Intraoperative Echocardiography for the Boards

Intraoperative Echocardiography for the Boards
Intraoperative Echocardiography for the Boards
Questions 1 to 4
A 60-year-old female with a history of hypertrophic cardiomyopathy (HCM) is listed for cardiac surgery. Her prepump
intraoperative transesophageal echo (TEE) images (Fig. 51.1,
Fig. 51.2, Fig. 51.3, Fig. 51.4 and Video 51.1) show that the left
ventricle (LV) is hyperdynamic without regional wall motion
Chapter 51
for the Boards
Dermot Phelan and William Stewart
Figure 51.1
Figure 51.2
Figure 51.3
Figure 51.4
Intraoperative Echocardiography for the Boards
(c) 2015 Wolters Kluwer. All Rights Reserved.
442 Section XII Newer Applications
1. What is the diagnosis, and what are your recommendations
to the surgeon?
A. HCM with LV outow tract (OT) obstruction and at
least moderate mitral regurgitation (MR). Recommend
septal myectomy, and the patient will probably require
mitral valve repair/replacement.
B. HCM with LVOT obstruction and at least moderate
MR. Recommend septal myectomy, and the patient will
probably not require mitral valve repair/replacement.
C. HCM without LVOT obstruction and an abnormal
mitral valve. Recommend mitral valve repair/
replacement only.
D. HCM with midcavitary obstruction and MR.
Recommend mitral valve repair/replacement with
papillary muscle debulking.
E. Ventricular septal defect (VSD) with severe MR.
Recommend mitral valve repair/replacement and VSD
2. When is surgery in HCM recommended?
A. Mean outow tract gradient of >40 mm Hg
B. SAM resulting in MR
C. Peak outow tract gradient of >50 mm Hg
D. Presyncope during moderate exertion on beta blocker
therapy at resting HR of 52 bpm
E. HCM with malpositioned papillary muscles
3. During postpump intraoperative TEE assessment, what
intervention might be useful to provoke inducible SAM and
LVOT obstruction?
A. Isoproterenol
B. Amyl nitrite
C. Phenylephrine
D. Perindopril
E. Propranolol
4. Which of the statements is true regarding septal myectomy?
A. It is associated with high (>5%) postoperative mortality
even in experienced centers.
B. Shunts between the resected intramyocardial vessels
and the LV cavity are common.
C. Rates of heart block requiring pacemaker insertion are
higher than for septal ablation.
D. It results in intramyocardial scarring close to the site of
resection on delayed gadolinium-enhanced magnetic
resonance imaging.
E. There are randomized control trial (RCT) data
demonstrating the bene•cial effects of septal myectomy
on both symptoms and survival.
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