surgical approach to ischaemic heart disease and valvular heart disease

Question 1

indications for coronary artery bypass grafting

Answer 1

symptomatic (angina severe) and prognostic (any anatomy is in danger. usually LMSS or 2 Vdx)

Question 2

selection of patients for CABG

Answer 2

adequate lung function, adequate mental function, adequate hepatic function, ascending aorta OK, distal coronary targets OK, Left ventricular ejection fraction greater than 20%

Question 3

conduits for CABG

Answer 3

reversed saphenous vein, internal mammary arteries, radial arteries

Question 4

sternotomy related issues

Answer 4

wire infection, painful wires, sternal dehiscence, sternal malunion

Question 5

post op problems in cardiac surgery

Answer 5

cardiac tamponade, death, stroke

Question 6

features of cardiac tamponade following surgery

Answer 6

primary- raised JVP, raised heart rate, low BP

secondary- oliguria (low urine output), increased oxygen requirements, metabolic acidosis

Question 7

treatment of cardiac tamponade

Answer 7

chest reopening

Question 8

long term outcomes post CABG

Answer 8

50% have no further issues 10 years later, 5% may require repeat CABG, most issues are minor and can be easily treated or controlled

Question 9

adult cardiac surgery on valvular heart disease

Answer 9

mainly aortic and mitral valve surgery

Question 10

paediatrics cardiac surgery on valvular heart disease

Answer 10

4 heart valves operated with roughly equal frequency

Question 11

three commonest valve problems requiring cardiac surgery in Aberdeen

Answer 11

senile tricuspid aortic stenosis, bicuspid aortic stenosis, degenerative mitral regurgitation (all give systolic murmurs)

Question 12

indications for surgery in endocarditis

Answer 12

severe valvular regurgitation, karge vegetations, persistent pyrexia, progressive renal failure

Question 13

post operative treatment for endocarditis

Answer 13

antibiotics are given IV for 6 weeks post operatively

Question 14

when is aortic stenosis operated on

Answer 14

when AV gradient on the echocardiogram is greater than 50mmHg (severe aortic stenosis)

Question 15

when is aortic regurgitation operated on

Answer 15

severe AR especially with LV dilatation, in severe AR the entire LV is filled with contrast after one diastole interval during aortography, the louder the murmur the more severe the AR

Question 16

when is mitral stenosis operated on

Answer 16

easily heard murmur, if MVAreaon ECHO is less than 1.5cm squared

Question 17

when is mitral regurgitation operated on

Answer 17

severe MR- associated with LV and LA dilatation, onset of AF, pulmonary hypertension, loud murmur, systolic blood flow reversal in pulmonary veins on ECHO

Question 18

cardiopulmonary bypass

Answer 18

used to drain blood from right atrium and returned to aorta, heart and lung function taken over by CPB machine, systemic anticoagulation necessary, induced hypothermia, non pulsatile flow during CPB, max time limit 12 hours,

Question 19

choice of heart valve prosthesis

Answer 19

biological valve- no warfarin req but valve wears out after 15 years
mechanical- warfarin req for life, valve lasts more than 40 years

Question 20

max cardiac ischaemic time is

Answer 20

6 hours

Question 21

perfusionists

Answer 21

operate CPB machine

Question 22

issues with CPB

Answer 22

coagulation, air embolism

Question 23

air embolisms are more common in

Answer 23

open cardiac procedures such as valve replacement then in closed cardiac operations such as CABG

Question 24

ECMO

Answer 24

machine that oxygenates blood and pumps it back into body bypassing the lungs so that heart keeps beating. used for severe covid 19

Question 25

mitral valve repair used when

Answer 25

possible in many cases of degenerative MR. when complete valve competence is restored, repair is better than replacement for mitral valve