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Category: Critical Care Medicine-Cardiovascular Disorders--->Mechanical Circulatory Support and the Transplanted Heart
Page: 1

Question 1#Print Question

A 60-year-old male with a history of nonischemic dilated cardiomyopathy is admitted to the intensive care unit (ICU) after presenting to the emergency department with several days of progressive dyspnea and lower-extremity swelling. He is found to be hypotensive and tachycardic and on examination is noted to be confused with edematous, cool extremities. A 12-lead ECG shows rapid atrial fibrillation with nonspecific ST-segment changes. His last transthoracic echocardiogram performed 1 year ago showed a severely dilated LV cavity with a left ventricular ejection fraction of 28%, severe mitral regurgitation, moderate aortic insufficiency, and severe tricuspid regurgitation.

In this patient, which of the following represents a contraindication to the use of an intra-aortic balloon pump (IABP)?

 

A. Atrial fibrillation
B. Severe LV cavity dilatation
C. Moderate aortic insufficiency
D. Severe mitral regurgitation
E. Severe tricuspid regurgitation


Question 2#Print Question

A 78-year-old male is admitted to the ICU to undergo evaluation for urgent coronary artery bypass grafting after a coronary angiography revealed critical left main artery stenosis. During the catheterization procedure, an IABP was placed via the left common femoral artery because of ongoing chest pain. Chest pain abated after the IABP was placed. After several hours in the ICU, the patient complains of mild recurrent chest pain, and his nurse reports that there is new blood that can be seen in the IABP catheter that is connected to the console.

Which of the following is the most appropriate next step in the management of this patient?

A. Chest X-ray to confirm IABP placement
B. Urgent transthoracic echocardiogram
C. Repeat coronary angiography
D. Removal of the IABP
E. Abdominal CT scan


Question 3#Print Question

A 43-year-old woman is admitted to the ICU with palpitations and dyspnea because she is 10 weeks from successful orthotopic heart transplantation for severe idiopathic dilated cardiomyopathy. Her posttransplant course has been uneventful thus far. On admission her:

  • blood pressure is 107/62
  • heart rate is 113
  • oxygen saturation is 88% on room air
  • temperature is 37.9°C

Her physical examination is notable for:

  • bibasilar rales
  • an elevated jugular venous pressure
  • mild pitting pedal edema

Her cardiac examination reveals:

  • a rapid, irregularly irregular heart rate
  • a II/VI holosystolic murmur loudest at the right lower sternal border

A 12-lead ECG shows rapid atrial fibrillation.

Which of the following is the next best diagnostic test to obtain in the management of this patient?

A. Endomyocardial biopsy
B. Two sets of sterile blood cultures
C. Transesophageal echocardiogram
D. Coronary angiography
E. Cardiac MRI


Question 4#Print Question

A 64-year-old man with a history of coronary artery disease and severe ischemic cardiomyopathy is brought to the hospital by his wife, who found him at home confused and lethargic. He has a durable continuous flow left ventricular assist device (LVAD) that was surgically implanted 1 year ago as destination therapy for his end stage heart failure. On arrival he is arousable but somnolent. His blood pressure is unable to be obtained with a manual cuff; however, a reading obtained with a Doppler ultrasound is 54 mm Hg. His heart rate is 119 beats per minute, respirations are 26 per minute, and his temperature is 38.0°C. On examination, his jugular venous pressure is 5 mm Hg, his cardiac examination reveals a continuous hum, his peripheral pulses are not palpable, and his extremities are warm without significant edema. Interrogation of his LVAD shows high flow with normal power.

Which of the following would NOT be an appropriate intervention in the acute management of this patient?

A. Placement of an arterial line
B. Administration of IV norepinephrine
C. Initiation of broad spectrum antibiotics
D. Administration of IV dobutamine
E. Obtaining two sets of sterile blood cultures


Question 5#Print Question

A 32-year-old female with no prior medical history presents with several days of fevers, chills, myalgias, and progressive shortness of breath. She is found to have a blood pressure of 84/70, heart rate of 123, and oxygen saturation of 84% on room air. She is admitted to the ICU and an urgent echocardiogram shows a left ventricular ejection fraction of 15%, normal left ventricular end diastolic diameter, and severe right ventricular systolic dysfunction. She is started on intravenous norepinephrine and dobutamine, given intravenous furosemide and is intubated for progressive hypoxia; however, she remains persistently hypotensive with poor urine output despite escalating doses of intravenous therapy and diuretics.

Which of the following would be the most appropriate choice for mechanical circulatory support in this patient?

A. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO)
B. Percutaneous LVAD
C. IABP
D. Durable, surgically implanted LVAD
E. Veno-venous (VV) ECMO




Category: Critical Care Medicine-Cardiovascular Disorders--->Mechanical Circulatory Support and the Transplanted Heart
Page: 1 of 2