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What artery is most often used in CABG?

Internal mammary artery, usu to LAD


How does intra-aortic balloon pump work?

Inflates during diastole to increase coronary artery flow. Deflates during systolic to create negative pressure, decreasing afterload.


What valvular disease may cause hoarse voice?

Mitral stenosis -> left atrial dilation and impingement on recurrent laryngeal nerve


Nonsurgical choices for mitral stenosis?

Endocarditis ppx, tx for heart failure, tx afib if present. Balloon valvuloplasty works pretty well (unlike for aortic stenosis)


Surgical choices for mitral stenosis

Open commissurotomy: incise fused leaflets, debride calcification etc. Valve replacement: if too much debridement would be required. Minimally invasive MV surgery (port access).


Causes of mitral insufficiency (MR)

Papillary muscle dsyfunction (ischemia, infarction), rupture of chordae tendinae, damage to valve from rheumatic dz or post-endocarditis, prolapse that has progressed to incompetence.


Why is there a widely split S2 in cases of severe MR?

Premature emptying of LV


Why is there paradoxical splitting of S2 in aortic stenosis?

Delayed emptying of the LV


Indications for aortic stenosis surgery (valve replacement)

Any symptoms; no symptoms with high transvalvular gradient and LVH or declining LVEF; valve area


Causes of aortic regurgitation

Aortic root dilation: idiopathic (e.g. HTN and age), Marfan, collagen vascular disease. Valvular: rheumatic heart disease, endocarditis. Proximal aortic root dissection: cystic medial necrosis, syphilis, HTN, Ehlers-Danlos, Turner syndrome, third trimester.


What's the deal with cystic medial necrosis of the aorta?

Familial thoracic aortic aneurysm (also referred to as familial aortic dissection or cystic medial necrosis of aorta) is an autosomal dominant disorder of large arteries.
Assoc with Marfan syndrome, massive baclofen overdose, and other hereditary connective tissue disorders. A degenerative breakdown of collagen, elastin, and smooth muscle caused by aging -> weakening of aortic wall.


Causes of tricuspid stenosis

Rheumatic heart disease, congenital, carcinoid tumor associated


How to tell tricuspid stenosis murmur from mitral stenosis murmur?

Both are rumbling diastolic murmurs, however tricuspid murmur will increase with inspiration


Causes of tricuspid regurgitation

Increased PAP (e.g. left-sided failure or mitral regurg/stenosis). RV dilation. Right papillary muscle rupture (infarction). Tricuspid valvular lesions (rheumatic heart disease, endocarditis).


Murmur of tricuspid regurgitation

Holosystolic, blowing murmur accentuated with inspiration


What is a common complication of tricuspid valve replacement?

Heart block, due to close proximity of conduction bundle to tricuspid annulus (see attached)


Valve prostheses types

Mechanical: last longer but need to have lifelong anticoagulation. Bioprosthetic: less durable, no need for anticoag but don't last as long, better for elderly


Small cell lung cancer

Centrally located. Sensitive to chemo, no surgery indicated. Poor prognosis, majority are metastatic at time of diagnosis.


Non-small cell lung cancer

Includes squamous cell, large cell, and adenocarcinoma. Not very responsive to chemo. Debulking surgery indicated. Malignant pleural effusion precludes curative resection. Prognosis varies with type/stage.


Squamous cell cancer location

Central (remember: centrally located lung cancer are the two "S"entral ones: small cell and squamous


Adenocarcinoma and large cell lung cancer are located..?



Lambert-Eaton syndrome

Antibodies against presynaptic nerve terminals decrease ACh release. 40% of cases assoc with small cell lung cancer


Two main types of thoracic aortic aneuryms

Degenerative: due to abnl collagen metabolism, such as Ehlers-Danlos, Marfan. Atherosclertoic: due to remodeling and dilation of aortic wall.


DeBakey classification

Type I: ascending and descending
Type II: ascending only
Type III: descending only


Stanford classification

Stanford A: ascending aneurysm
Stanford B: descending aneurysm

NB: ascending is worse


Diagnosis of aortic dissection

CXR first. Stable: CT angio. Unstable: echo (TEE or TTE)


Treatment of aortic dissection

Control HTN with beta-blocker. Surgical repair (only 1/2 of those that make it to surgery survive)


What is one major complication of aortic aneurysm repair?

Paraplegia (due to anterior spinal artery ischemia)


Crawford classification of abdominal aortic aneurysm

Type I: most of descending thoracic aorta + abdominal aorta proximal to renal arteries.
Type II: most of descending thoracic aorta + abdominal aorta distal to renal arteries.
Type III: distal 1/2 of descending thoracic aorta + abdominal aorta proximal to renal arteries
Type IV: distal 1/2 of descending thoracic aorta + abdominal aorta distal to renal arteries


Screening for AAA

One time US screening for any male that ever smoked, from age 65-75