Cardiothoracic Surgery

Question 1

What is a coin lesion?

Answer 1

Solitary pulmonary nodule on CXR; DDx primary lung cancer, granuloma (TB or fungi), hamartoma, metastatic cancers

Question 2

How do you manage a coin lesion?

Answer 2

First thing is always to get an older CXR for comparison studies. If suspicious, sputum cytology and CT scan.
If indeterminate, resection is indicated
Likely metastatic if there are multiple lesions (vs solitary lesion is more likely lung cancer)

Question 3

What are the signs of a benign coin lesion?

Answer 3

Calcification = granuloma
Bull's-eye shape or popcorn shape = hamartoma
Air-crescent sign = aspergilloma
Southwest region = coccidiomycosis
Ohio river valley = histoplasmosis

Question 4

How do you manage lung cancer?

Answer 4

First thing is always CXR –> if suspicious, then sputum cytology and CT scan –> if still suspicious, bronchoscopy and mediastinoscopy with biopsy

Question 5

What is NSCLC Tx?

Answer 5

Stage I: local
Stage II: hilar LN
Stage III: distal LN
Stage IV: metastatic cancer
If stage I/II: first get spirometry and V/Q scans to see if patient is a surgical candidate, then do pneumonectomy or sleeve lobectomy
Stage III/IV: chemotherapy and radiation

Question 6

What is the surgical contraindication for NSCLC?

Answer 6

FEV1 <800 mL, mediastinal LN involvement, distal metastases

Question 7

What is SCLC staging and treatment?

Answer 7

Limited stage involves ipsilateral lung only, extensive stage involves contralateral lung
Tx is chemotherapy and radiation

Question 8

What is a Pancoast tumor?

Answer 8

Superior sulcus tumor at the apex of the lung, presents as Horner syndrome (ipsilateral ptosis, miosis, anhidrosis, flushing due to loss of sympathetic tone) because the tumor invades the superior cervical ganglia
Treated by irradiation followed by surgical resection

Question 9

What is a bronchial adenoma?

Answer 9

Tumors that arise from within the bronchi and cause obstruction; MC lung cancer in a nonsmoker under 30 y/o, Sx are hemoptysis and atelectasis, Dx CT scan and bronchoscopy
Tx: lobectomy is curative

Question 10

What is mesothelioma? (Dx, Px and Tx?)

Answer 10

Cancer arising from pleural mesothelium, shipyards and asbestos exposure are risk factors.
Dx: CT scan shows thick pleural walls
Px: Not responsive to medical therapy, <1 year to live without surgery
Tx: extrapleural pneumonectomy is curative, but high rate of morbidity and mortality

Question 11

What is a pleural effusion? (with DDx and management)

Answer 11

Fluid build-up in pleural space, cancer in older patient until proven otherwise;
DDx CHF, bronchogenic carcinoma, mesothelioma, empyema, pneumonia, TB effusions
Management: get thoracentesis and culture pleural fluid, pleural biopsy

Question 12

What is a spontaneous pneumothorax?

Answer 12

Rupture of apical blebs in healthy young people causes sudden chest pain and dyspnea; tx is thoracostomy on water-seal drainage

Question 13

How do you treat recurrent/persistent pneumothorax?

Answer 13

Indicated for thorascopic excision of belbs, and pleurodesis causing pleural adhesions

Question 14

What is an empyema?

Answer 14

Collection of pus within pleural cavity; presents with cough, fever, chest pain, and pleural effusion on CT scan; MCC is staph aureus

Question 15

How do you treat an empyema?

Answer 15

Initiate appropriate antibiotics, insert a chest tube, evacuate pus collection, then re-expand the lung

Question 16

What is unstable angina?

Answer 16

Progressive ischemia of myocardium resulting in increasing angina at rest and an ischemic EKG pattern

Question 17

How do you manage unstable angina?

Answer 17

Cardiac catheter and evaluate for potential revascularization, tx bypass or angioplasty

Question 18

What is an abnormal ejection fraction?

Answer 18

SV/EDV; normal EF is 67%, EF <35% is high-risk for operative MI

Question 19

What is coronary artery disease?

Answer 19

Blockage of coronary arteries, high risk of sudden death due to ventricular arrhythmias, Tx bypass or angioplasty

Question 20

What is three-vessel disease?

Answer 20

Blockage of LAD/RCA/LCX

Question 21

What is a coronary artery bypass?

Answer 21

open via median sternotomy, isolate internal thoracic artery or greater saphenous vein, put on bypass and stop the heart, sew grafts to arteries, restart the heart and close up

Question 22

What is a coronary angioplasty?

Answer 22

Insertion of stent to prolong patency of clogged coronary arteries, 33% rate of restenosis in one year

Question 23

What is cardioplegia solution?

Answer 23

Solution used to stop heart mid-diastole to protect it from ischemia and provide a motionless field; often used with hypothermia to prolong time of safe ischemia (up to 2.5 hours)

Question 24

What is off-bypass coronary surgery?

Answer 24

Grafting of ITA or GSV to coronary arteries without bypass in order to avoid complications of bypass, reserved for high-risk patients

Question 25

What is dilated cardiomyopathy?

Answer 25

Dilation of myocardium causing systolic dysfunction leading to progressive dyspnea and fatigue, often preceded by viral URI.
Beta blockers will improve heart function, but heart transplant is indicated

Question 26

What is constrictive pericarditis?

Answer 26

Presents as dyspena, hepatomegaly, and ascites due to diastolic failure
Dx cardiac cath shows “square root sign”, tx is surgical correction

Question 27

What are the symptoms of aortic stenosis?

Answer 27

Angina, dyspnea, syncope, and high risk of sudden death; dx is harsh mid-systolic murmur
MCC is congenital bicuspid valve with dystrophic calcification, tx valve replacement when symptomatic

Question 28

What are the symptoms of aortic regurgitation?

Answer 28

Loud, blowing diastolic murmur and bounding pulses; if chronic–> valve replacement when symptomatic
if acute–> emergent valve replacement and long-term abx

Question 29

What are the symptoms of mitral stenosis?

Answer 29

Presents as dyspnea and fatigue, caused by rheumatic fever, results in cor pulmonale (RVH+PH) and AFib; Tx is valve repair or replacement

Question 30

What are the symptoms of mitral regurgitation?

Answer 30

Presents as dyspnea and fatigue, caused by MVP, high pitched holosystolic murmur
Tx: annuloplasty or valve replacement

Question 31

When are you concerned about mitral prolapse?

Answer 31

Eccentric closure of mitral leaflets; common in women, precedes severe disease in men

Question 32

What is on the differential for an anterior mediastinal mass?

Answer 32

thymomas, lymphomas, teratomas, and other metastatic germ cell neoplasms

Question 33

How does a thymoma present?

Answer 33

Often presents with progressive muscle weakness secondary to myasthenia gravis
Tx is surgical removal via median sternotomy

Question 34

What is on the differential for a middle mediastinal mass?

Answer 34

lymphomas, bronchogenic cysts, pericardial cysts

Question 35

What is a bronchogenic cyst?

Answer 35

Develops from foregut remnants, treat with surgical removal via thoracotomy

Question 36

What is on the differential for a posterior mediastinal mass?

Answer 36

Neurogenic tumors, neurilemoma is the MCC

Question 37

What is a neurilemoma?

Answer 37

Dumbbell-shaped tumor found adjacent to vertebral bodies, develops from nerves and nerve sheathes, tx is surgical removal via thoracotomy