CVS

Question 1

Present

Answer 1

From the end of the bed, the patient appeared __________ (comfortable/in distress), with no evidence of __________ (cyanosis, pallor, breathlessness).

The hands showed no stigmata of cardiovascular disease. Pulse was _____ bpm, __________ rhythm, with __________ character. BP was /.”

There were no ocular or oral abnormalities. JVP was __________. Carotid pulse was __________ in character, no bruit heard.”

On inspection, a __________ scar was seen. The apex beat was felt in the _____ ICS, _____ MCL, __________. No heaves or thrills.
On auscultation, S1 and S2 were __________, with __________ (murmur/click/normal sounds). Lung bases were __________.

Question 2

What investigations would you order preoperatively?

How would you manage this patient’s anticoagulation?

Answer 2

This patient appears well but would require a baseline ECG and echo preoperatively. In addition, he would require bloods including an INR as he is on warfarin.

General guidelines (you should always check local policy and ask the advice of a hematologist)

• Low Thromboembolic risk o Stop warfarin 5 days pre-op.

o Restart warfarin post-op as soon as oral fluids are tolerated

• High thromboembolic risk o Stop warfarin 4 days pre-op and start low molecular weight heparin (LMWH) at therapeutic dose o Stop the LMWH 12-18h pre-op o Restart LMWH 6hpost-op (assuming hemostatics is achieved) o Restart warfarin when oral fluids are tolerated o Stop LMWH when INR is in range again

The patient presents with fever 5 days postoperatively…? Might have infective endocarditis

Question 3

Indications of pacemaker?

Who would you inform about the pacemaker?

What precautions would you take?

Answer 3

• Symptomatic sinus bradycardia
• SA node disease
• Symptomatic AV node disease
• Hypertrophic obstructive cardiomyopathy (HOCM)
• Dilated cardiomyopathy (DCM)
• Long QT syndrome

An anaesthetist, ideally the consultant who will be doing the case. I would ensure it is clearly documented in the notes.

• I would arrange a pre and postoperative pacemaker check and contact their pacemaker follow-up clinic to inform them of the operation and ask for advice.

• During the operation I would avoid using a monopolar diathermy or limit its use to short bursts only.

• The return electrode should be placed so that the pathway between the diathermy electrode and return electrode is as far away from the pacemaker and leads as possible

• I’d ensure that appropriate resuscitation equipment was available

Question 4

Causes of valve lesions?

Answer 4

Mitral Stenosis

→ Rheumatic heart disease (post-inflammatory scarring) ✅ only major cause

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Mitral Regurgitation

Think: 3 areas – valve, support, ventricle
1. Valve leaflets – RHD, IE, prolapse, drugs (Fen-Phen)
2. Support (papillary/chordae) – rupture or fibrosis (after MI)
3. LV/annulus – dilated LV or annular calcification

🧠 “Leaflet, Support, LV”

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Aortic Stenosis
1. Rheumatic (post-inflammatory)
2. Degenerative (senile calcific)
3. Congenital bicuspid valve with calcification

🧠 “Rheumatic, Old, Bicuspid”

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Aortic Regurgitation

Think: Valve vs Root
1. Valve – RHD, IE
2. Root – dilation or disease (Marfan, syphilis, RA, ankylosing spondylitis)

🧠 “Valve – RHD/IE; Root – dilation/systemic disease”