Cardiac Surgery Flashcards
cardiac anatomy review
vessels off aorta
cardiac vessels
valves
aorta gives off
- brachiocephalic artery (anominant) into the righ carotid and r subclavian a
- left subclavian a
- left carotid a
Cardiac Vessels
- Right Cornary A (in coronary sulcus)
- Left Coranary A ( in ^^ sulcus)
- left cornary gives LAD (anterior interventricular) and circumflex
- LAD : gives off septal braches and diagnoal branches
- LCx. : gives off obuse marginal branches
Valves
- the Tricuspid Valve: between RA and RV
- the bicuspid (mitral): between LA nad LV
- blood from RA to RV to pulmonary A to lung to pulm v. to LA to LV to A
- pulmonary semi-lunar valve
- aortic semilunar valve
chordae tendinae pull the valve: help by papillary muslces
Cornary Artery Disease: CAD
risks
procedures
Risk
- #1 = smoking
- HTN
- HLD
- DM
- Obestiy
- family history
Managment
GDMT (medications)
PCI: percutaneous cornary intervention (stent placement with IR)
CABG: bypass
Indications for CABG procedure
those with stable CAD
ACS pt.
Indications for Coronary Artery Bypass Graft
stable CAD pt.
- symptomatic relief (rest and nitro)
- significant left main sentosis of > 50%
- three vessel disease: with or wihtout proximal LAD
- two vessel disase with porximal LAD involved
ACS pt.
- left main stenosis > 50%
- 3 vessel disease
- 2 vessel with prox. LAD AND LV abnormal function or ischemia on testing
- 1-2 vessel disease with prox. LAD but large area od myocardium is high risk on testing
- unable to do PCI
- failed PCI
- persistnet ischemia
- hemodynamically unstable
CABG
grafts used for where and who
Grafts
- LIMA: left internal mammary artery is used for the LAD eith best longer term patency
- Saphenous vein: minically invasive but high failure rate (used for RCA)
- Radial artery (less common): for those , 75 y/o but risk with vasospasm
PCI
- what is it
- primary PCI done when
- delayed PCI done when
PCI = percutaneous cornary intervention (going in through the fem. or alike and balooning with/without stent to reopen the vessel)
- stent can be drug eluding or not
Primary PCI
- done when pt. is super sick they wouldnt survive the CABG
- this is door to balloon time is 90 minutes or 120 if transfer
- those whose symptoms are < 12 hours
- thoe who also ahve acute severe HF and/or cardiogeneic shock
Delayed PCI ; often after thrombyolytics or no reperfusion)
- those who developed shock or severe HF afer inital resenation
- those who develop ischemia upon testing or start exhibiting ischemia later in stay
in sum how to determined PCI v CABG
PCI
- lesser extent of disease
- those who are HIGH risk for surgery: significant comorbid conditions
- those who are high risk: the plaque is in a bad spot for a graft
CABG
- those with severe severe left main disease > 50%!!
- those iwth complex vessel disease
- those with mechanical complications: MR, papillary muclse snap, ventricaul rupture
- those with bad anatomy and too sharp of turn for PCI
Aortic Stenosis
etiolgoy
symptoms
PE (murmur)
lead to waht
Aortic Stenosis
Etiology
- calcification of the aortic valve due to atherosclerotic plaques, rheumatic HD or congential
Symptoms
- syncope
- angina
- dyspnea
- dissy
- fatigue and weak
PE
- murmur crecendo-decrecendo systolic murumr
Lead to
- HF, angina, syncope and sudden death
- because angina = the cornary arteries vessles leave just after the aortic valve: if blood isnt perfusing, they wont get perfused either
Treatment
- SAVR or TAVI
- SAVR: replacement of the alve
- TAVI: like PCI: transcath.
Aortic Insufficiency
etiology
symptoms
PE
complcaitions
Etiology
- failure of the valve to close fully: backflow of blood from aorta into the LV
- dialted root, congenitial, prosthetic valve
- infective endocard., aortid dissection
Symptoms
- dyspnea
- syncope
- angina
PE
- decrecendo diastolic murmur
- austin flint murmur: low-pitch rumble of diastole
can lead to
- mitrial valve regurg. and left ventricaulr hypertrophy
surgical repair
- valve replaced (AVR)
TAVR proceudre
Transcatheter aaortic valve replacement = IR procedure
- nonnative valve replaces native valved without removing the natve valve
- severe Aoritic stenosis = indication
Contraindications
- left expect < 1 year
- unlikley to help with QOL
- anatomical aborm. or other serious valvular conditions that can be treated by surgery over the IR
SAVR
how to determined who gets SAVR v TAVR
decide
- durability and surgical risk are the key considerations
TAVR for
- high surgical risk pt.
- lowe to intermediate risks but > 85 y/o
SAVR
- low surg. risk
- younger pt. can replace the valve completelym for beter outcomes long term
Mitral Stenosis
etiology
symptoms
PE
complcaitions
surgery
Mitral Stenosis
most common cause is rheumatic heart disease others can be infective endocard. , calcification, etc.
- narrowing of teh valve leading to lack fo flow out
Symptoms
- DOE
- fatigeu
- otehr symptoms of a fib!!: since blood stays in the LA longer: sirupting the electricity
PE
loud low pitch rumble following an opening snap
graham steel murmure high pitch blowing
Complcaitons
afib, HF, pulm. edema and clot because of a fib
Surgery
- a ballooning of the valve or replacement
- indications = have other cardiac complcation or those who are not high risk surgery with class III-IV but failed ballooning
Mitral Regurguitaion
etiology
- systolic backflow of blood fro the LV to LA due to abnormal valve
- endocarditis, MI (beacuase leaflets dead), trauma
Symptoms
- HF symptoms
- LE edema
- dyspnea (to the lungs)
PE
- systolic murmur
complications
- HF, pulmonary HTN and A fib
Surgery
- asymptomaic severe regurg + LFEF < 60% or LFED > 40
- symptomatic severe regurg
- going for other cardiac procedure
determining repair v replace of the mitral valve
MV repair recommended for
- most all pt. over replace
- where removal of anatomical bad valve can be repaired and recovery is good
Tricuspid Valve regurg v stenosis
TV regurgitatino
- systolic retorgrade flow from RV to RA
- due to infective endocrditis commonly
TV stenosis
- narroinwg due to congential ebsteins commonly
Symptoms
- RV failure: periphearl edema, fatigue, poor appetite, etc.
PE
- pansystolic murmmue
- can lead to RV failure and edema, a fib too!!!
Surgery
- indications all lead to surgery but not urgent
Pulmonic valve regurg or stenosis
pretty rare: rarely surgical
regurg: pulmoanry valve regurg back into the RV
- usually congenital or surgical damange
stenosis: pulmonic turbulent flow: usually congenital
Sympomts: dyspnea, edema, syncope, angina, fullness
PE
diastolic murmur blowing
can lead to RV failure
Surgery
- for those with RV dilation = should do it
- for thsoe with concom. tricuspid regurg as a result with
- EKG evidence, QRS prolongation
deciding between tissue and mechanical mitral valves
anticaog. for valves
mechanical
- need anti-coag. for LIFE
- but will work forever
Tissue
- overtimet they will calcify
- good for 10-15 years
- anticoag. but not for life
Anticoagulation for valve replacements
Aortical Valve
- mechanical valve: lifelong anticoag (no risk facotrs INR 2-3, risk factrs 2.5-3.5INT)
- tissue valve: anticoag for 2-3 months at INR 2-3
Mitral Valve
- mechanical valve: lifelong coag (INR 2.5-3.5-)
- tissue alve: 3-6 months coag. (INR 2-3)
Thoracic Aortic Anyuresum
etiology & RF
symptoms
Etiolgo and RF
- a dilation of the aorta usually due to degeneratvive disease in the media layer
- most common location is aortic root (marfans) and acending aorta
- RF: smoking, HTN, marfans
Symptoms
- most commonly asymptomaic
- chest pain, AV murmur, cough, SOB (if they are symptomatic: ruptured)
Debakey and Stanford
- Stanford A: acending only or acending and decening
- Standford B: decedning only
- Debakey I: acending and decedning
- Debakey II: ccedning
- Debakey III: decending
Thoracic Aortic Anyuresum
Surgical Indications
Indications
- elective for those with rapid growing ( > 0.5 cm/year) that are acending and small (< 5.5cm)
- elective for those > 5.5 cm with degenerative disease
- Marfans: > 5cm or > 4.1-4.5 for women preg.
- open repair is best for acending and arch
when is the TEVAR used for aortic anyuresums
TEVAR: thoracic endovascualr aortic repair
- a stent graft to exclude and cut of the anyuresmal sac
good for decending aortic pt. +
- > 5.5 cm
- saccualr
- postop
not for marfans pt.
Thoracic Aortic Dissection
the anyuresum so big it started creating the false lumen: getting stuck in the intima and media
- can occur with or without an anyuresum
Classes
A = all dissections involved the acending aorta or arch
B = all dissections involving the decending aorta
sudden, severe sharp chest/back pain
Surgery
- urgent repair for acute type A
- open surgery for chronic dissection + anyuresum > 5.5
- TEVAR for those with type B or if complications that would make open repair difficult
- complcaitons = recurrent pain, uncontrolled HTN, earl oritc expansion, malperfusion, sign of rupture
cardiopulmonary bypass
- provides circulatory and respisratory support during surgerywhile heart is stoped = bloodless field
Function
- it draines venous blood and return O2 blood
- delivers cardioplegia
- filters, cools and warms blood as needed
Complications of Cardiac Surgery
Bleeding
- bypass destorys the platelets
- but need to give heparin to allow the blood to flwo through bypass = super thin
Vasoplegia
- low systemic vascuar resistance after CPB
- give lots of vasopressors (NR, vasopression or methylene blue)
Refractory Shock
- sustained hypotension and hypoperfusion or sudden hemodynamic issues
- can prevent as failure in the OR from bypass
- management: cardiac pacing, ECMO or VAD
LV ro RV failure
- can be due to to the studdened heart after CPB
Cardiac Tamponade (bleeding into pericardium)
Stroke
Respiratory Failure
- due to prolonge vent
- PNA and edema risk
AKI (temporary)
- because hypoperfusion and cahgnes in preload and afterload
A fib = biggest complications!!! becase youre inturrpteing the hearts normal electricaity
- typically 2-4 days post op
- trainsiet usually
- give BBlockers prophlyatically to help (metoprolol) or amioderone if need to
