Cardiology & Cardiac Surgery – Full Test

Frederick Atwater is a 52-year-old male admitted to ICU after heart transplant one day earlier.  Transplant indication was ischemic cardiomyopathy.  Pre-operative right heart catheterization showed the following:

CVP 12mm Hg ABP 98/54 (MAP 68mm Hg).  Pulmonary artery pressure 42/18 (Mean PAP 30mm Hg).  Cardiac Index 2.2L/m.  Pulmonary wedge capillary pressure 30mm Hg.

Calculate pulmonary vascular resistance using Woods units and SI units (2 marks)

Describe the measurement from hemodynamic profiling consistent with pulmonary hypertension (1 mark)

Calculate left ventricular stroke work index (1 mark)

Post-operatively the patient is hypotensive with clinical features of low cardiac output including oliguria, decreased capillary refill and increasing lactate.  Echocardiogram shows right ventricular dilatation with decreased RV contractility.  Left ventricle has normal contractility and appears underfilled.

Describe the pathophysiology of cardiogenic shock in this patient (2 marks)

List four management options for this situation (4 marks)

Kyron Burton is a 51-year-old female with hematopoetic stem cell transplantation for acute lymphoblastic leukemia.  The following arterial waveform is displayed on their bedside monitor.

Describe the waveform and outline any impacts on pressures measured or display (2 mark)

List four potential reasons for this abnormality (4 marks)

Yvonne Enas is a 32-year-old female admitted to hospital with fever and shortness of breath.  The patient uses intravenous drugs and has suffered multiple extremity orthopedic injuries from trauma.  She has no allergies and smokes one pack of cigarettes daily.

On exam the patient looks cachectic and unwell. Temp 39.2^oC Pulse 40bpm  BP 108/38, RR 26 with SaO₂ of 88% on room air

Bloodwork reveals a WBC of 14, Hb 110, Plt 160, a creatinine of 153. Remaining electrolytes are unremarkable. CXR and ECG are below.

Identify the most likely diagnosis (1 mark)

Provide the two most important additional investigations to clarify the diagnosis (2 marks)

Outline the definitive management strategy (2 marks)

Wallace Sorkin is a 74-year-old woman with rheumatic heart disease who presents to the Emergency department in respiratory distress requiring intubation for pulmonary edema.  She was seen in clinic by her cardiologist two days ago. Echocardiogram revealed aortic stenosis with mean gradient of 30 mm Hg and preserved ejection fraction as well as mitral stenosis with a mitral valve area of 1.2 cm², her ECG at the clinic is below.  On examination BP 95/50 HR 140/min in atrial fibrillation. Previous coronary angiogram revealed 60% left anterior descending lesion with fractional flow reserve of 0.95.

Explain the PATHOPHYSIOLOGY underlying her decompensation including which cardiac lesion is likely MOST RESPONSIBLE (2 marks)

Describe the MOST IMPORTANT immediate management priority (1 mark)

Provide two benefits of non-invasive ventilatory support in acute cardiogenic pulmonary edema (2 marks)

Dolly Rankin is an 88-year-old female admitted to the intensive care unit after hip replacement with significant hemorrhage.  To avoid iatrogenic complications, placement of an arterial catheter is deferred.

Describe the technique incorporated in automated blood pressure cuffs (2 mark)

Highlight the most accurate component of the measured blood pressure with this technique (1 mark)

Sol Kenny is a 50-year-old male with severe left ventricular dysfunction and severe mitral regurgitation post-operative day zero from mitral valve repair.  Intra-aortic balloon pump was inserted for low cardiac output in the operating room.  Refer to the IABP pressure waveform tracing for the following two questions.

Comment on the waveform appearance and timing (2 marks)

Describe the anticipated physiologic effect from augmentation as depicted (1 mark)

Quin Eketerina is a 42-year-old female admitted to the Cardiovascular Intensive Care Unit four hours ago after mitral valve replacement for mitral stenosis.  The anesthesia team inserted a pulmonary artery catheter to monitor hemodynamics.

Identify the thermodilution cardiac output curves representing higher cardiac output. Justify your answer (2 marks)

Rupert Tagan is a 52-year-old gentleman admitted to the intensive care unit for hypotension requiring vasopressors.  Central venous and peripheral arterial catheters were inserted for resuscitation.  The following is taken from a patient breathing spontaneously with an arterial catheter in place.

Describe the physiologic abnormality in arterial pressure (1 mark).

Explain the physiology underlying this abnormality (2 marks)

List three clinical conditions associated with this abnormality (3 marks)

Katrina Edmonds is a 44-year-old female admitted with hypoxemic respiratory failure from the community.  Medical history is significant for orthotopic liver transplantation two years ago for primary sclerosing cholangitis.  Cardiac point of care ultrasound is performed to evaluate the etiology of hypoxemia.

Identify the plane of cut in the attached image (1 mark)

Identify the anatomical structures corresponding to numbers 1-5 (5 marks)

Alice Robie is a 45-year-old female with non-Hogkin lymphoma two months after completion of R-CHOP therapy.  She presented to the emergency department with orthostatic dyspnea and hypotension.  Point-of-care-ultrasound revealed a 1.5cm circumferential pericardial effusion.  Complete the following chart by placing an X in the appropriate section.

Identify the hemodynamic goals for patients with physiologically significant tamponade (2 marks)

List three components of Beck’s Triad (3 marks)

Azure Yasmina is a 70-year-old female presenting to hospital with abdominal pain and CT demonstrating enlarging abdominal aortic aneurysm.  Vascular Surgery will be performing endovascular repair.  Pre-operative chest x-ray is obtained and pictured below.

Describe the pacemaker and describe the clinical situation in which this would be implanted (4 marks)

Erica Jones is a 30-year-old woman admitted 5 days ago for a heroin overdose with pulmonary edema, community-acquired pneumonia and respiratory failure requiring intubation and mechanical ventilation. Her ICU course has been further complicated by agitation and atrial fibrillation. Her current medications include methadone, levofloxacin, clarithromycin, haloperidol, and amiodarone. This morning the following cardiac arrhythmia developed. Electrolytes, including magnesium levels are normal

Interpret the arrhythmia (1 mark)

Provide the most likely etiology for this rhythm (1 mark)

List one pharmacologic and one non-pharmacologic management option (2 marks)

Despite the treatment above there are continued episodes of the arrhythmia.  Provide a third line pharmacologic strategy (1 mark)

List one pharmacologic agent contraindicated for management of this rhythm (1 mark)

Johnny Engels is a 70-year-old male admitted to the intensive care unit with heart block secondary to aortic valve infective endocarditis and paravalvular abscess.

Interpret this rhythm strip and outline your management (2 marks)

Francis Brooke is a 45-year-old male admitted to the intensive care unit with severe mitral stenosis post laparotomy for bowel obstruction due to adhesions.

Provide the most common etiology of mitral stenosis (1 mark)

The patient’s heart rate is 112, preoperatively it was 68.  Describe the anticipated tolerance of this change in heart rate in mitral stenosis. Justify your answer (2 marks)

Mallory Cayley is an 18-year-old female patient admitted to the psychiatry service with major depression.  ECG is ordered by the primary team for palpitations and you are asked to assess for the medical emergency team.

Explain one mechanism to differentiate atrial flutter with 2:1 block, sinus tachycardia and supraventricular tachycardia (1 mark)

Describe the physiology for your mechanism, contraindications and expected effects on each rhythm in the differential (3 marks)

Mike Davis is a 50-year-old patient monitored in the intensive care unit with end-tidal CO₂ monitoring.  The patient has been admitted with an exacerbation of chronic obstructive lung disease.  Ventilator settings are:  pressure control ventilation 22 cmH20, tidal volume is 400 – 450 ml, and respiratory rate is set at 18.  The patient is sedated and not triggering the ventilator.  Blood gases show pCO₂ 68, HCO₃ 38 and pH 7.36. The capnography tracing is shown below.

Comment on the capnography waveform (2 marks)

The patient abruptly loses consciousness and the oxygen saturation is undetectable.  CPR is initiated.  The end-tidal tracing is shown below. Provide a physiologic explanation for the decrease in end-tidal CO₂ with cardiac arrest and CPR (2 marks)

The pCO2 on blood gas is 66, and the peak end-tidal CO₂ is 49 mmHg.   Explain the difference between the end-tidal CO₂ and the arterial CO₂ measurement (2 marks)

Identify the minute along the X-axis at which ROSC likely occurred (1 mark)

A bolus of 50 mEq of sodium bicarbonate is given intravenously during resuscitation.  Explain what changes, if any, effect would you expect on the ETCO₂ tracing due to intravenous bicarbonate. Explain your answer (2 marks)

Describe two theories for the mechanism of forward flow with external cardiac compressions (2 marks)

Alexandra Denise is a 22-year-old female with dilated cardiomyopathy and decompensated congestive heart failure secondary to stress induced cardiomyopathy.  List five pharmacological management considerations for treatment of congestive heart failure with reduced ejection fraction that improve outcomes (5 marks)

Martine Vallejo is a 44-year-old male admitted to the critical care unit with inferior STEMI status post revascularization.  He takes sildenafil.  Nitrates must be used cautiously in patients receiving phosphodiesterase-5 inhibitors.

Describe the pathophysiological interaction between these medications, including their mechanism of action (3 marks)

You are the intensivist on call at a community coronary care unit (CCU). You are called to see Bryce Elrick, a 45-year-old man with chest pain and ECG below

Interpret the ECG (1 mark)

The interventional cardiologist on-call is currently performing a angiogram on another patient and is unavailable 90 minutes.  There are no other cardiac catheterization labs within 90 minutes of your hospital.  Outline your management including doses of medication if appropriate (1 mark)

He is subsequently admitted to the CCU where he develops hemodynamic instability with sinus tachycardia (110 bpm) and persistent hypotension (systolic blood pressure 80-85 mm Hg). Additional findings on physical examination include normal breath sounds and distended neck veins with a positive Kussmaul sign. The chest radiograph does not demonstrate overt congestive heart failure.  List four hemodynamic principles of management (4 marks)

With appropriate therapy, the patient’s condition improves and his hemodynamic status is stabilized. Several hours later, he develops the following rhythm with clinical deterioration.

Interpret the ECG (1 mark)

Describe your management strategy, including pacing modality if appropriate (2 marks)

You are asked to see Wilford Pollie, a 56-year-old man who had an anterior STEMI 5 days ago.  He has deteriorated over the previous 2 hours with increased heart rate, decreased BP (from 126/68 to 98/67), and shortness of breath and tachypnea.  He is breathing with a respiratory rate of 40 and his saturation is 89% on a non-rebreathing mask.  The following are his pulmonary artery catheter values:

HR 108 (sinus) SBP 86mm Hg DBP 56mm Hg MAP 66mm Hg CVP 14cm H₂O PAP 39/18mm Hg PWP not attempted pO₂ right atrium 26mm Hg pO₂ pulmonary artery 68mm Hg

Provide the most likely diagnosis with justification (2 marks)

List THREE additional mechanical complications of anterior acute myocardial infarction (3 marks)

You are called to assess Flint Watson, a 60-year-old male with acute onset chest discomfort.  Medical history is significant for hypertension treated with hydrochlorothiazide.  There is no history of smoking or excessive alcohol consumption.  Pain is searing and retrosternal.  It began four hours prior during light exertion without prodrome or preceding illness. On examination: BP 214/130mm Hg HR 90 (sinus) SpO₂ 98% R/A RR 16 T 37.0^oC. He appears distressed but is alert, oriented and speaking in full sentences.  Left radial pulse is present but weak.  Heart sounds are normal with no murmur.  Chest is clear.

Outline two findings on physical examination with high positive likelihood ratios for the presumed diagnosis (2 marks)

The positive likelihood ratio for one of your findings is 33. Explain the meaning of this value (1 mark)

Provide one investigation to confirm the most likely diagnosis (1 mark)

Outline your management plan including monitors (3 marks)

List three anti-hypertensive agents to treat this patient.  Identify one adverse effect from each, aside from hypotension (6 marks)

List four complications of the most likely diagnosis (4 marks)

Lorne Campbell is a 40-year-old male with an intra-aortic balloon pulsation device inserted during high-risk percutaneous coronary intervention for occlusion of his left main coronary artery.  Refer to the attached arterial blood pressure transduction.

Provide the systolic and diastolic values displayed on the bedside monitor (2 marks)

Provide the systolic and diastolic values displayed on the IABP console (1 mark)

Explain the difference between values displayed on the beside monitor and IABP console (2 marks)

The mean BP is recorded as 85mm Hg on IABP console.  Provide the mean BP displayed on bedside monitor (1 mark)

Isla Grace, a 32-year-old female is admitted to the ICU following orthotopic liver transplantation for decompensated cirrhosis from primary sclerosing cholangitis.  Due to her medical history significant for hypertrophic obstructive cardiomyopathy the transplant was performed using venovenous extracorporeal membrane oxygenation.  A pulmonary artery catheter was placed. Medications after arrival into the ICU are as follows:  Propofol 1mg/h Norepinephrine 0.1mcg/kg/m.  Examination demonstrates equal and symmetrical pupils GCS 3T5, HR 110 (sinus) ABP 85/60 MAP 68 SpO₂ 90% Pressure Controlled Ventilation PEEP 10cm H₂O Pressure Control 15cm H₂O FiO₂ 1.0 frequency 16 breaths/m.  Hemodynamics:  PA 85/45 Cardiac Index 3LPM CVP 12cm H₂O SV 94mL SVRI 907

Chest X-ray is below

Given her high fraction of inspired oxygen, endotracheal suction is performed with blood aspirated.

Interpret the chest x-ray, commenting on line and tube placement (3 marks)

Identify one probable emergent complication (1 mark)

List three (3) risk factors for this complication (3 marks)

Pre-operative hemodynamic studies demonstrated resting left ventricular intra-cavitary pressure gradient of 20mm Hg. The current gradient is 50mm Hg.  Based on this information and the hemodynamic profile, outline your vasoactive pharmacologic strategy with justification (2 marks)

Rhonda Andrews a patient on the cardiac surgery floor.  While consulting on the ICU outreach team you are called to assess her four days post heart transplant.  The patient is receiving a milrinone infusion at 0.125mcg/kg/m and oxygen by nasal prongs at 3LPM.  The outreach team was called for symptomatic bradycardia.  Heart rate 36bpm blood pressure 68/52 (previously 84/60).  Immediately prior to your arrival the patient received atropine 0.6mg IV push by the attending service.  An ECG is attached.

Identify the rhythm (1 mark)

Describe the mechanism of action of atropine (1 mark)

Describe the chronotropic changes in a transplanted heart as compared to a native heart (2 marks)

Describe the heart rate effect of atropine on this patient.  Justify your answer (2 marks)

In addition to atropine, list two alternative therapies you would consider (2 marks)

Tanya Bowers is a 70-year-old female on the ward after undergoing coronary artery bypass grafting and bioprosthetic aortic valve replacement four days ago.  You are called to assess with the ICU RRT and RN on an outreach team.  The nurse alerted you to a change in rhythm.  Epicardial pacing wires are in place and the pacemaker is on.  The rhythm strip is below.

Interpret the rhythm strip (2 marks)

List two interventions you would consider to address this problem (2 marks)

Carter Digby is a 44-year-old male admitted with cardiogenic shock with intra-aortic balloon counterpulsation device inserted during high risk percutaneous coronary intervention to the left main coronary artery.

List four methods for timing intra-aortic balloon pump (IABP) inflation (4 marks)

Isabelle Forti is a 50-year-old female admitted with high risk PCI for which an intra-aortic balloon pump was inserted.

For the IABP waveform label the letters A, B, C and D (2 marks)

Interpret the waveform and timing of balloon inflation (1 mark)

Describe the physiologic implication (1 mark)

Adjustments are made to the IABP based on your analysis.  The bedside nurse notifies you to the presence of blood tracking proximally through the IABP catheter.  Explain the cause of bleeding (1 mark) and provide the management strategy (3 marks)

Mark Langdon is a 66-year-old male admitted to the post-operative cardiac surgery intensive care after undergoing coronary artery bypass grafting for critical left main coronary artery stenosis.  IABP was inserted for pre-operative left ventricular dysfunction.

For the IABP waveform, DESCRIBE the waveform and DESCRIBE the physiology impact (2 marks)

Mark has PEA cardiac arrest. DESCRIBE the IABP timing you would program into the console (1 mark)

Miroslav Jacek is a 38-year-old male admitted to the cardiac surgery intensive care unit following a Ross procedure, exchanging a pulmonic autograft into the aortic position for congenital bicuspid aortic stenosis.  Past medical history is significant for hypertension and idiopathic deep venous thrombosis.  Medications are ramipril and aspirin. Intraoperatively the valves were implanted with no perivalvular leak and no insufficiency.  Biventricular function was normal. Cardiopulmonary pump time was 266 minutes and aortic cross clamp time was 150 minutes. One packed red blood cell, 400mL of acute normovolemic hemodilution blood and four litres of Ringer’s lactate were infused during the case to maintain CVP of 8 and based on surgical field bleeding. Total heparin from all sources was 50,000 units and 400mg protamine was administered to achieve baseline activated clotting time of 110s.

On arrival in intensive care the underwater seal chest drainage system accumulates 600mL in thirty minutes.  Provide four explanations for large volume hemorrhage in Mr. Jacek’s case not including anatomical issues requiring surgical revision (4 marks)

Interpret the thromboelastographic tracing below and provide two management recommendations (4 mark)

Central venous pressure abruptly increases from 7mm Hg to 35mm Hg accompanied by systemic mean arterial pressure decreasing from 100/90mm Hg to 70/40mm Hg.  Provide TWO plausible etiologies for this acute decline (2 marks)

Alec Panine is being cared for in the critical care unit after suffering an out of hospital cardiac arrest from hypothermia.  Despite rewarming he continues to lose a pulse and has intermittent CPR in the unit.  Capnography is recommended by the AHA as a monitoring device during CPR.

List THREE roles for CO₂ monitoring during cardiac arrest (3 marks)

Below is a typical capnograph tracing. Identify the four phases. (4 marks)

Irma Smith is admitted to intensive care post-operatively from pancreaticoduodenectomy with a central venous catheter located within the right internal jugular vein.  The CVP is 14mm Hg on the bedside monitor.  Describe the anatomic landmark at which point the transducer should be positioned (1 mark)

You note the transducer is 14cm higher that the correct refence point. Provide the correct CVP once the transducer has been leveled correctly. Show your calculation (2 marks)

Pavithra Mithra is a 50-year-old patient with Eisenmenger Syndrome admitted to the intensive care unit for decompensated pulmonary hypertension and hypoxemia.  Pulmonary artery catheter is inserted.  Provide the following equations (3 marks)

Systemic Vascular Resistance (SVR)

Pulmonary Vascular Resistance (PVR)

Left ventricular Stroke Work Index (LVSWI)

A NEJM study on oxygenation/ventilation and blood gases in climbers on Mount Everest was published. Using the following data from a subject in the study: Hemoglobin concentration (g/L) = 200, Arterial oxygen saturation = 45%, PaCO₂ = 10 mmHg, PaO₂ = 25 mmHg, Barometric pressure = 250 mmHg. Assume the relative proportion of oxygen consumption and carbon dioxide production is unchanged at higher altitudes.

Calculate arterial oxygen content showing work (2 marks)

Calculate alveolar pO₂ showing your work (2 marks)

Calculate alveolar-arterial oxygen difference showing your work (2 marks)

Anand Wilde is a 60-year-old male with large saddle pulmonary embolism occupying part of the main pulmonary artery.

Identify four findings on POCUS that support the diagnosis of right ventricular failure (4 marks)

Ramona Vitale is a 67-year-old female admitted to the Intensive Care Unit for monitoring after undergoing successful PCI to the circumflex artery for STEMI four days ago. Her course was complicated by non-sustained ventricular tachycardia requiring amiodarone infusion. She has progressively deteriorated with increased work of breathing, tachypnea and hypoxemia. Currently she is awake and mentating. Vitals include BP 100/60mm Hg HR 90 (sinus rhythm) SpO2 92% FiO2 0.6 by facemask, RR 26 and Tmax 36.5. Medications include aspirin, clopidogrel, amiodarone infusion, norepinephrine infusion at 0.1mcg/kg/m and atorvastatin. Chest x-ray reveals increased interstitial markings. Echocardiogram reveals a mobile mass in the left ventricle prolapsing into the left atrium and ejection fraction of 25%.

Identify the BEST management strategy of the three options below (1 mark)

1. Nitroglycerin infusion, dobutamine infusion, furosemide bolus, non-invasive ventilatory support
2. Vasopressin infusion, 500mL Ringer’s Lactate, esmolol infusion, high-flow nasal oxygen
3. Unfractionated heparin infusion, metoprolol 25mg oral, invasive mechanical ventilation

Provide the DEFINITIVE management for Ramona’s condition at this point (1 mark)

The multidisciplinary team is considering intra-aortic balloon counter-pulsation and veno-venous extracorporeal membrane oxygenation. Identify which of these two forms of mechanical circulatory support you would recommend with brief justification (2 mark)

Stuart Chan is a 70-year-old male who was admitted to the intensive care unit with sub-arachnoid hemorrhage fourteen days ago complicated by refractory vasospasm. This was initially treated with aggressive fluid resuscitation, oral nimodipine, induced hypertension, intravenous milrinone and intra-arterial verapamil via the carotid artery. With improvement in vasospasm furosemide infusion was initiated four days ago with daily fluid balance -1.5L. Medical history is significant for heart failure with preserved ejection fraction and hypertension.

Current medications are: nimodipine, milrinone 0.75mcg/kg/m, furosemide 10mg/h, dalteparin, lansoprazole, norepinephrine 0.1mcg/kg/m and propofol 1mg/kg/h. Vital signs are: BP 140/70mm Hg HR 130 bpm SpO2 95% CMV VC 450mL PEEP 12 FiO2 0.3 rate 20. Capillary refill time is 6 seconds and the patient is cool.

Pulmonary artery catheter is inserted with the following values: CVP 5mm Hg PAWP 7mm Hg Cardiac Index 1.9L/min/m², SVO₂ 58% SVR 1,300 dynes.s/cm⁵ lactate 6.2 mmol/L. POCUS reveals moderate pericardial effusion with diastolic right ventricular collapse and no respiratory variation in mitral inflow velocity.

Identify the most likely etiology of shock (1 mark)

Provide the MOST IMPORTANT medical and interventional management consideration immediately (2 marks)

List THREE conditions outside of pericardial effusion associated with inspiratory decrease in systolic blood pressure by greater than 10mm Hg (3 marks)

Dean Murdoch is a 49-year-old gentleman admitted to your critical care unit from the medical floor. He was admitted fourteen days ago with dyspnea found to have pulmonary edema. Echocardiography revealed mitral valve endocarditis with severe mitral regurgitation. He was diuresed with a negative fluid balance of 10L in the preceding week. On examination he is awake, alert and mentating denying pain. BP 88/55 MAP 66mm Hg HR 105 (sinus) T 39.0^oC with cool extremities, no edema and no mottling. Chest sounds are coarse bilaterally with increased work of breathing based on scalene muscle use. SpO₂ 96% RR 40 on non-invasive bilevel ventilatory support IPAP 15cm H₂O EPAP 8cm H₂O room air.

Pulmonary artery catheter reveals: pulse pressure variability 11, CVP 25 PA 64/31 (PAm 44mm Hg) Cardiac Index 3 Cardiac Output 5.8LPM SV 58mL PAOP (wedge) 38mm Hg SVR 699 (N 800-1200 dyn/s/cm⁵)

Arterial blood gas: pH 7.50 PaO₂ 79 PaCO₂ 30 Base Excess 0 Lactate 1.3. Mixed venous blood gas: pH 7.46 PmvO₂ 31 PmvCO₂ 35 BE 1 Hb 110

Calculate the pulmonary vascular resistance (1 mark)

Which hemodynamic value from the pulmonary artery catheter is MOST SUPPORTIVE of the decompensation being a result of DISTRIBUTIVE shock? (1 mark)

Complete the following chart indicating HEMODYNAMIC GOALS for acute mitral regurgitation

Calculate the OXYGEN CONSUMPTION (VO₂) (2 marks)

Calculate the OXYGEN DELIVERY (DO₂) (2 marks)

Outline TWO potential impacts of positive pressure ventilation on the hemodynamic measurements from the pulmonary artery catheter (2 marks)

Theo Matisse is a 50-year-old male admitted with decompensated congestive heart failure from ischemic cardiomyopathy.  Label A, B, C and D on the Frank-Starling curve (4 marks)

Heather William is a 56-year-old female admitted to the intensive care unit with decompensated congestive heart failure from progressive non-ischemic cardiomyopathy.  Compare milrinone and dobutamine across the following domains (10 marks):

• Class
• Mechanism of action
• Cardiac Output Impact
• Half-Life
• Metabolism

Nancy Smithson is a 67-year-old female admitted with cardiogenic shock from left main coronary artery occlusion and STEMI.  Intra-aortic balloon counterpulsation was initiated in the angiography suite to facilitate high-risk percutaneous coronary intervention.  The IABP is set at 1:2. Label the following tracing (6 marks)

Micaela Frank is a 32-year-old female admitted with toxic shock syndrome.  She presented two days prior with hypotension, septic shock and multi-organ dysfunction syndrome.  Despite volume resuscitation she remains hypotensive.

Compare and contrast vasopressin and norepinephrine on the following components (6 marks):

• Mechanism of Action
• Half-Life
• Endogenous production location

Conrad Hildebrand is a 59-year-old male with non-ischemic cardiomyopathy admitted to the intensive care unit following implantation of a durable left ventricular assist device in hopes of future transplantation.  Conrad was admitted to the Cardiology service two weeks prior to implantation in an attempt to optimize medical therapy, however, he developed refractory ventricular fibrillation. He was extubated six hours after surgery.  You are called to assess twenty-four hours post operatively for decreased pulsatility index.  He is mentating, awake alert and conscious receiving no sedatives.  Blood pressure mean is 59mm Hg, heart rate is sinus rhythm with left bundle branch block at 80bpm.  Peripheral examination reveals cool mottled extremities, increased in comparison to previous exams. Inspection of the ventricular assist device confirms low pulsatility index, low flow and high power. Transthoracic ultrasound reveals no anterior pericardial effusion.

Provide the most likely diagnosis (1 mark)

Describe the MOST important next step in management (1 mark)

Following intervention, Conrad develops ventricular fibrillation on the cardiac monitor.  Identify the MOST IMPORTANT DIFFERENCE between management of ventricular fibrillation in this context and routine advanced life support (2 marks)

Complete the following chart indicating high low or normal power and PI for a durable left ventricular assist device (4 marks)

Conrad undergoes cardiac transplantation.  Provide one immunosuppressant targeting T-cell function or cellular rejection and one immunosuppressant targeting antibody mediated rejection (2 marks)

Annie MacDougall is a 27-year-old patient with severe asthma is intubated and mechanically ventilated. Sequential arterial line measurements are obtained:

Timeline: T0 = before intubation; T1 = 5 min post-intubation; T2 = after 500mL crystalloid bolus and ventilator adjustment; T3 = after additional 500mL bolus

Describe the physiologic trajectory from T0 to T1 that explains the blood pressure change (1 mark)

Identify which intervention between T1 and T2 (fluid vs ventilator adjustment) contributed more to the blood pressure improvement and justify using specific parameter changes (2 marks)

Briefly explain the difference between pulse pressure variability and pulsus paradoxus (2 marks)

Identify TWO clinical situations where pulse pressure variability is unreliable as a marker for preload responsiveness, assuming the arterial line is calibrated correctly (2 marks)

Shannon Lam is a 66-year-old woman is admitted to ICU with acute septal MI. On day 4, just before planned transfer to ward, her blood pressure falls to 70/50 mmHg. A loud systolic murmur with palpable thrill is noted.

a) State the most likely diagnosis/complication. (1 mark)

b) A Swan-Ganz catheter shows: RA O2 saturation 60%, PA O2 saturation 72%, PAP 40 mmHg, PCWP 38 mmHg, CO 1.8 L/min. Calculate pulmonary vascular resistance (PVR) and state whether it is normal, low, or high. (2 marks)

c) Explain these hemodynamic observations in EXACTLY THREE physiologic points. (3 marks)

d) Explain why the RA saturation is only 60%. (1 mark)

You are on your CV ICU rotation and asked to insert a Swan Ganz Catheter into Hans Ruben. Before doing so, your attending asks questions to assess your understanding of its clinical relevance.

a) List EXACTLY THREE parameters that a Pulmonary Artery Catheter (PAC)/Swan Ganz Catheter (SGC) can measure. (3 marks)

b) List EXACTLY TWO of the most common clinical settings in which it is used. (2 marks)

c) State the normal distances at which you expect to see waveform changes during Swan-Ganz catheter insertion for EXACTLY FOUR locations: right atrium (RA), right ventricle (RV), pulmonary artery (PA), and pulmonary artery wedge (PA wedge). (2 marks – 0.5 per location)

You’ve inserted a PAC and obtained the following parameters: MAP 60 mmHg, CO 1.8 L/min, CVP 14 mmHg, PAOP/PCWP 20 mmHg, PA 45/30 (mean 35), SvO2 55%.

d) State the formula for calculating mean arterial pressure (MAP) from systolic and diastolic blood pressure. (1 mark)

e) Calculate the systemic vascular resistance (SVR) using the provided values and show your calculation. (1 mark)

f) State whether this SVR is normal, low, or high. (1 mark)

g) List EXACTLY TWO causes of low SVR. (1 mark)

h) List EXACTLY TWO causes of high SVR. (1 mark)

Becky Trell is a 56-year-old woman is admitted to the ICU with septic shock and intubated for respiratory failure. A right internal jugular central venous line (CVL) is inserted under ultrasound guidance without technical difficulty. Post-insertion chest X-ray is shown below.

Ultrasound confirms the catheter is within the right internal jugular vein. Blood gas drawn from the CVL on FiO2 0.5 shows PaO2 102 mmHg; simultaneous radial arterial PaO2 is 96 mmHg.

a) State the most likely diagnosis. (1 mark)

b) List the FOUR steps of the systematic diagnostic approach to confirm this diagnosis, in order. (2 marks)

c) State TWO appropriate management options for the malpositioned CVL. (2 marks)

A 59-year-old woman, Vivian Dion, is found apneic and pulseless. Chest compressions generate a systolic blood pressure of 90 mmHg. Several attempts at direct laryngoscopy intubation are made due to a difficult airway. After the last attempt a disposable colorimetric capnometer is attached to the endotracheal tube. An initial color change indicating CO2 is observed but after five bag breaths CO2 is no longer detected.

a) List TWO possible reasons for the initial CO2 color change followed by loss of CO2 detection. (2 marks)

Farquhar Anzo is a 57-year-old man who develops ventricular fibrillation following acute MI. Immediate defibrillation is unsuccessful. He is intubated and chest compressions are commenced. Breath sounds are equal bilaterally, no air entry is heard over the stomach, and chest wall movement is symmetric. Colorimetric capnometry detects a persistently low end-tidal CO2 of approximately 0.5% over five minutes of resuscitation.

a) List THREE potential causes of low end-tidal CO2 during resuscitation in this setting. (3 marks)

Leila Mansour is a 58-year-old woman with ischaemic cardiomyopathy and an implantable cardioverter-defibrillator (ICD) who is admitted to the ICU in haemodynamic distress. The attached ICD interrogation stripe is provided. She has received multiple shocks today. Electrolytes and volume status have been optimized. She has failed amiodarone, lidocaine, and beta-blockade.

a) Identify the underlying rhythm shown on the ICD interrogation stripe. (1 mark)

b) Briefly explain why recurrent ICD shocks worsen rather than treat the underlying arrhythmia substrate. (2 marks)

c) List EXACTLY ONE medical non-antiarrhythmic option and EXACTLY ONE interventional or surgical option you would consider now. (2 marks)

d) Mechanical circulatory support is discussed. Based on the information available, classify this MCS by bridge type. (1 mark)

A 74-year-old woman, Elaine Gold, presents with her first anterior STEMI and no prior cardiac history. On day 3 post-infarction she develops sudden hemodynamic collapse. The team suspects left ventricular free wall rupture.

a) List THREE risk factors for LV free wall rupture following myocardial infarction. (3 marks)

Adam Missoula is a 68-year-old man with severe COPD exacerbation who is intubated and mechanically ventilated in the ED. Minutes after intubation he develops pulseless electrical activity (PEA) arrest. The team is systematically identifying reversible causes specific to this clinical context.

a) List THREE causes of PEA arrest in a newly intubated COPD patient and state the specific treatment for each. (6 marks)

Karim Rahim is a 33-year-old man admitted two days ago with urosepsis secondary to E. coli urinary tract infection, treated with ceftriaxone. He now develops severe hypoxemia with SpO2 70% on FiO2 1.0 despite RR 22 with no respiratory distress and full sentences. BP is 90/45 mmHg with warm peripheries and capillary refill of 2 seconds. Lactate is 1.0 mmol/L and CXR is clear. Echocardiography reveals a non-restrictive ventricular septal defect, overriding aorta, and right ventricular hypertrophy.

a) State the most likely cardiac diagnosis. (1 mark)

b) State the most important pathophysiologic mechanism of hypoxemia in this patient. (1 mark)

c) The respiratory therapist proposes intubation for hypoxemia. List EXACTLY TWO mechanisms by which positive pressure ventilation could worsen hypoxemia, and state EXACTLY ONE non-invasive respiratory adjunct that could be considered first. (3 marks)

d) Given intact mentation and normal perfusion markers, state your MAP target for vasopressor titration choosing between 55, 65, or 75 mmHg, with brief justification. (2 marks)

e) Briefly describe the effect dobutamine initiation would have on oxygenation in this patient. (1 mark)

Mirela Bogdanovic is a 42-year-old woman on chronic hemodialysis who undergoes tricuspid valve replacement for infective endocarditis secondary to a tunnelled catheter infection. Her home medications include citalopram, lansoprazole, and darbepoetin. She develops refractory vasoplegia on separation from cardiopulmonary bypass. In the ICU her lactate is 20 mmol/L, she has inducible clonus in both feet, lead-pipe lower extremity rigidity, and CK has risen from 400 to 6000 U/L. She is allergic to oxycodone, hydromorphone, and morphine.

a) State the mechanism of action of methylene blue in vasoplegia and name ONE contraindication relevant to this patient’s home medications. (2 marks)

b) State why fentanyl is a high-risk analgesic choice in this patient and name TWO diagnostic facets from the criteria that are already met. (3 marks)

c) State ONE non-opioid analgesic option in lieu of opioids (1 mark)

d) State the optimal fluid balance strategy for CRRT in this post-operative patient given her concurrent RV dysfunction from tricuspid valve repair (1 mark)

A 19-year-old woman with severe closed head injury is undergoing therapeutic hypothermia at 32°C. She is receiving propofol 3 mg/kg/hr and cisatracurium titrated to one twitch on train-of-four monitoring. BIS is 40, ICP is 20 mmHg, lactate is 2.4 mmol/L, and mixed venous oxygen saturation is 80%. She develops sinus bradycardia with a heart rate of 38 bpm.

a) List TWO causes of her bradycardia. (2 marks)

b) List TWO management steps to address the bradycardia. (2 marks)

Steve Nance is a 71-year-old man on postoperative day 1 following emergency CABG for STEMI complicated by cardiogenic shock. He required epinephrine 0.1 mcg/kg/min post-bypass and his CI improved to 2.3 L/min/m² by hour 4.

Hour 4: CI 2.3, MAP 70, CVP 10, chest tubes draining 60 mL/hr serosanguineous.

Hour 8: CI 1.6, MAP 54, CVP 17, HR 124, chest tubes now draining 0 mL/hr for 90 minutes. TEE focal pericardial effusion with complexity compressing left atrium

a) State the most likely explanation for the clinical deterioration at Hour 8. (1 mark)

b) State two reasons why needle pericardiocentesis is generally not the preferred initial intervention for post-surgical tamponade. (2 marks)

c) State two hemodynamic maneuvers to temporize this patient at Hour 8 while awaiting definitive treatment. (2 marks)

Prakash Rajmund is a 45-year-old man who develops anterior ST-elevation MI and cardiogenic shock on postoperative day 3 following elective hernia repair. He has been anticoagulated, medically optimized, and started on milrinone. Cardiology is consulted for possible PCI and intra-aortic balloon pump (IABP) insertion.

a) List TWO mechanisms by which an IABP improves cardiac function. (2 marks)

b) List FIVE major complications of IABP insertion. (5 marks)

c) List THREE contraindications to IABP insertion. (3 marks)

Laila Mansur is a 66-year-old woman on postoperative hour 3 following redo mitral valve replacement requiring 3.5 hours on cardiopulmonary bypass. Chest tube output is 280 mL in the last hour and 190 mL in the preceding hour. MAP is 58 mmHg on norepinephrine 0.15 mcg/kg/min, CVP is 5 mmHg, CI is 1.9 L/min/m², Hgb 74 g/L, INR 2.3, fibrinogen 0.9 g/L, platelet count 58 × 10⁹/L, and temperature 35.6°C. Bedside echo shows no pericardial effusion and a hyperdynamic LV.

a) Identify the two most important contributors to coagulopathy in this patient, based on the available data. (2 marks)

b) State the blood product most urgently required in this patient (1 mark)

c) List three non-product interventions to reduce surgical bleeding in this patient. (3 marks)

Esperanza Villanueva is a 61-year-old woman who required peripheral VA-ECMO cannulation for refractory cardiogenic shock during weaning from cardiopulmonary bypass after mitral valve replacement. On postoperative hour 6, ECMO flow is 4.2 L/min, but MAP is 44 mmHg despite norepinephrine 0.28 mcg/kg/min. CVP is 4 mmHg, PCWP is 7 mmHg, SVR is 380 dynes·sec·cm⁻⁵, and temperature is 36.8°C. Chest tube output is 35 mL/hr. Bedside echo shows a small, hyperdynamic LV with no pericardial effusion and an aortic valve opening on every third beat.

a) State the diagnosis responsible for the refractory hypotension and identify two features from the data that support it. (3 marks)

b) Name two vasopressors from different pharmacologic classes you would consider (2 marks)

c) State one specific hemodynamic risk of VA-ECMO that is relevant to this patient’s LV, and briefly explain (1 mark)

Kaan Celik is a 56-year-old male admitted from the emergency department to the intensive care unit for septic shock secondary to pyelonephritis. Despite 4L intravenous balanced crystalloid Kaan remains unstable with systolic blood pressure of 81mm Hg when fluid administration pauses. Heart rate is 130bpm in sinus rhythm.  Breath sounds are clear, SpO₂ 100% 2L NP O₂. Abdomen is tender diffusely but soft and not peritonic.  Norepinephrine is infusing at 40mcg/kg/m.  Cardiac point of care ultrasonography demonstrates dynamic left ventricular outflow tract obstruction with systolic anterior motion of the mitral valve and mitral regurgitation. Ejection fraction by visual inspection is increased.  LVOT velocity time integral is 30cm.

Outline hemodynamic principles for the following variables: Preload, Afterload, Heart Rate, Contractility

Nadia Okonkwo is a 68-year-old woman on postoperative day 1 following three-vessel CABG. She develops progressive hypotension (MAP 52 mmHg) with HR 118, CVP 18 mmHg, cardiac index 1.7 L/min/m², mixed venous saturation 52%, and urine output of 8 mL/hr. Chest tube output has been 30–40 mL/hr throughout. Norepinephrine is running at 0.12 mcg/kg/min. CXR shows a mildly widened mediastinum without obvious cardiomegaly.

a) List the two most important diagnoses to differentiate in this presentation. (2 marks)

b) State two immediate management steps if tamponade is confirmed. (2 marks)

Nomvula Nyembe is a 52-year-old woman on postoperative day 1 after emergency laparotomy for bowel ischemia with delayed abdominal closure. She is on volume control ventilation with plateau pressure rising from 22 to 31 cmH2O over 6 hours without a ventilator change. Bladder pressure is 21 mmHg. PA catheter shows CVP 19 mmHg, PCWP 21 mmHg, CO 8.6 L/min, SVR 540 dynes·sec·cm⁻⁵. Arterial line shows a narrowed pulse pressure with marked respiratory variation. Bedside echo shows a hyperdynamic, vigorously contracting LV with EF 70%. Urine output is 10 mL/hr.

a) State the diagnosis. (1 mark)

b) State why CVP and PCWP are both elevated in this patient despite a hyperdynamic LV with normal intravascular volume. (1 mark)

c) State whether rising plateau pressure reflects worsening lung compliance (Write YES or NO) (1 mark)

d) Briefly explain the pathophysiology of oliguria despite high CO and elevated EF. (2 marks)

Aiyana Monteiro is a 39-year-old woman with septic shock from a urinary source. On admission HR 105bpm atrial fibrillation, MAP is 58 mmHg on norepinephrine 0.10 mcg/kg/min, lactate 4.2 mmol/L. POCUS shows an IVC diameter of 1.1 cm with >50% respiratory collapse. After 2L crystalloid, MAP improves to 70 mmHg, lactate trends to 2.8 mmol/L, and repeat echo shows a hyperdynamic LV with high velocity time integral and an IVC now 2.3 cm with minimal collapse. Norepinephrine is weaned to 0.04 mcg/kg/min. Six hours later her SpO2 drops from 97% to 90% on the same FiO2, and repeat POCUS shows multiple bilateral B-lines and a dilated, hypokinetic RV with septal flattening.

a) State what the initial IVC findings indicate about fluid responsiveness. (1 mark)

b) State the hemodynamic phenotype of sepsis demonstrated after the fluid bolus, based on the echo findings. (1 mark)

c) State what the new B-lines and RV findings indicate has occurred and the appropriate change in management  (2 marks)

d) List two additional POCUS findings that would support fluid intolerance if present. (2 marks)

e) State one limitation of using IVC diameter alone to assess fluid responsiveness in this patient population. (1 mark)

You are called to the Emergency Department to see Adam Brent, a 25-year-old male with return of spontaneous circulation. Adam was found unresponsive without a pulse in a community pool after diving from a 10M platform. It is unclear when Adam lost consciousness (on platform, during dive, in water). Initial rhythm was shockable by AED thus bystanders delivered defibrillation in addition to CPR. Immediate angiography has normal anatomy and no obstructive coronary artery disease.

a) List TWO LIKELY diagnoses for this clinical scenario if the initial ECG and echocardiogram are NORMAL (2 marks)

b) List TWO LIKELY diagnoses for this clinical scenario if the initial ECG is abnormal and the echocardiogram is normal (2 marks)

c) List TWO LIKELY diagnoses for this clinical scenario if the initial ECG is abnormal and the echocardiogram is abnormal (2 marks)

d) Post-ROSC blood pressure is 220/100mm Hg for 20 minutes after discontinuation of inotropes. An intravenous anti-hypertensive medication is administered with immediate development of pulseless electrical activity. STATE the MOST LIKELY medication administered and STATE ONE ALTERNATIVE medication that could have been administered for refractory hypertension (2 marks)

Henry Watkins is a 56-year-old patient admitted to ICU from the ward. They were admitted four days ago with sub-massive pulmonary embolism in the context of immobility from knee replacement six weeks ago. Prior to ICU transfer they received 6L of crystalloid for hypotension and oliguria.  They were intubated prior to ICU transfer for decreased level of consciousness.

Current vitals: HR 50bpm BP 60/30mm Hg SpO₂ 90% (Volume control Vt 500mL Frequency 20 FiO₂ 1.0 PEEP 10 Ti 0.8s). X-ray is unremarkable. POCUS shows RV volume and pressure overload. IV tPA has been administered.

List FIVE principles of management of acute right ventricular failure and outline FIVE specific management strategies you would implement for Mr. Watkins (10 marks)

Stephen Duncan is a 50-year-old male with cardiogenic shock admitted to the intensive care unit after reperfusion for an anterior STEMI and left anterior descending coronary artery occlusion.  You are performing cardiac point of care ultrasound to evaluate left ventricular function.

Describe four techniques or components used to determine left ventricular function using POCUS (4 marks)

Nicholas Rose is a 70-year-old male admitted to surgery following laparotomy for perforated diverticulum.  The ICU outreach nurse requests your assistance with assessing the patient.  Surgery was complicated by an intra-abdominal abscess that required drainage with a percutaneous drain.  This evening he complained of palpitations and shortness of breath when he got back to bed.  ICU was called after the patient’s vital signs revealed: Pulse 200, BP 90/60, RR 28, SaO₂ 92% on FiO₂ 0.4.  The surgery team got the following ECG:

List three possible rhythms (3 marks)

Explain strategies you might consider to achieve a diagnosis (2 marks)