CV Anesthesia

Valvular Disorders

100

"Slow, Full, Tight" is a common anesthesia mnemonic used to guide the hemodynamic management of patients with this severe valvular disease.

Aortic Stenosis

• Slow → Increases diastolic time → improves coronary perfusion and reduces myocardial O₂ demand.
• Full → The hypertrophied LV is stiff and preload dependent.
• Tight (maintain SVR) → Preserves coronary perfusion pressure and systemic blood pressure. 

200

What hemodynamics will increase regurgitant volume in aortic regurgitation

• Bradycardia (Longer diastolic filling time)
• Increased afterload (increase pressure gradient drives blood back to the ventricles)

300

Identify which valvular disorder is presented on this pressure volume loop

Mitral regurgitation 

400

A patient with an aortic valve area of 0.8 cm² is at high risk for developing this classic symptom triad.

Syncope, angina, and dyspnea (SAD)

Stenotic aortic valve creates a fixed cardiac output. The left ventricle cannot sufficiently increase stroke volume to maintain cerebral perfusion.

500

Chronic aortic regurgitation causes ______ ventricular hypertrophy, in which sarcomeres are added in ________?

Eccentric hypertrophy and sarcomeres added in series

The left ventricle stretches and enlarges to hold the extra volume.

CPB Management

100

During a coronary artery bypass graft  procedure, awareness under anesthesia is most likely to occur during this phase 

Sternotomy

200

What is the minimum ACT required before CPB can safely be initiated?

ACT >480 sec is required before initiating CPB. 

This threshold must be maintained throughout bypass (re-check every 30 minutes; add heparin as needed). Inadequate anticoagulation is one of the two main causes of oxygenator clotting — a life-threatening emergency.

300

During aortic cannulation for cardiopulmonary bypass, maintaining this mean arterial pressure range helps reduce aortic wall stress, minimize blood loss, and decrease the risk of aortic dissection.

SBP 90-100mmHg

400

To administer cardioplegia during cardiac surgery, cardioplegia is administered antegrade cannula via ________ and retrograde via the ________

Aortic root 

Coronary sinus

500

What is the primary mechanism by which cardioplegia arrests the heart?

KCl depolarizes the myocyte, closing & inactivating Na⁺ channels → diastolic arrest

KCl is the primary active ingredient. It depolarizes the cardiac myocyte membrane and inactivates Na⁺ channels, holding the cell in an unexcitable diastolic arrest state. As cardioplegia washes out, the cell repolarizes and becomes excitable again

CPB Weaning & CPB Catastrophes

100

The TWO most common causes of oxygenator failure are

Inadequate heperanization (Reason for high ACT requirement)

Inadvertent protamine administration

200

An AA gave a bolus of protamine through the central line, what symptoms may present

• Sudden severe hypotension
• Pulmonary hypertension 
• Bronchoconstriction

300

On CPB initiation, you notice the LEFT radial line reads 45/30 while the RIGHT reads 140/90. The patient's face has asymmetric blanching on the right. What is happening?

Classic carotid/innominate hyperperfusion pattern: LEFT radial HYPO, RIGHT radial HYPER, ipsilateral facial blanching. This is why you check the patient's face for color asymmetry every time CPB is initiated. SBP 90–100 during aortic cannulation helps prevent this and aortic dissection.

400

During protamine administration after cardiopulmonary bypass, the surgeon and perfusionist should be notified of what percentages of the dose has been given? (2 percentages)

• 10%: Last use of the pump sucker 
  • Allows blood remaining in the surgical field to be returned while anticoagulation is still present
• 50%: Removal of cannulas to prevent thrombotic formation

500

During initiation of cardiopulmonary bypass, the venous and arterial lines are accidentally reversed. The venous line delivers blood to the aorta while the arterial line drains blood from the vena cava. This catastrophic error presents with these findings.

• Systemic perfusion failure:
  • Extreme hypotension
  • Facial edema
  • Severe conjunctival edema

• Cardiac/vascular findings:
  • Flaccid aorta 
  • Tense vena cava 
  • Distended right ventricle 
  • Collapsed left ventricle

Vascular Anesthesia

100

The progressive enlargement and increased risk of rupture of an aortic aneurysm are explained by this physical law

Law of Laplace- T= P x R

Wall tension is directly proportional to vessel radius and intraluminal pressure. 

200

What is the triad of a ruptured abdominal aortic aneurysm?

• Back/abdominal pain
• Pulsatile abdominal mass
• Hypotension

300

During thoracic aortic aneurysm repair, cross clamping that compromises blood flow through this artery____ may result in paraplegia, bowel and bladder dysfunction

Artery of Adamkiewicz

400

Following carotid endarterectomy, injury to these CN VII, IX, X, XI, and XII can result in these postoperative findings

• VII (Facial) → Facial weakness
• IX (Glossopharyngeal) → Impaired gag reflex
• X (Vagus) → Hoarseness (RLN injury)
• XI (Accessory) → Shoulder weakness
• XII (Hypoglossal) → Tongue deviation

500

What intraoperative strategies can be employed to reduce the risk of cerebral ischemia during carotid endarterectomy?

• Increase Cerebral Oxygen Supply
  • Carotid shunt utilization
    • Provides continued cerebral blood flow during carotid cross-clamping.
  • Maintain MAP at or slightly above baseline to optimize collateral cerebral blood flow.
  • Optimize oxygen delivery
  • Minimize carotid clamp time
    • Reduces the duration of decreased cerebral blood flow (surgeon-dependent).
• Decrease Cerebral Oxygen Demand 
  • Mild hypothermia
    • Reduces cerebral metabolic activity and oxygen consumption.
  • Pharmacologic reduction of CMRO₂
    • Anesthetic agents (e.g., propofol, volatile anesthetics, barbiturates) decrease cerebral metabolic demand.
  • Prevent seizures
    • Avoids increased cerebral metabolic activity and oxygen requirements.