Chapter 6 - Cardiothoracic Surgery

Question 1

When a child has expiratory wheezing, it suggests ___.

Answer 1

Bronchoconstriction, i.e., asthma

Question 2

When a child has inspiratory wheezing, it suggests ___. If the child also has difficult swallowing, as well as episodes of respiratory distress, with crowing respiration, stridor, and hyperextension of the neck, what is the problem?

Answer 2

Tracheomalacia, where the tracheal rings collapse

Vascular ring, a congenital anomaly in which the trachea and esophagus are encircled by abnormal blood vessels

Question 3

Dx and Rx vascular ring?

Answer 3

Extrinsic compression demonstrated by barium swallow and bronchoscopy

Surgery divides the smaller of the two aortic arches

Question 4

Dx morphologic cardiac anomalies (congenital or acquired)?

Answer 4

Echo

Question 5

Presentation of L to R shunts in general?

Answer 5

Murmur
Overloading of pulmonary circulation with long-term damage to the pulmonary vasculature

(Volume and consequences of shunt vary based on location)

Question 6

List the 3 major L to R shunts.

Answer 6

ASD
VSD
PDA

Question 7

Presentation of ASD?

Answer 7

Very minor, low-pressure, low-volume shunt
Typically recognized in late infancy
Pulmonary flow systolic murmur and fixed split second heart sound
History of frequent colds

Question 8

Rx ASD?

Answer 8

Closure can be achieved surgically or by cardiac catheterization

Question 9

Presentation of a small, restrictive VSD low in the muscular septum?

Answer 9

Murmur, but otherwise few symptoms

Question 10

Rx small restrictive VSD low in the muscular septum?

Answer 10

None - likely to close spontaneously within the first 2-3 years

Question 11

Presentation of VSD (typical location high in the membranous symptom)

Answer 11

Failure to thrive in the first few months
Loud pansystolic murmur best heard at the left sternal border
Increased pulmonary vascular markings on CXR

Question 12

Rx VSD?

Answer 12

Surgical closure

Question 13

Presentation of PDA?

Answer 13

Symptomatic in the first few days of life
Bounding peripheral pulses
Continuous machinery-like heart murmur

Question 14

Rx PDA?

Answer 14

Premature infants who have not gone into CHF - indomethacin

Premature infants who fail indomethacin, those already in failure, and full-term babies -> surgical division or radiological embolization with metal coils

Question 15

Shared features of a R to L shunt?

Answer 15

Murmur
Diminished vascular markings in the lung
Cyanosis

Question 16

List the 2 most common R to L shunts.

Answer 16

1. Tetralogy of Fallot (most common)

2. Transposition of the great vessels

Question 17

Presentation of Tetralogy of Fallot?

Answer 17

Allows children to grow up into infancy
Small for their age
Bluish hue in the lips and tips of fingers
Clubbing
Spells of cyanosis relieved by squatting
Systolic ejection murmur in the L 3rd intercostal space
Small heart
Diminished pulmonary vascular markings on CXR
EKG signs of RVH

Question 18

Rx Tetralogy of Fallot?

Answer 18

Surgical repair

Question 19

Presentation of transposition of great vessels?

Answer 19

Kept alive by ASD, VSD, PDA, or a combination, die if not corrected
1 or 2-day-old child with cyanosis who is in deep trouble

Question 20

Presentation of aortic stenosis?

Answer 20

Angina and exertional syncopal episodes

Harsh mid-systolic heart murmur heard best at the R second intercostal space and along the L sternal border

Question 21

Work-up for suspected aortic stenosis?

Answer 21

Start with echo

Question 22

When is surgical valvular replacement indicated in aortic stenosis?

Answer 22

If there is a gradient of more than 50 mm Hg

At the first indication of CHF, angina, or syncope

Question 23

Presentation of chronic aortic insufficiency?

Answer 23

Wide pulse pressure
Blowing high-pitched, diastolic heart murmur best heard at the second intercostal space and long the left lower sternal border with the patient in full expiration

Question 24

Rx chronic aortic insufficiency?

Answer 24

Medical therapy for many years

Should undergo valvular replacement at the first evidence on echo of beginning left ventricular dilatation

Question 25

Presentation in acute aortic insufficiency?

Answer 25

2/2 endocarditis - young drug addicts who suddenly develop CHF and a new loud diastolic murmur at the R second intercostal space

Question 26

Rx acute aortic insufficiency (2/2 endocarditis)?

Answer 26

Emergency valve replacement | Long-term ABX

Question 27

Who needs antibiotic prophylaxis for subacute bacterial endocarditis?

Answer 27

Patients with a prosthetic valve

Question 28

Presentation of mitral stenosis?

Answer 28

Caused by rheumatic fever many years before presentation Produces dyspnea on exertion, orthopnea, PND, cough, hemoptysis Low-pitched, rumbling diastolic apical heart murmur With progression, patient becomes thin and cachectic and develop AF

Question 29

Work-up and Rx mitral stenosis?

Answer 29

Start with echo | As symptoms become more disabling, MV repair becomes necessary with a surgical commissurotomy or a balloon valvuloplasty

Question 30

Presentation of mitral regurgitation?

Answer 30

Most commonly caused by valvular prolapse Develop exertional dyspnea, orthopnea, and AF Apical, high-pitched, holosystolic heart murmur that radiates to the axilla and back

Question 31

Work-up and Rx mitral regurgitation?

Answer 31

Start with echo As symptoms become disabling, symptoms become necessary with repair of valve (annuloplasty) preferred of prosthetic replacement

Question 32

Typical patient with coronary disease?

Answer 32

Middle-aged sedentary man with a family history, history of smoking, DM2, and hypercholesterolemia

Question 33

Main reason to do a cardiac catheterization?

Answer 33

Progressive, unstable, disabling angina, evaluate candidacy for revascularization

Question 34

When is revascularization indicated?

Answer 34

If 1+ vessels have 70% or greater stenosis and there is a good distal vessel.

Question 35

Rx options for coronary artery disease?

Answer 35

The general rule is the simpler the problem, the more it is amenable to angioplasty and stent whereas more complex situations do better with surgery. Single vessel disease that is not the left main or the anterior descending is perfect for angioplasty and stent Triple vessel disease makes multiple coronary bypass (using the internal mammary for the most important vessel) the best choice.

Question 36

Post-op care of heart surgery patients often requires that cardiac output be optimized. If CO is considerably under normal (___), what should be measured? Low numbers suggest what? High numbers?

Answer 36

5 L/min or a cardiac index of 3 Pulmonary wedge pressure or left atrial pressure or left end-diastolic pressure ``` Low numbers (0-3) - more IV fluids High numbers (20+) - ventricular failure ```

Question 37

A coin lesion found on CXR has what % chance of being malignant in people over the age of 50 and even higher if there is a history of smoking?

Answer 37

80

Question 38

Work-up of coin lesion?

Answer 38

First step is always to seek an older CXR, as a 1-2 year old CXR showing the same unchanged lesion is not cancer. If not available, or the lesion was not present in a previous film, some do a biopsy right away. However, it is prudent to do non-invasive studies before invasive ones, and thus I suggest that the next step should be sputum cytology and CT scan of the chest and upper abdomen to look for mets.

Question 39

If not established by cytology, how is cancer of the lung diagnosed?

Answer 39

Bronchoscopy and biopsy for central lesions or percutaneous biopsy for peripheral lesions If unsuccessful -> video-assisted thoracic surgery (VATS) and wedge resection may be needed.

Question 40

What determines how far you progress through the work-up for possible lung cancer (beyond sputum cytology and CT scan)?

Answer 40

Probability of cancer (higher in elderly with history of smoking and non-calcified lesion in CT) Assurance that surgery can be done (residual pulmonary function will suffice) Chances that the surgery may be curative (no mets to mediastinal or carinal nodes, the other lung, or the liver)

Question 41

Rx small cell cancer of the lung?

Answer 41

Chemo and radiation NOT SURGERY - operability and possibility of surgical cure applies only to non-small cell cancer

Question 42

What determines operability of lung cancer?

Answer 42

Residual function after resection (assuming pneumonectomy is required; for lobectomy, function is less of an issue)

Question 43

What types of lesions require pneumonectomy vs. lobectomy?

Answer 43

Central lesions - pneumonectomy | Peripheral lesions - lobectomy

Question 44

For pneumonectomy, what is the minimum FEV1 needed?

Answer 44

800 mL

Question 45

How should the decision be made regarding operability of lung cancer?

Answer 45

Minimum FEV1 800 mL needed If clinical findings (COPD, SOB) suggest this may be the limiting factor, PFTs are done. Determine FEV1, determine fraction that comes from each lung (VQ scan), figure out what would remain after pneumonectomy. If less than 800 mL, stop - not a surgical candidate. Treat w/chemo and radiation

Question 46

Potential cure by surgical removal of lung cancer depends on the extent of ___. Discuss.

Answer 46

Mets; hilar mets can be removed with the pneumonectomy, but nodal mets at the carina or mediastinum preclude curative resection. CT may identify nodal mets. Addition of PET scanning has helped define the presence of an actively growing tumor in enlarged nodes. Endobronchial U/S is more invasive option to sample mediastinal nodes. Mets to other lung, adnrela, or liver should be evidence on CT

Question 47

Immunotherapy options for Rx of non-small cell lung cancer?

Answer 47

Pembrolizumab and nivolumab