Cardiovascular Surgery, C72 P648-671 Flashcards

Question

What is a normal CI? | P649

Answer 1

2.5 to 4 L/minute

Answer 2

Remember “MR. PAIR”: 1. Mechanical assistance (IABP, VAD) 2. Rate—Increase heart rate 3. Preload—Increase preload 4. Afterload—Decrease afterload 5. Inotropes—Increase contractility 6. Rhythm—Normal sinus

Answer 3

During diastole (66%)

Answer 4

1. Left Anterior Descending (LAD) 2. Circumflex 3. Right coronary

Answer 5

1. Calcium (inotropic) 2. Potassium (dysrhythmias) 3. Magnesium (dysrhythmias)

Answer 6

Atherosclerotic occlusive lesions of the coronary arteries; segmental nature makes CABG possible

Answer 7

CAD is the #1 killer in the Western world; >50% of cases are triple vessel diseases involving the LAD, circumflex, and right coronary arteries

Answer 8

``` If ischemia occurs (low flow, vasospasm, thrombus formation, plaque rupture, or a combination), patient may experience chest pain, crushing, substernal shortness of breath, nausea/upper abdominal pain, sudden death, or may be asymptomatic with fatigue ```

Answer 9

Patients with diabetes (autonomic | dysfunction)

Answer 10

``` HTN Smoking High cholesterol/lipids (240) Obesity Diabetes mellitus Family history ```

Answer 11

``` Exercise stress testing ( ± thallium) Echocardiography Localize dyskinetic wall segments Valvular dysfunction Estimate ejection fraction Cardiac catheterization with coronary angiography and left ventriculography (the definitive test) ```

Answer 12

Medical therapy (-blockers, aspirin, nitrates, HTN medications), angioplasty (PTCA), +/- stents, surgical therapy: CABG

Answer 13

Coronary Artery Bypass Grafting

Answer 14

``` Left main disease ≥2-vessel disease (especially diabetics) Unstable or disabling angina unresponsive to medical therapy/PTCA Postinfarct angina Coronary artery rupture, dissection, thrombosis after PTCA ```

Answer 15

``` CABG = Survival improvement for diabetics and ≥2-vessel disease, ↑ short-term morbidity PTCA = ↓ short-term morbidity, ↓ cost, ↓ hospital stay, ↑ reintervention, ↑ postprocedure angina ```

Answer 16

``` Coronary arteries grafted (usually 3–6): internal mammary pedicle graft and saphenous vein free graft are most often used (IMA 95% 10-year patency vs. 50% with saphenous) ```

Answer 17

Radial artery, inferior epigastric vein

Answer 18

``` Hemorrhage Tamponade MI, dysrhythmias Infection Graft thrombosis Sternal dehiscence Postpericardiotomy syndrome, stroke ```

Answer 19

1% to 3% for elective CABG | vs. 5%–10% for acute MI

Answer 20

Aspirin, ℬ-blocker

Answer 21

Yes, today they are performed with or | without bypass

Answer 22

Pericarditis after pericardiotomy (unknown etiology), occurs weeks to 3 months postoperatively

Answer 23

``` Fever Chest pain, atrial fibrillation Malaise Pericardial friction rub Pericardial effusion/pleural effusion ```

Answer 24

NSAIDs, +/- steroids

Answer 25

Dressler’s syndrome

Answer 26

``` Pump and oxygenation apparatus remove blood from SVC and IVC and return it to the aorta, bypassing the heart and lungs and allowing cardiac arrest for open-heart procedures, heart transplant, lung transplant, or heart-lung transplant as well as procedures on the proximal great vessels ```

Answer 27

Yes, just before and during the procedure, | with heparin

Answer 28

Rate, rhythm, afterload, preload, inotropes, | mechanical (IABP and VAD)

Answer 29

Cardiac tamponade, pneumothorax

Answer 30

↓ Cardiac output, ↑ heart rate, hypotension, | ↑ CVP = ↑ wedge pressure

Answer 31

``` Trauma to formed blood elements (especially thrombocytopenia and platelet dysfunction) Pancreatitis (low flow) Heparin rebound CVA Failure to wean from bypass Technical complications (operative technique) MI ```

Answer 32

Protamine, ↑ PEEP, FFP, platelets, | aminocaproic acid

Answer 33

``` Increased anticoagulation after CPB from increased heparin levels, as increase in peripheral blood flow after CPB returns heparin residual that was in the peripheral tissues ```

Answer 34

Warm the patient; administer sodium | nitroprusside (SNP) and dobutamine

Answer 35

Inotropes (e.g., epinephrine) | VAD, IABP

Answer 36

``` Rule out PTX (ABG, CT scan), acidosis (ABG), electrolyte abnormality (LABS), and ischemia (EKG), CXR ```

Answer 37

Minimally Invasive Direct Coronary Artery Bypass—LIMA to LAD bypass without CPB and through a small thoracotomy

Answer 38

``` TransMyocardial laser Revascularization: laser through groin catheter makes small holes (intramyocardial sinusoids) in cardiac muscle to allow blood to nourish the muscle ```

Answer 39

Off Pump Coronary Artery Bypass— | median sternotomy but no bypass pump

Answer 40

Destruction and calcification of valve leaflets, resulting in obstruction of left ventricular outflow

Answer 41

Calcification of bicuspid aortic valve Rheumatic fever Acquired calcific AS (7th to 8th decades)

Answer 42

``` Angina (5 years life expectancy if left untreated) Syncope (3 years life expectancy if left untreated) CHF (2 years life expectancy if left untreated) Often asymptomatic until late ```

Answer 43

Aortic Stenosis Complications = Angina | Syncope CHF—5,3,2

Answer 44

``` Murmur: crescendo-decrescendo systolic second right intercostal space with radiation to the carotids Left ventricular heave or lift from left ventricular hypertrophy ```

Answer 45

CXR, ECG, echocardiography Cardiac catheterization—needed to plan operation

Answer 46

Valve replacement with tissue or | mechanical prosthesis

Answer 47

If patient is symptomatic or valve crosssectional area is (normal 2.5 to 3.5 cm) and/or gradient >50 mm Hg

Answer 48

Mechanical valve is more durable, but | requires lifetime anticoagulation

Answer 49

Balloon aortic “valvuloplasty” | percutaneous

Answer 50

Implies a high gradient, which indicates | preserved LV function

Answer 51

It may imply a decreasing gradient from | a decline in LV function

Answer 52

Incompetency of the aortic valve | regurgitant flow

Answer 53

``` Bacterial endocarditis (Staphylococcus aureus, Streptococcus viridans) Rheumatic fever (rare) Annular ectasia from collagen vascular disease (especially Marfan’s syndrome) ```

Answer 54

Bicuspid aortic valve, connective tissue | disease

Answer 55

``` Palpitations from dysrhythmias and dilated left ventricle Dyspnea/orthopnea from left ventricular failure Excess fatigue Angina from ↓ diastolic BP and coronary flow (Note: Most coronary blood flow occurs during diastole and aorta rebound) Musset sign (bobble-head) ```

Answer 56

``` ↑ diastolic BP Murmur: blowing, decrescendo diastolic at left sternal border Austin-Flint murmur: reverberation of regurgitant flow Increased pulse pressure: “pistol shots,” “water-hammer” pulse palpated over peripheral arteries Quincke sign (capillary pulsations of uvula) ```

Answer 57

``` 1. CXR: increasing heart size can be used to follow progression 2. Echocardiogram 3. Catheterization (definitive) 4. TEE ```

Answer 58

Aortic valve replacement

Answer 59

``` Symptomatic patients (CHF, PND, etc.), left ventricle dilatation, decreasing LV function, decreasing EF, acute AI onset ```

Answer 60

Surgery gives symptomatic improvement and may improve longevity; low operative risk

Answer 61

Calcific degeneration and narrowing of the mitral valve resulting from rheumatic fever in most cases

Answer 62

``` 1. Dyspnea from increased left atrial pressure, causing pulmonary edema (i.e., CHF) 2. Hemoptysis (rarely life-threatening) 3. Hoarseness from dilated left atrium impinging on the recurrent laryngeal nerve 4. Palpations (AFib) ```

Answer 63

Murmur: crescendo diastolic rumble at apex Irregular pulse from AFib caused by dilated left atrium Stroke caused by systemic emboli from left atrium (AFib and obstructed valve allow blood to pool in the left atrium and can lead to thrombus formation)

Answer 64

Echocardiogram | Catheterization

Answer 65

1. Symptoms (severe) 2. Pulmonary HTN and mitral valve area /m 3. Recurrent thromboembolism

Answer 66

1. Open commissurotomy (open heart operation) 2. Balloon valvuloplasty: percutaneous 3. Valve replacement

Answer 67

>80% of patients are well at 10 years | with successful operation

Answer 68

Incompetence of the mitral valve

Answer 69

``` Severe mitral valve prolapse (some prolapse is found in 5% of the population, with women ≥men) Rheumatic fever Post-MI from papillary muscle dysfunction/rupture Ruptured chordae ```

Answer 70

``` Rheumatic fever (#1 worldwide), ruptured chordae/papillary muscle dysfunction ```

Answer 71

Often insidious and late: dyspnea, | palpitations, fatigue

Answer 72

Murmur: holosystolic, apical radiating to | the axilla

Answer 73

1. Symptoms 2. LV 45 mm end-systolic dimension (left ventricular dilation)

Answer 74

1. Valve replacement 2. Annuloplasty: suture a prosthetic ring to the dilated valve annulus

Answer 75

Replacement of damaged valves with | tissue or mechanical prosthesis

Answer 76

Tissue and mechanical

Answer 77

NO anticoagulation but shorter duration (20%–40% need replacement in 10 years); good for elderly

Answer 78

``` Last longer ( > 15 years) but require ANTICOAGULATION ```

Answer 79

Dialysis (calcify), youth

Answer 80

Pregnancy (or going to be pregnant due to anticoagulation), bleeding risk (alcoholic, PUD)

Answer 81

From 1% to 5% in most series

Answer 82

Antibiotics

Answer 83

Aortic valve replacement with a pulmonary | autograft (i.e., patient’s own valve!)

Answer 84

Microbial infection of heart valves

Answer 85

Preexisting valvular lesion, procedures | that lead to bacteremia, IV drug use

Answer 86

``` S. viridans: associated with abnormal valves S. aureus: associated with IV drug use S. epidermidis: associated with prosthetic valves ```

Answer 87

``` Murmur (new or changing) Petechiae Splinter hemorrhage (fingernails) Roth spots (on retina) Osler nodes (raised, painful on soles and palms; Osler = Ouch!) Janeway lesions (similar to Osler nodes, but flat and painless) (JaneWAY = pain aWAY) ```

Answer 88

Echocardiogram, TEE | Serial blood cultures (definitive)

Answer 89

Prolonged IV therapy with bactericidal antibiotics, to which infecting organisms are sensitive

Answer 90

Infection can progress, requiring valve | replacement

Answer 91

Most common congenital heart defect

Answer 92

``` Failure of ventricular septum to completely close; 80% of cases involve the membranous portion of the septum, resulting in left-to-right shunt, increased pulmonary blood flow, and CHF if pulmonary to systemic flow is >2:1 ```

Answer 93

Pulmonary artery hyperplasia from increased pulmonary pressure caused by a left to right shunt (e.g., VSD)

Answer 94

``` Irreversible pulmonary HTN from chronic changes in pulmonary arterioles and increased right heart pressures; cyanosis develops when the shunt reverses (becomes right to left across the VSD) ```

Answer 95

Only option is heart-lung transplant; | otherwise, the disease is untreatable

Answer 96

30% of heart defects (most common | defect)

Answer 97

Physiologic right-to-left shunt in fetal circulation connecting the pulmonary artery to the aorta bypassing fetal lungs; often, this shunt persists in the neonate

Answer 98

Hypoxia, increased prostaglandins, | prematurity

Answer 99

Often asymptomatic Poor feeding Respiratory distress CHF with respiratory infections

Answer 100

Acyanotic, unless other cardiac lesions are present; continuous “machinery” murmur

Answer 101

Physical examination Echocardiogram (to rule out associated defects) Catheter (seldom required)

Answer 102

Indomethacin is an NSAID: prostaglandin (PG) inhibitor (PG keeps PDA open)

Answer 103

Surgical ligation or cardiac catheterization closure at 6 months to 2 years of age

Answer 104

``` Misalignment of the infundibular septum in early development, leading to the characteristic tetrad: 1. Pulmonary stenosis/obstruction of right ventricular outflow 2. Overriding aorta 3. Right ventricular hypertrophy 4. VSD ```

Answer 105

Hypoxic spells (squatting behavior increases SVR and increases pulmonary blood flow)

Answer 106

Cyanosis Clubbing Murmur: SEM at left third intercostal space

Answer 107

CXR: small, “boot-shaped” heart and decreased pulmonary blood flow Echocardiography

Answer 108

95% survival at specialized centers

Answer 109

Idiopathic Hypertrophic Subaortic | Stenosis

Answer 110

Aortic outflow obstruction from septal | tissue

Answer 111

Similar to aortic stenosis

Answer 112

Narrowing of the thoracic aorta, with or without intraluminal “shelf” (infolding of the media); usually found near ductus/ ligamentum arteriosum

Answer 113

1. Preductal (fatal in infancy if untreated) 2. Juxtaductal 3. Postductal

Answer 114

60% (bicuspid aortic valve is most | common)

Answer 115

Subclavian artery to the IMA to the | intercostals to the descending aorta

Answer 116

Turner’s syndrome, male > female

Answer 117

Headache Epistaxis Lower extremity fatigue → claudication

Answer 118

Pulses: decreased lower extremity pulses Murmurs: 1. Systolic—from turbulence across coarctation, often radiating to infrascapular region 2. Continuous—from dilated collaterals

Answer 119

CXR: “3” sign is aortic knob, coarctation, and dilated poststenotic aorta; rib notching is bony erosion from dilated intercostal collaterals Echocardiogram Cardiac catheterization if cardiac defects

Answer 120

Surgery: Resection with end-to-end anastomosis Subclavian artery flap Patch graft (rare) Interposition graft Endovascular repair an option in adults

Answer 121

Symptomatic patient | Asymptomatic patient >3 to 4 years

Answer 122

``` Paraplegia “Paradoxic” HTN Mesenteric necrotizing panarteritis (GI bleeding), Horner’s syndrome, injury to recurrent laryngeal nerve ```

Answer 123

Aortic dissection, HTN

Answer 124

``` Aorta originates from the right ventricle and the pulmonary artery from the left ventricle; fatal without PDA, ASD, or VSD—to allow communication between the left and right circulations ```

Answer 125

From 5% to 8% of defects

Answer 126

Most common lesion that presents with cyanosis and CHF in neonatal period ( >90% by day 1)

Answer 127

CXR: “egg-shaped” heart contour | Catheterization (definitive)

Answer 128

Arterial switch operation—aorta and pulmonary artery are moved to the correct ventricle and the coronaries are reimplanted

Answer 129

``` Tricuspid valve is placed abnormally low in the right ventricle, forming a large right atrium and a small right ventricle, leading to tricuspid regurgitation and decreased right ventricular output ```

Answer 130

400x the risk if the mother has taken | lithium

Answer 131

Many types; represent an anomalous development of the aorta/pulmonary artery from the embryonic aortic arch that surrounds and obstructs the trachea/esophagus

Answer 132

Barium swallow, MRI

Answer 133

Most prominent is stridor from tracheal | compression

Answer 134

``` Five “Ts” of cyanotic heart disease: Tetralogy of Fallot Truncus arteriosus Totally anomalous pulmonary venous return (TAPVR) Tricuspid atresia Transposition of the great vessels ```

Answer 135

Myxoma in adults

Answer 136

Left atrium with pedunculated morphology

Answer 137

Dyspnea, emboli

Answer 138

Rhabdomyosarcoma

Answer 139

Vast majority result from atherosclerosis, | connective tissue disease

Answer 140

Aortic dissection

Answer 141

≈33%! (Rule out AAA)

Answer 142

Most are asymptomatic Chest pain, stridor, hemoptysis (rare), recurrent laryngeal nerve compression

Answer 143

Routine CXR

Answer 144

CXR, CT scan, MRI, aortography

Answer 145

>6 cm in diameter Symptoms Rapid increase in diameter Rupture

Answer 146

Replace with graft, open or endovascular | stent

Answer 147

Paraplegia (up to 20%) | Anterior spinal syndrome

Answer 148

Syndrome characterized by: Paraplegia Incontinence (bowel/bladder) Pain and temperature sensation loss

Answer 149

Occlusion of the great radicular artery of Adamkiewicz, which is one of the intercostal/lumbar arteries from T8 to L4

Answer 150

Separation of the walls of the aorta from an intimal tear and disease of the tunica media; a false lumen is formed and a “reentry” tear may occur, resulting in “double-barrel” aorta

Answer 151

DeBakey classification | Stanford classification

Answer 152

Involves ascending and descending | aorta

Answer 153

Involves ascending aorta only

Answer 154

Involves descending aorta only

Answer 155

``` Ascending aorta (requires surgery) ± Descending aorta (includes DeBakey types I and II) ```

Answer 156

Descending aorta only (nonoperative, except for complications) (same as DeBakey type III)

Answer 157

``` HTN (most common) Marfan’s syndrome Bicuspid aortic valve Coarctation of the aorta Cystic medial necrosis Proximal aortic aneurysm ```

Answer 158

Abrupt onset of severe chest pain, most often radiating/“tearing” to the back; onset is typically more abrupt than that of MI; the pain can migrate as the dissection progresses; patient describes a “tearing pain”

Answer 159

1. Cardiac tamponade; Beck’s triad— distant heart sounds, ↑ CVP with JVD, ↓ BP 2. Aortic insufficiency—diastolic murmur 3. Aortic arterial branch occlusion/ shearing, leading to ischemia in the involved circulation (i.e., unequal pulses, CVA, paraplegia, renal insufficiency, bowel ischemia, claudication)

Answer 160

``` CXR: 1. Widened mediastinum 2. Pleural effusion TEE CTA (CT angiography) Aortography (definitive gold standard but time-consuming!) ```

Answer 161

``` Surgical because of risk of: 1. Aortic insufficiency 2. Compromise of cerebral and coronary circulation 3. Tamponade 4. Rupture ```

Answer 162

Medical (control BP), unless complicated | by rupture or significant occlusions

Answer 163

Open the aorta at the proximal extent of dissection, and then sew—graft to— intimal flap and adventitia circumferentially (endovascular an option)

Answer 164

Control BP with sodium nitroprusside and -blockers (e.g., esmolol); -blockers decrease shear stress

Answer 165

Lifetime control of BP and monitoring of | aortic size

Answer 166

Dissection involves the coronary arteries | or underlying LAD

Answer 167

Misnomer! Not an aneurysm!

Answer 168

Irregularly irregular

Answer 169

Premature Ventricular Complex: | Wide QRS

Answer 170

ST elevation

Answer 171

ST elevation/ST depression/flipped | T waves

Answer 172

ST elevation throughout leads

Answer 173

Right Bundle Branch Block: wide QRS | and “rabbit ears” or R-R in V1 or V2

Answer 174

Left Bundle Branch Block: wide QRS | and “rabbit ears” or R-R in V5 or V6

Answer 175

Delta wave = slurred upswing on QRS

Answer 176

Prolonged P-R interval (0.2 second)

Answer 177

Dropped QRS; not all P waves transmit | to produce ventricular contraction

Answer 178

Second-degree block with progressive | delay in P-R interval prior to dropped beat

Answer 179

Complete A-V dissociation; random | P wave and QRS

Answer 180

Thrombophlebitis of the | thoracoepigastric veins

Answer 181

Ventricular Assist Device

Answer 182

IntraAortic Balloon Pump has a balloon tip resting in the aorta Balloon inflates in diastole, increasing diastolic BP and coronary blood flow; in systole the balloon deflates, creating a negative pressure, lowering afterload, and increasing systolic BP

Answer 183

I’s and O’s, CXR, JVD, edema, daily | weight

Answer 184

Diastolic murmur of AI secondary to | regurgitant turbulent flow

Answer 185

Coronary sinus

Answer 186

Metastasis

Cardiovascular Surgery, C72 P648-671 Flashcards

(216 cards)