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Flashcards in CARDIO Deck (45):
1

RFs for CAD

gender (begins to equalize with advanced age) HTN DM age cholesterol smoking family history obesity

2

Gold standard for Dx of CAD

Cardiac catheterization Others: EKG, echo, stress tests, CT angio

3

"Angiographically significant" finding of cardiac cath

Diameter is reduced by > 50%, corresponding to a reduction in cross-sectional area > 75%

4

Artery of concern in the heart

Left anterior descending artery (LAD) "Widow maker"

5

Who goes to the OR in CAD?

Severe angina (CCS class III/IV) Unstable angina Triple vessel dz Left main dz Failed medical therapy Thrombosis, post PTCA or in-stent restenosis Emergently from cath lab (coronary dissection)

6

CABAG post-MI

Postinfarction ventricular septal defect (VSD) Papillary muscle rupture with acute mitral insufficiency LV free wall rupture

7

Postinfarction ventricular septal defect

4-5 days after MI Present with CHF and pulmonary edema and new systolic murmur Need intra-aortic balloon pump (IABP) placed and undergo emergent repair

8

Papillary muscle rupture with acute mitral insufficiency

4-5 days post MI Heart failure, new murmur Prompt valve repair or replacement

9

LV free wall rupture

Cardiogenic shock, often acute tamponade Emergent surgery = 50% successful

10

CABG

Aim to restore flow from aorta to the coronaries distal to obstruction Does NOT rid patient of disease or disease process Uses vascular "conduits" With or without assistance of bypass ("on pump" vs "off pump")

11

Benefits of off-pump CABG

Less risk of encephalopathy, sternal infection, blood transfusion, and renal failure

12

Advantages of cardiopulmonary bypass

Quiet, bloodless field Better distal anastamoses Still the standard

13

Disadvantages of cardiopulmonary bypass

Increased time in surgery pt must be heparinized then reversed platelet dysfunction (HIT) complications can include hypoperfusion fluid retention CVA Ischemia

14

Gold standard for conduit

Left internal mammary artery to LAD (aka left internal thoracic artery) Others: saphenous vein (for lateral and posterior walls), radial artery

15

Mechanical Valves

Tilting disk and older ball-in-cage designs -Highly durable, require permanent anticoagulation therapy (INR at 2.5 to 3.5 times normal) -Preferable in patients with long life expectancy

16

Tissue for valve replacement

Xenograft (porcine or bovine), homograft (cadaver), or autograft (pulmonic valve) -Less thrombogenic, do not require anticoagulation -More prone to structural failure due to calcification -15-20 years

17

Aortic Stenosis (AS)

Stenosis from thickening, calcification, fusion of aortic leaflets causing LV outflow obstruction Pressure overload of LV leads to LVH Younger patients with congenital bicuspid valves Older-- history of rheumatic fever Sx: angina, syncope, CHF Dx: Echo, +/- cardiac cath PE systolic murmur in 2nd R IC space Surgery indicated if symptomatic or based on cross sectional area of valve and gradient across valve

18

Aortic Valve Incompetence

Incompetence of aortic valve, backflow causes LV dilation, LVH Causes: bacterial endocarditis, hx of rheumatic fever, aortic root dilation, bicuspid valve predisposes Dx: echo, cath PE: "Blowing" decrescendo diastolic murmur L sternal border Surgery if symptomatic

19

Mitral Valve Stenosis (MS)

Thickening of mitral leaflets, narrowing of valve, usually due to rheumatic fever Sx: dyspnea (increased LA pressures causing pulmonary edema, afib from dilated LA) Dx: echo/cath PE: diastolic murmur at apex, "rumble," with opening snap Surgery based on sx/degree of MS

20

Options for surgery in MS

percutaneous balloon valvuloplasty open commissurotomy Valve replacement

21

Mitral Valve Regurgitation (MR)

Incompetence of mitral valve from prolapse, rheumatic fever, papillary muscle dysfunction (post MI), ruptured chordae, dilation of annulus Dx: Echo/cath PE: holosystolic murmur from apex to axilla Sx: dyspnea, palpitations, fatigue. Late onset. Surgery: based on cath/echo findings

22

Surgical options for MR

Flail leaflet mitral repair or ring annuloplasty: for degenerative MR, dilated annulus Mitral replacement (long-standing rheumatic disease)

23

Aortic Dissection

Tear in intima which enables blood to flow into the media creating a false lumen Causes: HTN, bicuspid aortic valve, atherosclerotic disease, Marfan's Presentation: severe chest pain, "tearing" sensation to the back Dx: CXR (widened mediastinum), TEE, CT angio Considered acute if dx within 2 weeks of onset Most common cause of death is rupture

24

Stanford classification (aortic dissection)

Type A: ascending aorta Type B: Aorta distal to left subclavian

25

DeBakey Classification (aortic dissection)

Type I: Both ascending and descending Type II: Only ascending aorta Type III: Only descending aorta

26

Tx for Aortic dissection

Surgery: type A (I & II) Medically: Type B (III) unless complicated or uncontrollable HTN or persistent pain or rupture

27

Crawford Classification (aortic aneurysm)

Type I: Proximal descending to proximal abdominal Type II: Proximal descending to infrarenal Type III: Distal descending with abdominal Type IV: Primarily abdominal

28

Descending aortic aneurysm

2nd most common Distal to left subclavian artery Fusiform Secondary to arteriosclerosis Surgical repair > 5 cm or rapid growth May be consequence of deceleration injury (ligamentum arteriosus, increased mediastinum width, different BP in UE)

29

Ascending Aortic Aneurysm

Cystic medial necrosis Secondary to Marfans, HTN, aging May cause AI, CHF Chest pain worrisome (deep, diffuse, aching) Decision to repair depends on size, presence of AI, associated CHD

30

Aortic arch aneurysm

Least common Sx secondary to pain or compression of adjacent structures (dysphagia, dry cough, hoarseness, dyspnea) Fusiform from arteriosclerosis, saccular if syphlitic

31

Thoracic aortic aneurysm: medical management

Management based on size and location Medical management: BP control, serial imaging, surveillance, B-blockers

32

Thoracic Aortic Aneurysm: surgical indications

Symptoms ascending >5.5 cm in diameter descending >6.5cm in diameter rapid increase in diameter (>1 cm per year) Evidence of dissection Arch and Crawford II have highest morbidity and mortality after repair

33

Arteriosclerotic Obliterans

Artheromatous disease similar to coronaries, but peripheral Intimal plaque that partially obstructs and gives "angina" of ischemic limb "Intermittent claudication"-- occurs predictably with activity and is relieved within 1-2 mins of rest "Leriche" syndrome-- claudication of buttocks and means narrowing higher up in terminal aorta Check in diabetics!

34

Arteriosclerotic Obliterans: Tx

Walking program Stop smoking Ideal body weight Optimize diabetic therapy Lipid management Meticulous foot care

35

Leriche's Syndrome: Tx

Aorto-bifemoral or endarterectomy Balloon angioplasty w/wo stent

36

Arteriosclerotic obliterans: surgical tx

Balloon angioplasty/stent Surgery: aorta bi-femoral bypass, pem-popliteal bypass, lumbar sympathectomy

37

Carotid Stenosis

Narrowing of carotid arteries due to atherosclerosis and accumulation of plaques Stable and asx or source of embolization Sx: transient or permanent focal neuro sx related to ipsilateral retina or cerebral hemisphere

38

Sx of carotid artery stenosis

Ipsilateral transient visual obscuration (amaurosis fugax) from retinal ischemia Contralateral weakness or numbness of an arm, a leg, or the face, or a combination Visual field defect Dysarthria In the case of dominant (usually left) hemisphere involvement, aphasia

39

RFs for carotid artery stenosis

Similar to those for other types of heart disease: Age Smoking HTN-- most important treatable RF for stroke Abnormal lipids or high cholesterol Diet high in sat fat Insulin resistance DM Obesity Sedentary lifestyle FH

40

Dx of carotid artery stenosis

Carotid bruit Carotid duplex US (screen) MRA or CTA (diagnostic)

41

Tx of carotid artery stenosis

Medically: antiplatelet therapy (90%), antihypertensive therapy, lipid-lowering therapy Weight loss, girth loss Smoking cessation Surgical: Carotid endarterectomy (CEA) is gold standard; Carotid angioplasty and stenting (CAS) is valid alternative

42

"High surgical risk" for endarterectomy: anatomical factors

High carotid bifurcation (above C2) Low common carotid artery (below clavicle) Contralateral carotid occlusion Restenosis of ipsilateral prior carotid endarterectomy Previous neck irradiation Prior radical neck dissection Laryngeal nerve palsy Presence of tracheostomy

43

"High surgical risk" for endarterectomy: Physiological factors

Age 80+ L ventricular EF

44

Option for patients who are high risk for endarterectomy

Carotid Artery Stenting

45

Cardiac surgery post op complications/management

Hemodynamic monitoring Pleural effusions Vent dependence/respiratory failure Stroke Pericardial tamponade Afib (25%) Sternal wound infection Post op MI/acute graft closure Early ambulation, deep breathing