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SURGERY II > Cardiac Surgery > Flashcards

Cardiac Surgery Flashcards

1
Q

3 Surfaces of the Heart

A
  1. Sternocostal (Anterior)
  2. Diaphragmatic (Inferior)
  3. Base (Posterior)

• It also has an apex, which is directed downward, forward, and to
the left.

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2
Q

Borders of the Heart

A
  1. Right Border – formed by right atrium.
  2. Left Border – left auricle; and below, by the left ventricle.
  3. Lower/ Inferior Border – formed mainly by right ventricle but
    also by the right atrium; the apex is formed by the left ventricle.
  4. Upper/ Superior Border – right and left atrium and the great
    vessels.
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3
Q

Blood Flow

A

Superior and Inferior Vena Cava -> Right Atrium -> Tricuspid Valve
-> Right Ventricle -> Pulmonary Valve -> Pulmonary Arteries (2
arteries) -> Lungs (Oxygenation) -> Pulmonary Veins (4 veins) ->
Left Atrium -> Bicuspid/ Mitral Valve -> Left Ventricle -> Aortic
Valve -> Aorta

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4
Q

2 Atrioventricular Valves

A

Bicuspid/ Mitral and Tricuspid Valve.

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5
Q

Tricuspid Valve – 3 cusps:

A

anterior, septal and inferior/posterior

cusps.

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6
Q

Mitral Valve – 2 cusps:

A

anterior and posterior.

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7
Q

2 Semilunar Valves –

A

Pulmonary and Aortic Valve.

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8
Q

Pulmonary Valve – 3 cusps:

A 
1 posterior (left cusp), 2 anterior
(anterior and right cusps).
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9
Q

Aortic Valve: 3 cusps:

A

1 situated in the anterior wall (right cusp),
2 located at posterior wall (left and posterior cusps). Behind
each cusp, the aortic wall bulges to form an aortic sinus.

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10
Q

Aortic Sinus/ Sinus of Valsalva –

A

anterior aortic sinus gives origin
to the right coronary artery, and the left posterior sinus give
origin to the left coronary artery.

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11
Q

Drains most of the blood from the heart wall. It opens into the right atrium between the inferior vena cava and
atrioventricular orifice. Guarded by a rudimentary, nonfunctioning valve.

A

Coronary Sinus

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12
Q

The remnant of a thin fibrous sheet that covered the foramen ovale during fetal development.

A

Fossa Ovalis

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13
Q

Projecting ridges that gives the ventricular

wall a sponge-like appearance.

A

Trabeculae Carnae

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14
Q

3 Types of Trabeculae Carnae

A
  1. Papillary Muscles, which project inward, being attached by their bases to the walls; their apices are connected by fibrous
    chords (Chordae Tendineae) to the cusps of the valves.
  2. Moderator Band, crosses the ventricular cavity from the septal to the anterior wall. It conveys the right branch of the AV bundle.
  3. Prominent Ridges
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15
Q

Conducting System of the Heart

A

Sinoatrial Node -> Atrioventricular Node -> Atrioventricular Bundle (Bundle of His) -> Right and Left Terminal Branches ->
Subendocardial Plexus of Purkinje Fibers.

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16
Q

Located in the wall of the right atrium in the upper part of the sulcus terminalis just to the right of the opening of the superior vena cava.

A

Sinoatrial Node/ SA Node

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17
Q

Strategically placed on the

lower part of the atrial septum just above the attachment of the septal cusps of the tricuspid valve.

A

Atrioventricular Node/ AV Node

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18
Q

Only pathway of cardiac muscle that connects the myocardium of the atria and the myocardium of the ventricles and is thus the only route along which the cardiac impulse can travel from the atria to the ventricles.

A

Atrioventricular Bundle/ Bundle of His

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19
Q

3 Internodal Conduction Pathways

A
  1. Anterior Internodal Pathway (Bachmann’s Bundle)
  2. Middle Internodal Pathway (Wenckebach)
  3. Posterior Internodal Pathway (Thorel)
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20
Q

Arises from the anterior aortic sinus of the ascending aorta and runs forward between the pulmonary trunk and the right auricle.

A

Right Coronary Artery

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21
Q

Right Coronary Artery Branches

A
  1. Right Conus Artery
  2. Anterior Ventricular Branches
  3. Posterior Ventricular Branches
  4. Posterior Interventricular (Descending) Artery
  5. Atrial Branches
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22
Q

Supplies the anterior surface of the pulmonary conus (infundibulum of the right ventricle) and the upper part of the anterior wall of the right ventricle.

A

Right Conus Artery

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23
Q

2 or 3 in numbers and supplies the anterior surface of the right ventricle. The
marginal branch is the largest and runs along the lower margin of the costal surface to reach the apex.

A

Anterior Ventricular Branches

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24
Q

2 or 3 in numbers and supply the diaphragmatic surface of the right ventricle.

A

Posterior Ventricular Branches

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25
Q

Runs toward the apex in the posterior interventricular groove. It supplies
branches to the posterior part of the ventricular septum but not to the apical part, which receives its supply from the
anterior interventricular branch of the left coronary artery.

A

Posterior Interventricular (Descending) Artery

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26
Q

supplies the anterior and lateral surfaces of the right atrium. One branch supplies the posterior surface of both the right and left atria.

A

Atrial Branches

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27
Q

Arises from the left posterior aortic sinus of the ascending aorta and passes forward between the pulmonary trunk and the left auricle.

A

Left Coronary Artery

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28
Q

Left Coronary Artery Branches

A
  1. Anterior Interventricular (Descending) Branch

2. Circumflex Artery

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29
Q

May arise directly from the trunk of the left

coronary artery.

A

Left Diagonal Artery (Branch of Ant. Interventricular Branch)

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30
Q

Supplies the pulmonary conus.

A

Left Conus Artery (Branch of Ant. Interventricular Branch)

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31
Q

Winds around the left margin of the heart

in the atrioventricular groove.

A

Circumflex Artery

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32
Q

Supplies the left margin of the left ventricle down to the apex.

A

Left Marginal Artery (Branch of Circumflex Artery)

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33
Q

Descends behind the septal cusp of the tricuspid valve to reach the inferior border of the membranous part of the ventricular septum.

A

Atrioventricular bundle

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34
Q

It usually divides into two branches (anterior and posterior), which eventually
become continuous with the fibers of the Purkinje plexus of the left ventricle.

A

Left bundle branch (LBB)

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35
Q

Passes down on the right side of the ventricular septum to reach the moderator band, where it crosses to the anterior wall of the right ventricle. Here, it becomes continuous with the fibers of the Purkinje plexus.

A

Right bundle branch (RBB)

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36
Q

Pierces the septum and passes down on its left side beneath the endocardium. It usually divides into two branches (anterior and posterior), which eventually become continuous with the fibers of the Purkinje plexus of the left ventricle.

A

Left bundle branch (LBB)

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37
Q

Leaves the anterior end of the SA node and passes anterior to the superior vena caval opening.

A

Anterior Internodal Pathway (Bachmann’s Bundle)

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38
Q

Descends on the atrial septum and ends in the AV node.

A

Anterior Internodal Pathway (Bachmann’s Bundle)

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39
Q

Leaves the posterior end of the SA node and passes posterior to the superior vena caval opening.

A

Middle Internodal Pathway (Wenckebach)

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40
Q

Descends on the atrial septum to the AV node.

A

Middle Internodal Pathway (Wenckebach)

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41
Q

Leaves the posterior part of the SA node and descends through the crista terminalis and the valve of the inferior vena cava to the AV node.

A

Posterior Internodal Pathway (Thorel)

42
Q

Arterial Supply of the Heart

A

Provided by the right and left coronary arteries, which arise from the ascending aorta immediately above the aortic valve.

43
Q

Coronary arteries and their major branches are distributed over
the surface of the heart, lying within _______ connective
tissue.

A

subepicardial

44
Q

Descends almost vertically in the right atrioventricular groove, and at the inferior border of the heart it continues posteriorly
along the atrioventricular groove to anastomose with the left coronary artery in the posterior interventricular groove.

A

Right Coronary Artery

45
Q

Usually larger than the right coronary artery, supplies the major part of the heart, including the greater part of the left
atrium, left ventricle, and ventricular septum.

A

Left Coronary Artery

46
Q

The left coronary artery enters the atrioventricular groove and divides into:

A

an anterior interventricular branch and a circumflex branch.

47
Q

Runs downward in the anterior interventricular groove to the apex
of the heart. Usually, it passes around the apex of the heart to enter the posterior interventricular groove and anastomoses
with the terminal branches of the right coronary artery.

A

Anterior Interventricular (Descending) Branch

48
Q

Supplies the right and left ventricles with numerous branches that also supply the
anterior part of the ventricular septum.

A

Anterior Interventricular (Descending) Branch

49
Q

Supply the left ventricle.

A

Anterior ventricular and posterior ventricular branches

50
Q

Supply the left atrium.

A

Atrial branches

51
Q

Right Coronary Artery

A

Right Coronary Artery -> descend on right AV groove to supply right ventricle -> branches to anterior RV and terminate to right posterolateral and the right posterior descending collaterals with circumflex

52
Q

Left side of the heart

A

Left side of the heart -> Left Main Coronary Artery -> Left Anterior Descending (LAD) supply most ateroseptal to apex.

53
Q

LAD septal branches with diagonal arteries which supplies

_______ aspects.

A

lateral

54
Q

AV groove and the posterior aspect and branches to obtuse marginal arteries.

A

Circumflex

55
Q

Narrowing of one or more coronary arteries.

A

CORONARY ARTERY DISEASE

56
Q

Cause of coronary artery disease

A

Atherosclerotic Disease

57
Q

Consequence of coronary artery disease

A

Limitation of myocardial blood flow

58
Q

Pathophysiology of coronary artery disease

A

Increasing degrees of stenosis -> Limit reserve flow -> Reduce flow at rest -> May totally occlude the vessel.

59
Q

Lesions of atherosclerosis

A
  1. Fatty streak begins in childhood.
  2. Lipid laden macrophages and T-lymphocytes with smooth muscle cells cause focal intimal thickening.
  3. More smooth muscle cells and connective tissue form in the intima.
  4. Eccentric fibrous plaque develops, which is white and elevated.
  5. Lipid deposition in cells and connective tissue.
  6. A luminal fibrous cap form.
  7. Zone of necrotic tissue beneath the cellular area.
60
Q

But if plaques are less than ___% stenosis, vessels will not have enough time to develop collaterals, once occlusions in
myocardium sets then the distal portion to the stenosis will be infarcted.

A

50%

61
Q

Probable cause of most unstable angina and acute myocardial infarction.

A

Rupture and thrombosis of a plaque

62
Q

Acute ischemia commonly develops in vessels with?

A

Less than 50% stenosis.

63
Q

Play a role I acute narrowing/occlusion

A

Platelet aggregation, vessel stenosis, and coronary spasm

64
Q

The _____ are more often involved than the Circumflex.

A

LAD and RCA

65
Q

___% of patients studied for symptoms will have significant stenosis in all 3 vessels.

A

40%

66
Q

____% of patients with 1 completely occluded artery will have significant stenosis in at least one other artery.

A

95%

67
Q

____% of patients with significant disease will have L main involvement.

A

10-20%

68
Q

Severity of lesions and size of distal vessels may be underestimated.

A

Coronary Angiography

69
Q

75% reduction in cross-section =

A

50% diameter reduction (moderate).

70
Q

90% reduction in cross-section =

A

67% diameter reduction (severe).

71
Q

Ejection fraction should be considered with _______, as the _______ can be normal even in severe LV dysfunction.

A

heart size

72
Q

Gold standard

A

Coronary angiography

73
Q

Depends on the amount of myocardium

devoid of scar.

A

Resting LV function

74
Q

Reflects loss of coronary flow reserve, and

is typically depressed when compared to resting function.

A

Exercise LV function

75
Q

Usually visually estimated on angiography

as ejection fraction.

A

Global LV function

76
Q

Can also be evaluated by CASS score, which is the sum of five segmental scores.

A

Global LV function

77
Q

Assessed by local wall motion or thickening during cardiac cycle. assessed by local wall motion or thickening during cardiac cycle.

A

Segmental LV wall function

78
Q

“widower’s disease” decreased ejection fraction -> heart failure.

A

LAD

79
Q

Denote more

rapid progression of coronary stenoses.

A

Young age, hyperlipidemia, and presence of PVD

80
Q

As areas of ischemia become more extensive, ______ will fall during exercise testing.

A

global LV systolic function

81
Q

_______ will increase from the decreased systolic function.

A

LVEDV

82
Q

_________ also falls from inspired myocardial relaxation during early diastole.

A

LV diastolic function

83
Q

All factors ultimately result in?

A

increased LVEDP

84
Q

LV dysfunction at rest is usually from?

A

myocardial scarring

85
Q

Myocardial stunning or _______ can cause resting LV dysfunction as well.

A

Myocardial stunning or hibernation

86
Q

______ helps quantify the degree of reduction in flow reserve.

A

Graded exercise testing

87
Q

Severe and persisting angina with EKG evidence of ischemia and minor CK-MB changes.

A

Unstable Angina

88
Q

Severe class IV angina within _____ months of onset.

A

two months

89
Q

Severe angina lasting more than 15min. occurring within 10 days of presentation.

A

Unstable Angina

90
Q

Severe angina within 2 weeks of acute myocardial infarction.

A

Unstable Angina

91
Q

Probable cause of unstable angina.

A

Plaque fissure and/or rupture

92
Q

These patients have increase tendency to develop myocardial infection.

A

Unstable Angina

93
Q

_______ is prone to cause acute MI.

A

Severe proximal LAD disease

94
Q

____% of patients studied will have an acute MI within 5 years.

A

30%

95
Q

Probability of acute MI is increase by?

A

Number of previous MIs

and number of vessels involved.

96
Q

Thrombolytics have reduced current hospital mortality to less than _____%.

A

10%

97
Q

Death usually the result of?

A

Acute cardiac failure or sudden ventricular arrhythmia

98
Q

____% of patients have sudden death.

A

20%

99
Q

10-year survival is about _____%.

A

60%

100
Q

30% diameter loss =

A

50% cross sectional area loss

SURGERY II (2 decks)

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