CARDIO Flashcards

Question

What is the grading for aortic stenosis ?

Answer 1

- Open surgical repair – gold standard - Transcatheter aortic valve implant – TAVI - Balloon valvuloplasty – no long term benefits, bridging / palliative therapy

Answer 2

- Open surgical repair o Bleeding o Arrhythmias – AF o Stroke o Mediastinitis / infection - TAVI o Bleeding – retroperitoneal, intrathoracic vessels o Arrhythmias – injury to conduction system – AV block o Stroke – embolus of atheroma / calcified valve o Infection o Aortic annulus rupture or paravalvular regurgitation

Answer 3

- Clinically indicated e.g. severe AS + symptoms / EF < 50% - (for TAVI or open) - If young and fit enough – better long term outcomes - TAVI contraindicated e.g. I.E , valve anatomy - Having other cardiac surgery anyway e.g. CABG - Need for mechanical valve

Answer 4

* Absolute: Infective endocarditis * Relative: Small annulus / difficult anatomy, severe co-morbidities and unlikely to improve QoL

Answer 5

- Frail / comorbid e.g. age >75 - Previous CABG / sternotomy - Chest wall deformity

Answer 6

- Open – o Gold standard , preferred for younger fitter patients o longer hospital stay o Most complications are higher with open repair o Can implant mechanical or bioprosthetic valves - TAVI o Can only use bioprosthetic valves o Less invasive – preferred in elderly o Less complications however less definitive

Answer 7

- Mechanical o Life long coagulation, more durable , better for younger patients - Bioprosthetic o Made from animal tissue, no need for long term anti coag, lasts 10-15 yrs – better for elderly

Answer 8

Balloon placed across aortic valve and then inflated to decrease valvular pressure gradient.

Answer 9

* Femoral artery - commonest * Also subclavian / carotid * Transaortic – mini sternotomy / thoracotomy * Transapical – via thoracotomy

Answer 10

- A stiff guidewire is advanced from the femoral artery to the aortic valve using fluoroscopic guidance - A brief period of systemic hypotension is achieved by rapid pacing – 180 to 220bpm. During this time the native valve is dilated by balloon aortic valvuloplasty - The TAVI is then positioned.

Answer 11

- Option – local , local + sedation, GA o GA for uncooperative patient or non femoral approach - Full AABGI monitoring - Heparin given 3000-5000 units ACT >250 s - Haemodynamic goals o Maintain SVR, preload, contractility, Sinus rhythm, tight HR control

Answer 12

- **Maintain Sinus rhythm** – CO more dependant on atrial contraction (40%) o Electrolytes , acid base, hypoxia/ hypercapnoea, antiarrhythmics - **Maintain SVR** – MAP dependant on SVR now CO reduced – ensures coronary perfusion o Vasopressors , avoid spinal - **Tight HR control** o Bradycardia – reduced CO o Tachycardia – reduces filling time / coronary perfusion and increases O2 demand = Good analgesia / opioids on laryngoscopy - **Maintain preload** o Optimises CO , ensures max filling of impaired LV - **Maintain contractility** o Supports LV in pumping against outflow obstruction o **Minimise cardiac depressants, ionotropes** * Maintain sinus rhythm * Maintain SVR * Tight HR control * Maintain preload * Maintain contractility

Answer 13

- Bleeding o Aortic injury / femoral injury o Aortic dissection o Tamponade - Arrhythmias – AVN block - Rapid ventricular pacing during valve deployment – reduces CO - Aortic regurgitation - Ischaemia – blockage of coronary ostium - Other general o Pain / anxiety – HTN / tachy o Fasting – dehydration o Anaesthetic – drop SVR / myocardial depressant

Answer 14

- No if good functional capacity and minor op then not required - If symptomatic or major op or ECG changes – then required

Answer 15

* Rheumatic heart disease * Endocarditis * Autoimmune diseases (e.g., SLA, RA) * Dilated aortic root acute - aortic dissection

Answer 16

- Hx , examination - ECHO – regurgitation fraction / jet, LV ejection fraction, LV end diastolic / systolic volume

Answer 17

* Severe symptomatic AR * Severe asymptomatic with LVEF <50% * Significant enlargement of ascending aorta

Answer 18

- Conservatively / surgical - if it develops acutely e.g dissection it is an emergency

Answer 19

Rheumatic heart disease.

Answer 20

* Acute: MI and papillary muscle rupture * Chronic: Primary valve disease, secondary LV dilation

Answer 21

* Dyspnoea * Fatigue

Answer 22

* Pulmonary oedema & PAH * Atrial fibrillation

Answer 23

- Regurgitant jet – severe >8cm2 , mild < 4cm2 - Pulmonary artery pressures measures

Answer 24

* Open surgery * Transcatheter valve repair

Answer 25

* Younger, lower risk patients * Having open surgery for another procedure * transcatheter repair contraindicated

Answer 26

* Old and frail * Previous sternotomy / chest wall deformity * Suitable valve anatomy

Answer 27

- Open = better MR reduction and more durable , longer hospital stay - Transcatheter = fewer complications, less invasive – can be done under local / sedation

Answer 28

- frailty , multiple comorbidities - chest wall deformities - previous sternotomy

Answer 29

- valve features o valve area too small < 3cm o leaflet length < 6cm o calcification at grasping area o thrombus / mass on valve o valve perforation - atrial access o small LA - endocarditis

Answer 30

- bleeding – retroperitoneal bleeding, aorta , tamponade - TOE related injury – oesophageal perforation - Arrhythmias = AF most common - Pulmonary oedema – ASD, mitral stenosis - Device embolization – uncommon but serious neurological complication

Answer 31

- MDT approach – interventional cardiology, anaesthetist, echocardiographer, cardiac surgeon - Detailed pre op assessment – usually frail and need optimising - ECHO - Medications review – e.g. stop anticoagulants - Discussion with patient and family r.e. risks and consent

Answer 32

- Remote anaesthesia – cath lab - TOE required - GA + intubation OR local + sedation - Arterial line - Defib pads attached - Haemodynamic goals maintained – reduce afterload, avoid bradycardia, Sinus rhythm etc

Answer 33

- Reduce SVR / afterload – promotes forward flow - Maintain HR / avoid bradycardia – minimises regurgitation time and excess preload - Sinus rhythm – atrial contraction helps LV filling - Maintain contractility – supports forward flow – ionotropes - Avoid fluid overload - B agonists preferred over vasopressors – supports contractility and avoids high SVR

Answer 34

- REDUCE LV SIZE o Easier for surgeons to grasp leaflets o Furosemide o PEEP – reduces pre load o Ionotropes – dobutamine , milronone - REDUCE MOVEMENT o Low TV 3-6ml/kg – help reduce heart motion to assist leaflet grasp o Avoid ventilatory changes when crossing atrial septum or when placing clips

Answer 35

- Femoral access via seldinger - Heparin given - ACT 250-300 – prior to venous access - Transeptal puncture – TOE can guide position - Wire into LA , balloon dilated and clip delivery system advanced – using TOE - After procedure the atrial septal defect is assessed if significant shunting, it can be repaired - Final TOE – function and complications ## Footnote .

Answer 36

- Most don’t need ITU - Pain is minimal - CXR – confirm clips and rule out pneumothorax / pulmonary oedema - Transthoracic acho within 24 hours – asses function / mitral stenosis - Restart anticoag

Answer 37

- Clinical syndrome in which heart is unable to pump sufficient blood to meet the metabolic demands of the body

Answer 38

* Breathlessness * Leg swelling * Fatigue * Poor exercise tolerance * Orthopnoea and paroxysmal nocturnal dyspnoea ## Footnote Symptoms can vary in severity and presentation.

Answer 39

* Elevated JVP * Pitting oedema * Basal crepitations on auscultation * 3rd heart sound ## Footnote These signs help in the clinical diagnosis of heart failure.

Answer 40

* Raised BNP * Pulmonary oedema on CXR * Cardiomegaly on CXR * ECHO findings of reduced EF ## Footnote These findings are crucial for confirming heart failure diagnosis.

Answer 41

* By side: left, right, congestive (both) * By ejection fraction: Reduced < 40% (HFrEF), Mildly reduced 40-50% (HFmrEF), Preserved >50% (HFpEF) o Improving = below 40% then increasing to >40% ## Footnote Classification aids in management and treatment strategies.

Answer 42

- At risk – stage A – patients with HTN, T2DM, obesity, FHx of cardiomyopathy - Pre HF – stage B – without symptoms but evidence of 1 of the following – structural heart disease, abnormal filling pressures, elevated BNP - HF – stage C – symptomatic HF - Advanced – stage D – severe symptoms at rest, requiring hospitalisations, considered for advanced therapies

Answer 43

- HTN , IHD, valvular disease, myocarditis , HOCM, dilated cardiomyopathy

Answer 44

- NYHA = new York heart association - Class 1 = no symptoms - class 2 = symptoms on exertion, mild limitation - class 3 = symptoms on minimal exertion - class 4 = symptoms at rest

Answer 45

- crepitations at lung bases, 3rd heart sound, quiet lung bases (effusions)

Answer 46

- increases afterload – LV hypertrophy – results in diastolic dysfunction and increased O2 demand - increased LV end diastolic pressure – reduces myocardial supply / perfusion - also close link between HTN and IHD

Answer 47

- intrinsic – infarction or cardiomyopathy - increased afterload o pulmonary HTN secondary too…  chronic hypoxic / COPD  mitral valve disease  P.E – acute / chronic  Drugs - Increased RV volume o LV failue o L to R shunt – ASD / VSD ## Footnote Understanding these causes is critical for targeted treatment.

Answer 48

- Pitting oedema - Hepatomegaly - Raised JVP - Ascites

Answer 49

- P.E causes rise in pulmonary artery pressures – physical blockage and hypoxic vasoconstriction - This increases RV afterload and hence wall tension – increased RV O2 demand - RV cannot maintain this and will dilate - Can result in intraventricular septum bending towards LV - Reduced diastolic filling of LV and hence LV stroke volume = ventricular interdependence - Can result in reduced CO and coronary perfusion

Answer 50

- ECG o Pulmonary HTN – Right axis deviation, p pulmonale o RV ischaemia – ST changes I, III and aVF - ECHO o Loss of spherical shape o Increased RV:LV size ratio o Tricuspid regurgitation

Answer 51

- Systemic inflammation results in microvascular endothelial inflammation and myocardial fibrosis – LV hypertrophy and stiffness - Results in Diastolic dysfunction - LV failure with reduced EF has systolic dysfunction = LV dilation ## Footnote HFpEF differs from HF with reduced EF as it primarily involves diastolic dysfunction.

Answer 52

- Scoring system to assess risk of HF in unexplained dyspnoea - BMI > 30, HTN, AF, PAH, > 60yrs, filling pressures - Score out of 9 = If score > 6 then likely HFpEF

Answer 53

- Symptoms and signs - BNP – raised - ECHO – EF – may be normal in HFpEF - Exclude other causes of breathlessness – anaemia, AF - Diagnostic toold – H2PEF score

Answer 54

- Obesity , female, normal renal function, younger

Answer 55

- First line = SGLT2 inhibitor, diuretic + treatment of co-existing comorbidities - Non pharm = exercise rehabilitation, weight losss ## Footnote Effective management of HFpEF often requires addressing multiple health issues.

Answer 56

- Diuretic effect – osmotic diuresis - Improve cardiac energetics – ketones - Anti inflammatory and hence anti fibrotic - Reduced hospitalisation and mortality

Answer 57

- 4-6x increased mortality & morbidity - Cardiopulmonary complications - Non cardiopulmonary – AKI, strokes, sepsis

Answer 58

- Standard pre op ... - Focus on HF o exercise tolerance – subjectively (METS) or objectively (CPET) o Orthopnoea / PND o NYHA class ... - Detail on associated comorbidities – IHD, HTN, diabetes ... - Ix o FBC – anaemia exacerbates HF o ECG – arrhythmias o CXR ... - Cardiologist input in moderate/severe cases - Withhold SGLT 2 = 2-3 days before op

Answer 59

- maintain contractility by minimising anaesthetic depth where possible - induction - Smooth, slow, lower doses Coronary O2 - minimise O2 demand – avoid tachycardia - maintain MAP hypoxic pulmonary vasoconstriction – worsen RHF – normocapnia, avoid acidosis and hypoxia. Consider pulmonary vasodilators AABGI + arterial line +/- BIS Careful fluids

Answer 60

- Fasting - Surgical stress - Dehydration

Answer 61

- If elective stop 2-3 days before, if emergency stop on admission - Monitor CBG and ketones in peroop period

Answer 62

- Ketones >1.5 mM/l and pH < 7.3 and other causes of acidosis excluded

Answer 63

- 10% glucose at 125ml/hr - Insulin 0.1units /kg/hr – i.e. treat as DKA

Answer 64

- After surgery when normal E+D and volume replete - If had episode of euglycaemic DKA – don’t restart, talk to diabetic team

Answer 65

- A mechanical pumping device that helps to provide circulatory support. - Can be temporary or long term and used to support LV/RV/both - They are pre-load dependant and after load sensitive ## Footnote VADs can be temporary or long-term and support LV/RV/both.

Answer 66

- Inflow cannula – ventricle - Outflow cannula – ascending aorta - Pump – sits in pericardial space - Controller / battery connected to pump ## Footnote Each component plays a crucial role in the device's function.

Answer 67

- Heartmate 3 = 3rd generation = continuous flow centrifugal pump

Answer 68

- Today’s devices are continuous flow centrifugal pumps – lower incidence of pump thrombosis, stroke, GI bleeding - Previously pulsatile/ axial flow , more complications

Answer 69

- Flow rate = Cardiac output - Pulsatility index

Answer 70

- Support whilst awaiting transplant - Long term for those ineligible for transplant - Temporary support bridging recovery after MI

Answer 71

- GI bleed – continuous flow devices predispose to AV malformations plus anticoagulated. Common , up to 40% - Pump thrombosis - Stroke - Infections around the device ## Footnote Complications highlight the need for careful monitoring and management.

Answer 72

- INR 2-3 - Warfarin + aspirin (+/- clopidogrel)

Answer 73

- Usually co-morbid patients with poor CVS function - Potential for intra op VAD related complications - Anticoagulated - Mechanical ventilation can affect VAD functioning

Answer 74

- Specialist centre - Emergency surgery – close liaison with specialist centre

Answer 75

* MDT approach – anaesthetist, cardiologist, VAD specialist nurse, other * Evaluating VAD function and any previous complications * anticoagulation status. * Assessing right ventricular function. / ECHO * Reviewing the patient's volume status and end-organ function and functional status * Standard pre op etc * Post op planning – ITU/ specialist centre

Answer 76

- Connect to an uninterrupted power supply - Care in movement and positioning - VAD specialist nurse present – monitor settings and function throughout - Place external defib pads on all patients

Answer 77

- Stop warfarin 5 days pre op - Wait for INR < 2 then start IV heparin - Stop heparin 2-4 hours before surgery - Emergency surgery – reverse warfarin with prothrombin complex concentrate

Answer 78

- AABGI - Arterial line - CVP monitoring if large fluid shift / ionotropes requires - Consider TOE

Answer 79

- Neuraxial usually contraindicated due to anticoag - Haemodynamic management o Preload dependant and afterload sensitive o Maintain MAP 60-80mmHg - Infection prevention o Strict asepsis for all procedures o Broad spec Abx inc antifungals - Bleeding risk o Patients have a von Willebrand deficiency due to pump degrading this o Desmopressin can help - Bipolar diathermy is preferred

Answer 80

- Head up – reduces pre load and hence pump flow - Head down – increases pre load, can impair filling - Pneumoperitoneum – reduces pre load, increases after load – risk of suction event, inflate gradually

Answer 81

- Aortic regurgitation and pump thrombosis

Answer 82

- Pump thrombosis + blockage– due to stopping anticoag - Suction event - RV dysfunction – triggered by IPPV, hypoxia/ hypercarbia - Cardiac arrest

Answer 83

- The pump is dependant on preload and if there is inadequate preload it can cause LV to collapse and occlude the inflow cannula - Results in severe hypotension, ventricular arrythmias - Low flow alarm will sound - Caused by hypovolaemia, reduced venous return (pneumoperitoneum, Trendelenburg), RV failure, cardiac tamponade

Answer 84

- Reduce pump speed - IV fluid bolus - Use ECHO to guide treatment

Answer 85

- Defibrillation and cardioversion are safe - Chest compressions are relatively contraindicated – can damage device – but if MAP < 50mmHg / EtCO2 < 20mmHg then necessary

Answer 86

- High care bed / cardiology - Monitor for bleeding - Restart warfarin after 1-2 days, bridge with heparin - VAD specialist nurse to check VAD function

Answer 87

- Pacemaker - Cardiac resynchronisation therapy device - Implantable cardiac defibrillator - Loop recorder – for investigating arrhythmias not detected by halter monitors

Answer 88

* 3rd degree heart block * 2nd degree HB Mobitz type 2 * Unexplained syncope + bifascicular block * Symptomatic bradycardia ## Footnote These conditions warrant the need for pacing to maintain heart function.

Answer 89

- Electrical implantable device with pacemaker and or defibrillator function that improves cardiac coordination and efficiency in severe HF - a form of biventricular pacing - Patients with HF often have dyssynchronous contractions between LV and RV and hence mechanical energy is lost and function is inefficient ## Footnote It addresses mechanical inefficiencies due to dyssynchronous contractions.

Answer 90

- Passed into left subclavian vein - Right electrode passes through tricuspid valve - Left electrode passes through coronary sinus and into coronary veins to reach apex of LV

Answer 91

- Symptomatic HF with LVEF < 35% despite optimal medical therapy with… o LBBB and QRS >130ms o QRS > 150ms o AF and QRS >130ms - Symptomatic AF with uncontrolled HR in patients who are candidates for ablation - Best result if QRS >150 and LBBB

Answer 92

- Primary prevention of life threatening arrhythmia = long QT, brugada , HOCM - Secondary prevention o Previous life threatening arrhythmia leading to cardiac arrest o Previous sustained symptomatic VT o Asymptomatic VT with HF

Answer 93

- Change response mode to asynchronous mode o this is if there is significant pacemaker dependency e.g. pacing spikes before most complexes. o This is because the pacemaker may misinterpret the diathermy as activity and stop pacing. - Advanced CIED functions may cause unhelpful rate changes periop o e.g. sometimes rate response uses minute ventilation to regulate pacing when sleeping / resting. Not appropriate perioperatively - Turn off ICD o switched off to eliminate risk of firing in response to electromagnetic interference if diathermy is used. o Attach external defibrillator pads - Disable any anti-tachycardia functions if diathermy used

Answer 94

- Pacemaker interrupts the diathermy current as cardiac electrical activity and doesn’t generate an appropriate rate response

Answer 95

- Asynchronous mode if very reliant on pacing - Bipolar diathermy - If monopolar needed, place the diathermy plate distant from pacemaker - Short rather than long bursts of diathermy

Answer 96

* Transcutaneous pacing * Correcting cause e.g. electrolyte abnormalities, hypoxia, CO2, releasing surgical stimulus

Answer 97

* Atropine 500mcg * Glycopyrrolate 200mcg * Isoprenaline 5mcg/min * Adrenaline 2-10mcg/min

Answer 98

- Mechanical device that sits in aorta and inflates and deflates in counterpulsation with cardiac cycle. It is used to support cardiac function for those in severe HF, myocardial ischaemia or weaning of CPB.

Answer 99

- Inflation in diastole and deflation just before systole - Inflation in diastole o Improves forward flow of blood and CO o Improves retrograde flow of blood and coronary perfusion - Deflation just before systole o Reduces LV afterload and wall tension – hence less O2 demand o Reduction in afterload also improves CO and allows forward flow of blood by heart - Overall .. o Improves coronary perfusion o Decreases myocardial O2 demand o Enhances cardiac output

Answer 100

- Aortic diastolic pressure – LV end diastolic pressure - Aortic balloon Increases aortic diastolic pressure - Inflation of the pump may also stimulate NO release from endothelium and coronary dilation

Answer 101

- Acute HF with hypotension - MI with o papillary pupture + mitral regurgitation o acute LV failure o support needed during PCI - unstable angina while awaiting therapy – improves O2 blood supply and reduces demand - low CO after CABG / separation from CPB

Answer 102

- Aortic disease o regurgitation – will promote this o dissection o aneurysm - uncontrolled sepsis - bleeding risk - tachyarrhythmias – cant synchronise with this - untreated PVD – could worsen perfusion

Answer 103

- Balloon catheter inserted into aorta via femoral artery – fluoroscopic guidance - Sits in descending aorta , 2-3cm distal from subclavian artery - Distal end above renal arteries - Check position with Xray or TOE

Answer 104

- Arterial waveform o Inflation with dicrotic notch o Deflation just before upstroke of waveform - ECG o Inflation with T wave o Deflation with peak of R wave

Answer 105

- Arterial waveform because ECG no longer reliable e.g. PEA – false impression of cardiac output

Answer 106

- Inflates too early o Increases afterload and reduces intrinsic CO o Increases O2 demand o Potential aortic regurgitation - Late inflation o Suboptimal coronary perfusion and forward flow - Early deflation o Suboptimal reduction in LV afterload / O2 demand - Late deflation o Increases afterload and reduces intrinsic CO o Increases O2 demand

Answer 107

- Aortic damage o Dissection o Bleeding o False aneurysm - Infection - Thromboembolism – foreign body + pump promotes embolization - Bleeding related to anticoagulation - Thrombocytopenia and haemolysis - Blocked vessels by device o Worsening of PVD / compartment syndrome o Spinal cord ischaemia - Cardiac tamponade – dissection / rupture of aorta - Dyssynchrony - Balloon rupture and gas embolus

Answer 108

- Helium - Low density = flow will be laminar to allow for rapid transfer from machine to balloon tip - Rapidly absorbed into blood in event of balloon rupture – minimises gas embolus risk

Answer 109

12-20mmHg.

Answer 110

- Mean pulmonary artery pressure of 25mmHg or greater at rest or 30mmHg on exercise measured by right heart catheterisation - Recent guidelines suggest 20mmHg

Answer 111

- Female > male - Patients with SLE, sickle cell

Answer 112

* Breathlessness * Exertional syncope * R side HF * Angina-like chest pain

Answer 113

- RH hypertrophy o Diastolic dysfunction o Increased O2 demand (plus increase EDV/P – reduces supply) - Increased pressure / remodelling – Tricuspid regurgitation - Eventually systolic dysfunction - Can lead to LV failure as RV size increases and septum deviates

Answer 114

- Supportive = anticoagulation, diuretics, LTOT o Warfarin / DOACs as high risk of VTE / PE - Treatment = o CaCB – nifedipine, amlodipine o Endothelin receptor antagonist – bosentan o phosphodiesterase inhibitors = sildenafil o prostaglandins – inhaled iloprost - Definitive = lung transplant

Answer 115

- Reduce RV after load o Nebulised prostacyclin o Inhaled nitric oxide o IV sildenafil - Improve RV contractility o Ionodilator – milronone , levosimenden o Ionotropes – dobutamine, NA - Maintain SVR – metaraminol, NA, vasopressin - Optimise fluid balance – diuretics/ fluids

Answer 116

* High risk mortality

Answer 117

- Avoid increase in PAH / pulmnonary vasoconstriction – avoid hypoxia/ hypercarbia/ acidosis, hypothermia, pain , high airway pressures/ PEEP - Avoid fall in SVR – maintain coronary perfusion – invasive BP monitoring, pressors , cardiostable induction agents – fentanyl - Maintain sinus rhythm and contractility – avoid tachy (increases O2 demand and reduces diastole for coronary perfusion), ionotropes , minimise depressive effects of anaesthesia - Maintain optimum preload – avoid excess fluids – consider CO monitoring to guide this IPPV can worsen pressures and RV failure and decompensation

Answer 118

- WHO classification 1. Pulmonary artery HTN - idiopathic, associated with systemic diseases e.g. HIV, drugs/ toxins or pulmonary HTN of new born. Remodelling of pulmonary vessels 2. LEFT heart disease 3. Chronic lung disease – COPD, OSA 4. Chronic thromboembolic disease 5. Other multisystem / unknown mechanisms

Answer 119

Supraventricular tachyarrhythmia characterized by irregularly irregular ventricular contraction.

Answer 120

AF that occurs within after surgery usually within the first week. - highest prevalence after cardiac / thoracic surgery e.g. CABG / valvular surgery - correlated with poorer outcomes, increased M&M, increased hospital stay, increase ICU need, overall hospital costs.

Answer 121

- breathlessness, palpitations - syncope, chest pain - strokes - may be asymptomatic

Answer 122

* Cardiac: HTN, valve disease, IHD, cardiomyopathy * Non-cardiac: thyrotoxicosis, alcohol, stress, electrolytes

Answer 123

- loss of P waves - fibrillating/ irregular baseline - irregularly irregularly QRS complexes

Answer 124

- Pre op = age, male, HTN, renal dysfunction, diabetes, high BMI , pre-existing CVS disease - Intra op = cardiac surgery – valve / CABG, use of bypass, long aortic cross clamp time - Post op = stopping B blockers / ACEi, electrolyte imbalance, critical illness / ITU

Answer 125

- stress response and sympathetic activation – increased catecholamines - Direct surgical irritation in cardiac surgery - electrolyte disturbances - arrhythmogenic - ischaemia from hypotension and anaemia and hypoxia - hypoxia / hypercarbia and increased pulmonary pressures and right atrial dilation

Answer 126

- CHA2DVASc (not just for assessing thrombosis and anticoag risk) - POAF = post op AF score

Answer 127

- Estimates risk of post op AF - Includes age, history of AF, male sex, HTN, COPD, CHF, valve surgery , LA enlargement - The higher the score, the higher the risk of post op AF

Answer 128

- Thromboembolic – strokes - MI - Congestive HF - Risk of cardiac arrest - Risk of pneumonia - Increased hospital stay

Answer 129

- Continue B blockers perioperatively - Optimise chronic illness / patient factors e.g. HTN - Intra op homeostasis – fluids, electrolytes, hypoxia/ hypercarbia - Steroid use - Regional anaesthesia / multimodel analgesia = reduces stress response

Answer 130

- Life style – caffeine, alcohol, weight loss - Rate control – B blockers, CaCB , digoxin - Rhythm control – electrical or pharmacological (amiodarone/ flecainide) - Ablation - Anticoagulation - Symptomatic unstable – DC cardioversion

Answer 131

* Congestive HF * HTN * Age >75 * Diabetes * Stroke * Vascular disease * Age >65 * Sex – female

Answer 132

- Assess if currently in AF – check pulse - Check if adequately rate controlled e.g. 60-80bom - Assessing for signs of HF - breathlessness / exercise tolerance / previous ECHO results / orthopnoe / pitting oedema/ pulmonary oedema - Medication history including use of anticoagulation - Potential causes of AF – goitre?

Answer 133

factor Xa inhibitors

Answer 134

- A to E, call for help, 100% O2 - 12 lead ECG - Reverse possible causes o Pain – opioids o Light anaesthetic o Anxiety – increase sedation if neuroaxial o Fluids if dehydrated o Rule out anaphylaxis, tension pneumothorax , LAST etc - If life threatening features o DC Cardioversion – 2joules/kg o Amiodarone 300mg IV over 15-20mins – if unsuccessful - Can also try o Valsalva o MgSO4

Answer 135

- Amiodarone 300mg loading and then 900mg over 24 hours - MgSO4

Answer 136

- In recovery until fully awake / alert - 12 lead ecg + bloods

Answer 137

- Any life threatening signs – chest pain/ MI , syncope, heart failure , hypotension

Answer 138

- Cardiovascular complication / injury after non-cardiac surgery within 3 days - Characterised by a rise in troponins indicating myocardial damage - No evidence of myocardial ischaemia - Associated with poor post op outcomes, increased M&M

Answer 139

- MI o Rise in troponins plus one of  symptoms of MI  ECG changes associated with is ischaemia / LBBB  New regional wall motion abnormality on ECHO  Identification of thrombus on angio - Myocardial injury o Injury does not have evidence of ischaemia e.g. ECG changes / wall motion abnormalities etc o Can lead to infarction

Answer 140

- Type 1 = atherosclerosis - Type 2 = rate dependant - Type 3 = sudden death associated with MI

Answer 141

- Reduced blood flow - Increased demand – e.g. tachycardia - Reduced O2 delivery – hypoxia , anaemia - Haemodynamic strain e.g. increased preload / afterload – catecholamines, fluids, IPPV

Answer 142

- Age, male - Pre-existing risk factors – HTN, IHD, previous MI, HF, CKD - Emergency surgery - General surgery > ortho

Answer 143

- Optimise CVS health pre op o Life style – smoking, alcohol, weight loss o HTN and diabetic control and statins o Correct anaemia o Continue aspirin and statins periop - Intra op o Avoid hypotension - Intra op hypotension, particularly systolic < 90mmHg has been associated with PMI o Avoid hypoxia o Avoid tachycardia - Post op o Good analgesia

Answer 144

* Initiate statins and aspirin * No routine troponin checks in everyone post-op

Answer 145

- HX o PMHx, DHx, allergies, smoking hx o Screen for signs and symptoms of IHD o Detailed exercise tolerance Hx o Nature and duration of pain, radiation o Chest pain at rest o Associated symptoms with the pain – dyspnoea, syncope, palpitations - Examination o CVS exam – heart sounds, pitting oedema, pulmonary oedema , JVP , HR and rhythm - Investigation o 12 lead ECG o Hb

Answer 146

**- Exercise ECG** o Walking on tredmill increasing speed and incline gradually o Test stopped if blood pressure drops, ischaemic changes on ECG or patient symptoms o However not good for those who are limited to exercise for other reasons e.g. OA , limb amputation **- Dobutamine stress echocardiogram** o Baseline echo – ventricular function, valve function, ventricular wall motion abnormalities o Small IV dose of dobutamine o Assess echo – may identify regional wall motion abnormalities which indicate ischaemia **- CPET - Cardiac MRI**

Answer 147

- Central chest pain - May radiate to left arm / jaw - Crushing / tightness in nature - Triggered by activity, Relieved by rest

Answer 148

- Atherosclerosis of coronary vessels resulting in narrowing - During times of exercise, blood flow does not meet the increased O2 demand of heart - May be stable – fixed stenosis, cant dilate to meet demand, relieved by rest - Unstable – increased frequency or at rest – caused by plaque rupture and sudden decrease in coronary flow but not full occlusion - Vasospasmic angina – epicardial artery vasospasm e.g. cocaine

Answer 149

- Atherosclerosis - Plaque rupture - Thrombosis - Myocardial ischaemia - Infarction

Answer 150

Non-modifiable: Male, Age, Family History. Modifiable: Smoking, Hypertension, Hyperlipidaemia, Diabetes, Obesity. ## Footnote Addressing modifiable risk factors can help in prevention strategies.

Answer 151

* Class 1: Occurs only during strenuous exercise * Class 2: Mild dyspnoea/angina in moderate exercise * Class 3: Marked limitation to activity due to pain/dyspnoea, comfortable at rest * Class 4: Angina/dyspnoea even at rest ## Footnote This classification helps in the management and treatment of angina.

Answer 152

- The heart is innervated by T1-T4 sympathetic fibres - Visceral afferents fibres of the heart are transmitted via these sympathetic paths - Sensory somatic afferents from T1 – T4 dermatomes (arm and shoulder) also synapse at these levels of the dorsal horn - Brain interprets the visceral afferents of the heart as the T1-T4 somatic dermatomes ## Footnote This phenomenon is known as referred pain.

Answer 153

Cardiogenic shock. ## Footnote This condition results from inadequate blood flow and can lead to multiple organ failure.

Answer 154

- LAD then RCA then left circumflex

Answer 155

- Immediate = MONA – morphine, oxygen, nitrates (GTN), aspirin 300mg - < 120 mins since presentation = PCI + DAPT - > 120 mins = thrombolysis +/- rescue PCI - Anticoagulation during PCI = unfractionated heparin +/- GPIIb/IIIa inhibitor (abciximab / tirofiban) - DAPT = aspirin + P2Y12 inhibitor (clopidogrel) = 12 months ## Footnote DAPT refers to dual antiplatelet therapy, typically aspirin and a P2Y12 inhibitor.

Answer 156

- MONA - Fonduparinux (factor Xa inhibitor) – unless bleeding risk / immediate PCI planned - Aspirin + Clopidogrel - Risk stratification using GRACE score – if high then angiography +/- PCI

Answer 157

A type of AV re-entrant tachycardia due to an accessory pathway between the atria and ventricles. ## Footnote This condition can lead to rapid heart rates and is associated with specific ECG changes.

Answer 158

* Delta waves * Short PR interval ## Footnote These findings are characteristic of the accessory conduction pathway in WPW syndrome.

Answer 159

- Accessory pathway allows fast conduction of depolarisations - Can lead to VF

Answer 160

- Avoid sympathetic stimulation – can result in AVN re-entry tachy o avoid ketamine o good analgesia - avoid glycol/atropine - avoid neostigmine – blocks AVN and promotes accessory pathway

Answer 161

- Inadequate circulatory function resulting in organ hypoperfusion and tissue hypoxia as a result of cardiac dysfunction - Clinical parameters o Persistent hypotension = systolic BP < 80-90 / MAP < 30mmHg o Cardiac index < 1.8 L/min/m2 unsupported with adequate LVEDP (filling pressure) o Clinical signs = cool peripheries, confusion, oligouria o LAB results – lactic acid, high creatinine ## Footnote This condition is often a result of severe myocardial infarction.

Answer 162

- Thrombosis of coronary vessel results in LV ischaemia / infarction and ultimately dysfunction - Reduced contractility – hence lower CO + hence lower MAP - LVEDP increases as a result o worsens coronary perfusion o Pulmonary oedema and hypoxaemia - Additionally to pump failure o Neurohormonal activation – RAAS + sympathetic o Vasoconstriction and fluid retention – further tissue hypoperfusion o Vicious cycle as now more circulating volume – increased EDP + pulmonary congestion - Hypoxia, acidaemia etc

Answer 163

- Hx - Examination - IX = bloods, troponins, pH/lactate, renal , urgent ECHO

Answer 164

- Regional wall motion abnormality - LV / RV dysfunction - Valve dysfunction

Answer 165

* A: At risk * B: Beginning * C: Classic CS * D: Deteriorating * E: Extremis (e.g. cardiac arrest) ## Footnote This classification aids in determining the severity and management approach.

Answer 166

- All have reduced CO however SVR and wedge pressure varies o Wet and cold – high SVR (cool peripheries) pulmonary congestion and increased pulmonary capillary wedge pressure o Cold and dry = high SVR, low PCWP o Wet and warm = low SVR, high PCWP ## Footnote These phenotypes help guide treatment strategies based on hemodynamic profiles.

Answer 167

Revascularization and reperfusion through PCI or surgical revascularization. ## Footnote Timely intervention is critical to improve outcomes in cardiogenic shock.

Answer 168

- When PCI not successful in revascularization - Valve repair e.g. acute severe mitral regurgitation - Ventricular septal rupture

Answer 169

**- Mechanical circulatory support (MCS devices)…** o Intra aortic balloon pump= increases coronary perfusion, some CO support, reduces LV afterload o Left Ventricular assist device = impella = Higher CO support, reduces LV wall stress and myocardial O2 demand o VA- ECMO= Strong CO support however can increase LV afterload **- Ventilatory support** o CPAP o Invasive ventilation may be required to support before and to facilitate procedure

Answer 170

- Boost CO and hence organ perfusion - Reduce amount of catecholamines needed - improve myocardial O2 supply / demand balance ## Footnote These devices can provide temporary support while awaiting definitive treatment.

Answer 171

- Pros = o maximise oxygenation – can add PEEP, max FiO2, lung recruitment o reduces LV afterload (uncoupling of LV) o reduces venous return and pre load for those overloaded - Cons = o reduces venous return which may be a problem in those deplete o reduces RV output due to higher pressures o requires sedation / anaesthesia which has negative cardiac ionotropic effects ## Footnote The use of IPPV must be carefully considered in the context of the patient's hemodynamic status.

Answer 172

- avoid excess fluids for resuscitation - noradrenaline 1st line o ionotropy and vasoconstrictor o titrate careful to prevent excess LV afterload - ionodilators – reduce afterload whilst improving contractility o milrinone and levosimenden - Ionotropic agents – dobutamine ## Footnote It is titrated carefully to prevent excess LV afterload.

Answer 173

- Arterial line for invasive BP monitoring and taking regular gas’s - ECHO – cardiac output and function and can guide changes to ventilator setting / vasopressors - Pulmonary artery catheterization – detailed haemodynamic

Answer 174

- Sedation – to facilitate ventilation, reduce O2 demand - Renal – AKI is very common , monitoring U&E, ?dialysis - Hepatic – monitor LFTs , hepatic dysfunction can occur from congestion - GI ulcer prophylaxis + DVT prophylaxis - Haematological – Hb target of 90-100 g/L

Answer 175

- Improve oxygenation - Improve haemodynamics – reduces LV afterload and reduces pre load - Facilitate surgery / intervention

Answer 176

- Often conscious sedation o Risk of airway loss o CVS instability - May need GA o Slow induction – low cardiac output states delays onset of anaesthesia o High dose fentanyl and reduce propofol - Remote site anaesthesia - Post op ITU arranged – high risk of MoF and usually need some period of stabilising before extubating

Answer 177

- Levosimenden = calcium sensitiser, improves Ca binding to troponin C , opens ATP K+ channels – vasodilation = ionodilator - Milronone = phosphodiesterase 3 inhihibitor – reduces breakdown of cAMP – more Ca influx - Dobutamine = B1 agonist – increases cAMP – more Ca influx - Digoxin = inhibits Na/K ATPase – increase in intracellular Na drives Na/Ca exchanger – more Ca

Answer 178

- Sustained hypotension and organ hypoperfusion as a result of pathological vasodilation - Characterised by increased vasopressor requirements, organ hypoperfusion and capillary leak Sustained hypotension and organ hypoperfusion due to pathological vasodilation. ## Footnote This condition can occur in various clinical settings, including sepsis and anaphylaxis.

Answer 179

* Anaphylaxis * Sepsis * Burns and trauma * Pancreatitis * Spinal cord injury * Neurogenic shock * Spinal anaesthesia * Cardiopulmonary bypass ## Footnote Identifying the underlying cause is crucial for effective management.

Answer 180

- blood contact with extracorporeal circulation sets up SIRS response. - Also tissue injury and reperfusion injury ## Footnote Severe hypertension can have wide-ranging effects on multiple organ systems.

Answer 181

- Impaired heart function - Extended bypass time - Use of pre op ACEi / ARBs

Answer 182

**- Systemic inflammation** o PAMPS – pathogen associated molecular patterns = Lipopolysaccharide and porins) o DAMPS - damage associated molecular patterns (DNA, ATP) o Results in cytokine release **- 4 main mechanisms** o Vasodilation = cytokines trigger NOS – smooth muscle relaxation o Vascular responsiveness = high levels of catecholamines and angiotensin leads to receptor down regulation. Acidosis activates K+ ATP channels – hyperpolarisation. Overall smooth muscle relaxation o Microcirculatory dysfunction = capillary leak from damaged glycocalyx. microthrombi formation and impaired blood flow o Cellular hypoxia and mitochondrial dysfunction

Answer 183

- Hypotension – with low diastolic pressure - Warm peripheries - Bounding pulse – often tachycardic - Prolonged cap refil

Answer 184

- Low MAP, low SVR, high CO

Answer 185

- Pulmonary artery catheter – gold standard but uncommon - ECHO - PiCCO and LiDCO - using arterial line + central catheter

Answer 186

- Fluid resuscitation – monitoring for fluid responsiveness to prevent overload - Vasopressors – o Noradrenaline = 0.05-0.1 ug/kg /min - If there is catecholamine refractory shock e.g norad >0.2ug/kg/min o Start vasopressin 0.02 – 0.04 units / min o Others adrenaline, dopamine, methylblue o Often multi model strategy required due to receptor insensitivity / down regulation - Hydrocortisone 200mg / day - Treat underlying cause e.g. sepsis - Constant re-evaluation of MAP, end organ function, lactate and cap refil

Answer 187

- Corticosteroids – hydrocortisone +/- fludrocortisone

Answer 188

- Not recommended , adverse events

Answer 189

- 2.5-3.5 L/min / m2 - Higher in vasoplegic shock

Answer 190

- Higher because of lower CO

Answer 191

- Presence of acute HTN + organ damage – heart , retina, kidneys , brain

Answer 192

- Acute HTN without organ damage

Answer 193

- >180/110mmHG

Answer 194

- Hypertensive emergencies and urgencies

Answer 195

- Aortic dissection - Pheochromocytoma - Ischaemic stroke - Subarachnoid haemorrhage - Drug related – cocaine, MAO inhibitors + tyramine rich foods - Pre eclampsia

Answer 196

- Respiratory = pulmonary oedema - Neuro = o altered consciousness o encephalopathy (seizures, lethargy, coma) o posterior reversible encephalopathy syndrome (PRES) o stroke - renal dysfunction - CVS: o Arrhythmias o myocardial ischaemia (increase afterload and myocardial O2 demand and vasospasm)

Answer 197

- BP all 4 limbs - Look for end organ damage o 12 lead ECG , troponin o Fundoscopy – papilledema, retinal haemorrhages o U&Es , urine dip , urine albumin: creatinine o CXR - Cause o CT angiography aorta o Urinary catecholamines / meteniphrines o Pregnancy test

Answer 198

- Control BP o Usually require rapid control within 1 hr e.g. ACS, pulmonary oedema, aortic dissection, pre-eclampsia and pheochromocytoma crisis o Try avoid bolus’s and use steady infusions o Avoid hypotension - Treat underlying cause

Answer 199

- Post op if bleeding is a concern o carotid endartectomy – risk of rebleed / haematoma / cerebral hyperperfusion syndrome o Aortic surgery – strict target to prevent aortic injury but maintain spinal cord perfusion o cardiac surgery – HTN can compromise suture integrity – vessel rupture, tamponade - Neurological conditions – acute ischaemia stroke , acute intracranial haemorrhage - Major bleeding / major trauma

Answer 200

* ACS: Systolic < 140 * Aortic syndromes: Systolic < 120, HR < 60 * Pre-eclampsia: < 160 * Pheochromocytoma: Systolic < 140 ## Footnote These targets are important for managing specific hypertensive crises.

Answer 201

- ACS = IV nitrates and labetolol (plus IV opioids for pain) - Acute pulmonary oedema = GTN - Acute aortic syndromes = esmolol / labetolol - Pheo = phentolamine - Pre-eclampsia = MgSO4 , labetolol

Answer 202

Infection of cardiac endothelium that can result in significant systemic complications

Answer 203

- Main one = S.Aureus - associated with IVDU or invasive proceeedures - Also o Steptococcus viridans – subacute – linked to oral cavity o Enterococcus faecalis – GI and GU procedures o Streptococcus bovis – GI malignancy o Coagulase neg staphylococcus e.g. epidermidis = prosthetics valves o MRSA, fungal , HACEK organisms S. Aureus - associated with IVDU or invasive procedures

Answer 204

* Cardiac: CHD, prosthetic valve/implantable device, bicuspid valve, rheumatic fever, previous I.E * Non-cardiac: IVDU, poor dentition, immunocompromised, diabetes, malignancy, > 65 years, long-term venous device, haemodialysis

Answer 205

- Turbulent flow can cause trauma to endothelium - Sets up platelet activation and coagulation cascade – sterile vegetation forms on surface of endothelium - Transient bacteraemia can attach to this and grow

Answer 206

- Cardiac o Valve regurgitations – HF, pulmonary oedema, shock o AV node conduction defects e.g. aortic root abscess o AF o Perivalvular abscess and fistula formation - Sepsis - Renal o Septic emboli – AKI and glomerulonephritis , also caused by sepsis - CNS o Septic emboli – strokes - Septic emboli can also infarct liver, spleen, limbs abscess and fistula formation

Answer 207

Resistant organisms, abscess, larger vegetations lasting > 7-10 days despite antibiotics requiring surgical intervention

Answer 208

- New onset Murmur + fever - Systemic – weight loss, malaise, fatigue - Sepsis - Clinical signs = Janeway lesions, oslers nodes, splinter haemorrhages - Other features / complications – AKI, pulmonary oedema, cognitive changes etc

Answer 209

- DUKES criteria - 2 major OR 1 major 3 minor OR 5 minor - Major = o 2x positive blood cultures of typical organism o ECHO or CT findings consistent with I.E- vegetation, abscess, new valve lesion - Minor o Risk factor o Fever >38 o Vascular phenomena – emboli, Janeway lesions, intracranial lesions o Immunological phenomena – oslers nodes, roth spots o Microbiological evidence that is not in keeping with major criteria

Answer 210

Transthoracic echocardiogram - TOE more sensitive – can be done if transthoracic is inconclusive

Answer 211

- MDT approach – IDU, cardiologist, critical care, other organ systems involved, surgeons - A to E resuscitation - IV Abx – ideally after cultures o 4-6 weeks o Choice depends on micro and pt hx and native or prosthetic valve o E.g. native valve = amoxicillin + gentamicin o E.g. native valve pen allergy = vancomycin + gentamicin o E.g. prosthetic = Vancomycin, gentamicin and rifampicin o I would use trusts local microbiology guidelines

Answer 212

Vancomycin OR daptomycin

Answer 213

* Large vegetations > 10mm post embolization/valve dysfunction OR > 15mm * Infection of prosthetic material * High embolic risk * Severe valvular regurgitation * Uncontrolled infection/persistent infection

Answer 214

- Standard pre op - MDT planning – other organs involved - Assess complications – renal, CNS , HF , arrhythmias, coagulopathy – correct and optimise - Ensure effective Abx dose and type started - Review imaging – TOE / ECHO findings - Consent and risk discussion - Organise ITU bed post op

Answer 215

- Monitoring – AABGI + Arterial line + central venous access + continuous TOE - Maintain haemodynamics – vasopressors / iontropes – guided by CO monitoring

Answer 216

* Patient factors: older, prosthetic valves, diabetic * Clinical features: stroke, shock, heart failure, renal failure * Microbiology: S. Aureus, fungal * ECHO: severe regurgitation, large vegetation, abscess, low EF

Answer 217

- Right side of heart – tricuspid valve – murmur 4th intercostal left sternal border, systolic murmur - Pneumonia and septic P.E - Same as before – fever, malaise, weight loss Right side of heart - tricuspid valve - murmur at 4th intercostal left sternal border, systolic murmur, pneumonia, and septic pulmonary embolism

Answer 218

* Good aseptic care of wounds * Good oral and skin hygiene * Avoid tattoos and piercing * Avoid central lines where possible

Answer 219

- Those at high risk undergoing high risk procedure - E.g. prosthetic valve, previous I.E, cyanotic CHD , HOCM - High risk procedure – certain dental procedure e.g. dental extraction or perforation of oral mucosa

Answer 220

- 30-60 mins before procedure - Amoxicillin OR clindamycin in pen allergy

Answer 221

Naturally occurring glycosaminoglycan with a molecular weight ranging from 3-30kDa, can be unfractionated or fractionated

Answer 222

- Potentiates the breakdown of factor Xa and thrombin by antithrombin 3 by binding AT3 - LMWH has minimal thrombin inhibition but potentiates breakdown of factor Xa - At high doses heparin also acts a tissue factor pathway inhibitor independent of ATIII

Answer 223

- Unfractionated has variable effects - Heparin response varies in individuals and risk of heparin resistance - Side effects o Bleeding o Heparin induced thrombocytopenia o Hyperkalaemia o Hypotension – histamine release at hight doses

Answer 224

With protamine, a cationic protein that binds heparin and neutralizes it

Answer 225

* Hypotension / haemodynamic instability – most common can be minor or severe * Pulmonary HTN * Anaphylaxis * Risk of bleeding if ratio not correct… - Unbound protamine inhibits platelet activity, adhesion and aggregation - bleeding - downregulates other clotting factors - Enhances fibrinolysis - activates tissue plasminogen activator

Answer 226

Inadequate response to heparin despite adequate dose, with ACT <480 despite 300-400 units/kg

Answer 227

* ATIII deficiency - Congenital – auto dom - Acquired – liver failure (reduced synthesis), nephrotic syn (increased clearance), DIC, recent use of heparin. * Increased heparin clearance * Elevated heparin binding proteins – I.E / sepsis , malignancy * Haemodilution e.g. extra volume in CPB , dilutes heparin / ATIII * Hypothermia – reduces ATIII activity and hence heparin function

Answer 228

* Administration error – not flushed through, cannula tissued , wrong drug

Answer 229

* Repeat heparin dose * Give ATIII – FFP or recombinant ATIII concentrate * Give other anticoagulants if persistent = Bivalirudin

Answer 230

* False impression that patient is not responding to heparin however actually due to another reason e.g. other factors – elevated fibrinogen / factor 8

Answer 231

* Residual heparin post op and risk of bleeding * Caused by incorrect protamine dosing or poor clearance of heparin

Answer 232

* Can measure ACT and then add heparinase and compare ACT – helps differentiate the ACT from other coagulation issues * However ACT not that accurate * Could technically do a anti-Xa assay (heparin assay) but this takes time so not practical

Answer 233

* Point of care test used in cardiac surgery to assess coagulation * Uses kaolin or celite = surface reactor that activates clotting pathway * Measures time taken to clot * The longer the time, the less coaguable

Answer 234

* Antiphospholipid syndrome - Autoantibodies activate endothelial cells and platelets – arterial / venous thrombosis - APTT and ACT often elevated at baseline and cause monitoring difficulties * Factor V leiden - Mutation in factor 5 and resistance to protein C - No effects on heparin, protamine and ACT monitoring * Protein C and S deficiency - No effects on heparin, protamine and ACT monitoring * Haemophilia - X linked recessive – factor 8 or 9 deficiency - Replace factors pre op to normalise pre op in vitro clotting tests - Then use heparin and ACT monitoring as normal

Answer 235

Complication of heparin administration * Type 1 and 2 * Type 1 = mild thrombocytopenia and resolves upon discontinuation , presenting 2-3days after heparin exposure , non immune mediated (direct platelet activation by heparin). * Type 2 = immune mediated platelet destruction, severe thrombocytopenia, presenting 5-14 days after administration.

Answer 236

* Immune complexes between heparin , platelet factor 4 and IgG * Autoimmune destruction of platelets and endothelial damage

Answer 237

- Platelet count < 150 x 10^9 g/l

Answer 238

* High dose >32,000 units * Pre/post op continuous infusions * > 4 days * IV route > SC * Female * Unfractionated > LMWH

Answer 239

* 4 Ts - Thrombocytopenia - >30% drop - Timing of platelet fall – onset 5-10 days - Thrombosis – new DVT / PE / skin necrosis - Likelihood of other causes of thrombocytopenia * Total of 8 points, if >/=4 then high risk * If high risk = ELISA ab screening – immunoassay

Answer 240

- Sudden significant platelet drop - Thrombosis while on heparin

Answer 241

- Arterial Thrombosis – MI, strokes, PVD - Venous thrombosis – PE - Local skin necrosis - Systemic – fever etc

Answer 242

* Post pone non urgent surgery until resolves >100days * Urgent procedure – use other agents - Direct thrombin inhibitors = Bivalirudin preferred, other option argatroban - Factor Xa inhibitor = fondaparinux - not ideal as long half life - Danaparoid – not in UK - OR plasmapheresis to remove IgG

Answer 243

* No specific reversal agent * ACT non linear and less reliable * Prolonged effect in renal failure

Answer 244

- Consumptive – DIC - Dilutional - Decreased production – chemo - Sequestration – splenomegaly - HIT

Answer 245

- Extracorporeal circulation used to support heart during cardiac surgery - Provides both pumping support and oxygenation - Allowing a bloodless motionless field for surgery

Answer 246

- Any process whereby blood volume is circulated outside the body

Answer 247

- Venous reservoir o Collects blood from heart = Via cannula into right atrium / vena cava o Blood can also be collected from various surgical salvage devices / suction - Pump o An arterial pump then pumps blood from a venous reservoir too… o a heat exchanger and oxygenator - Splitting of blood stream o A fraction of the blood is combined with cardioplegia solution and then reintroduced into the coronary circulation proximal to the aortic cross clamp o The remainder passes through an arterial filter and is returned to the systemic circulation

Answer 248

- Venous o RA, SVC, IVC o Sometimes femoral for minimally invasive or emergency CPB - Arterial o Ascending aorta o Subclavian artery – if aorta diseased o Femoral artery – minimally invasive surgery

Answer 249

- Gas exchange o Increase FiO2 on membrane oxygenator o Increase gas flow to remove CO2 - MAP o Increase CPB flow rate – increases MAP o SVR manipulated pharmacologically - Temperature o Via heat exchanger - Haematocrit o Volume added / removed via ultrafiltration - Acid base management o pH stat or alpha stat methods

Answer 250

- pH stat = constant pH regardless of temp change o add CO2 to maintain pH as temp changes o cooling increases pH so CO2 added to maintain pH o CO2 will increase cerebral blood flow and improve cerebral cooling and O2 delivery - Alpha stat = pH rises with cooling during CPB o Allows for alkalosis during cooling as more physiological for protein ionisation and autoregulation maintained.

Answer 251

- Solution added to coronary vasculature to support heart and surgery during CPB - Achieves intentional and temporary diastolic arrest and myocardial protection

Answer 252

- Cold crystalloid – 4 degrees - Cold blood – 4 degrees - Warm blood

Answer 253

- Reduce O2 demand and metabolism – protects against ischaemia

Answer 254

- Proximal to the aortic cross clamp - And thus delivered to heart o Anterograde via aortic root and coronary ostium (arteries) = dependant on adequate root pressure, coronary artery perfusion and competent aortic valve o Retrograde via coronary sinus (venous) – e.g. if significant coronary artery occlusion

Answer 255

- Facilitates surgery o Motionless relaxed heart – K+ creates state of diastolic arrest o Bloodless field - Myocardial protection o Diastolic arrest – reduces metabolic demand o Cooling of heart – reduces metabolic demand o Blood can be used to improve O2 delivery * Facilitates surgery * Motionless relaxed heart * Bloodless field * Myocardial protection * Reduces metabolic demand

Answer 256

- Direct vessel damage during cannulation o Bleeding o Embolic strokes - From solution o Haemodilution – anaemia / thrombocytopenia o Overload o Electrolyte distubances o Air embolus – coronaries or systemic - From infusion o High pressure – oedema , coronary rupture o Non uniform spread – areas of warm ischaemia

Answer 257

- Intermittent aortic cross clamp o Clamped to stop blood flow – brief period of ischaemia o Unclamp – reperfusion and oxygenation o Repeated to limit injury to myocardium - Fibrillation technique o VF induced to prevent contraction and then cardioverted to prevent ischaemic damage - Off pump cardiac surgery

Answer 258

- Intermittent aortic cross clamp o Reperfusion injury and damage o May dislodge atheroma o However useful for short procedure and avoids cardioplegia - Fibrillation technique o Ongoing O2 demand – risk of ischemia during fibrillation o Risk of embolization o May not be able to revert to sinus

Answer 259

- Intraoperative o Circuit clotting o Bleeding associated with anticoagulation / consumptive coagulopathy / platelet dysfunction o Haemolysis o Aortic dissection o Gas embolization - Post op o SIRS o Renal dysfunction – overload/ AKI/ electrolytes o Neurological – post op cognitive dysfunction and stroke due to hypoperfusion or emboli

Answer 260

- Adequate perfusion pressures - Normoglycaemia - Normothermia - Cerebral oximetry in high risk - Confirmation of de-airing by surgeons

Answer 261

- Age - Aortic atheroma - Previous stroke - Diabetes - Surgical factor – valve replacements

Answer 262

- Anticoagulation – heparin, ACT and protamine - Temperature management – falls in bypass , ensure normalisation before coming off bypass - Acid base / electrolytes – normalised before coming off bypass - Maintain anaesthesia – TIVA / volatiles via CPB circuit - Maintain haemodynamic and cerebral perfusion pressure – vasopressor support , closely work with perfusionist - Coordination with surgeon / perfusionist when coming off bypass o Lungs re-expanded and ventilated o Heart progressively filled by clamping venous line and giving boluses

Answer 263

- May use o Normothermia o Hypothermia – 25-32 degrees o Deep hypothermia – 15-18 degrees - Drop in temp to reduce O2 consumption and risk of ischaemia. Plus cerebral protection - However risk of coagulopathy and impaired protein / membrane function

Answer 264

- Extracorporeal circulation with artificial surface – activates clotting cascade - Vessel injury during cannulation – coagulation activated - Anti coagulation offsets this and prevents clot formation and circuit failure / strokes etc

Answer 265

- 300-400units / kg heparin IV - total body weight - Wait 3-8 mins and check ACT - Aim for ACT >480 seconds before starting CPB - Recheck ACT every 30 mins - Repeat 1/3 dose of heparin after 90 mins then every 60 mins - Adjust in renal failure

Answer 266

- Protamine sulphate - 1mg / 100units of heparin given - Infuse over 15 mins

Answer 267

* Dosing of protamine should be based on the heparin concentration * Should aim to give a protamine: heparin ratio of 0.6- 0.8 * If >1.3: 1 then risk of bleeding due to platelet dysfunction (from excess protamine) * If <0.6 then bleeding risk due to excess heparin

Answer 268

- Both extracorporeal circulations used to support ventilation and cardiac function - However ECMO o Uses peripheral vessels o Longer term use – circuit is more biocompatible and membrane oxygenator is longer lasting o Centrifugal pump – gentler - CPB o Central vessels o Short term use o Roller pump – harsher on blood – higher flows but haemolysis o Cardioplegia o 2 return streams – pre and post aortic clamp

Answer 269

- This refers to a CABG on a beating heart without the use of cardiac bypass - An immobilisation device (octopus stabilisation system) is used to reduce movement of area of myocardium operating on CABG on a beating heart without the use of cardiac bypass.

Answer 270

- Saphenous vein - Radial artery – in younger patients without calcified arteries - Internal mammary artery

Answer 271

* Avoids complications of CPB * Earlier extubation * Reduced hospital/ITU stay

Answer 272

- More technically demanding as moving heart – overcome partly by stabilisation device - Haemodynamic instability during handling of heart – lifted up and impairs LV filling / valves - Still risk of needing bypass – which may be more challenging when surgery already started

Answer 273

- Reduced LV filling , contraction and CO o Heart lifted out of pericardial sac o Immobilised by octapus stabilisation system o Ischaemia - Arrhythmias and reduced CO o From handling the heart, ischaemia and reperfusion - Valve distortion and regurgitation - Bleeding

Answer 274

- Standard AABGI - Invasive arterial pressure monitoring - 12 lead ECG – conventional ECG is altered as heart is out chest. 12 lead is more accurate - TOE = to detect regional wall motion abnormalities (ischaemia) or air around the heart

Answer 275

- MAP >70mmHG – using fluids, vasopressors or ionotropes - Maintain sinus = Treat arrhythmias / bradycardias – may need pacing wires / electrolyte Mx - Maintain temperature – hypothermia causes arrhythmias and coagulopathy - Good communication with surgeon e.g. TOE findings

Answer 276

- Surgeon: o Minimise surgical manipulation and stop if major instability o Minimise periods of ischaemia by utilisation of shunts - Anaesthetist o Avoid electrolyte disturbances – keep K+ over 4.5 and give magnesium routinely o Keep HR low / normal – minimises O2 demand and hence reduces effects of ischaemia o Ensure patient is adequately filled guided by cardiac output monitoring

Answer 277

- Temperature measurement before and during case to target correctly - Increase ambient theatre temp - Warm IV fluids - Hot air warms – bair hugger - Foil hat - Minimise leaving patient uncovered

Answer 278

- Patients optimised after a period on critical care o Weaned from respiratory support o Haemodynamically stable o Normal acid base / coagulopathy o No suspicion of bleeding

Answer 279

- Bleeding - Arrhythmias - Tamponade - Pulmonary HTN - Neurological complications – cognitive dysfunction, stroke, ischaemic spinal cord - AKI

Answer 280

- Post operative cognitive dysfunction o Subtle decline in cognitive function e.g. memory, concentration, executive function - Delirium o Acute, fluctuating disturbance in consciousness and attention. Shorter term than above - Stroke – hypoperfusion, embolic, haemorrhagic - TIA - Ischaemic spinal cord injury

Answer 281

- Brachial plexus = CVC, positioning, internal mammary artery havesting - Ulnar nerve = radial artery harvesting - Saphenous nerve = saphenous nerve harvesting - Phrenic nerve = internal mammary artery harvesting - Recurrent laryngeal = intubation , IMA harvesting

Answer 282

- Age - Pre op dementia - Pre-existing cerebrovascular disease e.g. hx of stroke , carotid stenosis - Diabetes, HTN

Answer 283

- Prolonged surgical time - Clamping diseased aorta and embolization - Use of CPB – clots from circuit, disruption to autoregulation in hypothermia / rewarming - Bleeding – poor cerebral perfusion pressure and O2 carrying capacity

Answer 284

- Hypotension – low MAP and inadequate CPP - Prolonged deep hypnotic state i.e. high level of burst suppression

Answer 285

- Surgical o Minimally invasive – less stress response o USS To check for plaques before handling o Use bubble traps and filters when using CPB – remove air embolus and clots - Anaesthetic o Maintain MAP – arterial BP monitoring , vasopressors o Avoid excess anaesthesia – BIS o Normal physiological parameters – CO2, O2, electrolytes glucose o Use of cerebral oximetry o Avoid rapid rewarming – can result in cerebral oedema

Answer 286

- Prone to arterial spasm o Avoid NA o GTN may be helpful

Answer 287

- Intrapericardial fluid build up – either serous fluid or blood - Resulting in ability of normal cardiac contraction - Obstructive shock

Answer 288

- BECKS TRIAD – hypotension, muffled heart sounds, raised JVP - Increased vasopressor requirement - Tachycardia - Pericardial rub - If awake – breathless, chest pain

Answer 289

- Pulsus paradox o >10mmHg drop in systolic BP during inspiration - Kussmaul sign o Rise / lack of fall of JVP with inspiration

Answer 290

- CABG / cardiac surgery - Aortic dissection - Trauma - Iatrogenic damage to aorta during interventional cardiology procedure - Infectious pericarditis - Non infectious pericarditis – autoimmune, uraemia

Answer 291

- Pericardial effusions - >20mm fluid around heart - Swinging heart sign – heart suspended in pericardium - Collapse of chambers - IVC dilation - Intraventricular septum left shift during spontaneous ventilation

Answer 292

- Large globular heart - Evidence of HF / pulmonary oedema

Answer 293

- Tachycardia - Low voltage QRS - Electrical alternans – beat to beat variation in QRS - Atrial arrhythmias

Answer 294

- Raised pulmonary artery wedge pressure

Answer 295

- A to E = O2, avoid PPV where possible, vasopressors/ ionotropes / fluids - Diagnosis - Pericardiocentesis – now USS guided - Urgent cardiothoracic surgical review – thoracotomy / pericardiotomy?

Answer 296

- Apical o 1-2cm lateral to apex beat in 5th,6th or 7th intercostal space - Parasternal o Left parastenal edge 5th intercostal space 1cm lateral to sternum - Subxiphoid o Between xiphistenum and lower rib edge

Answer 297

- Pneumothorax - Intercostal vessel damage - Laceration of coronary vessel / ventricle - Arrhythmias - Pneumopericardium - Pericardial depression syndrome – LV dysfunction and cardiogenic shock

Answer 298

- If time – drain first - Otherwise – emergency decompressive sternotomy o Preparations – consultant anaesthetist / cardiothoracic surgeons , ECMO available, MHP activated o RSI with ketamine o Haemodynamic goals – full, fast and tight  Maintain SVR – MAP reliant on this and poor CO – coronary perfusion  Maintain preload  Maintain SR and avoid bradycardia – SV limited so CO dependant on rate  Maintain contractility – avoid excess cardiac depressants o Ventilatory strategies  Lowest possible pressures  Good FiO2  Avoid hypercarbia

Answer 299

- Re-expansion pulmonary oedema o During tamponade lungs may be partially collapsed due to pleural effusions, high thoracic pressures and reduced pulmonary perfusion o When decompressed sudden increase in venous return and abrupt re-expansion - Arrhythmias - Reoccurrence .

Answer 300

- Increased thoracic pressure - Initially causes compression of pulmonary vasculature and increase venous return to LEFT heart and increased SV - However also reduces venous return to right heart and reduced CO

Answer 301

- Avoid rise in pulmonary pressures – e.g. hypoxia, hypercarbia, acidosis - Pharmacological – inhaled nitric oxide / prostacyclin , IV sildenafil - Support cardiac function – IV milronone

Answer 302

* VF * Bleeding * Cardiac tamponade

Answer 303

- Same approach + work through reversible causes - If no reversible cause found and one cycle of external CPR / defib is unsuccessful then immediate chest re-sternomy o No time for skin prep – sterile gloves and gowns only o Internal cardiac massage and defibrillation

Answer 304

* Independent risk factor for perioperative mortality * Surgery is prolonged and complex due to adhesions * Increased risk of major blood loss * VF can occur on sternotomy/adhesiolysis * More likely in older patients with advanced comorbidities/poor physiological reserve

Answer 305

- Post CABG myocardial revascularisation – PCI first line but surgical revascularisation may be needed - Repeat valve surgery – mechanical valve , I.E or small annulus -i.e. transcatheter approach not possible.

Answer 306

- MDT planning – cardiac surgeon, anaesthetist, cardiologist, radiologist – risks, surgical approach - Surgical Hx – more challenging if within 3 weeks – 6months as adhesions more dense OR if previous radiotherapy - Risk scoring – e.g. Euroscore 2 - Imaging – CT / MRI to predict risk based on anatomy - Cross match and optimise anaemia - Patient counselling / risks discussed

Answer 307

- AABGI + arterial line + TOE + CVC - CPB required? - Manage bleeding risk… o Good IV access o TXA – reduced transfusion need o Cell salvage o Reverse Trendelenburg to move heart away from sternum during sternotomy – decompresses heart o Ventilatory pause during sternotomy to move heart away from sternum o Prepare for CPB – preparation of cannulation site etc - Abx prophylaxis – risk of mediastinitis

Answer 308

- Accidental injury of RV on re-sternotomy - Adhesions and prolonged dissection - Injury to great vessels on re-sternotomy

Answer 309

- Oscillating saw – cut under vision

Answer 310

- Apply direct pressure - If peripheral cannulas already in place, initiate full heparinisation and CPB and cardiotomy suction immediately - If no access – massive transfusion protocol activated and start CPB as soon as possible - Clotting factors – guided by ABG and ROTEM o Calcium o Fibrinogen / prothrombin complex

Answer 311

- CABGs should be routed away from the midline - Proximal CABG tagged with radiopaque marker to aid visualisation on angio - Safer sternal entry by covering heart and great vessels to reduce sternal adhesions - Possible to close pericardium but then risk of effusions and tamponade

Answer 312

- ITU care - Abx prophylaxis - Monitoring bloods / coagulopathy

Answer 313

- Procedures that avoid traditional midline sternotomy - May use endoscopes or smaller incisions o Mini sternotomy o Video assisted thoracoscopic surgery o Transcatheter methods

Answer 314

* TAVI * Coronary angioplasty * Endoscopic thoracic sympathectomy * Minimally invasive CABG * Aortic valve replacement

Answer 315

* Reduced post-op pain * Quicker recovery * Reduced bleeding * Reduced stress response * Better cosmetic appearance

Answer 316

* More technically difficult * May need to convert to sternotomy * No internal defib pads can be placed * Bleeding may not be apparent

Answer 317

- Immunosuppressant – calcineurin inhibitor – tacrolimus / cylosporin - Steroids – prednisolone - Other – azathioprine - Common regime = antimetabolite (azothiprine / mycophenolate mofetil) + calcineurin inhibitor + steroid Side effects of these - Common to all – increased infection, increased malignancy - Tacrolimus – renal toxicity , diabetes, arrhythmias - Myophenolate mofetil – bone marrow suppression - Ciclosporin – renal toxicity, HTN, diabetes , tremor - Azathioprine – bone marrow suppression

Answer 318

- Aetiology of cardiac failure – systemic consequences? Congenital airway abnormalities - Graft function o ECHO , ECG , exercise tolerance - Medication related o Immunosuppression  Will need steroid replacement intra op  Risk of infection  Cyclosporin – hypertension  Steroids increase risk of diabetes  Tacrolimus – renal function o Seek advice from transplant team

Answer 319

- Avoid other nephrotoxic drugs – NSAIDS - Steroid cover - Strict asepsis and Abx cover due to increased infection risk - Good antiemetic cover to improve oral medication compliance - No use of atropine / glycol – use adrenaline for brady

Answer 320

* Toxoplasmosis * Pneumocystis jirovecii * CMV * Candida albicans * Herpes simplex

Answer 321

- Donor sino atrial node has no innervation - HR 90-100 bpm – loss of vagal tone - Loss of normal vagal reflexes to peritoneal stretch / laryngoscopy / occulocardiac - No compensatory tachycardia with hypotension – loss of baroreceptor reflex - Exercise tachycardia response is blunted as entirely catecholamine driven. Similarly HR responses to postural changes are blunted - No pain in ischaemia / infarction

Answer 322

- Atropine and glycopyrrolate have no effect - Sux and neostigmine have no bradycardic effects - Upregulation of receptors on donor heart means adenosine and adrenaline have an increased effect

Answer 323

- Steroid cover - Invasive monitoring – TOE / arterial line - Strict asepsis - Removal lines as soon as possible - Abx cover - Adequate pre load

Answer 324

- CVS o Cardiac allograft vasculopathy – immunological and non-immunological cause of atherosclerosis of donor coronary arteries o Rejection causing reduction in graft function o HTN and diabetes from immunospressive meds - other o Epilepsy and reduced seizure threshold with tacrolimus and ciclosporin o Ongoing consequences of original disease that required transplant e.g. sarcoid / amyloid

Answer 325

- ECG – resting HR and rhythm - ECHO – valve/ EF - CXR – pulmonary oedema/ HF - CT angiography - Functional test – CPET

Answer 326

Donor heart is placed in the same position as the old heart.

Answer 327

* Volumetric imaging * Quantitative analysis: accurate measurements of volumes, areas, and distances without geometric assumptions. * Enhanced spatial orientation: visualization of complex anatomy aiding in surgical planning * Improved assessment / visualisation of prosthetic valves and devices

Answer 328

* Lower temporal resolution: Compared to 2D imaging, which may affect the assessment of rapidly moving structures. * Potential for artifacts: especially in arrhythmias * Requires more processing power and storage capacity. * Demands additional training for interpretation

Answer 329

- Valve assessment – MR evaluation, AS severity or regurgitation jets quantification - Heart structure and function o Left atrial appendage o LV function and regional wall motion o abnormalities o RV size / function – aid diagnosis of PAH o CHD where anatomy is complex - Thoracic aorta aneurysm / dissection / atheroma - Perioperative planning and monitoring o Guidance for left atrial appendage closure or MR correction o Assists in transeptal puncture o Haemodynamic assessment – CO monitoring - Education – 3D models can be made for surgical planning and education

Answer 330

- Enface visualisation – provides precise surgical view of mitral valve - Quantitative assessment – regurgitant jet measurement using 3D colour doppler - Mechanism identification – assesses MR leaflet motion and annular geometry to differentiate between degenerative or function MR - Guides intervention o Pre op planning and surgical approach o Intra op monitoring for successful repair and assessing stenosis o Post op assessment

Answer 331

- Thrombus detection – e.g. before cardioversion - Morphology evaluation – e.g. LAA size / shape – for device sizing in occlusion proceedure - Device deployment guidance – aids positioning and confirm device placement for LAA closure

Answer 332

- Anatomical visualisation – real time imaging of intra-atrial septum and surrounding structures - Hence puncture site selection for optimal location to minimise complciations - Needling guidance – direct real time imaging of needle through septum

Answer 333

- Accurate volume measurement and hence EF calculation more accurate - Enhanced detection of regional wall motion abnormalities - Hence improved diagnosis of PAH through shape and size of RV

Answer 334

- Leaflet assessment – better visualisation of all 3 leaflets – identifies prolapse, perforation etc - Annular measurement – assesses dilation - Regurgitation jet quantification

Answer 335

* Improved visualisation and anatomical detail * Enhanced assessment of stenosis severity

Answer 336

* Diagnosis of Aneurysm, dissection, atheroma including if theres an embolization risk .

Answer 337

- Cerebral oxygenation measurements - Used during surgery e.g. cardiac surgery or carotid endartectomy or high risk pts

Answer 338

- Sensors applied to forehead and light emitted at 760nm and 850nm – near infrared range - Absorbed by oxy and deoxy Hb and scattered back and detected by sensor - The ratios are compared to determine the % saturations - Relies on beer and lamberts law

Answer 339

Tear in intima allows blood to flow between intima and media creating false lumen.

Answer 340

- Stanford o Type A – ascending aorta +/- arch o Type B – descending aorta only - DeBakey o Type 1 - ascending aorta + arch + descending o Type 2 – ascending only o Type 3 – descending only

Answer 341

* Hypertension * Marfan syndrome * Ehlers-Danlos syndrome * Trauma * Iatrogenic causes

Answer 342

- Chest pain radiating to back severe, sudden onset, ripping - Aortic diastolic murmur - Shock - Systolic BP/ pulse deficit difference in limbs - Focal neuro deficit

Answer 343

CT angiogram is the gold standard; ECHO can also be used.

Answer 344

- A to E - Depends on type o Type A – surgical emergency o Type B – medical management - Analgesia – reduces sympathetic surge / myocardial stress - BP – reduce BP and HR o aim systolic 100-120mmHg , HR < 60bpm - prepare for major haemorrhage - Cardiothoracic referral

Answer 345

- Tamponade - Stroke - MI - Renal failure - Spinal ischaemia

Answer 346

* Noradrenaline * Adrenaline * Vasopressin * Methyl blue

Answer 347

Noradrenaline - 0.05-0.1 ug/kg /min - A1 receptors to increase arterial and venous tone - Risks – tachyarrhythmias, MI, AKI Adrenaline - 0.01-0.05 mcg/kg/min - Alpha and beta agonist – more Beta activity than NA - Strong ionotrope too - However – tachyarrhythmias, hyperglycaemia, lactic acidosis, hypokalaemia (B2 effect)

Answer 348

Vasopressin - 0.02 – 0.04 units / min - V1 receptor agonist – non catecholamine – reduces NA requirements - Lower risk of tachyarrhythmias and preserves renal function - However risk of digital ischaemia , hyponatraemia , worst for splanchnic vasoconstriction

Answer 349

Methyl blue - Inhibits nitric oxide synthase and guanylate cyclase – reduces vasodilation - Side effects – green urine, pulse ox unreliable - Contraindicated in glucose 6P dehydrogenase deficiency – methaglobinaemia and haemolysis

Answer 350

* Previous ACS * CCF * Hypertension * Previous cardiac surgery * Aortic atheroma - CKD, COPD, neurological disease

Answer 351

- 12 questions related to activities of daily living - Allows estimation of metabolic equivalent of tasks - < 4 METS = risk of adverse outcome

Answer 352

- EuroSCORE o Patient related factors = > 60yrs, female, COPD, CKD, previous cerebrovascular disease, active endocarditis, previous cardiac surgery o Cardiac related factors = recent MI, unstable angina, PAH, LV dysfunction o Operation related = emergency, operation other than isolated CABG - Parsonett factors o Patient = age, sex, obsesity, diabetes, HTN , CKD o Cardiac – intra aortic balloon pump required , LV dysfunction o Surgical = mitral or aortic valve , valve plus CABG - Both predict mortality

Answer 353

- Patient factors: o Electrolyte imbalance  hypokalaemia (depresses automaticity, AV block, causes early depolarisations  hyperkalaemia – conduction delays, VF / VT  hypocalcaemia – prolongs AP, risk of torsades o Myocardial ischaemia – early depolarisations, re entry o Increased sympathetic activity – sepsis , hypoxia, acidosis, stress of surgery o Vagal stimulation – severe bradycardia - Pharmacological factors: o IV anaesthetic agents  Most depress sympathetic activity – bradycardias  Ketamine – increases sympathetic activity and prolongs QT o Opioids  Bradycardias  Methadone – increases QTc o Neostigmine  Bradycardia and AV block o Vasopressors  Reflex bradycardia - Surgical factors o Cardiac or thoracic surgery

Answer 354

* majority do not require treatment and self resolve * treatment includes o treating underlying cause o haemodynamic support o cardioversion – electrical or with antiarrhythmic drugs * Pre operative assessment o ECG for all patients with CVS disease – detect ischaemia, infarct, hypertrophy, long QTc, BBB, arrhythmias o ECHO o Cardiology consultant may be needed o Surgery delayed if trifascicular block, advanced heart block, new onset LBBB, SVT o Indications of antiarrhythmics  Symptom relief  Improving cardiac function  Preventing life threatening arrhythmias * Intra op o If arrhythmia develops, try treat the cause, o Evaluate cardiac function o Choose antiarrhymic carefull  Avoid b blockers in asthma  Avoid amiodarone in severe lung disease  Avoid CaCB in acute HF * Post op o May require continuous cardiac monitoring / ICU admission if unstable prevention - risk factors for arrhythmias should be corrected pre op ## Footnote Most arrhythmias are transient and do not need intervention.

Answer 355

- First line – esmolol / B blocker - For impaired ventricular function – Digoxin + B blocker/ CaCB - For cardioversion without electrical – amiodarone ## Footnote These medications help control heart rate in AF.

Answer 356

adenosine = 6mg, 6mg, 12mg amiodarone = 300mg bolus over 10 mins, 900mg over 23hr atropine = 600mcg - up to 3mg digoxin = 0.25 to 0.5mg bolus metoprolol = 1-5mg

Answer 357

- Amiodarone 300mg loading and then 900mg over 24 hours or lidocaine -torsades = MgSO4

CARDIO Flashcards

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