is okay. May need to establish axillary access. Small aortotomy and local repair.

Answer 15

chest pain at rest, exertional angina not relieved by rest, and new onset of chest pain

Answer 16

exertional angina - predictable, improves with rest

Answer 17

lifestyle modification, statin therapy (LDL goal 70-100), beta-blockade, aspirin, and ACE inhibition (if LV dysfunction, DM, or CKD)

Answer 18

Left main >50% non-LM >70%

Answer 19

< 0.80. Determines hemodynamic significance of the cumulative effect of proximal stenosis. Used to guide revasc in angiographically intermediate coronary stenosis in patients w/ stable angina.

Answer 20

16 segments in the coronary tree. Lesions in this tree are scored. The sum of these scores is the overall SYNTAX score.

Answer 21

>22 is intermediate complexity. >32 is high complexity. The results of the SYNTAX trial revealed that patients with 3-vessel (70%) or L main (50%) disease benefited from CABG over PCI.

Answer 22

Gated cardiac CT

Answer 23

They are obtained in preop CABG pts w/ EF <35%. They can predict an improvement in EF postoperatively, but this did not translate into a survival benefit. IE it should not be used as a way to rule out low EF patients for CABG over medical therapy.

Answer 24

Activity limiting symptoms despite maximal medical therapy. Active patients who want PCI for better QoL compared to med therapy. Anatomy with proven survival benefit.

Answer 25

1) 3v disease, especially w/ syntax >22 (mod) and low surgical risk. 2) Significant LM disease (50%). 3) Multivessel (>1) w/ either proximal LAD disease, or moderate/high complexity anatomy, or diabetes. 3a) Alternatively, pts w/ relatively well preserved LVEF, low complexity coronary anatomy, and no diabetes - CABG is reasonable. 4) For single vessel disease, pts for whom it is reasonable to prefer CABG include those with a large amount of potentially ischemic myocardium in the LAD distribution, those who are not candidates for long-term DAPT, or those who have failed prior PCI. Patients with ischemic cardiac arrest and anatomically complex disease may also be considered for CABG. ***I.E. Patients with single-vessel not meeting criteria above OR two-vessel disease involving the RCA and L Cx coronary arteries may reasonably choose PCI.*** Europe guidelines add: Multivessel (2+) w/ EF <40. Multivessel (2+) w/ >10% ischemic territory.

Answer 26

Concurrent CABG.

Answer 27

IMA. Left preferred. Right is second choice.

Answer 28

BIMA and radial.

Answer 29

Skeletonized.

Answer 30

Nonelective procedure, age, uncontrolled DM (HbA1c >7), BMI >40, female, COPD, preop hospitalization >3 days, smoking, immunosuppression regimen, radiation mediastinal injury

Answer 31

Preoperatively when they discover CAD is ideal. Within 6 hrs postop after CABG. Continued indefinitely.

Answer 32

Cancel the case. Plavix and ticagrelor (Brilinta) need to be stopped for 5 days preop. Aspirin, on the other hand, can be continued up to the day of CABG and resumed after.

Answer 33

Ideally, P2Y12 inh should be stopped 5 days preop. In an urgent setting, holding for 24 hrs preop will reduce major bleeding. Short acting IV antiplatelets (eptifibatide [Integrillin] or tirofiban [Aggrastat]; both gpIIb/IIIa inh) should stopped 2-4 hrs preop. Abciximab (reopro) should be stopped 12 hrs preop.

Answer 34

Reduce incidence and sequela of atrial fibrillation; of note, preoperative beta blockade does not seem to help.

Answer 35

reduce LDL <100 and achieve at least 30% dec in LDL

Answer 36

LVEF <40, HTN, DM, CKD. Unless otherwise contraindicated. Almost all of them.

Answer 37

blood glucose concentration <180

Answer 38

L Cx or RCA usually if critically stenosed and perfusing LV myocardium - can improve survival and decrease reintervention

Answer 39

Degree of proximal stenosis of the target vessel. Ie how much competitive flow is there?

Answer 40

Prone to spasm in periop period and sensitive to competitive flow. Only use for L side lesions >70% (severe) or R side lesions >90% (critical) - same for gastroepiploic arteries. Give ca channel blocker postop. Total arterial bypass is ideal.

Answer 41

<60, with few comorbidities (no DM, ESRD), severe L sided stenosis, and critical (90%) R sided stenosis (radials work better here). Skeletonize.

Answer 42

II, III, aVF

Answer 43

Inferior leads: II, III, aVF. Or posterior findings: reciprocal V1-2.

Answer 44

Anteroseptal: V1-V2. Anteroapical: V3-4. Anterolateral: V5-6, I, aVL.

Answer 45

Angina symptoms for 20 min w/ ST elevation 2+mm in 2 contiguous leads or new LBBB. Greater risk for transmural ischemia.

Answer 46

Angina symptoms >10 mins. Elevated cardiac biomarkers. ST elevation of 0.5-1mm - or ST depression >0.5 mm - or T wave inversion >1mm More likely to have subendocardial ischemia.

Answer 47

Refractory shock despite initial medical management; post-infarct VSD; acute papillary muscle rupture w/ MR. Often as a very temporary bridge. If the heart’s viability is significantly in question, then an impella may be a better choice as long as the RV works. If biventricular failure, then ECMO would probably be a better choice (may still need Impella or IABP or pressors to empty LV).

Answer 48

Severe AI and PVD precluding placement.

Answer 49

PCI. Door to balloon time of 90 min.

Answer 50

Failure of PCI + coronary anatomy suitable + persistent ischemia. OR MI complication - papillary muscle rupture, post-infarct VSD, LV rupture

Answer 51

>70% in LAD and L Cx

Answer 52

Maximize medical mgmt: heparin, ASA, O2 if needed, IABP if refractory angina or low EF. Urgent CABG (plavix should be stopped 24 hrs). The patient should not be DC home.

Answer 53

PCI of the INFARCT artery. THEN assess if cardiogenic shock. THEN assess for area of infarction. - If stable w/ low complexity - PCI of non-culprit arteries. - If cardiogenic shock - DON'T revasc non-culprit arteries. DEFER this... and determine at-risk myocardium. Non-culprit supplies large area of myocardium? No -> GDMT and heart team discussion. Yes -> Complex/multivessel? - No -> staged PCI. - Yes -> heart team: GDMT w/ staged PCIs vs CABG

Answer 54

CABG. Consider delaying until RV is optimized w/ inotropes, diuretics, or even mechanical support.

Answer 55

If it is wide open, no reason to bypass as it will likely fail 2/2 competitive flow.

Answer 56

Preop: evaluate groins and axilla w/ CT. Consider beating heart CABG - may need fluids, pressors, and shunt. If needed, peripheral cannulation: axillary or femoral. Try to use all arterials, and Y off the IMAs if needed. Where to place proximals? SVG may be anastomosed to innominate, carotid, SCA, R axillary artery, or descending aorta. Be ready to circ arrest.

Answer 57

LV vent via R SPV or LV apex (also Axillary CPB. Retrograde arrest w/ eventual direct ostial vs graft plegia). The patient will need ascending aortic replacement in order to place proximal anastomoses. The patient may need circulatory arrest if you cannot find a safe place to clamp.

Answer 58

perioperative MI - can be 2/2 incomplete revascularization, atheromatous emboli, damaged grafts, hypoperfusion through new grafts, or early graft occlusion

Answer 59

No touch technique - avoid embolization of debri

Answer 60

Antegrade alone may not protect areas supplied by patent pedicled IMAs and may dislodge debri in SVG. Retrograde allows washout of coronary debris and access to myocardial areas of occluded arterial grafts. Clamping of patent arterial grafts ensures uniform cooling. Do NOT do difficult dissection of open LIMA-LAD if risk injuring it. Consider cooling pt to 28-30 if keeping LIMA patent.

Answer 61

sequencing vein grafts

Answer 62

Grafts to that area on TEE should be reconstructed immediately.

Answer 63

End-to-side to patent arterial grafts. Use RIMA in situ if possible.

Answer 64

Suspect coronary/graft injury (bright red, unlike dark blood in innominate injury). Heparinize and obtain femoral bypass (there’s still too much dissecting to do to just attempt opening for central bypass). Can attempt repair once injury is exposed vs coronary perfusion catheter. Complete the operation.

Answer 65

Get on bypass. Clamp and arrest the heart. Try to repair the injured mammary. *Before dissection of the mammary, you need to be ready to clamp and arrest - heparinized w/ high ACT, cannulated, dissected ascending aorta.

Answer 66

EKG - rule out ongoing ischemia and arrhythmia. Echo *diagnostic* - color flow Doppler shows size and location of VSD (also valves, R side pressures, PA, tamponade). RHC - step-up in oxygenation b/w RA and PA is diagnostic >9%; can also see elevated pulm-to-systemic flow ratio (1.4:1 to 8:1). LHC - can determine if need for revasc.

Answer 67

Poor - 25% within 24 hrs, increasing with time up to 97% in 1 year. This is an indication for urgent surgery.

Answer 68

Reduce afterload to decrease L-to-R shunt (nitroprusside). Maintain cardiac output and perfusion (milrinone). Increase coronary perfusion pressure. IABP and inotropes. ECMO or biventricular support can be used for temporary salvage before more definitive surgery can be performed.

Answer 69

No PA catheter. Conduit harvest if needed. Bicaval cannulation. Antegrade cardioplegia. LV vent in R SPV. Cool to 25 C. LV transinfarct incision and infarctectomy including septum. Patch with horizontal mattress sutures, felt strip, and Dacron patch. Deair, wean CPB, TEE to assess residual VSD/shunt/LV fct/MR. +/- IABP.

Answer 70

Incision through infarcted apex. Debride necrotic tissue (may include LV, RV, septum). Reapproximate w/ interrupted mattress through felt (use felt b/w each layer).

Answer 71

CPB and arrest. The heart needs to be retracted (like for PDA bypass). LV transinfarct incision w/ 1 cm of space lateral to PDA. Debride necrotic tissue. Inspect mitral for papillary infarct. Inspect posterior septum - can re-approximate using double layer buttress. Large defects require patch (must be tension free).

Answer 72

Severe end-organ damage unable to undergo operative repair. May benefit to use Impella or IABP to improve end organ dysfunction and allow for maturation of the infarcted tissue. Biventricular assist device may be needed if LVAD worsens R-to-L shunt. Can also improve forward flow and decrease afterload on LV with Impella/IABP while using ECMO to decrease load on RV and oxygenate blood to bypass the VSD.

Answer 73

Time in cardiogenic shock

Answer 74

Previously, not on its own. New guidelines state that you can. Absolute surgical indications: low EF, sx (with or without stress testing), velocity >4.5. If intervention required, transfemoral TAVI should be considered in following settings: STS-PROM >8%, or 4-8 w/o high-risk anatomic features, or low risk w/ age >65; transfemoral feasible, trileaflet valve, absence of high-risk feaures.

Answer 75

exercise stress test (treadmill) - positive if… - Symptoms. - SBP dec by >10 mm Hg. - Dysrhythmias. - ST changes.

Answer 76

Peak gradient = 4(velocity)^2. Maximum gradient present when central aortic pressure is subtracted from LV systolic pressure. Obtained by echo w/ continuous wave doppler. Or during LHC.

Answer 77

In a patient with low cardiac output. Velocity, and thus gradient (4[velocity]^2), is affected by CO. This is a low gradient/low flow AS.

Answer 78

Stroke volume index <35% ml/min/m^2.

Answer 79

Dobutamine stress echo - if gradient increases while AVA remains the same, AS is confirmed.

Answer 80

Septal myectomy and possible mitral valve surgery

Answer 81

Cardiac cath to cross the valve and obtain a hemodynamic AV study. Can directly measure gradients.

Answer 82

TAVR CT scan - valve morphology (TTE unreliable), AV annulus and LVOT sizing, coronary height and orientation, and sinus height and width sizing.

Answer 83

Any of the following: - mean AV gradient >40 - peak velocity across AV >4 m/s - AVA <1 or indexed <0.6 - dimensionless index <0.25 Always confirm. Always r/o CAD, aneurysm, and MV disease.

Answer 84

Guidelines say you can choose either, but considerations are as follows: Anatomy. Age and medical conditions affecting long-term prognosis. Preference. It was previously trending that in principle, you should rule out TAVR as an option (anatomy etc) unless there are other indications for surgical intervention. The pendulum is swinging the other way. Stage B (Vmax 3-3.9) w/ other indication gets SAVR. Stage C (Vmax 4) w/ ETT showing dec BP or dec ex cap, or high severity (Vmax 5, BNP 3x nl, rapid progression) + low surgical risk gets SAVR.

Answer 85

STS >15%. TAVR shows survival benefit in these patients. >8% seems to favor TAVR as well.

Answer 86

TAVR - perivalvular leak, ppm. SAVR - bleeding, re-hospitalization, atrial fibrillation.

Answer 87

Lower reintervention rate in <60 yrs old. Superior survival at 15 yrs if b/w 50-70 yrs.

Answer 88

patient-prosthesis mismatch

Answer 89

TAVR initially not approved for use in this population. But new data is showing comparable outcomes of TAVR is similar to SAVR in BAV AS patients. Surgery remains first-line for AS BAV patients, but TAVR with the latest prostheses may be a safe alternative in patients with increased risk for surgery after meticulous workup of AV anatomy.

Answer 90

Effective orifice area (obtained by sizing valve and finding the corresponding EOA published by the manufacturer)/BSA. Used to predict PPM.

Answer 91

Predictive of PPM. 0.65-0.85 is predictive of moderate PPM. <0.65 is severe.

Answer 92

No. In a comorbid elderly patient w/ symptomatic severe AS, a risk of moderate PPM is preferred over cross-clamp time and surgical risk (ie TAVR w/ small EOAI is ok). Should try to do an AV annular enlargement if at all possible in a surgically fit patient.

Answer 93

Class IIa indication for replacement at time of surgery.

Answer 94

Make sure the heart isn’t blowing up. Check crossclamp. Check drainage. May just be slow d/t hypertrophy. Add LV vent in R SPV. Open aorta and give direct cardioplegia. Cool patient. May need higher dose of cardioplegia.

Answer 95

Clamp, arrest, open aorta, and reassess. If visible defect, place a stitch. If not, remove valve and start over. Ensure decalcification of entire annulus (retained Ca can lead to improper seating). May need to reconstruct with pericardium.

Answer 96

consider root enlargement or total root replacement

Answer 97

Low gradient w/ <50% EF. Critical AS (>5m/s velocity). Severe LVH. Concomitant cardiac operation. Severe calcification.

Answer 98

Confirm diagnosis and severity, assess for etiology, valve morphology, LV assessments, aortic root size.

Answer 99

More amenable to repair, especially with more normal sized roots and without calcification. The root (ie associated w/ ascending aortic aneurysm and dissection) is often affected, but a valve-sparing root replacement with valve repair is very effective in this population. Jet direction is critical. Of 85 valve-sparing root replacements for bicuspid aortic valve aneurysm disease, 99 percent were free of more than moderate AR at eight year.

Answer 100

Need: significant risk factors for CAD or those older than 40 in whom AVR is considered. It may be good to assess RV/pulm HTN as well.

Answer 101

LHC w/ root angiography and measurement of LV pressures

Answer 102

jet width >65% of LVOT vena contracta >0.6 cm holodiastolic flow reversal in the prox abdominal aorta regurgitant volume >60 ml/beat regurgitant fraction >50% effective regurgitant orifice >0.3 cm2 angio grade 3+ or 4+

Answer 103

LV dilation. Be more cautious in these patients. The heart is weakening, so be prepared to support (IABP, ECMO, Impella; pressors). The R heart may also be weak, and there could be pulm HTN to deal with.

Answer 104

Symptoms AND severe. ASYMPTOMATIC, SEVERE, AND: Other cardiac surgery (moderate AR is IIb). LVEF <55 (no other cause identified). Severe LV dilation - LVESD >50 mm (can’t squeeze) or indexed LVESD >25 (IIa). LVEDD >65 (overfill) and nl EF (IIb). Progressive decline in LVEF on 3 studies despite EF >55. *of note, for chronic AR, there is no operating on asymptomatic nl EF patients w/o other evidence of dysfunction (LVESD, LVEFF, progression) *all patients should get BP tx for goal systolic <140. *nonop patients should get GDMT including ACEi/ARB. *TAVI is not for SAVR candidates in AR (III: harm)

Answer 105

Prior to bypass, you should be ready for distention - have retrograde cardioplegia access. Arrest immediately. Create the aortotomy, then give direct cardioplegia.

Answer 106

Bicaval cannulation. Make room for the cross clamp, and ID the aortotomy site. Initiate CPB. Place the LV vent, clamp, aortotomy, then give direct cardioplegia. Once arrested, snare the SVC/IVC. If the retrograde line is still needed, make a R atriotomy and place direct retrograde catheter for cardioplegia (just past opening to ensure middle vein gets plegia).

Answer 107

Initiate CPB, clamp, give ostial cardioplegia.

Answer 108

Replacement is safest.

Answer 109

Institute CPB, empty the heart, and defibrillate again. If unable to empty the heart d/t severe AI, cross clamp and open the aorta. Decompress the heart with a sucker through the aortic valve and localize the coronary ostia to give antegrade cardioplegia w/ an ostial cannula.

Answer 110

Use a bovine or autologous pericardial patch to ensure no tension on the suture line. This can be avoided by not making the aortotomy incision too low and not trying to oversize the valve. Just do a root enlargement.

Answer 111

Do a good diagnostic evaluation with TEE - quantify and localize the leak, differentiate between prosthetic vs periprosthetic. You may have to remove the prosthetic to fix the problem. Leaks from the non-coronary sinus are most amenable to direct suture repair.

Answer 112

The ventricle has not had time to develop any adaptation to overcome the increased volume which can lead to rapid deterioration.

Answer 113

The lack of calcification and larger annulus size may mean a self-expanding prosthesis would be more successful. The 30-day mortality for TAVR for AR is higher compared to TAVR for AS.

Answer 114

Similar results for AVR w/o need for anticoagulation as opposed to mechanical implants and possibly improved durability compared to bioprosthetics

Answer 115

By aortic stenosis of the biologic prosthesis, but tend to last longer than porcine valve.

Answer 116

Mechanical valves, though they do limit lifestyle d/t need for anticoagulation, and they limit future TAVR options. Ideally, <50 gets a Ross.

Answer 117

Echo (consider TEE if concern for endocarditis). Coronary imaging. CTA C/A/P to eval for transcatheter options, root size, SJ width, coronary heights; access options. Carotid duplex PFTs if hx of pulm disease Vein mapping if previous CABG Prev op note: when, what was last valve, other procedures (root enlargement, ascending aorta), CABG conduits and if crossing midline

Answer 118

Redo AVR has… Lower vascular complications and perivalvular leak. Higher short-term stroke rate, atrial fib rate, AKI, bleeding.

Answer 119

Early complication rates are lower for ViV TAVR. Durability is unknown. Endocarditis is a contraindication. Mechanical valves preclude TAVR. Eval for risk of patient-prosthesis mismatch: What were the gradients postop? If they are high, the original valve may already be small => redo SAVR +/- root enlargement. If they are nonoperative, then the patient will have to tolerate some PPM. Eval for risk of coronary obstruction: coronary height needs to be >10mm.

Answer 120

<23 mm may require the smallest TAVR inside or require fracturing of the surgical valve via high pressure balloon dilation. At <23 mm, there should be a compelling reason not to do redo SAVR. Similar issues: narrow STJ, small root. **when performing bio SAVR, try to get at least a 23 valve in as to not eliminate future ViV option. This may be a reason in itself to do a root enlargement, and even with an ok EOAI, a small valve does not allow for much exercise.

Answer 121

The internal diameter of the previous surgical valve. Look up product guide to find the internal diameter, and confirm w/ CTA or TEE. When evaluating for SAVR, the external diameter of the valve matters as it must fit in place of the native valve annulus.

Answer 122

There needs to be a compelling reason to NOT do redo SAVR. Most current TAVRs are designed for AS, not AI.

Answer 123

Prior CABG w/ LIMA (esp if near sternum). HFrEF, >75-80 yrs, poor condition, renal failure. Calcified ascending aorta.

Answer 124

Self-expanding: Better gradients (important since valve area is being reduced more d/t ViV). Less traumatic in setting of calcified aorta. Do not require rapid pacing (important if HF/sick ventricle 2/2 recurrent AS). Higher pacemaker risk (somewhat mitigated in ViV by previous valve "protecting" conduction system when compared to first time).

Answer 125

Redo AVR. Especially if AR. Especially if small valve (<23 mm), narrow STJ, or small root. *Clue would be if initial postop gradients from previous SAVR are high*. Especially if high risk for coronary obstruction (eg surgical valve has leaflets outside the frame, effaced sinuses, low coronary height [<10 mm]). Especially if other concomitant surgical pathology.

Answer 126

Be prepared for anything - have preop imaging; axilla, groins, and legs prepped (vein if coronary injury). Consider placing femoral sheaths (4-5 Fr). Consider CPB prior to opening in following situations - aorta close to sternum, high PA pressures w/ RV close to sternum, critical bypass grafts under sternum, calcified aorta. Otherwise, with careful dissection, can do central cannulation.

Answer 127

Can arrest initially w/ retrograde cardioplegia then open aorta and deliver the rest as ostial plegia to ensure good protection. Can try arresting antegrade, but it's difficult to estimate how much is truly going down coronaries vs going into LV.

Answer 128

Higher risk of heart block. Make sure you have reliable wires, and consider a-wires. Near the underside of the R/non commissure.

Answer 129

Can be caused by CPB w/ an incompetent valve or bovie near the LV during dissection (keep cautery <45). Have external pads, so you can shock prior to heart being dissected out (100-200 joules). Having heart dissected out before CPB allows you to shock w/ paddles in case of fib during CPB. Instability - cannulate and go on pump immediately. Heart distends - LV vent (ideally R SPV; LV apex if exposed; or clamp aorta and aortotomy w/ ostial plegia)

Answer 130

Need preop cardiac cath and study of previous op note. LIMA patent - frequent plegia and cool to 30 vs clamp LIMA (must be easy dissection, don't risk injury) - can clamp across all tissue w/ vascular clamp, - if dissecting LIMA, be ready to clamp and arrest because injury will require immediate CPB and plegia May need to mobilize grafts for aortotomy vs transect and rebypass w/ ligation of the old graft.

Answer 131

Transect aorta.

Answer 132

Patch. May need homograft recon if extensive.

Answer 133

Preparation: have legs prepped for any root case so vein can be taken. Look at cath to ensure you are distal to disease during bypass.

Answer 134

Always assume regional functional issues are coronary problems. Rule out air in the coronary system. Assume new valve obstructed R coronary ostia - go back on pump, and graft R coronary system. DO NOT reopen aorta and redo valve. You should have made sure you could see coronary ostia before closing aortotomy.

Answer 135

Before closing aortotomy, visualize the ostia. Give retrograde plegia and look for blood return from the os.

Answer 136

In redo settings, the aorta can be less compliant. Use a patch, and try not to "oversize" the aortic valve.

Answer 137

Likely functional MR 2/2 AS. The principle is that the culprit lesion is the AS. In this difficult patient, it's best to think of the safest option... Safest: redo SAVR and monitor MR as outpt for need for Mitra Clip.

Answer 138

PPM - look for evidence of high gradients postop => may need enlargement and SAVR over ViV TAVR Endocarditis - echo and cultures in right clinical setting => no ViV TAVR for IE

Answer 139

Check BSA and CTA. If the required size is unlikely to fit the patient's anatomy, be prepared for a root enlargement. EOA (obtained via manufacturer) of valve / BSA should be > 0.80 to prevent PPM.

Answer 140

primary leaflet abnormalities - usually result of degenerative disease

Answer 141

structurally normal valve leaflets are unable to coapt completely - owing to a distortion of either the annulus or the subvalvular apparatus can be from ischemic cardiomyopathy or other causes of dilated cardiomyopathy

Answer 142

much worse; controversial whether revascularization alone is helpful; controversial whether addressing MR will be of value, but data seems to suggest that it does help

Answer 143

normal leaflet motion - results from LV enlargement and annular dilation (functional or secondary MR) can also be from perforation in leaflet

Answer 144

leaflet prolapse - can be degenerative, acute papillary rupture after MI

Answer 145

leaflet restriction, systole and diastole - rheumatic

Answer 146

restriction during systole alone - chronic ischemic disease

Answer 147

type 1 - normal leaflet motion pts may have severely depressed LV fct

Answer 148

Type IIIb - systolic restriction of leaflets. Chronic ischemia can cause asymmetric ventricular remodeling => mostly affects inferior and lateral LV wall => disruption of the subvalvular apparatus => downward and lateral (apical) displacement of the PM papillary muscle => leaflet tethering.

Answer 149

TEE - however, MR may be lower intraoperatively d/t anes and ventricular unloading

Answer 150

mitral valve REPLACEMENT, chordal sparing - bio valve is probably best since poor prognosis long-term *remember GDMT, as this is secondary MR *stage D - RVol >60ml, RF >50%, ERO >0.4 cm2 *2a evidence *either way, 2 yr survival is 20-25% - why bio valve is likely best

Answer 151

At the time of apical incision such as LVAD for Type I (nl leaflet motion) secondary MR

Answer 152

avoids excess manipulation of heart that predisposes to AV groove dissociation

Answer 153

LVAD. Consider Alfieri suture after apical coring.

Answer 154

Nothing. Concomitant MVr resulted in longer OR time, longer hospitalization, higher rates of a-fib, higher rates of stroke. MitraClip may be better option down the road.

Answer 155

Eval for transcatheter edge-to-edge MV repair (2a) *LVEF 20-50 *LVESD <70mm *PASP <70 mmHg If anatomy not good, then consider surgery (2b) In an RCT of mitral valve repair versus mitral valve replacement in patients with severe ischemic MR, there was no difference between repair and mitral valve replacement in survival rate or LV remodeling at 2 years. However, the rate of recurrence of moderate or severe MR over 2 years was higher in the repair group than in the replacement group, leading to a higher incidence of HF and repeat hospitalization. The lack of apparent benefit of valve repair over valve replacement in secondary MR versus primary MR, with less durable repairs in secondary MR, highlights that primary and secondary MR are 2 different diseases. (2020 ACC/AHA).

Answer 156

Single blood supply to posteromedial papillary muscle - either RCA or L Cx depending on dominance. Anterolateral has dual blood supply (LAD and L Cx). Acute inferior STEMI -> Papillary muscle rupture -> flail leaflet -> apical holosystolic murmur, pulmonary edema -> dyspnea. DO NOT increase afterload or cause volume overload. Give milrinone for inotropy and nitroprusside for vasodilation. IABP should be considered. ECMO may be needed. Surgery: mitral replacement w/ chordal preservation. *Can remember commissures by their blood supply: posteromedial has posterior (RCA) supply. Anterolateral has anterior (LAD) and lateral (LCx) supply.

Answer 157

anterior directed jet is from posterior leaflet prolapse and vice versa; when planning repair, need to know if pt can tolerate second pump run if repair fails

Answer 158

40% LA or holosystolic eccentric jet

Answer 159

This is for PRIMARY MR. There are two conditions. They have to be SEVERE AND have either... - symptoms - this includes EF <30% IF REPAIR can be done. - systolic dysfx: EF <60 (but >30), ESD >40. - new PAH (PA MAP >20, PVR >3 Wood units) or new AF. - inc LV size or dec in LV fct x3 studies. OR a center of excellence. Surgery is favored if LA >50mm and/or PAH mild (30-50 systolic). ***These parameters should be adjusted if REPAIR cannot be done.

Answer 160

Ring or band annuloplasty

Answer 161

Near right trigone - conduction tissue

Answer 162

Aortic valve (L/non commissure) - look for aortic insufficiency that wasn't there preop.

Answer 163

Circumflex artery - look for WMA on the lateral wall. Avoid by angling the needle toward the ventricle (away from the atrium).

Answer 164

Coronary sinus

Answer 165

In fibroelastic deficiency, there is a paucity of tissue. Neochords are often the best repair, or a very limited triangular resection.

Answer 166

There is excess tissue in almost all scallops. Perform quadrangular resection w/ sliding plasty. (B) in picture***

Answer 167

Any of the following: - LV ESD >40. - Mortality <1% and >95% of successful and durable repair. - Progressive increase in LV size or decrease in LVEF >3 studies. - If she develops sx or EF <60. ***DO NOT do replacement if leaflet pathology < 1/2 posterior leaflet (3: harm). If severely symptomatic, and not surgical candidate, TEER is reasonable (life expectancy >1 yr, anatomy reasonable). *2020 AHA **If this was secondary MR, she would not be offered anything. TEER could be offered for: - Severe w/ EF <50 and failed GDMT (EF >20, LVESD <70, PASP <70). 2a. Surgery for severe secondary MR: - With CABG. 2a. - MR 2/2 atrial dilation w/ EF >50 and persistent sx. 2b. - EF <50 w/ persistent sx. 2b. Chordal-sparing mitral valve replacement in CAD w/ severe secondary MR w/ EF <50.

Answer 168

Exercise induced acute chordal rupture resulting in severe MR w/ heart failure. The hx of murmur suggests an underlying structural problem - MVP puts pts at inc risk for rupture. Other predisposing factors: rheumatic heart disease and infectious disease. Blunt chest trauma is a rare cause. OR for urgent mitral valve repair. We know this is likely mitral d/t the acute overload presentation in the setting of a systolic murmur. AS is the only other systolic murmur like this, and acute native AS isn’t really a thing.

Answer 169

The treatment is different. Papillary muscle rupture often warrants replacement (they may also need a CABG). Ruptured chords can be repaired.

Answer 170

Get echo - can show severe MR 2/2 flail leaflet (AS would be less acute). Do NOT misdiagnose PNA and start abx. The murmur means you need to determine if this is MR, or pt will decompensate.

Answer 171

Most common approach. Incision of choice for robotic and mini-thoracotomy. Approach via R side through Sondergaard's groove (Waterston's).

Answer 172

Feasible w/ large LA in setting of chronic MR. Via fossa ovalis. Reduces risk of PPM, easier to close. Downside is there are two suture lines, and you have to look for ASD on TEE after surgery.

Answer 173

Situation is when you're in a redo case and can't access Sondergaard. You attempt a vertical transseptal, but there isn't enough exposure because LA isn't large. Vertical transseptal incision is extended superiorly onto the dome of the LA through the limbus of the fossa ovalis. Risk of damaging SA nodal artery (increased risk of PPM). May provide better exposure for a deep chest anatomy/wide AP diameter. Approach of choice in the setting of previous AVR or aortic root placement. Can be easily extended and connected with an aortotomy incision for a Commando operation (endocarditis and radiation).

Answer 174

Uncommon. Can be considered in the setting of a hostile anatomy b/w the aortic root and LA dome (presence of calcified aortic homograft). Difficult closure, risk of narrowing R superior pulmonary vein, risk of transseptal incision progressing/tearing AV node -> high risk of PPM.

Answer 175

Aortotomy is extended onto the dome of the LA. Useful in in endocarditis when both aortic and mitral valves need to be replaced (transaortic Commando). Exposure can be challenging, in which case the incision can be connected to the extended transseptal incision.

Answer 176

Very uncommon. Left thoracotomy. Alternative approach after multiple previous re-operations via R side.

Answer 177

If entering the LV for another reason (ventricular aneurysmectomy or LVAD).

Answer 178

R anterolateral thoracotomy via 4th intercostal space centered at the anterior axillary line. Cannulate through femorals. Fibrillatory arrest under moderate hypothermia (requires competent AV). Endoballoon (requires competent AV).

Answer 179

The patient has SAM. Wait for volume and consider adding beta-blocker to ensure not simply underfilled. Then aim to reduce the POSTERIOR leaflet height - folding valvuloplasty, revise triangular repair to quadrangular w/ sliding annuloplasty. Place a larger ring. If all fails, replace the valve. If the patient is too frail to replace, do an Alfieri stitch. Nipride would accentuate the problem by underfilling the ventricle thus increasing ventricular systolic contraction. Inotropic support and reduced afterload could make things worse.

Answer 180

Mitral surgery changes the line of coaptation to displace it more anteriorly towards the LVOT. The Venturi effect causes the anterior leaflet to get sucked into the LVOT during systole. At the same time, the posterior leaflet prolapses towards the atrium, creating an anteriorly directed jet. SAM thus causes both mitral regurgitation and LVOT gradient.

Answer 181

Posterior leaflet is >1.5 cm in height after repair (ie it is tall). Small hyperdynamic ventricle. Ring is UNDERsized too much - causes line of coaptation to bulge anteriorly. AL:PL ratio <1.3 Aorto-mitral plane angle <120 degrees (pic - the closer to 90 degrees, the more the anterior leaflet is pulled into LVOT). Coapt/septum distance <25 mm IVS thickness >15 mm Anterior displacement of prosthetic ring.

Answer 182

**AV dissociation after mitral valve replacement/ AV groove disruption.** Can happens up to hours after the procedure and is signaled by massive intrapericardial hemorrhage. Rupture occurs in the LV near the AV groove posteriorly. Tends to occur in women w/ small LVs. The cause is technical: - **too much traction on the annulus** during excision of the valve or insertion of the prosthesis - lifting the heart after valve replacement, tearing the annulus - stitching through the posterior AV groove - perforation from papillary muscle excision - perforation of the AV groove during calcium debridement Management: go back on pump and re-arrest. Open the LA. Remove the prosthesis. **Pericardial patch to recreate the annulus**. Reimplant the valve in the newly created rim. - if caused during repair, replace the valve and use the PL to buttress the patch repair and reduce tension on the suture

Answer 183

Differential includes postcardiotomy syndrome and cardiogenic shock from reperfusion or poor protection. Most likely is damage to the circumflex. Management: back on pump, harvest vein, bypass to distal OM.

Answer 184

Make sure there is a working vent/floppy sucker in the *RSPV. Check the *aortic cross clamp - ensure it is all the way across and occluding flow. Explore the septum for an *ASD - can be evaluated from LA, but may require *RA incision to repair.

Answer 185

EKG - rule out AF CXR - count sternal wires CT - assess distance b/w sternum and RV/aorta/innominate vein, aortic Ca CTA gated - if hx CABG, know course and distance of vessels CT abd/pelvis - assess femorals and CPB course Preop TEE - mitral pathology (especially for re-repair) Cath - figure out CAD RHC - if LV or RV dysfunction Carotid duplex - older pts, vascular disease, coronary disease, neuro sx PFTs - if COPD ***Op note - what was done to valve, valve manufacturer/size/material if replacement prev, how was it exposed

Answer 186

Yes. Re-repair is associated with lower mortality compared to replacement at reoperation. Severe calcification (leaflets, annulus, subvalvular apparatus) and extensive leaflet destruction (e.g., endocarditis) can prevent re-repairability. You will not be faulted for replacement in redo setting.

Answer 187

2-4 mm. Suspect injury: high-dose pressors when weaning. Pressor requirement persists. TTE shows lateral wall motion abnormality. EKG correlates w/ V5-V6 or 1 and AVL. * Right leads, V1-V2: Interventricular septum and right ventricle. Anterior leads, V3-V4: Anterior wall of the Left ventricle. Low lateral leads V5-V6: Low lateral wall. High lateral leads I and AVL: High lateral wall. Inferior leads II, III and AVF: Inferior wall.

Answer 188

Complete heart block 2/2 AV node damage 2/2 deep/wide posteromedial mitral commissure stitch during MVR or ring annuloplasty.

Answer 189

Early: within 2 mo, Staph, higher mortality Late: Strep, lower mortality

Answer 190

Mechanical valve: infection localized to sewing ring -> abscess and dehiscence. Bio: infection in leaflets -> vegetations, leaflet perforation

Answer 191

Freedom from reoperation at 15 yrs is 80% w/ bio valves in mitral position.

Answer 192

Mitral valves are exposed to increased hemodynamic stress during systole, so deteriorate faster. Valve design has improved, and transcatheter valve-in-valve is an option to avoid re-operation.

Answer 193

Try to spare them - improved outcomes. But do not compromise outflow.

Answer 194

Mitral valve area ≤1.5 cm2 Diastolic pressure half-time ≥150 ms Severe LA enlargement Elevated PASP >50 mm Hg Decreased exercise tolerance Exertional dyspnea

Answer 195

Maintain therapeutic anticoag w/ frequent monitoring. VKA has lowest maternal complications but highest likelihood of miscarriage, fetal death, and congenital abnormalities (esp 1st trimester and at dose >5). Use LMWH instead to target anti-Xa 0.8 - 1.2. Switch to UFH 6 hrs before delivery. If urgent delivery needed, reverse VKA and do C-section. (3:Harm - Must use anti-Xa for LMWH monitoring, dabigatran cannot be used, DOACs have not been assessed and shouldn't be used).

Answer 196

TEE. Same goes if there is a prosthetic valve obstruction. Pre-pregnancy: Should have gotten echo, seen cardiologist w/ expertise in pregnant VHD patients. Mechanical VHD pregnant pts in particular should be at a tertiary-care center w/ MDT. They should be told that pregnancy is high-risk, and that there is no anticoagulation strategy consistently safe for the mother and baby. Women should receive therapeutic anticoag w/ frequent monitoring during pregnancy. If they cannot maintain therapeutic levels, they should be counseled against pregnancy.

Answer 197

valve surgery (2a) In pregnant pts w/ severe disease w/o severe and refractory HF symptoms (at rest or with min activity), valve surgeries should NOT be performed (3:harm).

Answer 198

valve intervention is reasonable AS = mean gradient 40, V max 4, AVA <1

Answer 199

They should get TTE, be seen at a center w/ expertise, and consider exercise testing if asymptomatic and suspicious. Meds to consider are beta-blockers, diuretics. DO NOT give ACEi or ARBs. Intervention has standard indications. Prefer bio valves. Best management would have been to counsel a pt of childbearing age that they should have their MS treated first. *** MS = valve area <1.5 or diastolic PHT >150 (speed at which the LV fills in diastole based on the slope of the change in gradient) 1st: medical therapy. 2nd: PMBV.

Answer 200

Figure out PASP and if AF. So get TTE, TEE, LHC/RHC. If PASP >50 mm Hg or New AF -> Ensure no clot, valve pliable and not much MR (<2+) -> PMBC - perc mitral balloon commissurotomy

Answer 201

Commissurotomy - either percutaneous or open.

Answer 202

Severe (<1.5 cm MVA) + Symptomatic (dyspnea on exertion/dec exercise tolerance) + Not candidate for PMBC (valve not pliable, clot, >2 MR) + Surgical candidate.

Answer 203

Severe findings (<1.5 cm MVA) + PMBC candidate (pliable valve, no clot, <2+ MR) + New onset AF OR PASP >50 mm Hg.

Answer 204

Yes. IF... Exertional symptoms. Confirmed: Stress test shows hemodynamically significant MS. PMBC candidate: pliable valve, no clot, <2+ MR. ONLY PMBC offered.

Answer 205

There needs to be a reason not to do PMBC. Figure out if... valve is not pliable, clot is present, or MR is >2+. Then they have to be surgical candidate.

Answer 206

Distal coronaries. Aortic valve is excised - break it down. MVR. TVR. AVR. Proximal coronaries.

Answer 207

Usually old, frail, debilitated patients. DELAY intervention until severely limiting symptoms unable to be managed w/ diuresis and HR control. Some catheter-based strategies are being developed. Surgery may require radical debridement of the annulus down to pericardial fat, reconstruction with pericardial patch that saddles/sandwiches the annulus, then valve placement with sutures from LV to patch to LA to sewing ring.

Answer 208

TEE. Aortic insufficiency 2/2 anterior annular mitral stitches in the non-coronary or L cusp. Rearrest, open the aorta and LEFT atrium, and remove suture or redo the mitral surgery. Repair the aortic cusp or replace it.

Answer 209

Sutures too deep near the posterior leaflet near the PM commissure - bundle of His.

Answer 210

Prosthesis problem: high-profile mechanical valve, large stented bio valve posts, poorly seated valves. Could also be SAM. Either way… Diagnose on TEE, and may need to replace the valve w/ lower profile.

Answer 211

SAM. Stop inotropes, load, add betablocker, and add vasopressors - inc afterload and preload while reducing contractility (you can attempt these maneuvers for SAM after mitral surgery, but not after a myectomy for HOCM). You may need to do an aortotomy and do a transaortic excision of the offending subaortic mitral tissue +/- myectomy.

Answer 212

Small leaks stop after protamine. Significant leaks require reimplantation or repair.

Answer 213

Respiratory status - Many patients require aggressive diuresis. Pulmonary pressures - Inotropy and pulmonary vasodilation may be required. "High and dry."

Answer 214

2.5-3.5. This is higher than AC goal for atrial fibrillation, so it still increases risk in patients already on AC.

Answer 215

AV groove disruption/rupture. Prevent by minimizing retraction, preserving the posterior leaflet and its subvalvular apparatus, and using increased caution during debridement in pts w/ annular calcification.

Answer 216

1) conduction block of all micro and macro re-entrant circuits 2) reestablishment or maintenance of electrical AV synchrony 3) restoration of atrial mechanical function in order to improve diastolic filling (no re-entry circuits, good AV synchrony, good atrial kick)

Answer 217

Symptomatic AF. Refractory to class I/III AADs and/or catheter-based therapy (class IIA, level of evidence [LOE] B-R). According to The Society of Thoracic Surgeons (STS) 2017 Clinical Practice Guidelines for the Surgical Treatment of Atrial Fibrillation, primary stand-alone SA is a reasonable procedure.

Answer 218

4.5 cm end-diastolic diameter.

Answer 219

Peri-mitral flutter. Failure to interrupt conduction across the "LA isthmus" allows for this. It is the most common mode of failure of surgery for AF. LA isthmus - linear lesion connecting the box to the mitral annulus.

Answer 220

Conduction across the LA isthmus d/t incomplete lesion line involving the MV annulus. EP can do catheter intervention to complete the ablation line.

Answer 221

Mitral line (prevent conduction across the atrial myocardium). Coronary sinus lesion (prevent conduction across the coronary sinus; collapse the CS during cryoablation so a circumferential lesion can be assured; should connect to the level of the mitral annulus). Place both lesions in the same plane. Transmural ablation (epicardium and endocardium) is key.

Answer 222

Hemidiaphragm paralysis from damage to the R phrenic. This is usually temporary. Make sure the handle of the probe is not in contact with the phrenics (R or L).

Answer 223

A single break in the line can preserve a macro reentry circuit. These waves will find the weakness. Lesions should be uniformly transmural and contiguous. Ensure minimal tissue folding. Clean the tips of the clamp. Multiple burns per line.

Answer 224

Yes. The RF clamp relies on perfect contact b/w the tissue and electrodes. Char isolates and disrupts this contact, which can affect tissue from heating, breaking the line, and allowing macro-reentrant circuits through. It is recommended to clean the clamp after every 3 ablations.

Answer 225

It's an epicardial vestigial fold that marks the location of the embryologic LEFT SVC. It contains the nerve, vein (vein of Marshall), and muscle tracts. It is located on the epicardium between the left atrial appendage and the left pulmonary veins. The corresponding endocardial structure is the LA ridge. It is a source of paroxysmal AF. It helps to dissect it out to get better atrial clip during CMIV. Watch out for L Cx.

Answer 226

Rare. You may have compromised the position of the LV vent by accidentally entering the LA. It is still necessary to divide the LoM to access behind the L pulmonary antrum for L PV isolation. Close the defect. Finish the case.

Answer 227

The clip was not placed at the base of the appendage. It should be placed under direct visualization, otherwise a small pouch can be a source of thrombus.

Answer 228

LAA amputation. This will **not remove macro-reentry circuits** at the base. If this is done, you must anchor the **base to the PV isolation**. Can cause **bleeding** through the suture line or from tributaries at the AV groove near the coronary sinus.

Answer 229

Injury to L circumflex coronary artery causing MI at the time of LAA isolation. This occurs if the LAA orifice is unusually low (normally at level of frenulum b/w L PV several cm away from MV annulus), and the L Cx is unusually high (normally in the AV groove slightly below the coronary sinus).

Answer 230

Damage to the AV node - cryoprobe too posterior. Damage to the SA node - prevent by placing the final RA lesion from the distal end of the vertical atriotomy to the tip of the RA appendage. Go as far anteriorly as possible to avoid the pacemaker complex.

Answer 231

In patients who meet all 3: - failed or are intolerant to antiarrhythmic drug therapy - failed catheter ablation in the EP laboratory - feasible minimally invasive approach It is reasonable to attempt this procedure. Principle: failed other options and can get min invasive.

Answer 232

In a series of 305 patients, there was an equal efficacy of a left-only approach, but a higher pacemaker implantation in those who underwent a biatrial lesion set. Both of these findings were confirmed on a meta-analysis of 2225 patients from 10 studies. The equivalent sinus restoration is supported by a randomized subgroup analysis of mitral valve patients that compared patients undergoing biatrial Mazes with pulmonary vein isolation alone. There is an increased risk of recurrent AF with PVI only.

Answer 233

In a series of 305 patients, there was an equal efficacy of a left-only approach, but a higher pacemaker implantation in those who underwent a biatrial lesion set. Both of these findings were confirmed on a meta-analysis of 2225 patients from 10 studies. The equivalent sinus restoration is supported by a randomized subgroup analysis of mitral valve patients that compared patients undergoing biatrial Mazes with pulmonary vein isolation alone. However, in a 2008 analysis of 1723 patients, absence of a biatrial lesion set was a predictor of failure at 48 months. This finding was also supported by a 2006 meta-analysis of 5885 patients in 69 studies. It is currently unknown which patients do better with a biatrial set. Overall, many surgeons suggest PVI alone for pts w/ comorbidities who cannot tolerate a lengthier operation (especially if it is an isolated mitral) and full CMIV for those with persistent or recurrent AF.

Answer 234

Convert to open.

Answer 235

One should avoid placing an ablation line through the "sinus tachycardia line" at the right atrium. This can lead to an inability to generate an appropriate response to normal exercise. This was a common complication with CMI (30%).

Answer 236

Medial and superior to the roof lesion - transecting this will delay the arrival of a sinus impulse from the RA to the LA.

Answer 237

It is across the cavo-tricuspid isthmus (CTI) - damage results in the inability to develop appropriate bradycardia when asleep. That said, in patients with cavotricuspid isthmus (CTI)-dependent atrial flutter, ablation along the CTI may be necessary (pic).

Answer 238

Vena contracta width ≥0.7 cm. Regurgitant volume ≥45 mL. Central jet ≥50% RA. ERO ≥0.40 cm2. Dense continuous wave signal with triangular shape. Hepatic vein systolic flow reversal. These pts develop Dilated RV and RA w/ elevated RA with “c-V” wave. Symptoms include dyspnea on exertion, fatigue, ascites, edema.

Answer 239

Stage B: Central jet <50% RA, Vena contracta width <0.7 cm, ERO <0.40 cm2, Regurgitant volume <45 mL. MUST be during **L side valve** procedure. AND have **annular dilation >4.0 cm** OR **prior RHF**. TV surgery for this pt has a 2a indication.

Answer 240

Only level 1 indication is during L side valve surgery. If RHF (symptomatic; stage D): - primary TR has 2a indication. - secondary TR surgery if: poor GDMT response AND annular dilation WITHOUT inc PAP (2a). - prior L side valve surgery WITHOUT PH or severe RV dysfx has 2b indication. If asymptomatic (stage C): primary TR w/ progressive RV dilation or sys dysfx has 2b indication. Severe TR: Central jet ≥50% RA, Vena contracta width ≥0.7 cm, ERO ≥0.40 cm2, Regurgitant volume ≥45 mL, Dense continuous wave signal with triangular shape, Hepatic vein systolic flow reversal.

Answer 241

Triangle of Koch

Answer 242

Septal is fixed. Will dilate posteriorly more than anteriorly.

Answer 243

Do L side lesions first. Tricuspid can be addressed with the heart beating (PFO must be closed before unclamping).

Answer 244

Interrupted mattress sutures with a gap a Koch's triangle (1cm from anterospetal commissure to midpoint on septal leaflet).

Answer 245

Measure the septal leaflet and surface area of leaflet tissue arising from the anterior papillary muscle. Usually 30-32 mm for female, or 32-34 mm for male.

Answer 246

Preserve native leaflets, similar to mitral (unless infected). When placing sutures near the AV node, place them through the septal leaflet instead.

Answer 247

If not extensive damage, can excise vegetations to healthy tissue. Close gaps primarily or with a patch. Consider annuloplasty if valve incompetence is in question. Replace the valve if extensive destruction. 2-stage replacement can be considered in IVDU with normal RV fct and PAP (fallen out of favor).

Answer 248

No anticoagulation. Less structural valve deterioration than those in mitral position. Does not limit transvalvular PM leads in the future. Be careful placing Swan postop.

Answer 249

Rule out metabolic issues and air emboli. TEE for assessment. Eval RVOT for obstruction: eg, anterior leaflet tissue billowing -> central portion can be excised while maintaining chordal attachments. Eval for ST changes from RCA occlusion (inferior leads; caused w/ deep stitch at ant/post commissure) -> bypass RCA w/ vein. Make sure there's a Swan-Ganz that's surgeon directed after this procedure (cannot do if mechanical). If above ruled out, and pt has RHF, may not be able to come off. Transition to ECMO. You would expect CVP and PA pressures to go up some because the "popoff" that TR creates is now gone, and the RV is having to push all blood through the pulmonary system.

Answer 250

Similar principles to other RV failure: Improve hypoxia and decrease hypercarbia. Decrease pressure in lungs. Support contractility/inotropy w/ Epi, increase lusitropy (and inotropy) w/ Milrinone. Restrict fluids. Diurese. Can add nitric to vent or HFNC to unload PA more w/ less systemic effects than milrinone. Can use IABP to unload even more and improve RCA perfusion.

Answer 251

Principle: it has to be bad, and it can't be complicated: - Stage D (Central jet ≥50% RA, Vena contracta width ≥0.7 cm, ERO ≥0.40 cm2, Regurgitant volume ≥45 mL, dense continuous wave signal with triangular shape, Hepatic vein systolic flow reversal; AND RHF symptoms). - No PH or RV systolic dysfunction.

Answer 252

Sutures near the anteroseptal-septal commissure can easily damage the AV node. Radial force from a prosthetic valve (or dual prosthetics in the MV and TV position). 2 sets of V pacing wires would not be overkill; in addition to external pacing pads before eventual PPM placement.

Answer 253

Endocardial - percutaneous into atrium, then coronary sinus. - if unable to get into coronary sinus, can traverse repaired valve. Epicardial - avoids foreign object through repair/replacement. Only option for mechanical valve.

Answer 254

Remove the initial wires in setting of bacteremia and endocarditis. New epicardial leads on the RV can be placed (tunneled through the L intercostal space away from the mammary and out to a subcutaneous pocket). Transvenous atrial wires can be placed later if needed or if bacterial burden is too high on initial surgery.

Answer 255

Grossly, you will see white fibrous tissue deposits/plaques on the endocardium of valve cusps on the ventricular side, causing adherence to the RV wall. TV replacement required. Check pulmonic valve - may need to be replaced as well. L heart valves are not affected d/t inactivation by MAO as it passes through the lungs.

Answer 256

Preoperative TTE. This is where you will make your decisions.

Answer 257

PFO. Otherwise air gets into the L side.

Answer 258

70% any lesion. 50% LM.

Answer 259

Look at the heart and the EKG. TEE to eval for MWAs. Assess grafts with flow probe. Determine if there were issues with cardioplegia - if all above ruled out, it could be cardiogenic shock from poor protection. Rest the heart on full flow with the heart completely decompressed for 10-15 min. May require IABP. If the pt worsens over the next 12 hrs, consider catheterization to assess grafts.

Answer 260

Distals, aortotomy w/ AV resection, CMIV, MVR, AVR, proximals.

Answer 261

You've injured the circumflex likely during the placement of posterior leaflet mitral valve sutures. Re-heparinize and go back on bypass. Take vein, and bypass the circumflex. Keep in mind that you have a new mitral that could be easily dislodged, or you could cause an AV groove disruption when exposing the lateral wall.

Answer 262

LV rupture when the heart is contracting after coming off CPB. Higher risk of block requiring PPM. If concurrent with AVR, then oversizing MV can cause downsizing of the aortic valve -> pt prosthesis mismatch.

Answer 263

SVR drops, venous return decreasing, coronary flow decreases, ventricles fail. The incidence of arrest on induction is higher for combined pathology than for isolated severe AS. Secure the airway. Ventilate. Begin CPR/ACLS. Heparinize. Prep/drape/scrub. Emergency sternotomy and quick cannulation. Initiate CPB. Proceed with AVR/MVR. If truly worrisome preop, consider awake line placement, and prep and drape before induction w/ sheaths in the groin and a sternal saw working.

Answer 264

Circumflex artery

Answer 265

Do NOT lift the heart. This is likely AVG disruption. Go back on bypass first, then repair - depending on location, can do an internal patch repair, external primary repair with pledgets or strips. Risks: extensive annular decalcification near the posterior leaflet, use of an oversized prosthesis, or excessive traction on the left ventricle

Answer 266

Open aorta, excise leaflets and debride annulus, explore mitral and *do NOT oversize if requiring replacement (size aortic valve at the same time to determine if adequate AV prosthetic will fit), replace mitral, re-size aortic valve, replace aortic valve. *If mitral is oversized before you fit AV, you may end up with prosthesis mismatch.

Answer 267

Conduction system. Don't oversize valves - can compress this system. Place A and V wires on all double L valve cases. PPM risk is 5% for single valve. It's 15% for >1 valve.

Answer 268

MV strut is directed into the LVOT. Re-replacement of the valve should be done. This is more likely with bioprosthetic valves. These valves usually have markings for their struts that allow the surgeon to orient the valve in such a way that the space between the struts is over the LVOT.

Answer 269

Most symptomatic should go first with a 4-6 waiting period before second surgery. If both are symptomatic, can do synchronous procedure.

Answer 270

If immediately postop, would get bedside ultrasound evaluation of flow and return to the OR if flap or technical problem is found. If out of PACU, would get head CT and carotid duplex.

Answer 271

If time permits, the patient should go to the OR, prep and drape, intubate, then reopen. If not, open at bedside and be ready to hold pressure while you get to OR and intubate.

Answer 272

Major: microbio (atypical requires time b/w 2+ cxs or 3/4+ cxs); endocardial involvement (new regurg, abscess, vegetation, dehiscence of prosthetic).

Answer 273

Predisposition – Intravenous drug use or presence of a predisposing heart condition (prosthetic heart valve or a valve lesion associated with significant regurgitation or turbulence of blood flow). Fever – Temperature ≥38.0°C (100.4°F). Vascular phenomena – Major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages, or Janeway lesions. Immunologic phenomena – Glomerulonephritis, Osler nodes, Roth spots, or rheumatoid factor. Microbiologic evidence – Positive blood cultures that do not meet major criteria, OR serologic evidence of active infection with organism consistent with IE. *There are no echocardiographic minor criteria.

Answer 274

A firm alternate diagnosis is made. Resolution of clinical manifestations occurs after ≤4 days of antibiotic therapy. No pathological evidence of infective endocarditis is found at surgery or autopsy after antibiotic therapy for four days or less. Clinical criteria for possible or definite infective endocarditis is not met.

Answer 275

-Vegetation (oscillating intracardiac mass on a valve or on supporting structures, in the path of regurgitant jets, or on implanted material, in the absence of an alternative anatomic explanation). -Abscess. -New partial dehiscence of prosthetic valve. -New valvular regurgitation.

Answer 276

For patients with suspected IE who present WITHOUT acute symptoms, empiric therapy is NOT always necessary, and can be deferred until blood culture results are available, particularly since accurate microbiologic diagnosis is a critical first step in planning the treatment strategy. For acutely ill patients with signs and symptoms strongly suggestive of IE, empiric therapy may be necessary. Such empiric therapy should be administered only after at least two (preferably three) sets of blood cultures have been obtained from separate venipunctures and ideally spaced over 30 to 60 minutes.

Answer 277

In general, empiric therapy should cover staphylococci (methicillin-susceptible and methicillin-resistant), streptococci, and enterococci.

Answer 278

Clinical indications for repeat TTE and/or TEE include new murmur, embolic complications, new or progressive heart failure, and development of atrioventricular block. In addition, patients with persistent fever or persistent bacteremia (eg, longer than five to seven days) warrant repeat echocardiography to evaluate for abscess.

Answer 279

neither anticoagulant therapy nor aspirin reduces the risk of embolism in patients with IE; remember that pts w/ IE are also at increased risk for bleeding complications (particularly intracerebral)

Answer 280

mitral stenosis

Answer 281

IE due to common oral organisms. All active sources of oral infection should be eradicated.

Answer 282

colonoscopy is warranted - association w/ cancer

Answer 283

Indications for surgery in R NVE include: - very large vegx (≥20 mm) - recurrent septic pulmonary emboli - highly resistant organisms - persistent bacteremia

Answer 284

*Heart failure (HF) symptoms - benefits of surgery appear to be greatest among patients with severe valve dysfunction causing HF, surgery should be undertaken as soon as signs and symptoms of HF appear and before hemodynamic instability occurs. *Complicated infection - paravalvular extension of infection with development of annular or aortic abscess, destructive penetrating lesion (eg, fistula), and/or heart block *Difficult-to-treat pathogens - include fungi and multidrug-resistant organisms (eg, Pseudomonas aeruginosa and vancomycin-resistant Enterococcus). *NOT S. aureus.* *Persistent infection - bacteremia or fever lasting >7 days after initiation of appropriate antibiotic therapy.

Answer 285

Depends on how severe and what kind of stroke. No delay: silent microembolism, transient ischemic attack, cerebral abscess, or ischemic stroke with no hemorrhagic conversion and without severe neurological impairment or decreased level of consciousness. For patients with major ischemic stroke (ie, with severe neurologic deficit or altered consciousness), or intracranial hemorrhage, many would delay surgery for ≥4 weeks.

Answer 286

Valve REPAIR is preferable to valve replacement when feasible; valve replacement is associated with a small risk of infection of prosthetic materials. Valve repair may be possible when a leaflet perforation occurs in the absence of extensive leaflet destruction or annular involvement. Also, there is no increased reinfection risk b/w mechanical and bioprosthetic valve installed after IE.

Answer 287

Early surgery for prosthetic valve endocarditis is indicated for IE complications SIMILAR to native valve endocarditis (eg, HF due to prosthetic valve dysfunction, paravalvular regurgitation, or intracardiac fistula; annular abscess, difficult-to-treat pathogen, persistent infection).

Answer 288

Completely *unroof the abscess and debride grossly infected tissue. *Patch the defect w/ autologous or bovine pericardium. Involvement of a large part of the annulus may require replacement w/ *homograft/xenograft (muscular portion may fill in tissue defect after extensive debridement). The R/non-con is the site of the *membranous septum, so VSD can occur w/ aggressive debridement. R/non-con is also near the *conduction system, so inc risk for conduction disturbance and PPM need.

Answer 289

Excise and repair. Avoiding placement of prosthesis i preferred in an infected setting.

Answer 290

Careful debridement of all tissue. If enough tissue remaining, reinforce the posterior annulus w/ interrupted figure of 8 sutures from LA to LV, creating a fold of tissue which can be used to secure the prosthetic valve. Be careful of the coronary sinus, circumflex, and bundle of His.

Answer 291

HACEK: Hameophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella. Also fungal organisms. Consult ID.

Answer 292

Depends on patient risk factors and whether it is embolic or hemorrhagic. Controversial timing. For hemorrhagic stroke, most agree that operation should be delayed. The duration requires judgment and balancing risks of cardiac vs neurologic complications. Reasonable to delay 3 to 4 weeks after the stroke. If there is a significant decline in cardiac function, recurrent stroke/systemic embolism, or persistent sepsis, a delay of less than 4 weeks may be necessary. With embolic CVA in the absence of bleeding, an operation may be safe in 3 to 5 days.

Answer 293

Initial tx is abx. S aureus 70%. Strep and enterococci are next most common. Surgery indications: (get TEE in all, get cardiac CT if possible abscess) - 2cm vegetation - recurrent PE - highly resistant organism (MDR enterococci, P aeruginosa, fungi, other MDR GNB, MRSA [not MSSA], Brucella) - RHF 2/2 severe TR - heart block - paravalvular abscess

Answer 294

3.0. Same as mitral. Ball-in-cage and tilting disc valves (other than Medtronic) require 3.5 in the mitral or tricuspid position.

Answer 295

valve excision without replacement - if pulmonary pressures and pulmonary vascular resistance are not elevated and good RV and LV fct

Answer 296

Need to know timing and if complicated... Is it early or late? <2 mo after surgery is often aggressive (staph) and requires intervention within 1-2 weeks. If late PVE (>2 mo; strep), treat like native valve endocarditis. Is there valve dehiscence or paravalvular leak? Requires intervention within 24-48 hrs.

Answer 297

permanent epicardial atrial and ventricular epicardial pacing leads are less likely to become infected than transvalvular leads

Answer 298

Probably coronary artery injury. Use vein and bypass the injured coronary.

Answer 299

Clamp the RA and sew. No need for CPB. Eval the heart with TEE and ensure no ASD/VSD/valvular damage.

Answer 300

Larger defects may require a *patch. Otherwise pledgeted *horizontal mattress sutures often work. Make sure *septal injury and *valve injury are ruled out with echo if dealing with large defects or multiple chamber defects.

Answer 301

Ligate it. Patch can be considered if the patient and heart are not friable.

Answer 302

If it is distal, and there is not reversible ventricular dysfunction.

Answer 303

Hypertension. Other risk factors: connective tissue disease, fam hx of aneurysm or dissection, aortic valve dz, pregnancy, recent open or catheter aortic manipulation, stimulants.

Answer 304

right anterior aspect of ascending aorta, spiraling around the arch into the descending

Answer 305

aortic rupture, pericardial tamponade, acute AI and CHF, acute MI, stroke

Answer 306

CT angio from neck through femoral vessels, EKG-gated

Answer 307

If suspicion is high, get TEE on-table in OR.

Answer 308

Vascular history. Palpate pulses x4 extremities and carotids. BP in BUE to eval diff. Neuro exam. EKG, D-dimer, CBC, lytes, LDH, cardiac markers, coags, type/cross. CXR - widened mediastinum, single side effusion CTA EKG gated vs MRA. TEE if cross sectional imaging contraindicated or not available.

Answer 309

<500 ng/dL

Answer 310

Access and monitoring. HR <60 and BP 100-120 systolic. Esmolol w/ loading dose 250-500 mcg/kg, then 25-50 mcg/kg/min. Can add nitroprusside at 0.25-0.50 mcg/kg/min if esmolol controls HR, but BP needs control. Pain control. Foley.

Answer 311

Ensure good CT review to know where dissection is and isn't. Know what extent of dissection is to know how much of arch needs to be done. R axillary artery w/ graft. Direct cannulation of ascending aorta: Seldinger w/ TEE guidance vs samurai. Femoral artery. Venous cannulation: usually dual stage, but bicaval can be done if retrograde cerebral perfusion needed.

Answer 312

Hemiarch is often sufficient to completely resect the tear and exclude the false lumen to re-establish arch vessel perfusion. If the actual TEAR involves the arch vessels (not just the dissection), the arch may need to be replaced.

Answer 313

Arch rupture. >5.5 cm arch aneurysm. Tear involves arch.

Answer 314

Bentall, David.

Answer 315

CTD - Marfan, Loeys-Dietz, Turner (female). If CTD is known or suspected, the ENTIRE ROOT should be replaced.

Answer 316

failure to replace the whole root, failure to replace the entire ascending aorta, or aneurysm of the aortic wall at the coronary artery button

Answer 317

Treat like ascending dissection. CT IMH hallmarks: absence of intimal tear, absence of false lumen flow (differentiates from penetrating aortic ulcer).

Answer 318

RCA is more frequent than left, but both need to be evaluated. May need retrograde cardioplegia. If only ostia - mobilize the buttons and reapproximate the dissected layers. If the coronary vessel is dissected - bypass or interposition with GSV.

Answer 319

False lumen compression. It’s possible that either the femoral art line OR the arterial bypass cannula is in the false lumen. Check a radial pressure. If it's normal, then the femoral is either malperfused (possibly re-entry tear) or the femoral line is in the false lumen. Either way, it's unreliable. If radial pressure is dampened too, then check the TEE, but plan to recannulate. Due to re-entry tears, distal flow dynamics can change with changes in flow. Look for this to happen on initiation of CPB, cross clamping, or after circ arrest.

Answer 320

Often, re-establishing true lumen flow at the type A will be enough. If there is a question about bowel integrity, then do a laparotomy and assess. Stenting, fenestration, or bypass may be needed.

Answer 321

Patients with dense neurological deficits, have an extremely poor prognosis. It may be best not to offer surgery. In those with less severe neuro deficits, even paraplegia, surgical repair is warranted, all else being equal.

Answer 322

Ax-fem or fem-fem bypass. If no flow for 6 hrs, may require ppx fasciotomies (including operative time), especially if there is outflow/venous compromise, unless you can perform careful and frequent serial exams, including compartment pressure evaluation with a trigger for fasciotomy at delta pressure <30 (ie compartment less than 30 mmHg below diastolic blood pressure)

Answer 323

Defined as >90 days. Scenario is a CT done for another reason with the patient remembering an episode of severe tearing back pain a few months ago. Surgery is indicated for complications or symptoms, eccentric expansion, rapid expansion, or aortic insufficiency. Get an echo, a good physical exam, including BUE and lower extremity BP, and a good review of symptoms, including myocardial ischemia symptoms.

Answer 324

Risk: Aneurysmal dilation and rupture. Mgmt: strict BP control to <120 systolic. CT surveillance at 1, 3, 6, and 12 months is recommended. Yearly after this. 70% will be free from reoperation at 10 years. Echo to eval the aortic valve at some point is warranted.

Answer 325

1) Medical. BP and HR control (impulse control). Usually esmolol drip w/ nitroprusside if needed. Malperfusion treated as needed. 2) Look for complicated disease or high-risk anatomical features that would push for intervention.

Answer 326

This is an aortic dissection. Adventitial hematoma could be the cause, but the high line pressure makes this dx less likely. Confirm w/ TEE.

Answer 327

Increase in line pressure after arterial cannula placement. Purple hematoma involving the ascending aorta. MAPs drop. TEE to confirm via a flap in the ascending aorta. Eval EKG for ST changes. Eval pericardial well for blood.

Answer 328

Stop perfusing through the cannula. Treat hypotension w/ volume and pressors. Hypotension, if it occurs, in this setting is likely 2/2 myocardial ischemia or acute AI. There is no tamponade w/ the pericardium open, and rupture should be visualized. Cannulate the axillary or femoral artery. Clamp higher, evaluate coronaries, aortic valve, previous clamp site. Find tear. Hopefully it is contained within ascending aorta. Replace if so. If not, may need arch surgery.

Answer 329

Aortic valve incompetence. Place an LV vent or open the aorta.

Answer 330

Decompress via the L SPV or LV apex.

Answer 331

Removal of the cross clamp under pressure. Make sure "flows way down" before removing clamp. If this occurs, re-heparinize, and obtain axillary or femoral cannulation.

Answer 332

Evaluate the leaflets. If they are intact, repair the aortic dissection and resuspend the aortic valves as long as anatomy allows you to realign the center of coaptation. Reevaluate the valve w/ TEE before leaving the OR.

Answer 333

EKG to eval for ST changes in specific anatomy. CXR to eval for bleeding. TTE to eval for WMA and possibly dissection. If likely coronary problem, proceed to angio. If likely aortic dissection, get gated CTA if stable or TEE in OR.

Answer 334

If concerned, can do an angio to eval for dissection. If type B dissection is confirmed, check TEE to eval for ascending. Abort the procedure, do CTA to confirm extent. Medically manage for 4-6 wks and return to OR later. Cannulate a different site.

Answer 335

Symptomatic (aneurysm defined at 4 cm). Ruptured. End-diastolic diameter 5.5 cm. Aortic size index 2.75 cm/m2. Aortic area over height ratio 10 cm2/m. If undergoing AV surgery or CABG, then EDD 4.5 cm. If getting surveillance, expansion ≥5 mm per year for aneurysms <5 cm in diameter. If bicuspid aortic valve, 5 cm. Genetic factors also affect size cutoffs (image).

Answer 336

No changes for ascending aortic aneurysm (5.5 w/o additional risk factors, 5 for increased risk or high-volume centers, 4.5 if other cardiac surgery indication). No changes for AS/AR. Standard recommendations for aortic valve intervention apply to patients with bicuspid aortic valve.

Answer 337

If valve is normal, a valve sparing procedure can be performed - David. If <40 yrs old, consider Ross.

Answer 338

Consider technical problem with the RCA button. The change in orientation can cause kinking, stretching, or compression. Bypass the RCA. Prevent this by sizing and placing the button with the heart engorged. Can also manifest as difficulty coming off bypass, new WMA, arrhythmias, new EKG changes, or unexplained RV failure. DDx is poor myocardial protection, air embolism, protamine reaction.

Answer 339

Go back on, resect the valve, and replace it.

Answer 340

Probably bleeding from the root vs LCA suture line. Pack it and use topical agents. Stop the rest of the bleeding in the surgical field. If the bleeding persists, you may need to go back on CPB and place the stitch after the heart is arrested and emptied. If the pt cannot tolerate another pump run, pack the chest open, resuscitate, and go back. This is a difficult suture to place once the patient is off CPB. You can injure the LA dome. Prevent it by taking your time on the posterior portion of the aortic anastomosis.

Answer 341

BP control and anticoag mgmt (if valve surgery done). Postop CT is needed to assess growth of non-replaced aorta and to eval for aneurysm formation.

Answer 342

Control HTN. Optimize lipid profile. Smoking cessation. Reduce risk factors for atherosclerosis.

Answer 343

The implication is the coronary arteries will be difficult/dangerous to mobilize. Cabrol technique - coronary reimplantation by placing an interposition tube graft to the open coronary ostium then doing a side-to-side anastomosis to the main aortic graft. Hemi-Cabrol - direct implantation of the RC button (usually easer to mobilize) and reimplantion of LC artery w/ interposition graft b/w the LC ostium and aortic graft.

Answer 344

5.5 cm. 5 for Marfan, Ehler-Danlos, or with experienced surgeons.

Answer 345

5.5 cm. There isn't a 5.0 or 4.5 caveat here, unlike ascending aneurysms.

Answer 346

Need to know if risk factors for aortic complications - FHx of dissection, progressive aortic regurgitation, rapid expansion (increase by 0.5 cm or more per year). - no risk factors: 5 cm - risk factors: 4.5 cm *these cutoffs include TAA assd w/ following: familial thoracic aortic aneurysm/dissection, Turner syndrome, and other non-BAV congenital conditions. It is unclear when to intervene for EDS; some suggest surgery for acute events only.

Answer 347

Rapid: increase by 0.5 cm or more per year. 0.3 cm in 2 years. A lower diameter may be warranted (eg, 5.0 cm for sporadic TAA).

Answer 348

Need to know if risk factors for aortic complications - FHx of dissection, progressive aortic regurgitation, rapid expansion (increase by 0.5 cm or more per year). For LDS, additional risk factors include female sex and TGFBR2 mutations. - none: 4.5 cm - risk factors present: 4 cm

Answer 349

Same as for standard ascending. Need to know if risk factors for aortic complications - FHx of dissection, progressive aortic regurgitation, rapid expansion (increase by 0.5 cm or more per year). - none: 5.5 cm - risk factors present: 5 cm - severe AI or AS: 4.5 cm

Answer 350

tension = pressure x radius These aneurysms will continue to dilate, though smaller sized aneurysms can stay stable over a long period. >6 cm have significant increase in mortality. Repair usually indicated at 5.5 cm if asymptomatic. Can be smaller depending on other conditions/risk factors.

Answer 351

Mutation in TGF-B receptor. Hypertelorism, bifid uvula, arterial tortuosity. Aneurysms.

Answer 352

Autosomal disorder of COL3a1 gene for type III collagen. No formal aneurysm guidelines as surgery is very high risk. Often present w/ arterial rupture.

Answer 353

Syphilis - infection destroys muscular and elastic fibers of the media layer.

Answer 354

Aneurysm. The uncorrected portion of the aorta tends to continue to dilate. It is often at a faster growth rate with a higher risk of spontaneous rupture.

Answer 355

CTA or MRA - extent of aneurysm, include carotids; look at root and arch; include abd/pelvis if considering femoral cannulation; look at proximity to sternum. Echo - eval valves, cardiac function. Cardiac cath - eval coronary vessel disease. PFTs - if smoker w/ COPD; helps determine risk. CBC, CMP, Coags, T/C.

Answer 356

Cannulate and clamp **higher** than what needs to be replaced. Can do central if there's room for cannula, clamp, and sutures. If no room, can do **axillary**.

Answer 357

It can kink when the heart fills. Distal first. Use felt on aorta if tissues are bad. Move clamp on to graft to eval for hemostasis. Proximal anastomosis. Place root vent in graft prior to cross clamp removal and turn off vents while suturing to help deair. Postop BP control. DC w/ beta-block, ARB, and statin.

Answer 358

May need circ arrest.

Answer 359

Can attempt to plicate the lesser curve, but may need to cross clamp, arrest, excise excess graft, and sew graft to graft.

Answer 360

Significant aortic insufficiency may be present. This should be expected based on preop eval. Clamp and arrest w/ retrograde. Decompress with antegrade vent. If one is not in place, transect the aorta, and deliver direct coronary cardioplegia. Replace the valve.

Answer 361

Give heparin. CLOSE the sternum w/ towel clamps. Tell anesthesia. Get blood in the room. Get perfusion ready for cannulation. Get femoral access in case you need to cannulate there. Give heparin. Open the sternum and place manual pressure on the hole. Get on bypass. Use lots of suctions for bypass. Cool. Clamp the aorta above the rupture. Open it and arrest the heart. Place an LV vent and retrograde sinus cannula if needed. If aneurysm at high risk preop, may be better to axillary/femorally cannulate and be on bypass first. If risk very high, may even cool to 18 degrees for circ arrest before sternotomy.

Answer 362

The same for the cutoff for sporadic disease. Ascending aorta has caveats for centers of excellence for 5.0 cm cutoff.

Answer 363

Hemiarch, total arch, elephant trunk. Decision depends on distal extent of aneurysm.

Answer 364

R axillary artery; unclutters the field and allows for selective ACP

Answer 365

retrograde via SVC usually works; antegrade brain protection may be needed for more extensive repair; these methods extend the safe period (ie lower mortality/stroke) for circulatory arrest, selective ACP is just as safe as bilateral ACP; selective ACP extends the safe time more than retrograde CP.

Answer 366

After clamping and arresting, cool to 18-20 degrees and until EEG is silent. Give pentobarbital and mannitol. Turn off CPB. Transect aorta. Clamp the R innominate, and initiate antegrade brain perfusion: 500 ml/min (10-15 ml/kg) w/ mean pressure 40-60 mmHg and good backflow through L CCA. If not good flow/backflow, place a perfusion catheter up L CCA and Y into the antegrade perfusion circuit at similar rate. Finish the surgery.

Answer 367

When aneurysm extend into the mid/distal arch (past L CCA).

Answer 368

If they are aneurysmal, they may need reconstruction. If not, can be fashioned to the graft as an island.

Answer 369

The relatively safe time period for circulatory arrest at 18°C is 25 to 30 minutes.

Answer 370

When the distal arch or isthmus is involved. Only if a seal can be created. If not, conventional approach should be done.

Answer 371

Duplex eval of the RVA to ensure patency and antegrade flow. Eval for intact circle of willis. If RVA is ok, LVA can be temporarily occluded, and reimplanted during patient rewarming (into L CCA, SVG to aorta, tube graft). <2mm LVA w/ patent RVA can be ligated.

Answer 372

Normally you would want elephant trunk, but this isn't possible because a distal seal would not occur until the completion elephant trunk. Do hemi-clamshell incision extended into the L 4th ICS and do full arch and descending aorta surgery.

Answer 373

Elderly patients do not tolerate circulatory arrest as well as younger patients. Cannulate the R axillary artery (or go high on the aorta), and do a hemiarch.

Answer 374

Repair. ALL symptomatic TAAs should be repaired (ruptured, dissected, pain)

Answer 375

For most average-sized adults: Diameter of >5.5 cm. Of note, there isn't a 5 cm caveat for centers of excellence/experienced surgeons (as opposed to root/ascending). Patients with high surgical risk (eg, STS Predicted Risk of Mortality [PROM] score >8%, frailty score index >2, two compromised organ systems): Diameter ≥6 to 7 cm. Genetically mediated conditions: (syndromic or nonsyndromic), a smaller diameter is suggested as an indicator for repair. The specific threshold diameter depends on the condition. Smaller patients: including many women, a diameter >2x diameter of the nonaneurysmal aorta or the aortic size index can be used.

Answer 376

Asymptomatic TAA with rapid expansion ≥5 mm per year (or 3 mm x2 yrs) for aneurysms <5 cm in diameter

Answer 377

Basal resting gradient: >30 mmHg Provocative gradients (stress valsalva or amyl nitrite): >30 Intervention is considered when gradient is >50

Answer 378

Level and degree of LVOT obsx. Degree of SAM of mitral valve. If cavitary hypertrophy is diffuse (HOCM) or asymmetric/focal (assn AS or HTN). Gradients: **>30 for dx**, **>50 for intervention**. Septum: **15mm for HOCM**, **30mm assd w/ SCD**. Chamber size and fct: athletic hearts can be 13-15mm LV thickness but have normal relaxation and chamber dilation.

Answer 379

LV strain pattern, large T-wave in precordial leads, frequent PVCs

Answer 380

Some do it for all - risk stratification and assessment for LVOT gradient. Look for: Development of symptoms. LVOT gradient increase. Failure of BP to increase (as it should w/ exercise). Arrhythmia. ST depression. Mitral regurgitation.

Answer 381

Obstructive physiology. If non-obstructive, no surgery. Need EF to determine meds. If obstructive physiology, need to know of heart failure symptoms or angina. At this point, medical mgmt is still first line. Persistence of symptoms despite medical management will prompt surgical evaluation. The options are surgery (for those who can tolerate) vs alcohol ablation. DDD pacing is an option for non-surgical patients.

Answer 382

Alcohol ablation

Answer 383

DDD pacing - reduces the LVOT gradient and SAM, as well as improving MR and NYHA class https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9225325/

Answer 384

Differentiate between **primary MR** or **SAM**. Ask about the relationship between the PML and AML in terms of height, excess tissue, or chordae. If the PML height is excessive, may need to do repair (sliding valvuloplasty). This should be anticipated preoperatively because a surgeon uncomfortable in this may end up doing a mitral replacement or canceling the case.

Answer 385

If the patient got diuretics, vasodilators, or went into AF, then LV preload will decrease which could precipitate the recurrence of **SAM and MR** and could explain a similar presentation. **VSD** is rare, but should be on the differential, and this is the description. Get an echo to confirm. PA cath will also show step up in oxygen sat b/w proximal and distal ports. Go back to OR, get TEE, and **repair the VSD w/ pericardium**.

Answer 386

Vasoconstriction (phenylephrine and vasopressin). Positive inotropy, vasodilators, and diuresis should be avoided - can precipitate MR and SAM.

Answer 387

It will usually correct these pathologies (SAM causes the MR) when there is no other concomitant mitral pathology.

Answer 388

Aggressive as it gets. AF reduces LV preload and can induce recurrent MR or SAM. Cardiovert. Beta block. Give fluid. Give vasopressors (phenylephrine). Psx: harsh systolic murmur after HOCM surgery. You notice AF. Differential would be MR from SAM vs VSD.

Answer 389

11 blade incision below the **nadir of the RCA** and resect **3 cm** length of sub aortic muscle. This can be extended for 7cm to the apex if it is true HOCM.

Answer 390

Not used for establishing diagnosis, but only for screening. May predict progression or complications of HOCM. Counseling patients with HCM regarding the potential for genetic transmission of HCM is one of the cornerstones of care. Screening first-degree family members of patients with HCM, using either genetic testing or an imaging/electrocardiographic surveillance protocol, can begin at any age and can be influenced by specifics of the patient/family history and family preference. As screening recommendations for family members hinge on the pathogenicity of any detected variants, the reported pathogenicity should be reconfirmed every 2 to 3 years.

Answer 391

If TEE or cath document non-valvular LVOT w/ subvalvular gradients and normal valve leaflets, septal myectomy can be performed to improve symptoms of heart failure. Pay attention to TEE when coming off bypass to ensure complete myectomy is done and see if no AS.

Answer 392

Often diagnostic. Need to use it to eval size, extent, mobility, stalk, degree of obstruction, chamber and wall involvement, and proximity to valvular/electrical structures.

Answer 393

Tumor burden, wall penetration, relation to extracardiac structures. Can help eval consistency of mass.

Answer 394

Digital necrosis 2/2 distal embolization.

Answer 395

Tumor causes diastolic mitral orifice inflow obstruction.

Answer 396

Complete excision w/ a 5mm circumferential atrial septal excision with the stalk.

Answer 397

Ideally should vent through aortic root. RSPV vent risks tumor embolization.

Answer 398

Bicaval CPB w/ snares. Antegrade cardioplegia. Don't manipulate heart until clamped. **LV vent through aortic root** (not R SPV). Open **RIGHT atrium**. Visualize tumor stalk on septum, incise 5mm to this and excise the tumor through the septum w/ a 5mm margin. Inspect for any residual tumor and damage to the mitral valve. Use garbage suction here. Close septum with **patch**. Bi-atrial approach may be necessary. Higher risk of arrhythmia.

Answer 399

Loss of *vasomotor tone -> dec *preload -> tumor obstruction of *MV inflow. ACLS. Intubate and give *catecholamines. Immediate sternotomy, heparin, CPB w/ dual stage via RA vs SVC only vs peripheral.

Answer 400

Assess size and location. Unless the leak is tiny, go back on bi-caval CPB, find the hole, and fix it (this is why primary closure is not recommended; use a patch).

Answer 401

Preop assessment of tumor w/ *TEE and *CT/MRI or possibly venography eval the extent and plan for CPB. Depending on extent, the patient may require bypass via the *R IJ or and/or *femoral.

Answer 402

SA node. Make sure to go laterally. In addition, protect the the tricuspid valve and AV node.

Answer 403

Central aortic and peripheral venous - femoral and R IJ. CVL access through contralateral SCV. Mobilize the SVC high, possibly above the azygous. Clamp, antegrade, snare. R SPV vent can be used if no L side involvement. Incise RA and extend high and lateral to avoid SA node. Inspect RA, RV, TV, and RVOT. Separate incision can be used on PA to remove embolus.

Answer 404

Brief period of hypothermic arrest may facilitate full removal of the tumor burden from the distal PA.

Answer 405

Often actually extension from atria below the AV valve. Can approach via the outflow tract or the AV valve. If you can do a good inspection, a ventriculotomy is often avoided.

Answer 406

Repair or replacement of the valve will be necessary.

Answer 407

Take note of the exclusionary history and physical taken. This is likely a *papillary fibroelastoma. Benign and found incidentally. *Excise them d/t their *embolic potential. The stalk is usually very small and can be excised *flush with the leaflet without incurring any leaflet damage. Arise from valvular endocardium.

Answer 408

Carefully planned *CPB. Prevention of embolization by *avoiding manipulation before cross clamping and carefully evaluating chambers before closing. Operative exposure usually through RA, but possibly LA, rarely ventriculotomy. Septum should be closed w/ *tension free patch.

Answer 409

Venous stasis: immobility (intubated, spinal injury), bedrest Endothelial injury: surgery, trauma, access procedures Hypercoagulable state: malignancy, thrombophilia, oral contraceptives, hx of thrombosis

Answer 410

dilation, septal flattening

Answer 411

eval for clot extent and location

Answer 412

Hemodynamic compromise (shock/hypotension), RV dysfunction. Tx w/ heparin and thrombolysis vs embolectomy (as opposed to heparin alone). Risk of imminent death is 10%, 30-day risk is 30%.

Answer 413

Intracranial neoplasm, <2 mo intracranial or spinal surgery/trauma, hx of hemorrhagic stroke, active bleeding, bleeding diathesis (trhombocytopenia), nonhemorrhagic stroke w/in 3 mo.

Answer 414

Catheter-embolectomy vs surgical-embolectomy. If CV and/or resp unstable, consider ECMO.

Answer 415

It does not unload the RV. The RV is still pumping some blood against a clot, so there can be myocardial injury until the clot burden is removed.

Answer 416

Operative mortality is 6%. 1-year survival is 86%. According to 47 pt series by Leacche et al.

Answer 417

RA and RV for clot in transit. PFO/ASD. PA for extent of clot.

Answer 418

initiation of anticoagulant therapy, provided the patient is not at a high risk of bleeding, continued indefinitely

Answer 419

inferior vena cava filter until the bleeding risk is resolved and adequate anticoagulation can be provided

Answer 420

examine pulmonary artery catheterization (PAC) data: hemodynamic abnormalities at rest that almost invariably warrant surgery (eg, PVR of 240 to 1200 dynes-sec/cm-5 [3 to 15 Wood units] with the majority falling into the range of 600 to 1000 dynes-sec/cm-5 [7.5 to 12.5 Wood units]) for patients without a substantial increase in pulmonary hemodynamics with exercise, the benefits of PTE are less clear - can consider PTE when the patient’s exercise intolerance and quality of life dissatisfaction is of sufficient magnitude that the patient is willing to accept the risk of surgery

Answer 421

located proximally in the main, lobar, or segmental pulmonary arteries are amenable to surgical removal; digital subtraction pulmonary angiography (DSPA) is considered the gold standard in defining the extent and location of the thromboembolic obstruction patients with profound right ventricular failure and shock, the risk of DSPA may be prohibitive to this assessment - do computed tomographic pulmonary angiography (CTPA) or magnetic resonance pulmonary angiography (MRPA)

Answer 422

reperfusion syndrome (8-10%); mainly supportive tx w/ vent and pressors prn diurese and wean FiO2 resolves in 7-10 days

Answer 423

**Chronic radx pericarditis**, CHF, restrictive cardiomyopathy, recurrence. CXR to eval for **pericardial calcification** or effusions. CT or MRI may show **thickened or calcified pericardium**. EKG is nonspecific w/ ST-T changes. Echo may show **constrictive physiology - bowing of interventricular septum w/ inspiration**, thickened pericardium. Possible cath.

Answer 424

Echo - **bowing of interventricular septum** to the left w/ inspiration (instead of the RV expanding out w/ inc preload, it has to expand into the LV) Cath - square root sign, RV end diastolic P > 1/3 RV systolic P, **equalization of pressures across the atria during diastole, equalization of ventricular pressures during diastole** (except during inspiration).

Answer 425

Small or normal sized heart, reduced LV fct, pulmonary and hepatic congestion, BNP may be elevated (unlike in constrictive disease)

Answer 426

Endomyocardial biopsy or diagnostic surgical exploration with inspection of the pericardium.

Answer 427

surgery - pericardial stripping

Answer 428

excise pericardium from phrenic to phrenic, down to diaphragm, and around the AV groove to the entrance of the caval/pulmonary veins posteriorly - CPB is usually needed for at least the left side structures - there may be a lack of surgical planes, which can lead to significant blood loss and damage to coronaries or venous structures (may want groins exposed, would wait to give heparin until aorta is exposed)

Answer 429

esophagus - can palpate the TEE probe to stay clear

Answer 430

Send samples for frozen. If malignancy is found, abort and refer to an oncologist.

Answer 431

CPB Check for HD changes and EKG Repair, interpose, or re-bypass completely.

Answer 432

3rd or 4th space 7th space if distal access needed

Answer 433

Persistent pain, malperfusion (spinal, visceral, extremity), impending rupture, life-threatening complications (very general category...). Most Type B dissections are uncomplicated. Complicated dissections usually require surgical or endovascular intervention.

Answer 434

near the ligamentum and along the posterior proximal neck of the aorta

Answer 435

dissect them free from the transverse arch

Answer 436

prevent the need for re-implantation of the intercostal arteries and reduce risk of spinal ischemia and thus paraplegia

Answer 437

Dynamic malperfusion should be improved after the repair. Static malperfusion usually requires percutaneous balloon septal fenestration and uncovered stent by IR.

Answer 438

Lumbar drain. Ideally ICP less than 10. Do not drain >20ml/hr d/t risk for SDH. MAP support to 80-90 w/ fluids, phenylephrine, or vasopressin to improve spinal cord perfusion pressure. No steroids.

Answer 439

Will likely need circ arrest for the proximal portion. May need to reimplant the L SCA separately. R ax cannulation is ideal.

Answer 440

Go bicaval, open the atrium, and place the retrograde cannula directly.

Answer 441

1) Stop perfusing through the line. 2) Volume and pressors as needed to maintain MAP - can use venous line if you've placed one, just make sure it's deaired. 3) Alternate cannulation - axillary, femoral, percutaneous through ascending aorta confirmed with TEE. 4) Remove the first cannula, assess proximal/distal extent, assess for rupture, AI (LV distention), MI. 5) Retrograde coronary sinus. LV vent (not root vent). 6) Start cooling to 18. *** If heart distends and fibrillates, clamp and arrest. 7) Clamp, arrest retrograde, and vent the root via aortotomy. *** If AI, do proximal work on valve. 9) Circ arrest, brain perfusion. 10) Hemiarch. 11) Deair, resume full flow. 12) Proximal aorta anastomosis, add root vent. 13) Distal and proximal anastomoses for CABG.

Answer 442

Hematoma through the aorta visually. MAP drops. Line pressure is high. Confirm with TEE. They will see a flap. Determine proximal and distal extent.

Answer 443

Remove the IABP. If the leg is still without a pulse, check a duplex and CTA to include the chest, abdomen, pelvis, and runoff. If a type B is found, go to the OR emergently for fem-fem bypass.

TSRA Clinical Scenarios - Adult Cardiac Surgery Flashcards

(479 cards)