1. Cardiothoracic Procedures Flashcards
1
Q
3 cardiac surgery approaches
A
“open” heart surgery
davinci robotic
endovascular
2
Q
open heart surgery definition
A
any time the chest is opened (sternotomy or thoracotomy)
3
Q
davinci robotic cardiac surgery definition
A
more laparoscopic rather than open bc small incisions and smaller insufflation is utilized
4
Q
endovascular cardiac surgery definition
A
possible for valve repair and types of aortic repair
5
Q
is sternotomy invasive or minimally invasive?
A
invasive
6
Q
is thoracotomy invasive or minimally invasive?
A
minimally invasive
7
Q
is davinci invasive or minimally invasive?
A
minimally invasive
8
Q
is endovascular repair invasive or minimally invasive?
A
minimally invasive
9
Q
invasive
A
open sternotomy
provides best exposure but most complications
10
Q
minimally invasive cardiac surgery (MICS) types (3)
A
thoracotomy, davinci, endovascular
less common but gaining popularity
11
Q
“minimally invasive”
A
operation without sternotomy
12
Q
3 things specific to minimally invasive cardiac surgery
A
called MICS
double lumen tube must be used
can be off pump or on pump with femoral vessels
13
Q
two types of aorta surgery
A
open repair with cross clamps endovascular repair (minimally invasive)
14
Q
6 surgical options for CABG
A
full bypass with arrested or beating heart partial bypass with beating heart off pump sternotomy thoracotomy davinci
15
Q
MICS CABG
A
small thoracotomy incision
typically 1-2 anterior vessels
off pump or on pump with femoral vessels
16
Q
davinci CABG
A
robot harvest the LIMA thoracotomy is used to sew on graft
17
Q
hybrid coronary revascularization
A
1) anterior vessels are bypassed using MICS/thoracotomy
2) posterior vessels are stented by interventional cardiologist
allows cardiac option for all vessels without sternotomy
18
Q
purpose of hybrid coronary revascularization
A
avoid sternotomy
19
Q
what does the hybrid room require?
A
built in fluoroscopy
20
Q
what procedures will happen in a hybrid room?
A
- hybrid coronary revascularization
- TAVR/TAVI
transcatheter aortic valve replacement (TAVR)((or TAVI))
21
Q
what two types of surgeons will be in the hybrid room?
A
cardiac surgeon
interventional cardiologist
interventional cardiologist
22
Q
what is a good premedication for CABG
A
versed– prevent anxiety and tachycardia
CABG pts need more than valve replacement
23
Q
surgical options for valve repair/replacement 6
A
- full bypass with arrested or beating heart
- right heart bypass for tricuspid or pulm valve
- endovascular or transapical valve replacement (off pump)
- sternotomy
- thoracotomy
- davinci (femoral vessels)
24
Q
how do we normally fix stenotic valves?
A
replaced
25
how do we normally fix regurgitant valves?
repaired or replaced
| repair is more likely for regurg than for stenotic
26
can you use versed for valve repair/replacement?
NO,
| these pts need to maintain their preload and afterload
27
are MICS valve repair/replacement more commonly performed on or off pump?
on pump via femoral arteries
28
endovascular valve repair, what types of patients get this surgery?
ONLY pts who dont qualify for open heart surgery
29
what % of pts with aortic stenosis are considered too high risk for surgery?
30-40%
30
endovascular aortic valve replacement two names
TAVR transcatheter aortic valve replacement
TAVI transcatheter aortic valve implantation
| TAVI transcatheter aortic valve implantation
31
endovascular aortic valve replacement catheter/stent pathways 2
```
femoral artery (more common)
or
axillary artery
```
32
pathway for endovascular mitral valve repair
femoral vein -> intra-atrial septum -> mitral valve
33
pathway for tricuspid and pulmonic valve repair
starts in femoral vein and goes up to valve by passing through right heart
34
transapical open valve replacement
valve replacement that is performed off pump with an open approach
35
5 risks associated with TAVR
```
1 stroke & TIA
2 perivalvular leak
3 acute kidney injury
4 LBBB
5 postoperative bleeding and atrial fibrillation
```
36
overall paravalvular leak/aortic regurge post valve insertion
50-85%
37
which is a higher risk of stroke? surgical valve replacement or TAVR
TAVR
| 30 day frequency is 2-6%
38
30 day stroke risk post-TAVR
2-6%
39
what is the % of aortic regurg as high as immediately post TAVR?
85%
40
1 year aortic regurge post-TAVR
75%
41
what fraction of patients have more than mild mitral regurg?
1/3
42
how can you limit vascular complications?
use the transapical thoracotomy approach
43
why is there a risk of acute kidney injury during TAVR?
large contrast load used in placing the valve with fluoroscopy
44
how does cardiac conduction abnormalities happen during TAVR?
final prosthesis position impinges conduction system
| high incidence of LBBB
45
what is the incidence of complete heart block in pts that already have RBBB for TAVR surgery?
19-22%
| could require pacemaker implantation
46
most frequent adverse outcome with TAVR
bleeding from femoral blood vessels
47
what TAVR risk is less likely to happen than with open surgical approaches?
post op bleeding and a fib
48
10 steps of anesthetic management for endovascular TAVR
1 renal protection
2 stroke prevention
3 lower dose of heparin
4 placement of transvenous pacing leads
5 attaching of external defibrillator pads
6 utilization of TEE
7 amicar administration UNNECESSARY
8 prep to keep heart still during valve deployment
9 hemodynamic goals for typical pt with aortic stenosis
10 continuous postop EKG monitoring for 48 hrs
49
what 2 things can provide renal protection during TAVR?
1) adequate volumes
2) N-acetylcysteine
| N-acetylcysteine prior to surgery
50
stroke prevention steps TAVR
dual antiplatelet therapy is started before surgery and continued for 6 months
300-325mg loading dose of aspirin
300mg clopidogrel
51
what is the goal ACT after heparin dose for TAVR
>250
52
what are the two reasons that we place pacing leads during a TAVR
establish rapid ventricular pacing during valve placement (180-220bpm)
| pace heart in case of complete heart block at end
53
why do we attach external defibrillator pads on TAVR pts?
life threatening arrhythmias can occur in 4% of pts
54
life threatening arrythmias can occur in ______ % of TAVR pts?
4%
55
why do we use TEE during TAVR
provides information about results, position and complications of TAVR
56
what are the two options to keep the heart still during TAVR?
RVP rapid ventricular pacing
| 12 mg adenosine to stop the heart
57
RVP rate
180-220 bpm
58
what will happen to BP when you keep the heart still during TAVR? treatment?
hypotension
| -ask surgeon whether or not to treat (usually not bc its short)
59
how long does valve deployment take?
12 seconds
60
what are the 4 hemodynamic goals for a pt with aortic stenosis
preload augmentation
low heart rates (50-70bpm)
mx afterload
maintenance of sinus rhythm
61
why do you monitor EKG for 48 hr post TAVR?
monitors for onset of new rhythm disturbance
62
in what patients are the pacing wires left in place post op?
av block pts to prevent cardiac arrest
63
what are the two types of surgery to repair thoracic aorta
1. cross clamps with graft (open abdominal aortic aneurysm)
2. endovascular aortic stent
| endovascular stent
64
what is the more common thoracic aorta surgery?
endovascular stent
65
do endovascular stent patients receive heparin?
Yes - lower dosing
66
do endovascular stent patients receive amicar?
no
67
aortic root replacement anesthetic plan
clamp placed on ascending aorta and treated as traditional bypass with arrested heart
68
where is the clamp for aortic root replacement?
ascending aorta
69
surgical techniques for open ascending aorta repair (you can place cross clamp on ascending aorta)
traditional bypass
70
surgical techniques for open ascending aorta repair (you can NOT place cross clamp on ascending aorta)
1) deep hypothermic circulatory arrest (with or without retro or antegrade cerebral perfusion)
2) normothermic antegrade cerebral perfusion
71
what is the problem with descending aorta repair?
- not possible to perfuse head and lower body with one arterial cannula
- clamps increase chance of paralysis due to decr spinal cord perfusion
72
what are the bypass options for descending aorta repair?
```
left heart partial bypass
circ arrest (decrease risk of organ dysfunc. and paralysis)
```
73
LH partial bypass overview
1/2 blood out of LA perfuses distal to clamp
1/2 blood in heart perfuses proximal to clamp
74
LHPB: lower extremity perfusion
LA --> bypass --> arterial cannula --> lower extremities
(distal to clamp)
75
LHPB: head perfusion
LV --> head
(proximal to clamp)
76
how many a lines in LHPB?
2:
- right radial artery
- femoral artery
77
what do we compare during LHPB to assess filling of ventricles?
CVP vs PCWP
78
which a-line site is proximal to clamp?
right radial artery
79
why do you use the right radial artery?
because clamping proximal to the left subclavian might be necessary which will mean the left radial will not be proximal to clamp
80
which a-line site it distal to clamp?
femoral artery
foot artery
81
PLHB:
high proximal
low distal
How should you fix?
increased flow through circuit
82
LHPB:
proximal low
distal low
How to treat?
consider vasoconstrictor or fluids
83
LHPB:
proximal high
distal high
how to treat?
consider vasodilator
84
CVP >> wedge pressure
decrease flow through circuit
85
wedge >> CVP
increase flow through circuit
86
anesthetic management for open descending aorta repair (4)
place aline in right arm
insert a double lumen tube
prepare cardiac drugs
consider techniques for spinal protection
87
why do we need to place the aline in the right arm for open descending aorta repair?
bc the clamp may need to be placed proximal to the left subclavian
88
why do we need a double lumen tube for open descending aorta repair?
bc a thoracotomy approach will most likely be used
89
spinal cord protection techniques for open descending aorta repair (4)
1. SSEP/MEP monitoring
2. Lumbar drain
3. Steroids (decrease swelling)
4. Consider Mannitol
90
what does a lumbar drain do?
decreases ICP =
increases spinal cord perfusion pressure
91
spinal cord perfusion pressure equation
= MAP- CSF pressure
92
CPP =
CPP = MAP - ICP
93
why use mannitol to protect the spine?
increases spinal cord perfusion (decreasing CSF production)
improves renal perfusion
| improves renal perfusion
94
aortic wrapping procedure description
open chest procedure to treat aortic aneurysm
less common
reserved for those concomitant aortic valve replacement and too high risk
95
what is the aortic wrap supposed to do?
prevent aneurysm rupture
96
what are the two ways that heart transplants can be classified as
orthotopic heart transplant
heterotropic heart transplant
| heterotopic heart transplant (piggyback)
97
orthotopic heart transplant description and techiques used
replaced recipient heart with donor heart
| biatrial, bicaval, or total heart transplant
98
heterotopic heart transplant (piggyback)
donor heart is placed in right chest next to recipient heart and anastomosed so blood can flow through either or both
99
biatrial heart transplant
only ventricles are removed
leaving both atria intact
| donor heart attach at midatrial level
100
biatrial heart transplant attachment level
mid-atrial level
101
biatrial heart transplant anastomosis required
4
102
bicaval heart transplant
entire right atrium is removed but the left atrium remains intact
- right side of donor side attaches to right side of pts heart
103
bicaval heart transplant anastomosis required
5
104
total heart transplant
removes the entire heart including left atrium
105
total heart transplant anastomosis required
6
106
what are the advantages of having less anastomosis (comparing heart transplant techniques)
shorter operation times
| less anastomotic complications
107
What heart transplant method gives the best post op function? downfall?
total heart transplant
| downfall: longer operation times
108
pts with heart failure are more likely to develop
PHTN
RV hypertrophy
109
pts with heart failure and PHTN have
weak left ventricle
strong right ventricle
110
severe PHTN pt that receives heart transplant is more likely to ahve what problem?
right heart failure due to high pulmonary vascular resistance but with a new normal right ventricle
111
transplant options for pt with PTHN
heterotropic heart transplant
112
after heterotropic transplant in pt with CHF and PHTN: "old" heart
strong RV
effectively pumps majority of blood to lungs
113
after heterotropic transplant in pt with CHF and PHTN: "new" heart
strong LV
effectively pumps majority of blood to body
114
explain normal heart vagus nerve and SA node mechanism
presynaptic vagus nerve releases Ach binds to MR on SA node and slows HR (balances to prevent tachy)
115
explain normal heart when atropine/robinul are given
atropine/robinul block the MR on the SA node and the Ach does not bind
*HR increases*
116
pt with heart transplant is denervated, what does this mean
not connected to sym or parasym nerves
So the SA node does not have the constant vagus nerve input
pt expected to have *higher resting HR*
117
do atropine/robinul increase the HR in pts with heart transplants?
no
118
effect of atropine/robinul on pt with heart transplant
will still bind MR on heart but there is no Ach to block
*no effect on HR*
119
can neostigmine cause bradycardia in patients with heart transplant?
yes - floods body with Ach which will *Lower HR*
| bc neostigmine floods the BODY with Ach and that can reach the SA node
120
when can atropine/robinul increase the HR of a pt that had a heart transplant?
when the bradycardia was caused by neostigmine
121
do you still give atropine/robinul with neostigmine in pts with heart transplants?
yes, you still need to prevent the bradycardia due to neostigmine
Atropine/robinul will block flood of Ach
122
what is the heart transplant option for patients with pulmonary HTN?
heterotopic heart transplant
| 2 hearts in pt
123
what will happen after time with the heterotopic heart transplant?
pulm HTN will resolve and RV will return to normal size and more evenly share load with donor heart
124
heart transplant implications (7)
1- resting HR >90bpm
2- atropine/robinul administered alone have no effect
3- neostigmine causes bradycardia (antimuscarinics used to counteract)
4- bradycardia must be treated with pacing or beta 1 agonist
5- pt cannot experience angina
6- baroreceptor reflex doesnt work (reflex brady doesnt happen)
7- 2 SA nodes in biatrial technique will cause 2 P waves
(donor SA node is responsible)
125
what are the beta 1 agonists used to treat bradycardia when denervation
isoproterenol
dobutamine
epi
NE
126
what is the clinical significance of 2 SA nodes
original SA node signal cannot cross suture line
- donor SA node effects the HR of pt
| thus donor SA node is the only one that effects HR of pt
127
What should PAP be kept at during heart transplant?
low PAP to prevent RH failure
128
what electrolyte imbalance is common post-transplant?
hyperkalemia
129
how often is RV failure an issue with heart transplants?
accounts for 20% of early deaths
130
what are strategies to reduce pulmonary artery pressure during heart transplant?
hyperventilation
higher FiO2
pulm artery vasodilators
avoidance of acidosis
131
what is methylprednisolone
steroid that is used to prevent rejection of transplant
| dosed when crossclamp released
132
when is methylprednisone dosed?
when cross clamp is released
133
what are ways to lower plasma K?
hyperventilation
134
what is the bypass circuit for heart transplants
venous cannulas in SVC and IVC, arterial cannula in aorta
135
transmyocardial laser revascularization (TMLR) or TMR
laser creates series of holes in myocardium
| relieve angina for pt not eligible for bypass/anginoplasty or have no more grafts
136
TMR purpose
relieve angina in pts who are not eligible for bypass or angioplasty
137
what are the two theories for TMR efficacy?
1- stimulates angiogenesis (new channels for blood flow)
2- destroys nerve endings
138
what can the laser trigger in TMR?
arrythmias
- treat with antiarrythmic prophylaxis
decr CO
- treat with vasopressors/inotropes
139
how to treat decr CO in TMR?
vasoperessors
inotropes
140
what tube for TMR?
double lumen tube
(left anterior thoracotomy w/left lung isolation)
141
pericardial effusion
fluid around the heart
| "fluid accumulation in the pericardial cavity"
142
cardiac tamponade
when pericardial effusion is big enough to effect cardiac function (decrease EF)
143
what are cardiac tamponade patients at risk for?
hypotension
cardiac arrest
especially during induction
144
hemodynamic effects of cardiac tamponade 3
1. decreased CO (bc of decreased SV)
2. beck's triad
3. pulsus paradoxus
| 2 becks triad
145
what is becks triad
hypotension
jugular venous distention
muffled heart tones
146
what are the two treatment options for cardiac tamponade
```
pericardiocentesis (local or sedation)
pericardial window (general anesthesia)
```
147
pericardiocentesis anesthetic plan
MAC
148
pericardial window anesthetic plan
GA
149
what type of approach is used when the tamponade is an emergency?
subxiphoid approach (can be performed under local and sedation if required)
150
what type of tube is used in the subxiphoid approach?
single lumen ETT
151
what type of tube is used in the thoracotomy approach?
double lumen ETT
152
induction of anesthesia for pericardial window
head elevated 45 degrees
propofol avoided
avoid bradycardia
surgeon ready before induction
153
induction agent for pericardial window
ketamine
etomidate
154
in a patient with cardiac tamponade what does cardiac output depend on? SV or HR?
HR because the heart cannot increase SV
| **bradycardia must be avoided**
155
Do you want positive pressure ventilation or spontaneous ventilation during a pericardial window/tamponade?
*spontaneous*
PPV decreases venous return and CO
awake fiberoptic good option
156
mediastinoscopy
visualization of contents of space between lungs (mediastinum) usually for biopsy
157
what is the problem with the scope for mediastinoscopy?
ability to compress innominate (brachiocephalic) artery
| surgeon not aware **need to communicate this**
158
what does the innominate artery supply blood to?
right arm (subclavian) and right common carotid
159
what can happen with innominate compression?
decreased cerebral blood flow
160
what patients are at risk for cerebral ischemia with innominate artery compression?
pts who have left carotid stenosis
161
where should you place a-line in mediastinoscopy?
right radial artery will indicate innominate artery compression
162
aiway management for mediastinoscopy
single lumen ETT
no lungs need to be down
Spontaneous ventilation best
163
blood pressure monitors for mediastinoscopy
aline in right radial artery (know immediately if innominate is compressed)
NIBP left arm for when aline is jacked up
164
what is mandatory for mediastinoscopy?
monitor pulse in right arm
165
what is the less common blood pressure monitoring for mediastinoscopy?
aline in left arm (monitors continuously)
| SpO2 on right (use waveform to watch for compression)
166
what is the primary concern with mediastinal mass?
compression of vital structures
167
what vital structures can be compressed by a mediastinal mass?
heart
central blood vessels
trachea
bronchi
168
what are the pts with mediastinal mass at risk for during induction
airway collapse
| cardiovascular collapse
169
what are the signs/symptoms of mediastinal mass?
superior vena cava syndrome
pembertons sign
tracheobronchial compression
170
superior vena cava syndrome
obstruction to venous return through SVC
171
what is the most common cause of SVC syndrome?
malignancy
172
what can obstructed venous return lead to?
airway edema
decreased CO
increased ICP
(superior vena cava syndrome)
173
what happens to a persons face during SVC syndrome
swelling in face in morning
(can be positional)
| swelling resolved after being upright all day
174
pembertons sign
facial congestion
cyanosis
respiratory distress when raising both arms
(shifts mass to cause obstruction)
175
what does pembertons sign illustrate about positioning
positioning moves the tumor which can cause or alleviate the obstruction
176
what patients show pembertons sign?
venous obstruction
goiters
mediastinal mass
177
tracheobronchial compression leads to
shortness of breath
orthopnea (when lying down)
total airway obstruction
pinch off ETT
178
intrathoracic mass
open on inspiration
collapse on expiration
179
extrathoracic mass
collapse on inspiration
open on expiration
180
what diagnostic tests should you order for mediastinal mass?
CT
CXR
ECHO
Pulm function test
181
what is the best diagnostic test to assess tracheal compression?
CT
| <50%
182
at what % of occlusion is there a high risk of complications with GA
< 50%
183
what is the best diagnostic test to assess compression of the heart
ECHO
184
what do the results of diagnostic tests mean for anesthesia?
2 or more significant abnormal findings on CT, spiro, ECHO and there is high risk of complications for GA
185
what should be done to tumor prior to GA, if possible?
shrink tumor with steroids or radiation
186
intubation technique mediastinoscopy
awake fiberoptic intubation in sitting position
premedication limited to antimuscarinics
armored tube
187
armored tube
wire coil to prevent kinking or compression
188
surgical options for airway compression
1) laser removal of lesion
2) tracheal/bronchial stent
189
is it better to spontaneous or mechanically ventilate pt with airway stenosis?
spontaneously ventilation
190
sternotic airway flow
turbulent
191
what does turbulent flow cause?
decreased effective gas exchange
192
Why is Heliox used?
allows more laminar flow through partial airway obstruction
193
how can you decrease velocity (incr laminar flow)?
slow down RR
decr density of gas (Heliox)
194
diagnostic phase airway
LMA w/bronchoscope
195
diagnostic phase anesthetic management
sevo
lidocaine infusion
196
why is sevo good?
bronchodilator
better to mx spontaneous ventilation
197
lidocaine infusion
1-2 mg/min
(decrease airway reactivity)
198
ventilation during bronchoscopy
1) ventilate with bronchoscope
2) jet ventilation
199
inhalation induction for mediastinoscopy: pros
SV
200
inhalation induction for mediastinoscopy: Cons
partial obstruction is common
lg neg pressure
airway collapse
201
routine induction for mediastinoscopy
pts that show no clinical or radiological evidence of airway or cardio obstruction
202
ventilation with tracheal compression
have plan
if distal to obstruction manual ventilation can be attempted
if unsure about distal or proximal then spontaneous should be maintained
203
what should you do if you are unable to place the ETT distal to the obstruction mediastinoscopy
tracheal stent used placed with rigid bronchoscopy or jet ventilation (bronchoscopy should be on standby)
204
jet ventilation
- high pressure can be used to ventilated through small catheter
- allow ventilation past an area of stenosis
| "cant intubate, cant ventilate"
205
what anesthetic is required with jet ventilation?
TIVA
(no inhalational)
206
how do you turn on the jet ventilator
push the lever down
207
manual jet ventilation complications
barotrauma
breath stacking
tension pneumothorax
208
what position should the patient be in during mediastinoscopy
semi upright position to maintain airway and reduce airway edema
209
what should be avoided in order to maintain cerebral perfusion pressure
avoid hypotension
| obstructed venous drainage can cause increased ICP and compromise CPP
210
where should you place IVs in a person with SVC syndrome?
lower extremities
- if evidence of SVC syndrome
| consider preload augmentation
211
what is important to have immediately available during mediastinoscopy?
surgical intervention
heart team on standby
groins preped for bypass
212
in what case for mediastinoscopy should the bypass cannulas be placed prior to GA induction
all pts with >50% reduction of airway
213
laser lead extraction
pacing leads may become infected and need removal
tissues grow around leads
laser sheaths used to remove tissue
214
laser lead extraction precautions
aline placed
cardiac team standby
215
laser lead extraction complications
could have severe hypotension and hemorrhage
216
Maze procedure
treat Afib by inflicting scar tissue to disprupt abnormal conduction pathways
217
how to inflict scar tissue in Maze procedure?
incisions
cold temp/cryomaze
abnormal conduction pathways
218
Maze procedure open or endovascular?
open chest
- sternotomy
- thoracotomy
(typically combined with other procedures)
219
Left atrial appendage closure
prevent clot release from LA in pts with history of Afib during Maze procedure
220
LA appendage open or endovascular?
open chest
(typically combined with other procedures0
221
Watchman Device
placed in LA appendage to prevent clots from escaping and going to the head and causing a stroke
222
Watchman placement open or endovascular?
endovascular
223
gold std for carotid stenosis
carotid endarterectomy
224
CEA managment
EEG monitoring
<1 MAC
phenylephrine drip
NTG/Cardene
art line
225
when are vasodilators usually required during CEA?
emergence to prevent HTN from coughing during extubation
226
Transcarotid Artery Revascularization (TCAR)
arterial flow through the carotid artery is reversed and stent deployed
227
TCAR advantages
lower chance of stroke
less invasive surgery
228
TCAR anesthetic
MAC
