Valvular & ischaemic heart disease therapy/surgery Flashcards by Michael Alcorn

Summarise the causes of cardiac ischaemia

Atherosclerosis
Embolism
Coronary thrombosis
Aortic dissection

Arteritides
Congenital

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What does ‘arteritides’ mean?

Arteritis (type of vasculitis) is inflammation of the arterial walls caused by infection or autoimmunity

Can cause thrombosis which will cause Cardiac ischaemia if in coronary arteries

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Summarise the clinical manifestations of Ischaemic heart disease

Angina
MI
Arrythmias
Chronic heart failure
Sudden death

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Coronary artery disease (IHD) can be classed by what coronary arteries are affected

Give 2 examples of types of coronary artery disease

Left main stem stenosis - (left coronary artery stenosis)

3 vessel coronary artery disease

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In 3 vessel CAD, what coronary arteries are affected?

left anterior descending

Circumflex

Right coronary artery

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What is CABG?

Coronary artery bypass graft

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What are the criteria for selecting patient’s for CABG?

Lung function
Hepatic function
Mental function
Heart function - LV ejection fraction > 20%

Ascending aorta
Distal coronary targets

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One of the criteria for CABG patients is ‘DIstal coronary targets must be okay’

What is meant by this?

Must be suitable vessel for the bypass to be connected to

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In CABG surgery, what is a Conduit?

Vessel to be used for the bypass

This can be synthetic, but is usually just a vessel from elsewhere in the body

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What vessels in the body are used for Conduits?

Reversed saphenous vein - from leg

Internal mammary arteries - aka Internal thoracic arteries from chest

Radial arteries - arm

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What is a ‘Median Sternotomy’?

Surgical procedure in which a vertical inline incision is made along the sternum, after which the sternum itself is divided, or “cracked”

Allows access to heart for CABG

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What complications are associated with a sternotomy?

Wire infection

Painful wires

Sternal dehiscence:

process of separation of the bony sternum
often is accompanied by mediastinitis (infection of the deep soft tissues)

Sternal malunion:
- Sternum doesn’t join back together properly

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What are the main risks to patients post cardiac surgery

Stroke

Death

Cardiac tamponade:
- accumulation of fluid in the pericardial space

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How is cardiac tamponade bad for heart function?

Fluid accumulation results in reduced ventricular filling and subsequent hemodynamic compromise

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How would you identify a patient with cardiac tamponade?

Raised CVP,
Raised HR
Low BP

Oliguria (don’t pass urine)
Increased oxygen requirements
Metabolic acidosis

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How is cardiac tamponade fixed?

Chest reopening

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What are the long term outcomes for CABG patients?

50% have no further cardiac problems in 10 years

Of the 50% that do:

Most problems are minor and treated with medication
5% of patients may require a repeat CABG

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Contrast valvular heart disease surgery in adults & children

Adults - Mainly aortic & mitral valve surgery

Children - All 4 valves operated on at pretty much the same frequency

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What are the causes of valvular heart disease in adults?

Degenerative
Congenital
Infective
Inflammatory 
LV or RV dilatation
Trauma
Neoplastic 
Paraneoplastic

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What are the most common valves that are diseased/require surgery?

(in aberdeen)

Senile tricuspid AS

Bicuspid AS

Degenerative MR

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The Antistreptolysin O (ASO) titre test is used to test for what?

Rheumatic fever

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Why is Rheumatic fever linked to CVS disease?

RF causes pancarditis

Chronic rheumatic heart disease:
- Gradually progressive MVDx +/- AVDx

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What tends to cause rheumatic fever?

Streptococcal infections

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Rheumatic fever can cause a disorder characterised by uncontrollable twitching/jerking of parts of the body

What disorder is this?

Study These Flashcards

Sydenham’s chorea/ St Vitus’ Dance

streptococcal infections

Why is chronic rheumatic heart disease clinically important?

Worldwide most common heart problem Major cause of death in pregnancy Can cause cardiac surgery to be undertaken during pregnancy

What is Endocarditis?

Infection of endocardium

What causes endocarditis?

Bacterial infection: Strep viridans - Most common - SUB-ACUTE bacterial endocarditis Staph aureus - ACUTE bacterial endocarditis

Why does endocarditis have clinical manifestations involving heart valves?

Endocardium makes up the valves Therefore - damage to endocardium = damage to valves

How is endocarditis treated?

Antibiotics - if bacterial

The outcomes of antibiotic treatment of Valve endocarditis vary depending on the valves that are infected Describe the differences in outcomes

'Native' valve endocarditis (NVE): - 90% success from just Abx Prosthetic valve endocarditis (PVE)" - 50% success from just Abx

Another factor that determines how effective antibiotic treatment for Valvular endocarditis is, is what bacteria caused the infection Explain this

Bacterial infection of either Strep viridans or Staph aureus Strep viridans is easier to treat so success is higher than that of Staph aureus

If antibiotics do not cure valvular endocarditis, what happens?

Surgery (if suitable)

What are the indications for surgery for endocarditis?

Severe valvular regurgitation Large vegetations Persistent pyrexia Progressive renal failure

How are patients managed after they have received surgery for endocarditis?

IV antibiotics for 6 weeks post surgery

How does aortic stenosis present?

Usually through secondary effects: - Heart failure - Angina - Syncope / presyncope Incidental finding

How can aortic stenosis be identified on examination?

Auscultation: - Systolic murmur - Loss of aortic S2 sound (separates it from aortic sclerosis)

How can aortic stenosis be identified on an ECHO?

Left ventricular hypertrophy

Why can't LVH be identified on palpation?

Right ventricular hypertrophy causes a palpable HEAVE But LVH does not (usually) cause a heave

Why is an ECG useful for identifying Aortic stenosis?

AV gradient > 50mmHg = Aortic stenosis

What is the treatment for severe Aortic stenosis?

Replacement of Aortic valve | AVR

Aortic regurgitation & aortic stenosis can present with similar signs What are the signs of Aortic regurgitation, and how can the symptoms be used to differentiate between the two?

Heart failure Angina Aortic stenosis also causes syncope episodes so if patient had fainted or whatever, then that would indicate aortic STENOSIS and not regurgitation

How could you differentiate between Aortic regurgitation & aortic stenosis on examination?

Aortic stenosis = systolic murmur Aortic regurgitation = diastolic murmur (hard to hear)

If severe aortic regurgitation persists for a long time, what effect can it have on the heart?

LV dilation

How would aortography be used to diagnose severe aortic regurgitation?

Imaging would show the entire LV is filled with contrast after one diastolic interval

How does mitral valve stenosis sound on auscultation?

Murmur is usually difficult to hear (May have to exercise the patient to hear the murmur) If easily heard then the stenosis is severe Presystolic accentuation may be present

Because auscultation for mitral valve stenosis is fairly difficult, what other investigative technique is important?

ECHO

ECHO investigation can identify severe mitral stenosis & indicate the need for surgery How would an ECHO indicate that MVS is severe enough?

Surgery recommended if MVA on ECHO is < 1.5cm2

Which is easier to hear, Mitral stenosis or regurgitation?

Mitral regurgitation easily heard

What are the effects of severe mitral regurgitation on the Cardiovascular system?

Severe MR is associated with LV and LA dilatation, onset of AF and pulmonary hypertension

How would an ECHO indicate severe Mitral regurgitation?

Severe MR on ECHO characterised by systolic blood flow reversal in the pulmonary veins Severe MR = MVR surgery needed

Heart valve replacement surgery requires surgeons to be cutting up someones heart - meaning its not working (obviously) What bit of machinery is thus needed for this surgery?

Cardiopulmonary bypass machine Operated by perfusionists

How is the flow of blood different using a CPB machine?

Non-pulsatile flow

What type of drugs are needed when using CPB?

Systemic anti-coagulants | This creates the risk of coagulopathy

What happens to a patients body temperature when using a CPB machine?

Induced hypothermia No clue why

What is the time limit on cardiac surgery using a CPB machine?

12 hours max Maximum cardiac ischaemic time is 6 hours

What is a specific risk associated with open surgery, such as valve replacement surgery?

Air embolism

What are the 2 types of replacement valves, and the advantages/disadvantages of each

Biological valve: - No warfarin needed, however, it wears out after 15 years Mechanical valve: - Warfarin needed, but it lasts much longer > 40 years

Is Valve replacement the only surgical option for treating all these valve problems?

Mitral valve repair is often possible for degenerative Mitral regurgitation This is preferred to replacement if full competence can be restored

Valvular & ischaemic heart disease therapy/surgery Flashcards

(58 cards)