8.1

Summary

| COMPARISON OF ACYANOTIC VS. CYANOTIC HEART DISEASE | | :--- | :--- | | Feature | Details | | Mechanism | Acyanotic Heart Disease involves simple/single lesions with left-to-right shunts or obstructive lesions. Cyanotic Heart Disease involves complex lesions with right-to-left shunts, common mixing, or parallel circulations. | | Laboratory Finding | Cyanosis manifests clinically when capillary reduced hemoglobin is >5gm % (oxygen saturation usually <85%). | | Incidence | Congenital Heart Disease (CHD) occurs in 8 out of every 1000 live births. |

| SUMMARY OF COMMON CONGENITAL HEART DEFECTS | | :--- | :--- | :--- | :--- | | Disease Entity | Key Pathophysiology | Diagnostic Findings | Management / Treatment | | Atrial Septal Defect (ASD) | Left to right shunt; Ostium secundum is the most common type (80%). | Fixed splitting of S2; RV heave; 2D Echo shows shunt. | Surgery indicated if Qp:Qs > 1.5:1; Transcatheter closure requires 5mm rim. | | Aortic Stenosis (AS) | LVOT obstruction; Neonatal critical AS is ductal-dependent. | "Parvus et tardus" pulse; Crescendo-decrescendo murmur; LVH on ECG. | Ross procedure (harvesting pulmonary valve) used for growing patients. | | Patent Ductus Arteriosus (PDA) | Left to right shunt; survival of other defects may depend on it. | Continuous machinery murmur; Wide pulse pressure; Bounding pulses. | Indomethacin/Ibuprofen for closure in preemies; Rashkind device or ligation. | | Coarctation of the Aorta (COA) | Luminal narrowing distal to Left Subclavian Artery. | Rib notching on CXR; Femoral pulse < Upper limb pulse; Secondary HTN. | Resection with end-to-end anastomosis; Stenting for older patients. | | Tetralogy of Fallot (TOF) | Infundibular septum malposition: VSD, Overriding aorta, RVOT obstruction, RVH. | Most common cyanotic disease; Boot-shaped heart; "Tet spells" (squatting help). | Primary cardiac repair (VSD closure + infundibulectomy); Palliative mBTS. | | Transposition of Great Arteries (TGA) | Parallel circulation; VA discordance; LV atrophies if not corrected early. | "Egg-shaped" heart on CXR; Cyanosis at birth. | Arterial Switch (Jatene) ideally within 2-3 weeks; Senning/Mustard (Atrial repair). |

| PALLIATION STAGES FOR SINGLE VENTRICLE PHYSIOLOGY | | :--- | :--- | :--- | | Stage | Procedure Name | Key Mechanism/Timing | | Stage 1 | Norwood Procedure or BTS | Establishes systemic/pulmonary flow in neonates (e.g., HLHS or Tricuspid Atresia). | | Stage 2 | Glenn Shunt (Bidirectional) | Superior cavopulmonary anastomosis (SVC to RPA); done at ~6 months. | | Stage 3 | Fontan Procedure | Total cavopulmonary connection (IVC/SVC to PA); done at 2-4 years. |

QA

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1. Describe the mechanism of Acyanotic Heart Disease. | Simple/single lesions with left-to-right shunts or obstructive lesions.
2. Describe the mechanism of Cyanotic Heart Disease. | Complex lesions with right-to-left shunts, common mixing, or parallel circulations.
3. What is the laboratory threshold for clinical Cyanosis in terms of hemoglobin? | Capillary reduced hemoglobin >5gm %.
4. What oxygen saturation level is usually associated with clinical Cyanosis? | Usually <85%.
5. What is the incidence of Congenital Heart Disease (CHD) in live births? | 8 out of every 1000 live births.
6. What is the key pathophysiology of Atrial Septal Defect (ASD)? | Left to right shunt.
7. What is the most common type of Atrial Septal Defect (ASD)? | Ostium secundum (80%).
8. What is the hallmark S2 finding in Atrial Septal Defect (ASD)? | Fixed splitting of S2.
9. What are the diagnostic findings (3) of Atrial Septal Defect (ASD)? | 1) Fixed splitting of S2
   2) Right Ventricle (RV) heave
   3) 2D Echo shows shunt.
10. When is surgery indicated for Atrial Septal Defect (ASD) based on Qp:Qs? | If Qp:Qs > 1.5:1.
11. What is the anatomical requirement for transcatheter closure of Atrial Septal Defect (ASD)? | Requires a 5mm rim.
12. What is the key pathophysiology of Aortic Stenosis (AS)? | Left Ventricular Outflow Tract (LVOT) obstruction.
13. Why is neonatal Critical Aortic Stenosis (AS) life-threatening? | It is ductal-dependent (systemic flow depends on the PDA).
14. What pulse characteristic is diagnostic for Aortic Stenosis (AS)? | "Parvus et tardus" pulse (weak and late).
15. Describe the murmur and ECG finding in Aortic Stenosis (AS). | Crescendo-decrescendo murmur and Left Ventricular Hypertrophy (LVH) on ECG.
16. What is the Ross procedure used for in Aortic Stenosis? | Harvesting the pulmonary valve for use in growing patients.
17. What is the key pathophysiology of Patent Ductus Arteriosus (PDA)? | Left to right shunt.
18. Why might the survival of other defects depend on a Patent Ductus Arteriosus (PDA)? | Provides essential mixing or systemic/pulmonary flow in ductal-dependent lesions.
19. What is the characteristic murmur of Patent Ductus Arteriosus (PDA)? | Continuous machinery murmur.
20. What are the pulse findings (2) in Patent Ductus Arteriosus (PDA)? | 1) Wide pulse pressure
    2) Bounding pulses.
21. What medications are used for medical closure of Patent Ductus Arteriosus (PDA) in preemies? | Indomethacin or Ibuprofen.
22. Name the management options (2) for Patent Ductus Arteriosus (PDA) closure. | 1) Rashkind device
    2) Ligation.
23. What is the definition of Coarctation of the Aorta (COA)? | Luminal narrowing distal to the Left Subclavian Artery.
24. What classic finding is seen on CXR in Coarctation of the Aorta (COA)? | Rib notching.
25. How do pulses differ in Coarctation of the Aorta (COA)? | Femoral pulse is less than the Upper limb pulse.
26. What systemic complication is associated with Coarctation of the Aorta (COA)? | Secondary Hypertension.
27. Name the treatments (2) for Coarctation of the Aorta (COA) based on age. | 1) Resection with end-to-end anastomosis
    2) Stenting for older patients.
28. What is the primary cause of Tetralogy of Fallot (TOF)? | Infundibular septum malposition.
29. Enumerate the four components of Tetralogy of Fallot (TOF). | 1) VSD
    2) Overriding aorta
    3) RVOT obstruction
    4) RVH.
30. What is the incidence status of Tetralogy of Fallot (TOF)? | Most common cyanotic heart disease.
31. What is the characteristic CXR finding in Tetralogy of Fallot (TOF)? | Boot-shaped heart.
32. What behavioral maneuver helps "Tet spells"? | Squatting.
33. What are the components (2) of primary cardiac repair for Tetralogy of Fallot (TOF)? | 1) VSD closure
    2) Infundibulectomy.
34. What is the palliative procedure for Tetralogy of Fallot (TOF)? | modified Blalock-Taussig Shunt (mBTS).
35. What is the circulation type in Transposition of Great Arteries (TGA)? | Parallel circulation.
36. Describe the discordance in Transposition of Great Arteries (TGA). | Ventriculo-Arterial (VA) discordance.
37. What happens to the LV in Transposition of Great Arteries (TGA) if not corrected early? | Left Ventricle (LV) atrophies.
38. What is the characteristic CXR finding in Transposition of Great Arteries (TGA)? | "Egg-shaped" heart.
39. When does cyanosis typically present in Transposition of Great Arteries (TGA)? | At birth.
40. What is the ideal surgical treatment for Transposition of Great Arteries (TGA)? | Arterial Switch (Jatene procedure) within 2-3 weeks.
41. Name the atrial repair procedures (2) for Transposition of Great Arteries (TGA). | 1) Senning
    2) Mustard procedure.
42. Name the procedures (2) used in Stage 1 of Single Ventricle Physiology palliation. | Norwood Procedure or Blalock-Taussig Shunt (BTS).
43. What is the mechanism of Stage 1 Norwood/BTS? | Establishes systemic/pulmonary flow in neonates (e.g., HLHS or Tricuspid Atresia).
44. Name the Stage 2 procedure for Single Ventricle Physiology. | Glenn Shunt (Bidirectional).
45. Describe the mechanism and timing of the Glenn Shunt. | Superior cavopulmonary anastomosis (SVC to RPA); done at ~6 months.
46. Name the Stage 3 procedure for Single Ventricle Physiology. | Fontan Procedure.
47. Describe the mechanism and timing of the Fontan Procedure. | Total cavopulmonary connection (IVC/SVC to PA); done at 2-4 years.
48. What is the most common cause of acquired mitral stenosis in Acquired Heart Disease? | Rheumatic Heart Disease.
49. What is the required Heparin dosage for cardiopulmonary bypass? | 300 to 400 U/kg.
50. Define Carpentier Class IIIB Mitral Regurgitation. | Functional mitral regurgitation from ischemic systolic restriction of leaflets.
51. How does the Intra-aortic Balloon Pump (IABP) augment coronary perfusion? | By inflating during diastole.
52. What is the most common cause of Heart Failure? | Coronary Artery Disease (CAD).
53. What condition is frequently associated with Sinus venosus ASD? | Partial anomalous pulmonary venous drainage (PAPVD).
54. Define Eisenmenger Syndrome. | Irreversible pulmonary hypertension resulting from long-standing left-to-right shunts.
55. What is a "stroke-related" complication of Atrial Septal Defect (ASD)? | Paradoxical Embolization (venous embolus entering systemic circulation).
56. What is the Warden Procedure? | Specific surgical repair for Sinus Venosus type of ASD.
57. Enumerate the features (3) of Williams Syndrome. | 1) Elfin facies
    2) Hypercalcemia
    3) Supravalvular aortic stenosis.
58. What causes circulatory collapse in Critical Aortic Stenosis infants? | Closure of the Patent Ductus Arteriosus (PDA).
59. What complication arises from Recurrent Laryngeal Nerve injury during PDA surgery? | Vocal cord paralysis.
60. What causes Rib Notching in Coarctation of the Aorta? | Erosion of bone by dilated/enlarged intercostal arteries used as collaterals.
61. Define Truncus Arteriosus. | A single great artery supplying pulmonary, systemic, and coronary circulations.
62. Which genetic syndrome is associated with Truncus Arteriosus? | DiGeorge Syndrome.
63. What is the characteristic CXR finding for Total Anomalous Pulmonary Venous Connection (TAPVC)? | Snowman Sign (or Figure-8).
64. What is the hallmark physiological finding in Total Anomalous Pulmonary Venous Connection (TAPVC)? | Equal oxygen saturations in all chambers.
65. What is Cor Triatriatum? | A fibromuscular diaphragm dividing the left atrium, mimicking Mitral Stenosis.
66. How do you distinguish Aortopulmonary Window (APW) from Truncus Arteriosus? | APW has two separate valves (aortic and pulmonary).
67. Define Dysphagia Lusoria. | Difficulty swallowing caused by esophageal compression from vascular rings or aberrant right subclavian artery.
68. What is the mandatory survival shunt in Tricuspid Atresia? | Right-to-Left shunt via an ASD or PFO.
69. What characterizes the Ebstein Anomaly? | Displacement of the tricuspid valve towards the apex and an "atrialized" right ventricle.
70. Which arrhythmia syndrome occurs in 15% of Ebstein Anomaly patients? | Wolff-Parkinson-White (WPW) Syndrome.
71. What is the GOSE Ratio formula and use? | (RA area / RV area); used as a predictor of mortality in Ebstein Anomaly.
72. Describe the discordance in D-TGA. | Atrio-Ventricular (AV) concordance but Ventriculo-Arterial (VA) discordance.
73. What is the Rashkind Septostomy? | Emergency balloon procedure to create/enlarge an ASD to improve mixing in TGA.
74. What is the Taussig-Bing Malformation? | Double Outlet Right Ventricle (DORV) with a subpulmonic VSD, clinically resembling TGA.
75. Squatting in Tet Spells helps by doing what? | Increasing systemic vascular resistance (SVR) to drive blood into the lungs.
76. Identify the most common Congenital Heart Disease (CHD) overall. | Ventricular Septal Defect (VSD).
77. What is the most frequent subtype of Ventricular Septal Defect (VSD)? | Muscular type.
78. What are the components (2) of Partial AVSD? | 1) Primum ASD
    2) Mitral valve cleft.
79. What part of the aorta is involved in Type A Aortic Dissection? | The ascending aorta.
80. Why is Type A Aortic Dissection a surgical emergency? | Risk of rupture, tamponade, or coronary compromise.
81. At what diameter is Thoracic Aneurysm Surgery generally indicated? | 5.5 cm.
82. At what diameter is Thoracic Aneurysm Surgery indicated in bicuspid aortic valve patients? | 4.5 cm.
83. Compare ASD vs. VSD in terms of asymptomatic period and most common status. | ASD remains asymptomatic until adulthood; VSD is the most common CHD overall.
84. Compare ASD vs. VSD in terms of classic physical exam findings. | ASD has a fixed split S2; VSD presents with heart failure in infancy.
85. Differentiate Truncus Arteriosus vs. AP Window by valves. | Truncus has a single truncal valve; AP Window has two separate valves.
86. Compare CXR findings of TOF vs. TGA. | TOF is boot-shaped; TGA is egg-shaped.
87. Compare pulmonary flow and presentation of TOF vs. TGA. | TOF has decreased flow; TGA has parallel circulation and severe cyanosis at birth.
88. Compare Coarctation (COA) vs. Interrupted Aortic Arch (IAA) structures. | COA is a narrowing (stenosis); IAA is a complete lack of luminal continuity.
89. What is the physiological basis of the Cyanotic Hb Level? | Based on the absolute amount of reduced hemoglobin (>5g%), not just saturation percentage.
90. Categorize BTS, Glenn, and Fontan by stage. | BTS is Stage 1; Glenn is Stage 2; Fontan is Stage 3.
91. Compare connection sites of BTS vs. Glenn vs. Fontan. | BTS: systemic-to-pulmonary; Glenn: SVC to PA; Fontan: IVC to PA.
92. Compare Ross Procedure vs. Rastelli Procedure. | Ross moves the pulmonary valve to aortic position; Rastelli uses a valved conduit from RV to PA.
93. Compare management of Type A vs. Type B Dissection. | Type A requires emergency surgery; Type B is primarily managed medically (BP/HR control).
94. Compare the uses of Indomethacin vs. Prostaglandin (PGE1) for the PDA. | Indomethacin (or Ibuprofen) closes it; Prostaglandin keeps it open.
95. Differentiate Fixed Split S2 vs. Machinery Murmur diagnosis. | Fixed split S2 is ASD; machinery murmur is PDA.
96. Differentiate Parvus et tardus vs. Bounding Pulse diagnosis. | Parvus et tardus is Aortic Stenosis; bounding pulses occur in PDA or Aortic Regurgitation.
97. Differentiate D-TGA vs. L-TGA. | D-TGA is common cyanotic (VA discordance); L-TGA is "physiologically corrected" (AV and VA discordance).
98. What is the primary risk in adulthood for L-TGA (Physiologically Corrected)? | Later RV failure.
99. What are the diagnostic findings (2) of Coarctation of the Aorta (COA)? | 1) Rib notching on CXR
    2) Femoral pulse < Upper limb pulse.
100. What is the definitive treatment for Transposition of Great Arteries (TGA)? | Arterial Switch (Jatene).
101. What findings (2) occur in Aortic Stenosis (AS)? | 1) LVH on ECG
     2) Crescendo-decrescendo murmur.
102. Where does Coarctation of the Aorta (COA) typically occur? | Distal to the Left Subclavian Artery.
103. What are the key findings (2) for Patent Ductus Arteriosus (PDA) examination? | 1) Bounding pulses
     2) Continuous machinery murmur.

8.2 - Acquired Heart Diseases

Summary

SURGERY 2: ACQUIRED HEART DISEASES

GENERAL PRINCIPLES, CLASSIFICATION, AND PREOPERATIVE ASSESSMENT

• In NYHA Class I heart failure classification, physical activity is not limited by fatigue, palpitations, or dyspnea. • In NYHA Class III heart failure classification, there is a marked limitation of physical activity, as the patient is comfortable only at rest. • In CCS Angina Class II, walking more than 2 blocks or climbing one flight of stairs causes angina. • As part of the General Signs and Symptoms of heart disease, dyspnea in female and elderly patients often serves as an "anginal equivalent" rather than classic chest pain. • For Diabetic Patients with CAD, "silent ischemia" may occur due to autonomic neuropathy, leading to a lack of classic chest pain. • In Heart Failure physical examination, clubbing and cyanosis are late-stage signs indicating chronic tissue hypoperfusion or oxygen desaturation. • The Most Common Arrhythmia mentioned in the context of palpitations and valvular disease is Atrial Fibrillation (AF). • In the Physical Examination of cardiac patients, frailty and dementia are significant predictors of operative and late mortality. • During Preoperative Cardiovascular Risk Assessment, non-emergent surgery should be delayed for intensive evaluation if major active cardiac conditions like ACS or decompensated HF are present.

EXTRACORPOREAL PERFUSION AND MYOCARDIAL PROTECTION

• For Cardiopulmonary Bypass (CPB) management, systemic hypothermia helps by providing a 50% reduction in oxygen consumption for every 10°C drop in temperature. • The Protamine Reversal protocol is used at the end of CPB to neutralize heparin and achieve hemostasis. • A major complication of Cardiopulmonary Bypass (CPB) is Systemic Inflammatory Response Syndrome (SIRS), caused by the interaction of blood with the artificial circuit. • To achieve Myocardial Protection, the heart is intentionally arrested in the diastolic phase using a potassium-rich cardioplegia solution. • The Centrifugal Pump is a modern CPB component that uses a vortex principle to propel blood back to the patient. • In Myocardial Protection, hypothermia is used as a secondary strategy to further decrease metabolic demand and oxygen consumption. • The Myocardium is the only organ not perfused during CPB, which is why cardioplegia and cross-clamping are necessary to prevent infarction.

CORONARY ARTERY DISEASE (CAD) AND BYPASS GRAFTING (CABG)

• The Gold Standard Diagnosis for CAD is the Coronary Angiogram, which involves catheterization of the sinuses of Valsalva. • In CAD Etiology, the ultimate progression is from plaque rupture to thrombosis, resulting in Acute Coronary Syndrome (ACS). • The Most Durable Graft used in CABG is the Internal Mammary Artery (IMA), also known as the Internal Thoracic Artery. • For Internal Mammary Artery (IMA) grafts, the patency rate is approximately 98% at 5 years and 85–90% at 10 years. • Before using the Radial Artery as a bypass conduit, an Allen’s Test must be performed to ensure intact palmar arch circulation via the ulnar artery. • The Great Saphenous Vein (GSV) is a common venous conduit because it provides long segments for multiple grafts, though its patency (86% at 5 years) is lower than radial artery grafts. • According to the BARI Trial, CABG is impressively superior to PCI for patients with both Diabetes and CAD, showing lower 5-year cardiac mortality (5.8% vs. 20.6%). • In Myocardial Viability Testing, "hibernating myocardium" refers to myocytes that are viable but functionally depressed, which will benefit from revascularization. • For CABG Indications, Left Main (LM) disease and 3-vessel disease are considered Class I recommendations to improve survival. • During Conventional CABG, the LITA to LAD graft is usually performed last to prevent kinking of the conduit.

MITRAL VALVE DISEASES (STENOSIS AND REGURGITATION)

• In Mitral Stenosis (MS) diagnosis, 2D Echocardiography is the tool of choice to evaluate valve area and gradients. • The Wilkins Score is used to evaluate MS for balloon valvotomy based on leaflet mobility, thickening, calcification, and chordae involvement. • Percutaneous Mitral Balloon Commissurotomy (PMBC) is contraindicated if the patient has more than moderate MR or a Left Atrial thrombus. • In Mitral Regurgitation (MR), the most important cause in the United States is myxomatous degenerative disease. • In the Carpentier Classification for MR, Type II is defined as excessive leaflet motion, commonly seen in mitral valve prolapse or "flail" leaflets. • For Carpentier Type IIIb MR, the pathology is restricted closure during systole, usually due to ischemic or functional MR. • In Mitral Valve Repair, artificial chords are often made from Polytetrafluoroethylene (PTFE), also known as Teflon. • For Prosthetic Valve Selection, Mechanical Valves are preferred in younger patients for durability but require lifelong anticoagulation. • For Prosthetic Valve Selection, Bioprosthetic Valves are preferred in older patients to avoid the risks of lifelong anticoagulation and bleeding.

AORTIC VALVE DISEASES (STENOSIS AND INSUFFICIENCY)

• The classic physical finding of Aortic Stenosis (AS) is Pulsus Parvus et Tardus, characterized by a weak pulse and delayed systolic upstroke. • For patients with Aortic Stenosis (AS), the onset of symptoms significantly shortens survival: Angina (1 yr), Syncope (2 yrs) without intervention. • In Aortic Stenosis (AS) severity grading, "Severe" is defined as a valve area &lt1.0 cm² or a jet velocity >4.0 m/s. • A Bicuspid Aortic Valve is a congenital lesion that is highly prone to early calcification and may present as either AS or AI. • In Aortic Insufficiency (AI), volume overload leads to the development of a "bovine heart," which is a massively dilated myocardium due to eccentric hypertrophy. • The Ross Procedure involves using the patient's own pulmonary valve as an autograft to replace the diseased aortic valve. • In Acute Severe AI, the LV cannot compensate for sudden volume overload, quickly leading to cardiogenic shock and pulmonary edema. • During Aortic Valve Surgery, if the aorta measures >4.5 cm in a patient with a bicuspid valve, replacement of the ascending aorta is recommended. • Transcatheter Aortic Valve Replacement (TAVR) is currently the preferred treatment for aortic stenosis in patients at high surgical risk.

TRICUSPID VALVE, HEART FAILURE, AND PERICARDIAL DISEASE

• Tricuspid Stenosis (TS) is almost always caused by Rheumatic Heart Disease (RHD). • Tricuspid Regurgitation (TR) is most often a functional disease caused by RV dilation secondary to pulmonary hypertension or left-sided mitral valve disease. • In Tricuspid Valve Repair, an incomplete ring is used for annuloplasty to avoid damage to the AV Node conducting tissue. • The Dor Procedure is a surgical ventricular restoration technique used when the myocardium is scarred and balloons out (aneurysm) rather than contracting. • The Intra-Aortic Balloon Pump (IABP) works by inflating during diastole (augmenting coronary perfusion) and deflating during systole (reducing afterload). • For severe heart failure, a Ventricular Assist Device (VAD) can be used as a "bridge to transplant" or as "destination therapy" for life. • The Maze IV Procedure is a surgical treatment for Atrial Fibrillation (AF) that creates lines of ablation to interrupt macroreentrant circuits. • Acute Pericarditis is often characterized by pleuritic chest pain, a pericardial friction rub, and diffuse ST elevation with PR depression on EKG. • In Chronic Constrictive Pericarditis, the hallmark physical finding is elevated JVP with Kussmaul’s sign (rise in JVP on inspiration). • Cardiac Myxoma is the most common primary benign cardiac tumor and often presents with symptoms mimicking mitral stenosis. • In Chronic Constrictive Pericarditis, calcification of the pericardium is seen in approximately 25% of patients on Chest X-ray.

DIFFERENTIATION AND COMPARISON FOR EXAMS

• NYHA vs. CCS: NYHA Classifies Heart Failure (I-IV) based on dyspnea/fatigue; CCS Classifies Angina (I-IV) based on chest pain during exertion. • Antegrade vs. Retrograde Cardioplegia: Antegrade goes through the aortic root (needs competent valve); Retrograde goes through the coronary sinus (better for incompetent valve or diffuse blockages). • BMS vs. DES Delay: Bare metal stents (BMS) require a 30-day delay for elective surgery; Drug-eluting stents (DES) require 180-365 days due to higher stent thrombosis risk. • Mitral Stenosis vs. Mitral Regurgitation Etiology: MS is almost strictly Rheumatic; MR is more commonly Myxomatous/Degenerative in developed nations. • Concentric vs. Eccentric Hypertrophy: Aortic Stenosis (Pressure Overload) causes Concentric (thick walls); Aortic Regurgitation (Volume Overload) causes Eccentric (dilated/large heart). • Pulsus Parvus et Tardus vs. Pulsus Paradoxus: Parvus et Tardus is the hallmark of Aortic Stenosis; Pulsus Paradoxus is typically seen in Cardiac Tamponade. • Ross vs. David Procedure: Ross Procedure uses a pulmonary autograft (living valve); David Procedure is a valve-sparing root replacement (keeping the native aortic valve). • Mechanical vs. Bioprosthetic Valves: Mechanical is durable but needs Warfarin/Anticoagulation (Younger patients); Bioprosthetic is tissue-based and fails earlier but no lifelong thinners (Older patients). • Acute vs. Chronic AI: Acute AI presents with sudden circulatory collapse and pulmonary edema; Chronic AI can be asymptomatic for years while the heart progressively dilates. • IABP Timing: The balloon inflates at the start of diastole (dicrotic notch) and deflates just before systole (R wave). • Wilkins Score vs. Carpentier Classification: Wilkins evaluates if an MS patient can have a balloon procedure; Carpentier classifies the mechanism of leaflet motion in MR. • Hibernating vs. Infarcted Myocardium: Hibernating tissue is alive but "sleeping" due to low flow (recovers after CABG); Infarcted tissue is dead/scarred (does not recover function). • Suture vs. Ring Annuloplasty: Suture annuloplasty is simpler using pledgeted sutures; Ring annuloplasty uses a rigid/semi-rigid ring for more defined support. • Primary vs. Secondary TR: Primary TR is due to valve damage (IE/Trauma); Secondary (Functional) TR is due to annular dilation from RV failure/Mitral disease. • Surgical vs. Medical Pericarditis: Most pericarditis is medical (NSAIDs/Colchicine); Surgery (Window/Pericardiectomy) is reserved for Tamponade or Constriction. • Rotor vs. Centrifugal Pump: Rotor pumps sequentially compress tubing; Centrifugal pumps use a vortex principle and are more modern. • Classic Angina vs. Atypical equivalent: Classic is chest pressure; Atypical equivalents (common in women/elderly) is Dyspnea. • Cardiac Myxoma vs. Thrombus: On echo, Myxoma is a tumor (often moves through valves); Thrombus is a blood clot (requires anticoagulation while tumor requires resection). • Anterior/Posterior vs. Septal Annulus: Most tricuspid dilation occurs at the Anterior and Posterior annulus; the Septal annulus is near the conduction system. • STICH vs. BARI Trial: STICH looked at CABG in Heart Failure/LVD; BARI looked at CABG vs PCI in Diabetics.

QA

GENERAL PRINCIPLES, CLASSIFICATION, AND PREOPERATIVE ASSESSMENT

1. Define NYHA Classification. | Functional classification of heart failure based on physical activity limitation.
2. What are the four classes of NYHA Classification? | Class I (No limitation) to Class IV (Symptoms at rest).
3. Define CCS Angina Classification. | Grading of angina severity.
4. Enumerate the CCS Angina Classification levels (4). | Class I (Strenuous exertion) to Class IV (Angina at rest/any activity).
5. What tools are used for MACE Risk Estimation? | NSQIP or Revised Cardiac Risk Index (RCRI).
6. Which conditions are included in Major Cardiac Events (MACE)? (3) | 1) Ischemic heart disease
   2) HF
   3) Renal insufficiency.
7. How is Functional Capacity measured in cardiac assessments? | Metabolic Equivalents (METs).
8. What MET value indicates good Functional Capacity? | ≥4 METs.
9. What MET value indicates poor or unknown Functional Capacity? | <4 METs.
10. What is the PCI Stent Precaution regarding Bare Metal Stents (BMS)? | Delay elective surgery 30 days.
11. What is the PCI Stent Precaution regarding Drug-Eluting Stents (DES)? | Delay elective surgery 180–365 days.
12. Why is there a delay in surgery for PCI Stent Precautions? | To prevent thrombosis.
13. Describe physical activity in NYHA Class I heart failure. | Activity is not limited by fatigue, palpitations, or dyspnea.
14. Describe physical activity in NYHA Class III heart failure. | Marked limitation; patient comfortable only at rest.
15. What physical exertion triggers CCS Angina Class II? | Walking more than 2 blocks or climbing one flight of stairs.
16. What is the "anginal equivalent" in General Signs and Symptoms for females and the elderly? | Dyspnea.
17. Why do Diabetic Patients experience "silent ischemia"? | Due to autonomic neuropathy resulting in lack of classic chest pain.
18. Name late-stage signs in Heart Failure physical examination (2). | 1) Clubbing
    2) Cyanosis.
19. What do clubbing and cyanosis indicate in Heart Failure? | Chronic tissue hypoperfusion or oxygen desaturation.
20. What is the Most Common Arrhythmia in palpitations and valvular disease? | Atrial Fibrillation (AF).
21. Which factors are significant predictors of mortality in Physical Examination? (2) | 1) Frailty
    2) Dementia.
22. When should surgery be delayed during Preoperative Cardiovascular Risk Assessment? | If major active cardiac conditions (ACS or decompensated HF) are present.

EXTRACORPOREAL PERFUSION AND MYOCARDIAL PROTECTION

23. Enumerate the components of Cardiopulmonary Bypass (CPB) (4). | 1) Venous cannulae
    2) Reservoir
    3) Oxygenator
    4) Arterial cannula.
24. What is the primary purpose of Cardiopulmonary Bypass (CPB)? | Bypasses heart and lungs for a bloodless, still surgical field.
25. What is the Anticoagulation Strategy (drug and dose) for CPB? | Heparin (300-400 U/kg).
26. What target Activated Clotting Time (ACT) should be maintained? | 450 seconds.
27. Where is Antegrade Cardioplegia infused? | Aortic root or coronary ostia.
28. What is the requirement for Antegrade Cardioplegia? | A competent aortic valve.
29. Where is Retrograde Cardioplegia infused? | Coronary Sinus.
30. When is Retrograde Cardioplegia preferred? | Diffuse coronary artery disease or incompetent aortic valve.
31. How does systemic hypothermia help in Cardiopulmonary Bypass (CPB)? | Provides 50% reduction in oxygen consumption for every 10°C drop.
32. What is used for Protamine Reversal at the end of CPB? | Protamine (to neutralize heparin).
33. Define the major complication of Cardiopulmonary Bypass (CPB) known as SIRS. | Systemic Inflammatory Response Syndrome.
34. What causes Systemic Inflammatory Response Syndrome (SIRS) in CPB? | Interaction of blood with the artificial circuit.
35. In what phase is the heart arrested for Myocardial Protection? | Diastolic phase.
36. What solution is used for Myocardial Protection? | Potassium-rich cardioplegia solution.
37. What is the vortex principle mechanism in CPB called? | Centrifugal Pump.
38. What is the secondary strategy for Myocardial Protection metabolic reduction? | Hypothermia.
39. Which organ is NOT perfused during Cardiopulmonary Bypass (CPB)? | The Myocardium.

CORONARY ARTERY DISEASE (CAD) AND BYPASS GRAFTING (CABG)

40. What are the indications for CABG (On-Pump)? (4) | 1) Left Main disease
    2) 3-vessel disease
    3) DM
    4) LV dysfunction.
41. Describe the technique for OPCAB (Off-Pump). | Done on a beating heart; avoids systemic inflammatory response.
42. What is the primary indication for MIDCAB? | Isolated LAD (Left Anterior Descending) disease.
43. What conduit is used in MIDCAB? | LIMA (Left Internal Mammary Artery).
44. What is the proposed mechanism of benefit for TMR (Laser)? | Laser-induced angiogenesis.
45. What is the Gold Standard Diagnosis for Coronary Artery Disease? | Coronary Angiogram.
46. Describe the CAD Etiology progression to ACS. | Plaque rupture to thrombosis.
47. What is the Most Durable Graft used in CABG? | Internal Mammary Artery (IMA).
48. What is the 10-year patency rate for Internal Mammary Artery (IMA)? | 85–90%.
49. What test is required before using the Radial Artery as a conduit? | Allen’s Test.
50. Why is the Great Saphenous Vein (GSV) commonly used? | Provides long segments for multiple grafts.
51. What did the BARI Trial conclude about CABG in Diabetics? | CABG is superior to PCI (lower 5-year cardiac mortality).
52. Define Hibernating myocardium in viability testing. | Myocytes that are viable but functionally depressed.
53. What are the Class I indications for CABG to improve survival? (2) | 1) Left Main (LM) disease
    2) 3-vessel disease.
54. In Conventional CABG, why is the LITA to LAD graft performed last? | To prevent kinking of the conduit.

MITRAL VALVE DISEASES (STENOSIS AND REGURGITATION)

55. What is the etiology of Mitral Stenosis (MS)? | Almost always Rheumatic Heart Disease (RHD).
56. What score evaluates morphology in Mitral Stenosis (MS)? | Wilkins Score.
57. What is the first-line treatment for Mitral Stenosis (MS)? | Percutaneous Mitral Balloon Commissurotomy (PMBC).
58. What tool is used to evaluate Mitral Stenosis (MS) area and gradients? | 2D Echocardiography.
59. Enumerate components of the Wilkins Score (4). | 1) Leaflet mobility
    2) Thickening
    3) Calcification
    4) Chordae involvement.
60. Name contraindications for PMBC (2). | 1) More than moderate MR
    2) Left Atrial thrombus.
61. What is the most important cause of Mitral Regurgitation (MR) in the US? | Myxomatous degenerative disease.
62. Define Carpentier Classification Type II for MR. | Excessive leaflet motion (Probing/Flail).
63. Define Carpentier Type IIIb for Mitral Regurgitation. | Restricted closure during systole.
64. What is the material used for artificial chords in Mitral Valve Repair? | PTFE (Polytetrafluoroethylene) or Teflon.
65. When are Mechanical Valves preferred for prosthesis? | In younger patients for durability.
66. When are Bioprosthetic Valves preferred? | In older patients to avoid lifelong anticoagulation.
67. What is the surgical indication for Mitral Regurgitation (MR) in asymptomatic patients? | Ejection Fraction (EF) ≤ 60%.

AORTIC VALVE DISEASES (STENOSIS AND INSUFFICIENCY)

68. What is the most common cause of Aortic Stenosis (AS)? | Degenerative / Calcific.
69. What type of hypertrophy results from Aortic Stenosis (AS)? | Concentric LVH.
70. What are the management options for Aortic Stenosis (AS)? (2) | 1) SAVR (Surgical)
    2) TAVR (Transcatheter).
71. What is the most common cause of Aortic Insufficiency (AI)? | Aortic Root Disease.
72. What type of hypertrophy results from Aortic Insufficiency (AI)? | Eccentric hypertrophy.
73. Describe Pulsus Parvus et Tardus. | Weak pulse and delayed systolic upstroke.
74. What is the survival duration after angina symptoms in Aortic Stenosis (AS)? | 1 year (without intervention).
75. What is the survival duration after syncope symptoms in Aortic Stenosis (AS)? | 2 years (without intervention).
76. Define "Severe" Aortic Stenosis (AS) grading (Area/Velocity). | Valve area <1.0 cm² or jet velocity >4.0 m/s.
77. What is a Bicuspid Aortic Valve? | A congenital lesion highly prone to early calcification.
78. What term describes the heart in chronic Aortic Insufficiency (AI)? | "Bovine heart" (Massively dilated).
79. What is the Ross Procedure? | Using the patient's pulmonary valve as an autograft to replace the aortic valve.
80. What are the signs of Acute Severe AI? | Cardiogenic shock and pulmonary edema.
81. When is ascending aorta replacement recommended in Bicuspid Valve surgery? | If aorta measures >4.5 cm.
82. Who is the preferred candidate for TAVR? | Patients at high surgical risk.

TRICUSPID VALVE, HEART FAILURE, AND PERICARDIAL DISEASE

83. What is the primary cause of Tricuspid Stenosis (TS)? | Rheumatic Heart Disease (RHD).
84. What is the most common cause of Tricuspid Regurgitation (TR)? | Functional (RV dilation secondary to pulmonary HTN or mitral disease).
85. In Tricuspid Valve Repair, why is an incomplete ring used? | To avoid damage to the AV Node.
86. What is the Dor Procedure? | Surgical ventricular restoration for scarred/aneurysmal myocardium.
87. How does the Intra-Aortic Balloon Pump (IABP) work during diastole? | Inflates to augment coronary perfusion.
88. How does the Intra-Aortic Balloon Pump (IABP) work during systole? | Deflates to reduce afterload.
89. Give two roles for a Ventricular Assist Device (VAD). | 1) Bridge to transplant
    2) Destination therapy.
90. What is the Maze IV Procedure? | Surgical treatment for Atrial Fibrillation via ablation lines.
91. Enumerate Acute Pericarditis findings (3). | 1) Pleuritic chest pain
    2) Friction rub
    3) Diffuse ST elevation with PR depression.
92. What is Kussmaul’s sign in Chronic Constrictive Pericarditis? | Rise in JVP on inspiration.
93. What is the most common primary benign cardiac tumor? | Cardiac Myxoma.
94. Which disease mimics Mitral Stenosis symptoms? | Cardiac Myxoma.
95. What percentage of Chronic Constrictive Pericarditis patients show pericardial calcification on CXR? | 25%.

DIFFERENTIATION AND COMPARISON FOR EXAMS

96. Compare NYHA vs. CCS classifications. | NYHA classifies Heart Failure (dyspnea); CCS classifies Angina (chest pain).
97. Compare Antegrade vs. Retrograde Cardioplegia flow. | Antegrade: through aortic root/coronary ostia; Retrograde: through coronary sinus.
98. Compare BMS vs. DES Delay for surgery. | BMS: 30 days; DES: 180-365 days.
99. Contrast Mitral Stenosis vs. Mitral Regurgitation Etiology. | MS is strictly Rheumatic; MR is often Myxomatous/Degenerative.
100. Compare Concentric vs. Eccentric Hypertrophy causes. | Concentric: Pressure overload (AS); Eccentric: Volume overload (AI).
101. Contrast Pulsus Parvus et Tardus vs. Pulsus Paradoxus. | Parvus et Tardus: Aortic Stenosis; Pulsus Paradoxus: Cardiac Tamponade.
102. Compare Ross vs. David Procedure. | Ross: Pulmonary autograft; David: Valve-sparing root replacement.
103. Contrast Mechanical vs. Bioprosthetic Valves. | Mechanical: Durable but needs warfarin; Bioprosthetic: No lifelong thinners but fails earlier.
104. Contrast Acute vs. Chronic AI presentation. | Acute: sudden circulatory collapse/edema; Chronic: asymptomatic heart dilation.
105. What are the trigger points for IABP? | Inflation at start of diastole (dicrotic notch); Deflation just before systole (R wave).
106. Compare Wilkins Score vs. Carpentier Classification uses. | Wilkins: evaluates MS for ballooning; Carpentier: classifies mechanism of MR leaflet motion.
107. Contrast Hibernating vs. Infarcted Myocardium. | Hibernating: alive but "sleeping" (recovers); Infarcted: dead/scarred (no recovery).
108. Contrast Suture vs. Ring Annuloplasty. | Suture: simple pledgeted sutures; Ring: rigid/semi-rigid support.
109. Contrast Primary vs. Secondary TR. | Primary: valve damage (IE/trauma); Secondary: annular dilation from RV failure.
110. Contrast Surgical vs. Medical Pericarditis management. | Medical: NSAIDs/Colchicine; Surgical: Pericardiectomy for tamponade/constriction.
111. Contrast Rotor vs. Centrifugal Pump. | Rotor: tubing compression; Centrifugal: vortex principle (modern).
112. Contrast Classic Angina vs. Atypical equivalent. | Classic: chest pressure; Atypical: dyspnea (common in women/elderly).
113. Contrast Cardiac Myxoma vs. Thrombus treatment. | Myxoma: resection; Thrombus: anticoagulation.
114. Which parts of the Tricuspid Annulus typically dilate? | Anterior and Posterior annulus.
115. Compare the STICH vs. BARI Trial focus. | STICH: CABG in Heart Failure; BARI: CABG vs PCI in Diabetics.

8.3 - ERAS TOUR

Summary

ERAS: ENHANCED RECOVERY AFTER SURGERY

I. NOTABLE PERSONALITIES AND HISTORY

• Professor Henrik Kehlet is described as the founder of ERAS***, having first described a novel perioperative regimen for colon surgery in 1995 in Copenhagen, Denmark.
• Professor Henrik Kehlet's 1997 multimodal approach demonstrated a reduction in the median length of stay (LOS) to just 2 days following sigmoid resection*.
• The ERAS Study Group was founded in 2001 by Professor Ken Fearon and Professor Olle Ljungqvist to create a consensus on best practices and guidelines.
• Dr. Manuel Francisco Roxas is a Fellow of the PCS and PSCRS and serves as the First President of the Philippine ERAS Society.
• The Medical City (TMC) in Pasig City is recognized as the only ERAS Center of Excellence in the Philippines and hosted the 1st National ERAS Congress on September 8, 2016.
• Philippine General Hospital (PGH) has successfully implemented ERAS pathways for elective colorectal surgeries, significantly improving patient outcomes.

II. PREOPERATIVE OPTIMIZATION & EDUCATION

• The Primary Goal of ERAS is to treat the surgical patient using a multidisciplinary team approach throughout the entire perioperative course.
• The Unified Objective of ERAS is to accelerate functional recovery and optimize patient outcomes strictly based on evidence-based medicine.
• Preanesthetic evaluation by an anesthesiologist improves OR efficiency and identifies elevated respiratory risk, potentially reducing case cancellations by 88%.
• Patient Education establishes the patient as the leader in their own care, orienting them on what to expect regarding procedures, tubes, and discharge criteria.
• Therapeutic communication through preoperative teaching significantly reduces postoperative fatigue, fear, and unexpected pain.
• Education materials for patients should ideally be Clear, Concise, Friendly, and written at a ≤ 6th-grade reading level.
• Enteral Nutrition (EN) is the preferred route for nutritional support as it is more natural and has fewer risks than Parenteral Nutrition (PN).
• Standard oral nutrition supplements are high in protein and vitamins/minerals, and are widely available to ensure patients are well-nourished before surgery.
• Immunonutrition supplements contain added Arginine (improves immunity/tissue repair) and Omega-3 fatty acids (mediates inflammatory response).
• Milk supplementation for preoperative nutrition is most ideal at a concentration of 5 to 7 scoops per 250 mL.
• Prehabilitation is the process of enhancing an individual's functional capacity through exercise to enable them to withstand the stressful event of surgery.
• Brief exercise therapy for as little as 1-7 days before major abdominal surgery can decrease postoperative complications.
• Smoking cessation allows for bronchiolar and collagen remodeling; a longer duration of cessation prior to surgery portends better outcomes.
• Buerger disease is a condition where small blood vessels in the hands and feet become blocked with blood clots, a risk specifically noted for smokers.

III. METABOLIC STRESS RESPONSE & INSULIN RESISTANCE

• Insulin is the main anabolic hormone involved in glucose control; surgery disrupts this, leading to insulin resistance and protein catabolism.
• Insulin resistance means the body does not respond well to insulin, causing less sugar to move into cells and more sugar to stay in the blood (hyperglycemia).
• In the Fed state, insulin levels surge 6-8 times basal levels, stopping glucose production and increasing peripheral glucose uptake 3-4 fold.
• In the Fasting state, insulin remains at a relative steady state with minimal effects on glucose and protein metabolism.
• The Postoperative fasting state combined with surgical stress triggers a catabolic state, increasing protein catabolism several fold.
• Muscle function and mobilization capacity decrease during postoperative fasting because less glycogen is stored in the muscle and lean body mass is lost.
• Pain has been demonstrated to directly increase insulin resistance by decreasing insulin sensitivity.
• Magnitude of surgery is directly related to the severity of insulin resistance; open colorectal resection results in a 3.5-fold increase in IR compared to lap chole.
• Free radicals formed during insulin resistance trigger inflammation and change gene activity, creating a vicious cycle of further resistance and inflammation.
• Preoperative carbohydrate loading with clear liquids transition the metabolism to an anabolic state and improves postoperative muscle strength.
• The Carbohydrate loading regimen typically involves 100 g of carbohydrate the evening prior and 50 g of carbohydrate 2-3 hours before surgery.
• Clear liquids can be allowed up to 2 hours before surgery, while solid food requires 6 hours of fasting based on current guidelines.
• Aspiration risk does not increase in healthy adults undergoing elective surgery who consume carbohydrate drinks up to 2 hours preoperatively.

IV. INTRAOPERATIVE CONSIDERATIONS

• Surgical Site Infection (SSI) prevention includes patient bathing, skin preparation (betadine/chlorhexidine), and appropriate antimicrobial prophylaxis.
• Minimally Invasive Surgery (MIS) is preferred in ERAS as it demonstrates reduced LOS, fewer complications, and faster recovery.
• ERAS protocols are applied specifically to elective procedures and cannot be applied in emergency cases.
• Inadvertent postoperative hypothermia affects up to 90% of elective surgery patients, with those >60 years old being at higher risk.
• Radiation is the main cause and most common cause of heat loss, where the patient's body loses heat to the cooler OR environment.
• Convection involves heat being carried away by cool air flow, such as from operating room air conditioning systems.
• Evaporation refers to heat loss as fluids like antiseptics or irrigation solutions evaporate from the skin or surgical field.
• Conduction is the transfer of heat when internal tissues come into direct contact with cold fluids (e.g., cold irrigation).
• Forced-air warming, such as the “Bair Hugger,” is a key method to maintain normothermia and reduce blood loss and wound infections.
• Venous Thromboembolism (VTE) prophylaxis is essential; fatal Pulmonary Embolism (PE) can often be the first sign of VTE.
• DVT occurs in approximately 25% of major surgeries without prophylaxis; risk factors include age >40, obesity, and prolonged procedure times.
• Early ambulation is the cheapest and most effective non-pharmacologic method to prevent DVT by activating gastrocnemius muscle pumps.
• Goal-Directed Therapy (GDT) IVF aims for zero fluid balance, using monitors to ensure fluid is only given if it increases cardiac output.
• Excessive Normal Saline (NSS) can cause hyperchloremia, metabolic acidosis, and acute kidney injury (AKI).
• PlasmaLyte is a more balanced crystalloid solution that is associated with improved outcomes and lower mortality compared to 0.9% saline.
• Central Venous Pressure (CVP) monitoring (normal 8-12 mmHg) indicates hypovolemia if <8 mmHg and congestion/overload if >12 mmHg.

V. THE 5 W’s OF POSTOPERATIVE FEVER

• Wind (Pulmonary): Postoperative fever usually on Day 1, often caused by microatelectasis; prevented by incentive spirometry.
• Water (Urinary/Fluid): Fever caused by UTI (often due to catheterization) or dehydration due to the ADH surge in the first 48 hours.
• Wound (Surgical site): Fever caused by infection at the surgical site; requires physical inspection of the wound.
• Walking (Mobility): Fever related to DVT/thrombophlebitis caused by lack of early mobilization.
• Wonder drugs (Medications): Fever caused by drug reactions; considered a diagnosis of exclusion (last resort).

VI. POSTOPERATIVE CARE & PAIN MANAGEMENT

• Opioids are the traditional mainstay for pain but cause side effects like nausea, vomiting, and decreased GI motility.
• Multimodal analgesia is the point of ERAS—using multiple drugs to limit the dose of opioids and their side effects.
• Pain is completely subjective, and according to the International Association for the Study of Pain, patients cannot experience pain while unconscious.
• Postoperative Nausea and Vomiting (PONV) affects up to 80% of high-risk patients (females, non-smokers, history of motion sickness).
• PONV management includes drugs like perphenazine, aprepitant, dexamethasone, and ondansetron.
• Postoperative ileus (occurring in 19% of cases) is the most common cause of prolonged hospital stay after digestive tract surgery.
• Nasogastric tubes (NGTs) should not be used routinely for prophylaxis as they delay the return of GI activity and increase pulmonary complications.
• Alvimopan is a mu-opioid receptor antagonist administered to reduce postoperative ileus.
• Early mobilization is a critical component of ERAS; deconditioning and loss of muscle mass can be seen after only 2 days of bedrest.

VII. ERAS IN SPECIFIC SURGERIES

• Colorectal surgery has the most data and the largest preponderance of ERAS evidence, with first guidelines published in 2012.
• Bowel obstruction and skin/soft tissue infection are the most common reasons for readmission in colorectal ERAS programs.
• Pancreaticoduodenectomy (Whipple) patients often suffer from delayed gastric emptying; ERAS has reduced this incidence by nearly half.
• Gastrectomy guidelines from 2014 state there should be no routine NGT decompression and early feeding should start within the first POD.
• Esophagectomy is notoriously complicated; while ERAS is used, prolonged NGT decompression often remains due to surgical complexity.

VIII. DIFFERENTIATING SIMILAR ENTITIES FOR EXAMS

• Henrik Kehlet vs. ERAS Study Group: Kehlet is the founder (1995/1997); Study Group (Fearon/Ljungqvist) expanded ideas and created a consensus (2001).
• Enteral (EN) vs. Parenteral Nutrition (PN): EN follows the natural GI tract and is preferred; PN delivers nutrients to the bloodstream and is only for when EN is impossible.
• Laparoscopic vs. Open Cholecystectomy: Laparoscopic has 3-4 small wounds and faster recovery; Open has a 6-8cm wound and 2.5 times more insulin resistance.
• Radiation vs. Conduction: Radiation is heat loss to the environment/air (no contact); Conduction is heat loss through direct contact with cold fluids/tissues.
• Standard Supplements vs. Immunonutrition: Standard is high protein/vitamins; Immunonutrition adds Arginine and Omega-3 specifically to modulate the immune response.
• NSS vs. PlasmaLyte: NSS is traditional but can cause hyperchloremia/acidosis; PlasmaLyte is balanced and leads to fewer AKI/morbidity cases.
• Hypovolemia vs. Hypervolemia: Hypovolemia causes decreased renal perfusion; Hypervolemia causes splanchnic edema and anastomotic dehiscence.
• Traditional Fasting vs. ERAS Carbohydrate Loading: Traditional is 6-12 hours NPO (catabolic); ERAS allows clear liquids 2 hours prior and Carbohydrate Loading (anabolic).
• CVP <8 vs. CVP >12: <8 mmHg indicates hypovolemia; >12 mmHg indicates congestion/overload.
• PONV Risk: Smoking vs. Non-smoking: Non-smoking is a risk factor for PONV; Smoking is a risk factor for arterial obstruction (Buerger’s) and poor wound healing.
• Colorectal vs. Esophagectomy ERAS: Colorectal has the most robust data and emphasizes early NGT removal; Esophagectomy is complex and often retains NGT decompression.
• Primary Goal vs. Unified Objective: Primary Goal is the MDT approach; Unified Objective is accelerated functional recovery via evidence-based medicine.
• Active vs. Passive participant: In ERAS, the patient is the leader (Active); in traditional medicine, the patient is often a passive recipient of care.
• Prehabilitation vs. Mobilization: Prehabilitation is preoperative exercise; Mobilization is postoperative movement/walking.
• Nausea vs. Nauseous: "I feel nauseated" is the correct statement; "I am nauseous" implies you are the one causing nausea in others.
• Wind vs. Walking Fever: Wind is pulmonary/atelectasis (Day 1); Walking is DVT/thrombophlebitis (Day 5+).
• Crystalloid vs. Colloid: ERAS/Schwartz prefers crystalloids (especially balanced ones like PlasmaLyte) over colloids for perioperative fluid management.
• Traditional vs. ERAS Opioid use: Traditional uses opioids as the sole mainstay; ERAS uses Multimodal Analgesia to spare/reduce opioid dose.
• Standard vs. Goal-Directed Fluid Therapy (GDT): Standard is often liberal/fixed rate; GDT is individualized based on cardiac output and fluid responsiveness.
• Prophylactic vs. Avoided NGT: Traditional surgery used NGT prophylactically; ERAS recommends avoiding routine use as it delays GI return.

QA

<b>I. NOTABLE PERSONALITIES AND HISTORY</b>

1. Who is recognized as the <b><font color="red">founder of ERAS</font></b>? | Professor Henrik Kehlet
2. In what year and location did Henrik Kehlet first describe the novel perioperative regimen for colon surgery? | 1995, Copenhagen, Denmark
3. What was the outcome of <b><font color="red">Professor Henrik Kehlet's</font></b> 1997 multimodal approach regarding sigmoid resection? | 2 days median LOS
4. Which group was founded in 2001 to create consensus on ERAS guidelines? | ERAS Study Group
5. Who were the founders (2) of the <b><font color="red">ERAS Study Group</font></b>? | 1) Professor Ken Fearon<br>2) Professor Olle Ljungqvist
6. Who serves as the First President of the <b><font color="red">Philippine ERAS Society</font></b>? | Dr. Manuel Francisco Roxas
7. Which institution is the only <b><font color="red">ERAS Center of Excellence</font></b> in the Philippines? | The Medical City (TMC)
8. When did <b><font color="red">The Medical City</font></b> host the 1st National ERAS Congress? | September 8, 2016
9. Which hospital implemented ERAS pathways for <b><font color="red">elective colorectal surgeries</font></b> to improve outcomes in the Philippines? | Philippine General Hospital (PGH)

<b>II. PREOPERATIVE OPTIMIZATION & EDUCATION</b>

10. What is the <b><font color="red">Primary Goal of ERAS</font></b>? | Multidisciplinary team approach
11. What is the <b><font color="red">Unified Objective of ERAS</font></b>? | Accelerate functional recovery
12. What are the key interventions (6) in the <b><font color="red">Preoperative Phase</font></b> of ERAS? | 1) Evaluation<br>2) Education<br>3) Nutrition<br>4) Prehabilitation<br>5) Smoking Cessation<br>6) Carbohydrate Loading
13. What are the outcomes (4) of the <b><font color="red">Preoperative Phase</font></b>? | 1) ↓ Stress response<br>2) ↓ Anxiety<br>3) ↓ LOS/cancellations<br>4) Transition to anabolic state
14. How much can <b><font color="red">Preanesthetic evaluation</font></b> reduce case cancellations? | 88% reduction
15. In <b><font color="red">Patient Education</font></b>, who is established as the leader of their own care? | The patient
16. What should patients be oriented on during <b><font color="red">Patient Education</font></b>? (3) | 1) Procedures<br>2) Tubes<br>3) Discharge criteria
17. What are the benefits (3) of <b><font color="red">Therapeutic communication</font></b> in preoperative teaching? | 1) ↓ Postoperative fatigue<br>2) ↓ Fear<br>3) ↓ Unexpected pain
18. At what reading level should <b><font color="red">Education materials</font></b> for patients be written? | ≤ 6th-grade level
19. Which route is the <b><font color="red">preferred route</font></b> for nutritional support in ERAS? | Enteral Nutrition (EN)
20. Why is <b><font color="red">Enteral Nutrition (EN)</font></b> preferred over Parenteral Nutrition (PN)? | More natural; fewer risks
21. What are <b><font color="red">Standard oral nutrition supplements</font></b> high in? (2) | 1) Protein<br>2) Vitamins/minerals
22. What additives (2) are found in <b><font color="red">Immunonutrition supplements</font></b>? | 1) Arginine<br>2) Omega-3 fatty acids
23. What is the role of <b><font color="red">Arginine</font></b> in immunonutrition? | Improves immunity/tissue repair
24. What is the role of <b><font color="red">Omega-3 fatty acids</font></b> in immunonutrition? | Mediates inflammatory response
25. What is the ideal concentration for <b><font color="red">Milk supplementation</font></b> in preoperative nutrition? | 5-7 scoops per 250mL
26. Define <b><font color="red">Prehabilitation</font></b>. | Enhancing functional capacity (exercise)
27. How long should <b><font color="red">Brief exercise therapy</font></b> be performed before major surgery to decrease complications? | 1 to 7 days
28. What physiological remodeling does <b><font color="red">Smoking cessation</font></b> allow? (2) | 1) Bronchiolar remodeling<br>2) Collagen remodeling
29. What condition involving blood clots in hands/feet is a risk for smokers? | <b><font color="red">Buerger disease</font></b>

<b>III. METABOLIC STRESS RESPONSE & INSULIN RESISTANCE</b>

30. What is the main <b><font color="red">anabolic hormone</font></b> involved in glucose control? | Insulin
31. How does surgery affect <b><font color="red">Insulin</font></b> and protein metabolism? | Insulin resistance; protein catabolism
32. Define <b><font color="red">Insulin resistance</font></b> in the context of surgery. | Glucose stays in blood (hyperglycemia)
33. How much do <b><font color="red">Insulin levels</font></b> surge in the fed state compared to basal levels? | 6 to 8 times
34. What state is triggered by <b><font color="red">Postoperative fasting</font></b> combined with surgical stress? | Catabolic state
35. Why do <b><font color="red">Muscle function</font></b> and mobilization capacity decrease during postoperative fasting? (2) | 1) ↓ Glycogen storage<br>2) Lean body mass loss
36. What is the effect of <b><font color="red">Pain</font></b> on insulin? | Increases insulin resistance
37. How much higher is <b><font color="red">Insulin resistance</font></b> in open colorectal resection compared to lap chole? | 3.5-fold increase
38. What triggers inflammation and a vicious cycle during <b><font color="red">Insulin resistance</font></b>? | Free radicals
39. What is the benefit of <b><font color="red">Preoperative carbohydrate loading</font></b> regarding metabolism? | Transitions to anabolic state
40. What is the <b><font color="red">Carbohydrate loading regimen</font></b> for the evening prior to surgery? | 100 g carbohydrates
41. What is the <b><font color="red">Carbohydrate loading regimen</font></b> for 2-3 hours before surgery? | 50 g carbohydrates
42. According to guidelines, how many hours before surgery can <b><font color="red">Clear liquids</font></b> be consumed? | 2 hours
43. How many hours of fasting are required for <b><font color="red">Solid food</font></b>? | 6 hours
44. Does consuming carbohydrate drinks 2 hours preoperatively increase <b><font color="red">Aspiration risk</font></b>? | No

<b>IV. INTRAOPERATIVE CONSIDERATIONS</b>

45. What are the key interventions (5) during the <b><font color="red">Intraoperative Phase</font></b>? | 1) MIS<br>2) Hypothermia prevention<br>3) VTE prophylaxis<br>4) GDT<br>5) Multimodal analgesia
46. What are the outcomes (4) of the <b><font color="red">Intraoperative Phase</font></b>? | 1) ↓ Complications<br>2) Maintain normothermia<br>3) Prevent DVT/PE<br>4) Zero fluid balance
47. What are the components (3) of <b><font color="red">Surgical Site Infection (SSI) prevention</font></b>? | 1) Patient bathing<br>2) Skin prep<br>3) Antimicrobial prophylaxis
48. Why is <b><font color="red">Minimally Invasive Surgery (MIS)</font></b> preferred in ERAS? (3) | 1) Reduced LOS<br>2) Fewer complications<br>3) Faster recovery
49. To which type of procedures are <b><font color="red">ERAS protocols</font></b> specifically applied? | Elective procedures
50. What percentage of elective surgery patients are affected by <b><font color="red">inadvertent postoperative hypothermia</font></b>? | Up to 90%
51. Which age group is at higher risk for <b><font color="red">postoperative hypothermia</font></b>? | > 60 years old
52. What is the <b><font color="red">main cause</font></b> and most common cause of heat loss in the OR? | Radiation
53. Define <b><font color="red">Radiation</font></b> heat loss. | Loss to cooler environment
54. Define <b><font color="red">Convection</font></b> heat loss. | Heat carried by airflow
55. Define <b><font color="red">Evaporation</font></b> heat loss. | Fluid evaporating from skin/field
56. Define <b><font color="red">Conduction</font></b> heat loss. | Direct contact with cold fluids
57. What is a key method for <b><font color="red">Forced-air warming</font></b> to maintain normothermia? | Bair Hugger
58. What can often be the first sign of <b><font color="red">Venous Thromboembolism (VTE)</font></b>? | Fatal Pulmonary Embolism (PE)
59. What percentage of major surgeries result in <b><font color="red">DVT</font></b> without prophylaxis? | approximately 25%
60. What are the risk factors (3) for <b><font color="red">DVT</font></b>? | 1) Age >40<br>2) Obesity<br>3) Prolonged procedure time
61. What is the <b><font color="red">cheapest and most effective</font></b> non-pharmacologic method to prevent DVT? | Early ambulation
62. What is the target fluid status for <b><font color="red">Goal-Directed Therapy (GDT)</font></b>? | Zero fluid balance
63. What are the complications (3) of <b><font color="red">Excessive Normal Saline (NSS)</font></b>? | 1) Hyperchloremia<br>2) Metabolic acidosis<br>3) AKI
64. Which balanced crystalloid is associated with <b><font color="red">lower mortality</font></b> compared to 0.9% saline? | PlasmaLyte
65. What is the normal range for <b><font color="red">Central Venous Pressure (CVP)</font></b>? | 8 to 12 mmHg
66. What does a <b><font color="red">CVP < 8 mmHg</font></b> indicate? | Hypovolemia
67. What does a <b><font color="red">CVP > 12 mmHg</font></b> indicate? | Congestion or overload

<b>V. THE 5 W’s OF POSTOPERATIVE FEVER</b>

68. Enumerate the <b><font color="red">5 W’s of Postoperative Fever</font></b>. | 1) Wind<br>2) Water<br>3) Wound<br>4) Walking<br>5) Wonder drugs
69. When does <b><font color="red">Wind (Pulmonary)</font></b> fever usually occur? | Postoperative Day 1
70. What is the main cause of <b><font color="red">Wind (Pulmonary)</font></b> fever? | Microatelectasis
71. What are the common causes (2) of <b><font color="red">Water (Urinary/Fluid)</font></b> fever? | 1) UTI from catheter<br>2) Dehydration (ADH surge)
72. How is <b><font color="red">Wound (Surgical site)</font></b> fever managed? | Physical inspection of wound
73. What is the cause of <b><font color="red">Walking (Mobility)</font></b> fever? | DVT or thrombophlebitis
74. Why are <b><font color="red">Wonder drugs (Medications)</font></b> classified as a diagnosis of exclusion? | It is a last resort

<b>VI. POSTOPERATIVE CARE & PAIN MANAGEMENT</b>

75. What are the key interventions (4) in the <b><font color="red">Postoperative Phase</font></b>? | 1) Early Nutrition<br>2) Mobilization<br>3) PONV prevention<br>4) Opioid Sparing
76. What are the outcomes (4) of the <b><font color="red">Postoperative Phase</font></b>? | 1) Return of bowel function<br>2) ↓ Muscle loss<br>3) ↓ LOS<br>4) Return to work
77. What are the side effects (3) of <b><font color="red">Opioids</font></b>? | 1) Nausea<br>2) Vomiting<br>3) Decreased GI motility
78. What is the point of <b><font color="red">Multimodal analgesia</font></b> in ERAS? | Limit opioid dose/side effects
79. Can a patient experience <b><font color="red">Pain</font></b> while unconscious? | No
80. What percentage of high-risk patients are affected by <b><font color="red">PONV</font></b>? | Up to 80%
81. What are the risk factors (3) for <b><font color="red">PONV</font></b>? | 1) Females<br>2) Non-smokers<br>3) Motion sickness history
82. Name four drugs used in <b><font color="red">PONV management</font></b>. | 1) Perphenazine<br>2) Aprepitant<br>3) Dexamethasone<br>4) Ondansetron
83. What is the <b><font color="red">most common cause</font></b> of prolonged hospital stay after digestive tract surgery? | Postoperative ileus
84. What is the incidence of <b><font color="red">postoperative ileus</font></b>? | 19% of cases
85. Should <b><font color="red">Nasogastric tubes (NGTs)</font></b> be used routinely for prophylaxis? | No
86. What are the risks (2) of routine <b><font color="red">NGT</font></b> use? | 1) Delay GI activity<br>2) Increase pulmonary complications
87. What is the role of <b><font color="red">Alvimopan</font></b>? | Mu-opioid receptor antagonist (reduces ileus)
88. After how many days of bedrest can <b><font color="red">loss of muscle mass</font></b> be seen? | 2 days

<b>VII. ERAS IN SPECIFIC SURGERIES</b>

89. Which surgery has the <b><font color="red">most data</font></b> for ERAS evidence? | Colorectal surgery
90. What are the most common reasons (2) for readmission in <b><font color="red">colorectal ERAS</font></b>? | 1) Bowel obstruction<br>2) Skin/soft tissue infection
91. What complication does ERAS reduce by half in <b><font color="red">Whipple</font></b> procedures? | Delayed gastric emptying
92. According to 2014 guidelines, when should feeding start in <b><font color="red">Gastrectomy</font></b>? | Within the first POD
93. Why does <b><font color="red">prolonged NGT decompression</font></b> often remain in esophagectomy? | Surgical complexity

<b>VIII. DIFFERENTIATING SIMILAR ENTITIES</b>

94. <b><font color="red">Henrik Kehlet vs. ERAS Study Group</font></b>: Who is the founder? | Henrik Kehlet
95. <b><font color="red">EN vs. PN</font></b>: Which route follows the natural GI tract? | Enteral Nutrition (EN)
96. <b><font color="red">Lap vs. Open Chole</font></b>: Which has higher insulin resistance? | Open (2.5 times higher)
97. <b><font color="red">Radiation vs. Conduction</font></b>: Which involves direct contact with cold fluids? | Conduction
98. <b><font color="red">Standard Supplements vs. Immunonutrition</font></b>: Which contains Arginine? | Immunonutrition
99. <b><font color="red">NSS vs. PlasmaLyte</font></b>: Which causes hyperchloremia? | Normal Saline (NSS)
100. <b><font color="red">Hypovolemia vs. Hypervolemia</font></b>: Which causes splanchnic edema? | Hypervolemia
101. <b><font color="red">Traditional Fasting vs. ERAS Carb Loading</font></b>: Which results in an anabolic state? | Carbohydrate Loading
102. <b><font color="red">CVP < 8 vs. CVP > 12</font></b>: Which indicates congestion/overload? | CVP > 12 mmHg
103. <b><font color="red">PONV Risk: Smoking vs. Non-smoking</font></b>: Which is the risk factor? | Non-smoking
104. <b><font color="red">Colorectal vs. Esophagectomy</font></b>: Which emphasizes early NGT removal? | Colorectal
105. <b><font color="red">Primary Goal vs. Unified Objective</font></b>: Which refers to the MDT approach? | Primary Goal
106. <b><font color="red">Active vs. Passive participant</font></b>: What is the patient role in ERAS? | Active (The leader)
107. <b><font color="red">Prehabilitation vs. Mobilization</font></b>: Which occurs postoperatively? | Mobilization
108. <b><font color="red">Nausea vs. Nauseous</font></b>: Which refers to the feeling you experience? | Nauseated
109. <b><font color="red">Wind vs. Walking Fever</font></b>: Which occurs on Day 1? | Wind
110. <b><font color="red">Crystalloid vs. Colloid</font></b>: Which is preferred by ERAS/Schwartz? | Crystalloid (PlasmaLyte)
111. <b><font color="red">Traditional vs. ERAS Opioid use</font></b>: Which uses multimodal analgesia? | ERAS
112. <b><font color="red">Standard vs. Goal-Directed Fluid Therapy (GDT)</font></b>: Which is individualized based on cardiac output? | Goal-Directed Therapy (GDT)
113. <b><font color="red">Prophylactic vs. Avoided NGT</font></b>: What is the ERAS recommendation? | Avoid routine use