CABG & Valve repair/replacement sx PPt (test #2) josh's take Flashcards
what 2 items make up the cardiac skeleton
- tough fibrous rings surrounding Av valves
- 2 additional fibrous annuli develop in relation to the base of the aorta and the pulmonary trunk
the tough fibrous rings surrounding the AV valves are what?
the points of attachment
what is the fixation point for cardiac musculature?
annulus fibrosis
picture of the skeleton of the heart we just went over
2 chambers of the heart
ventricles
atria
which chamber is smaller and thinner
atria
the ventricles muscles are thicker than the atria which venticle is thicker? for extra credit what are their “nomal thickness?”
left
left is usually 1 cm thicker than right
right 0.5 cm
left 1.5 cm thick
RIGHT ATRIUM:
muscle wall thickness of what?
2mm
RIGHT ATRIUM:
recieves blood from where?
SVC
IVC
Coronary sinus (dont forget this one)
RIGHT ATRIUM:
consist of what 2 parts?
anterior
posterior
RIGHT ATRIUM:
which part is thin walled TRABECULATED portion?
which part is smooth walled portion?
- Anterior
- Posterior
RIGHT ATRIUM:
what 2 things are contained in it?
- intraatrial septum
- fossa ovalis cordis t(he fossa ovalis is a depression in the right atrium of the heart, the remnant of a thin fibrous sheet that covered the foramen ovale during fetal development.)
RIGHT VENTRICLE:
the RV ejects blood throught the_______ into the ________ for gas exchange in the lungs
pulmonary valve
pulmonary arteries
RIGHT VENTRICLE:
what is the muscle wall thickness?
4-5 mm (note mm not cm)
RIGHT VENTRICLE:
the papillary muscles attach to the ______ ______ and _____ _______
ventricular walls
chordae tendineae
RIGHT VENTRICLE:
the chordae tendineae and papillary muscles help prevent what?
the eversion of the tricuspid valve.
RIGHT VENTRICLE:
recap all of that shit!! include papillar muscles, what they do, and all other structures!!
papillary muscles attach to the VENTRICULAR WALLS and CHORDAE TENDINEAE
the CHORDAE TENDINEAE attach to the cusp of the TRICUSPID VALVE
The CHORDAE TENDINEAE and PAPILLARY MUSCLES help prevent the eversion if the tricuspid valve!!!
got it get it good
LEFT ATRIUM:
is a reservoir for what?
oxygenated blood from the pulmonary veins
LEFT ATRIUM:
provides a ___-___% increase in LVEDV called the “____ ____”
20-30%
“atrial kick”
LEFT ATRIUM:
diastolic dysfunction + loss of “atrial kick” = what?
impaired CO
LEFT ATRIUM:
is located posterior to what?
Left pulm artery
LEFT ATRIUM:
has a muscle wall thickness of what?
3 mm
LEFT ATRIUM:
is the LA wall rough or smooth
smooth motha fucker
LEFT VENTRICLE:
ejects blood into what?
the aorta
LEFT VENTRICLE:
what is the wall thickness
8-15mm
LEFT VENTRICLE:
what separates the RV from the LV?
ventricular septum
LEFT VENTRICLE:
the upper 1/3 of the ventricular septum is what?
the remaining 2/3rds of the septum and the rest of the ventricular wall is covered with what?
- smooth endocardium
- trabeculae carneae ( rounded or irregular muscular columns which project from the inner surface of the right and left ventricles of the heart.[1] They should not be confused with the pectinate muscles, which are present in the right atrium[1] and right and left auricle only.)
LEFT VENTRICLE:
present in the LV are 2 large _____ muscles?
papillary muscles
LEFT VENTRICLE:
Chordae tendineae of each of the 2 large papillary muscles are attached to the cusps of what?
mitral valve
CARDIAC VALVES:
ideally cardiac valves flow in what direction?
one way
CARDIAC VALVES:
open and close in response to what?
pressure gradients
and
action of papillary muscles
CARDIAC VALVES:
what are the 2 valves
AV
semilunar
TRICUSPID VALVE:
LOCATED WHERE?
right AV orfice
TRICUSPID VALVE:
are the 3 leaflets equal or unequal in size?
unequal
TRICUSPID VALVE:
what are the names of the 3 leaflets?
anterior
septal
posterior
TRICUSPID VALVE:
what is the normal area?
7 cm2
what valve has the largest area?
TRICUSPID VALVE:
MITRAL VALVE:
IS LOCATED WHERE?
left AV orfice
MITRAL VALVE:
how many leaflets does it have
2 all others 3
MITRAL VALVE:
the 2 major leaflets are connected by what?
commissural tissue
MITRAL VALVE:
what are the 2 leaflets named
anteromedial
posteriolateral
MITRAL VALVE:
of the 2 leaflets which one is easier to diagnose and repair? and why?
posteriolateral
b/c feild of view is better
Freddo
Cold
MITRAL VALVE:
what is normal surface area
4-6 cm2
SEMILUNAR VALVES:
what are the 2 valves?
aortic and pulmonary
SEMILUNAR VALVES:
are their valve configeration similar?
yepper!!!
SEMILUNAR VALVES:
which valve is slightly thicker?
why?
Aortic
due to higher pressures
SEMILUNAR VALVES:
are located where?
within the outflow tracts of their corrosponding ventricles
SEMILUNAR VALVES:
each valve has how many cusp ( i think cusp and and leaflets are interchangable)
3
SEMILUNAR VALVES:
normal aortic valve area in what?
1-3 cm2
self reminder!!
go back and do cards on NYHF scale
METs
canadian heart scale
PREOPERATIVE EVALUATION:
regardless of pathology preoperative evaluation should be primarily concerned with determining what?
- severity of disease
- hemodynamic signifigance
- residual ventrcular function
- presence of secondary effects on organ function
PREOPERATIVE EVALUATION:
how do you see if there is presence of secondary effects on organ function?
check labs is the heart fucking with their kidneys? check BUN?creatinine etc
PREOPERATIVE EVALUATION:
valvular heart disease history should focus on what? (4 things)
- functional class
- medication review
- concominant symptoms
- concominant CAD
PREOPERATIVE EVALUATION:
******
what are the 2 most major test to perform
ECHO
Left Heart Cath
(stress test not that important)
PREOPERATIVE EVALUATION:
what is teh gold standard for eval of valvular disease and ventricular function?
ECHOcardiography
PREOPERATIVE EVALUATION:
what are the 5 things the ECHO shows
- systolic/diastolic dysfunction
- LV muscular abnormalities
- intr-chamber defects
- Septal Abnormalities
- measures areas and estimates pressures
PREOPERATIVE EVALUATION:
what estimates pressures better? a cath or echo?
ECHO
PREOPERATIVE EVALUATION:
what type of ECHO is bets for mitral valve
TEE
PREOPERATIVE EVALUATION:
CAD:
what is the gold standard for preop eval?
coronary angiography
PREOPERATIVE EVALUATION:
CAD:
Why is coronary angiography the gold sandard for pr-op eveak?
direct engagement of coronary ostia with radio-opaque dye
PREOPERATIVE EVALUATION:
CAD:
what does the Coronary angiography show or do?
estimates areas
measures pressures
PREOPERATIVE EVALUATION: things to know
ECHO report
- valvular abnormalities
- areas
- pressure gradients
- pulmHTN
- LV function
PREOPERATIVE EVALUATION: things to know
LHC
- blockages/vessels
- LV function
- pressure gradients
- pulmHTN (RHC)
PREOPERATIVE EVALUATION: things to know
besides ECHO report and LHC report, what other 3 important things do you want to now about??
functional capacity
pressence of conduit (make sure they have grafts left)
recent infections
VALVE REPLACEMENT:
All valvular lesions can be classified in the same way! what is the phrase to help classify/differentiate them
“the_______ vale fails to open/close*** properly during ventricular ***systole/diastole”
note to self
get old murmur shit from health assessment
AVR:
describe of Aortic stenosis (AS)
“the_______ valve fails to open/close properly during ventricular systole/diastole”
“the Aortic valve fails to open*** properly during ventricular ***systole”
AVR: AS
is caused by what?
- rhumatic, bicuspid calcification origins
AVR: AS
complications!
- LVH
- prone to dysrhymias
- ****toeratesl tachy poorly****
AVR:
Aortic insufficiency (i am guessing regurg)
“the_______ valve fails to open/close properly during ventricular systole/diastole”
“the Aortic valve fails to close*** properly during ventricular ***diastole”
AVR: AI
caused by what?
- Annuluar dilation
- chordae rupture
AVR: AI
is often present with what other d/o as well?
AS (aortic stenosis)
AVR:
The surgical procedure is on full ______, and is usually performed through a median sternotomy incision
CPB
AVR:
Cardioplegia is often acheived how?
Antegrade and retrograde
AVR:
after the heart is arrested how is the rest of the sx performed?
- the aorta is opened to expose the AV
- leaflets removed and annulus debreded piecemeal
- prosthesis lowered into annulus and securely sutured in place
MVR:
Mitral Stenosis (MS)
“the_______ valve fails to open/close properly during ventricular systole/diastole”
“the Mitral valve fails to open properly during ventricular diastole”
AVR: MS
causes
- rheumatic (frequent origin)
MVR: MS
can cause what complications?
backing up up blood
- puml HTn
- Pulm Edema
- Afib
- Low CO (with normal EF)
MVR: MS
why is there a low CO but a normal EF remains?
b/c you are still ejecting 60% of LVEDV, but due to the restristion in filling the LV there is a low amount to actually eject
MVR:
Mitral regurgitation (MR)
“the_______ valve fails to open/close properly during ventricular systole/diastole”
“the mitral valve fails to close properly during ventricular systole”
MVR: MR
Common causes
- single leafelet pathology
- ruptured chord
MVR: MR
effects caused from MR
- Pulm HTN
- pulm edema
- A-fib
- Low CO (with normal EF)
“the_______ valve fails to open/close properly during ventricular systole/diastole”
Name them all!!!!
- Aortic stenosis (AS)
- Aortic insufficiency (AI)
- Mitral Stenosis (MS)
- Mitral Regurgitation (MR)
- “the Aortic valve fails to open properly during ventricular systole”
- “the Aortic valve fails to close properly during ventricular diastole”
- “the Mitral valve fails to open** properly during ventricular **diastole”
- “the Mitral valve fails to close properly during ventricular systole”
BAM !!!!
I know you awesome
Mind fucking you boyd and your wiggly little arms cant stop it!!!
MVR: MS
is this usually repaired?
NO
MVR: repair or replacement
repair is usually reserved for what?
mitral regurgitation (partial annular ring)
MVR: replacement or repair
what is almost always replaced not repaired
MS
MVR:
Key aspects to teither replacement or repair sx
- Full CPB
- antegrade & retrograde cardioplegia
- BiCaval canulation -surgical approach
CABG
graft materials
- mammary artery
- other arterial conduit
- Saphenous vein (RSVG)
- Cryo-vein
- Synthetic conduit
CABG
graft listed from best to worst in remaining natural blood flow
pedical > arterial > venous
CABG:
what are pedicle grafts flow?
native arterial flow
CABG:
what type of flow do free grafts have?
arterial flow from aorta
CABG:
for surgeries the involve CPB
- distal anastamoses are under what?
- proximal anastamosis are under what?
- total clamp
- surgeons choice
CABG:
for surgeries off the Pump (no CPB)
- what type of CABG is it?
- usually only use whatp of grafts?
- beating heart
- pedicle grafts (if possible)
TMR:
what the hell does it stand for?
transmyocardial revascularization
TMR:
what is used to perform the sx?
Cold Beam excimer laser
TMR:
the procedure cuts channels to acheive what?
improve angiogenesis
TMR:
what are its theraputic goals?
improved flow
denervation
CPB:
Failure to wean is most commonly caused by what?
poor left ventricular function
CPB:
what can occur with vasodilation and must be closely monitored?
Metabolic acidosis
CPB:
what type of emboli can occur?
particulate
CPB:
if weaning is not sucessfull and return to CPB is required what may need to be given? (drug)
additional heparin
CPB: failure to wean
with failure to wean what 2 things may be needed to be performed to assist the pt?
IABP
VAD
CPB: failure to wean
IABP does what?
diastolic augmentation improves coronary perfusion
CPB: failure to wean
with the VAD, what 2 things will be required
- requires anticoagulation
- requires close and vigilant observation by both perfusion and anesthesia
CABG & VALVE sx: Putting it all together
Anesthesia and OR set up
- standard machine, suction, defibrillator check
- Airway set up
- Largest ETT possible
- NC is preinduction line placement
- OG tube following TEE @ end of case
- IV poles with @ least 1 triple pump
- 2 Y-set IV’s set up and flushed devoid of air in tubing, one on a warmer
CABG & VALVE sx: Putting it all together
anesthetic interview
- H&P
- labs
- diagnostic test
- stress test
- ECHO
- cardiac cath
- Blood availability (and products)
- pt education
- Confirm pt
- consent verify
CABG & VALVE sx: Putting it all together
premedication
- benzo
- opiods
CABG & VALVE sx: Putting it all together
meds intra-op
- prop or etomidate
- fent 20 ml (1,000 mcgs)
- Versed 10 ml (10 mg)
- sux’s and NDMR
- Neosynephrine, ephedrine, NTG, epinephrine
- antifibrolytic
CABG & VALVE sx: Putting it all together
tell me the basics of the case (what you will do) once pt is on room throughout case!!
keep it short 5 simple steps
- Induction - opiods, induction agent, muscle relaxant
- DL and intubate (secure OETT)
- volatile
- Lines (in not done in preop)
- maintain normotension
- TEE completed
CABG & VALVE sx: Pre-CPB
what must you do during the sternotomy
put lungs down
CABG & VALVE sx: Pre-CPB
what do u want the SBP to be during aortic cannulation?
100mmHg
CABG & VALVE sx: Pre-CPB
whay may you be asked to “hand bag” the pt pre-CPB
decreased lung excersion
CABG & VALVE sx: Pre-CPB
what test is important to get pre CPB?
TEG
(Thromboelastography)
CABG & VALVE sx: Pre-CPB
how much heparin and when do u give it?
300 U/kg
on call by surgeon
CABG & VALVE sx: Pre-CPB
what is acceptable ACT?
>400 sec
CABG & VALVE sx: Pre-CPB
what should you expect with direct surgical manipulation?
hypotension
CABG & VALVE sx: Pre-CPB
what do you want to do with UOP
empty and record
CABG & VALVE sx: CPB
things to do during CPB!!!
- D/C all IV fluids,
- turn off ventilator and gasses
- withdraw PA cath 4-5 cm
- cardio plegia willl be administered
- continue dosing fent, versed, and NDMR prn
- Monitor UOP
- Calculate drug dosing for post-bypass infusions (we need all the time we can get)
CABG & VALVE sx: WEANING CPB
what do you do during rewarming?
- check TOF
- redose NDMR, versed, fentanyl prn
CABG & VALVE sx: WEANING CPB
what may be present during rewarming
sweating!!!
CABG & VALVE sx: WEANING CPB
when do you inflate the lungs?
when the surgeon says too ( this is the only time a surgeon will ever tell us what to do)
CABG & VALVE sx: WEANING CPB
when do you place pt back on ventilator?
ok one more time!!
when the surgeon says too
CABG & VALVE sx: WEANING CPB
what do you want to do right away when off pump
- obtain CO/CI
- TEE
- insert OGT
CABG & VALVE sx: WEANING CPB
when requested to give protamine ( a substance deriveted from the sweet nector of salmon sperm) how much do u give!
1 mg per mg of heparin
hmm but we gave heparin in Units??? how does that work out!!!! ready… we learned that 100 units = 1 mg last test (((( wow damn that hurt my head)))) bam bitches take that boyd!!!! boom bringing down the house fuck face!!!!
ok I am done!!!! got excited
CABG & VALVE sx: WEANING CPB
what may be necessary at times due tto arrythymias
defib with internal paddles and AV pacing
CABG & VALVE sx: Prepare for transport
what must you bring for transport!!
emergency equipment
resuscitation meds
CABG & VALVE sx:
The ICU note should include what?
- transported with monitors
- Ambu w/ 100% O2
- Record VS, PA, CVP, and CO/CI
- Vent settings: Rate, volume, FiO2, PEEP, PS
what is a new alternative to traditional procedures with valves
transcatheter aortic valve replacement
transcatheter aortic valve replacement
what is the pt population??
- ones deemed “too sick” for traditional valve replacement
transcatheter aortic valve replacement
what does the procedure do?
minimally invasive procedure
aortic valvuloplasty with deployment of new stent/valve
transcatheter aortic valve replacement
what are the current outcomes like?
unk (its too new)
your done
ahhhhh
