jdlevenson's version from 2015-06-21 03:01


Question Answer
Common cardinal veinsSVC*, which is to the right of the heart, posterolateral to ascending aorta, anterior to right PA and below level of carina.
All veins drain into the sinus venosus, which itself drains into thePrimitive atrium of the developing heart.
Three main groups of veins in embryoUmbilical (degenerates); Vitelline (form veins of the vitelline system) and cardinal (IVC).
Truncus arteriosus forms () with the help of ()Forms PA and Ascending aorta; needs neural crest cell migration to cause fusion and twisting of truncal and bulbar ridges.
Digeorge reviewChromosome 22 deletion; 4th and 3rd pharyngeal pouches; aplasia in thymus and so extreme deficiency in t-lymphocytes that improves over time and also may have hypocalcemia with tetanus (mssing parathyroid glands too), aortic arch abnormalities, aberrant formation of the mandible and cleft lip and palate
22q11 associated with which congenital heart diseaseTruncus arteriosus and tetralogy of fallot
Tetralogy of fallot, main determinant of degree of R-> L shunting?Pulmonary stenosis. Key prognostic indicator for hypoxemia symptom severity.
When are tetraology of fallot patients acyanoticWhen SVR is higher than pulm pressure so that more L-> Right than Right -> Left
Differential cyanosis vs whole body cyanosisWhole body cyanosis – shunt reversal in patients with septal defects or tetralogy of fallot whereas differential cyanosis – PDA
Persistent truncus arteriosus, there is always an associated VSD and it presents withCyanosis and results in death due to CHF within first year of life
2nd branchial cleft should be obliterated as part of development otherwise...Cyst. Around angle of mandible. Can form draining sinus tracts to the skin. Treat with excision.
3rd branchial archTissues innervated by CN9 including stylopharyngeus muscle, portions of the hyoid bone, and posterior 1/3 of the tongue
4th branchial archTissues innervated by the superior laryngeal branch of the tenth cranial nerve (vagus), mostly soft palate and pharynx but not stylpharyngeus or palatine muscle (CNV; 1st arch); also contributes to posterior 1/3 of tongue
Septum transversumMesoderm, gives rise to myoblasts that form the diaphragm and exists as a vestige as a central tendon of the diaphragm
1st pharyngeal arch/ aortic archTrigeminal nerve (v2 and v3); Part of maxillary artery and external caroid artery (muscles and bones too; muscles of mastication); Mandibular arch
2nd pharyngeal arch/ aortic archFacial nerve; Hyoid artery and stapedial artery (mostly regresses) (muscles and bones too; muscles of facial expression); Hyoid arch
3rd pharyngeal arch/ aortic archGlossopharyngeal; Common carotid and proximal internal carotid artery
4th aortic archSuperior laryngeal branch of vagus; Aortic arch (on left side) and proximal right subclavian
5th aortic archDegenerates.
6th aortic archRecurrent laryngeal branch of vagus; Proximal pulmonary arteries and on left sides, ductus arteriosus
ASD, R-L then L-R, what happens in pulmonary arteries to cause switchLaminated medial hypertrophy. Becomes so severe that PVR > SVR causing switch. Eisnmenger syndrome. Pulmonary vascular sclerosis can become so severe that closure of the septal defect can no longer be tolerated by the RV.
ASD, presentationAt 1 year/ late onset due to cyanosis, clubbing and polycythemia. ASD is considered a L-> R shunt like PDA, VSD, Eisenmenger and coarct. Vs. 5 T’s.
ASD leads to pulmonary HTN, RVH, RA enlargement but the only one that is irreversiblePulm HTN; needs to be corrected.


Question Answer
IVC splits to left and right common iliac atL4-5.
Renal arteries and veins atL1
Majority of anterior surface of heartRV.
Majority of posterior surface of heartLA (and then descending aorta)
Penetrating wound to right sternal borderRA
Enlargement of left atrium could compressEsophagus
Descending thoracic aorta is anterior or posterior to esophagusPosterior*, abuts left anterior surface of vertebral column
When does descending aorta become abdominal aortaAs it crosses the diaphragm
Recall, flow =(P1 – P2) / R where R is (viscosity x length of blood vessel) / radius to fourth power.
Resistance is inversely proportional to...Radius raised to the 4th power.
Coronary sinus, what is itEndpoint of venous drainage of coronary blood supply. Deoxygenated blood -> RAtrium.
What could cause coronary sinus dilatation?Elevated right sided BP secondary to pulm HTN (but anything that dilates right atrium will do)
Most of blood supply to heart itself occurs whenDuring diastole. Duration or length of diastole is a critical factor in determining coronary blood flow. Coronary arteries are partially compressed during systole by contracting myocardium. Only 30% of blood flow to coronaries occurs during systole.
With less time for blood to flow to coronaries during systole while exercising, what mechanism to ensure enough blood flowDuring stress and tachycardia, adenosine from ATP breakdown (which happens under hypoxic conditions) increases coronary blood flow rate by vasodilating coronary vessels; enlarged vessels can increase flow up to 5 times the resting rate to meet demands
For graft surgeries of LAD, what is artery of choiceLeft internal mammary/ thoracic artery
For graft surgeries that require more than one artery or non LAD, and saphenous needs to be used, where do surgeries take a piece?Surgeons access femoral vein near its point of termination in the femoral triangle of the upper thigh
Baker’s cysts occur whereSynovium; a/w arthritis
Most common peripheral artery aneurysm? Popliteal artery aneurysm
AV shunts have what effect on preload and afterloadIncrease preload and decrease afterload by routing blood from the arterial system to the venous system, bypassing the arterioles. High AV shunts can eventually result in high output cardiac failure.
AV shunt results fromAV fistula. Abnormal connection between artery and vein that bypasses arterioles.
AV fistula on examinationPulsatile mass with a thrill on palpation; auscultation reveals constant bruit over the site
Recurrent laryngeal nerves innervateAll the intrinsic muscles of the larynx except the cricothyroid muscle. Paresis of vocal cord muscles innervated by left recurrent laryngeal nerve may occur as a result of compression by enlargement of the left atrium and other structures in the vicinity as its loops behind the ligamentum arteriosum underneath and around the aortic arch and back up alongside the trachea to the larynx in situations such as mitral stenosis -> Left Atrial dilation may result in hoarseness. This is called Ortner syndrome.
Hoarseness may also be caused by vascular disease resulting in ischemia of the vocal cords, the recurrent laryngeal nerves and or the vagal motor nuclei in the brainstem...
Hoarseness – think nerve impingement, not epithelial sloughing (seen in laryngeal mucosal disease and maybe in patient with asthma or exposure to external gases or gastric acid)
Question Answer
In 90% of people, posteroinferior wall of LV is supplied by...RCA, posterior descending branch.
Sinus node normally receives its blood supply fromRCA
Transmural ischemia of septum would produce ST elevation mainly inV1 and V2
Occlusion of the proximal LAD would result in anteroseptal transmural ischemia with ST elevations inV1-V4 (whereas LCX -> V5, 6 and I and aVL)
PCWP equalsPressure in Left atrium. Increased with increases in afterload or in venous tone.
Patient with DVT of extremities and stroke thinkPatent foramen ovale; recall, this is a normal variant that is functionally closed but may open with increased RAP
Most common site of blunt aortic injuryAortic ismthus, which is tethered by ligamentum arteriosum and is relatively fixed and immotile compared to adjacent descending aorta. Usually from SUDDEN DECELERATION.
Aortic rupture on x-rayWidened mediastinum


Question Answer
At lower levels, what may look like a large blood vessel like aortaDUODENUM.
Figure 8 on lower levels of sliceLoops of ileum.
TTE can visualize LA, atrial septum, and mitral valve (anterior) as well as the descending thoracic aorta (posterior).


Question Answer
How and when do people die from lightning injury25% of the time and due to arrhythmias and or respiratory failure
Lightning, superficial and deep burns?Superficial; tendency to travel over skin surface; leads to Lichtenberg figures (erythematous cutaneous marks in a fern-leaf pattern) and others. However, superficial signs may underestimate internal injury such as causing arrhythmias or respiratory failure (cardiac arrest, peripheral nerve damage, seizures, autonomic dysfunction, rhabdomyolysis, cataracts...)
Erythematous cutaneous marks in a fern-leaf patternPathognomonic of lighting injury


Question Answer
When inserting a central catheter most important considerationStrict adherence to hand hygiene and use of aseptic techniques during insertion and handling of the CVC are most important. 5 steps – 1. Hand hygiene with an alcohol sanitzer or antimicrobial soap prior to donning surgical gloves; 2. Maximal barrier precuations, 3. Chlorhexidine for skin disinfection, 4. Avoidance of the femoral insertion site, 5. Removal of the catheter when no lingered needed. Topical antimicrobial resistance ointments have not been found to improve CVC-related infections and instead high higher rates of candida infection and antimicrobial resistance.
Who receives an IVC filterThose at risk for PE but who are contraindicated for anticoagulation.
Conversavation of mass equationVol in – A1xV1 = Vol out = A2xV2 (derived from constant density of blood). Flow = Flow Velocity x Cross Sectional Area = Constant. Applied to blood flow in whole cardiovascular system.


Question Answer
Pulseless diseaseTakayasu arteritis (weak upper extremity pulse)
Marked difference in left arm vs right arm BPAortic dissection
Upper extremity HTN (with lower extremity lower BP or cyanosis or delayed pulse in lowers)/ differential cyanosisCoarctation of the aorta
Water hammer bounding pulseAortic regurgitation
Pulsus tardus and parvusAortic stenosis
Radial pulse disappearing on inspirationCardiac tamponade
Dicrotic pulse, pulse with two distinct peaks (one during systole and diastole, best felt in carotids)Severe systolic dysfunction**
Hyperkinetic pulseRapid ejection of large SV against low afterload that occurs during fever or exercise or in patients with high output like PDA or AV fistula