What are symptoms of vascular rings
- stridor
2. crowing respiration (baby assumes hyperextended position). If only respiratory Sx then think of tracheomalacia
How do you dx vascular rings?
barium swallow and bronchoscopy (rules out tracheomalacia)
What is the treatment for vascular rings?
divide smaller of the 2 aortic arches
What is the best way to dx morphologic cardiac anomalies?
Echo
How do L to R shunts present?
murmur, pulmonary circulation overload, long term damage to pulmonary vasculature
Murmur of ASD
systolic flow murmur w/ fixed split 2nd heart sound
When is an ASD ususally dxed?
- late infancy. hx of frequent colds is common
How do most VSD’s present?
if they high in the membranous septum - they have FTT, loud pansystolic murmur at LSB, increased pulmonary vasculature on CXR
- if the VSD is small and low in muscular septum they ususally close in first 2-3 years of life
How do R to L shunts present?
presence of murmur, cyanosis.
What is the MC cyanotic anomaly 2/2 to the heart?
TOF
How does TOF present?
- small kids, bluish hue in lips, spells of cyanosis relieved by squatting
- systolic ejection murmur in left 3rd ICS
CXR findings of TOF
- small heart, diminished pulmonary vascular markings,
EKG of TOF
RVH
Tell me about TGA
- kept alive by ASD, VSD, or PDA>
- think of this in a 1 or 2 day old baby with cyanosis.
- get ECHO!
When to repair aortic stenosis
if gradient or more than 50 mmHg or at first indication of CHF, angina, or syncope
When should chronic AR be repaired?
- at first evidence on ECHO of beginning LV diltation
When is acute AR seen?
- endocarditis in young drug addcits who develop CHF and new murmur. Replace valve and start long term ABx
Associations with Mitral Stenosis
- think rheumatic fever
2. as it progresses patient become thin and cachectic and get a fib.
How is mitral stenosis repaired?
- surgical commissurotomy or balloon valvuloplasty
What is the post op care of heart surgery patients?
- optimize CO. if not normalget PCWP. if Low give IVFs if high it means ventricular failure
How does chronic constrictive pericarditis present?
- DOE, hepatomegaly, ascites
2. equalization of pressures on cardiac cath
Workup for suspected cancer of lung?
- get CXR
- sputum cytology
- CT scan for staging
How do you dx lung cancer?
- Cytology of sputum
- bronchoscopy for central bx
- percutaneous for peripheral bx
- if above unsuccessful do VATS and wedge resection
How to treat small cell cancer of lung?
chemo and radiation
How is operability of lung cancer determines?
on residual function after resection.
- central lesions require pneumonectomy
- peripheral ones can be removed w/ lobectomy
- Minimum FEV1 of 800mL is needed
What to do about lung cancer mets?
- hilar mets can be removed w/ pneumoectomy
2. nodal mets at carina or mediastinum preclude curative resection
How to dx lung cancer mets?
- CT
- PET
- endobronchial US - invasive option to sample mediastinal nodes
- cervical medistainal exploration is rarely needed
What is subclavian steal syndrome?
- arteriosclerotic stenotic plaque at origin of subclavian allows enough blood supply to reach the arm for normal activity but doesn’t allow enough to meet higher demands when arm is exercised
- so then arm sucks blood away from the brain by reversing flow in the vertebral artery.
What are the Sx of subclavian steal syndrome?
- arm claudication, posterior neurologic signs
- if only vascular Sx were present think of thoracic outlet syndrome.
How to dx subclavian steal syndrome?
- duplex scanning. Bypass surgery cures it
What to do with the different AAA sizes?
- < 4 cm, observe
- 5-6 cm have elective repair
- if grows 1 cm per year or faster do repair
how are most AAA treated now?
endovascular stents. These cases are unruptured and the neck should be at least 2.5 cm
What to do in pt w/ excruciating back pain in a patient w a large abdominal aortic anuerysm.
retroperitoneal hematoma is already forming so do emergent surgery.
What is the workup of disabling intermittent LE claudication?
- Doppler students for pressure gradient
2. CT angio or MRI angio to look for stenosis or complete obstruction and to look for a good distal vessel for a graft
What is the treatment of stenotic LE vascular segments?
- short ones - angioplasty and stenting
- extensive - bypass grafts
- multiple lesions - repair proximal ones
- if grafts originate at aortobifemoral do prosthetic. for distal vessels use reversed saphenous grafts
Arterial embolization from distant source Rx?
- early incomplete occlusions - do clot busters
- embolectomy w/ Fogarthy catheter for complete obstruction
- Fasciotomy if several hours have passes before revascularization
Who gets dissecting aneuryms of thoracic aorta?
poorly controlled HTN
- resembles an MI, pain radiates to back. unequal pules in UE. Xray shows wide mediastinum
- do EKG and cardiac enzymes to r/o MI.
- dx by noninvasive means first. Get spiral CT
How to treat aortic dissections?
- ascending ones - surgery
2. descending ones - control HTN