Cardiac Surgery Flashcards

1
Q

cardiac anatomy review
vessels off aorta
cardiac vessels
valves

A

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

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2
Q

Cornary Artery Disease: CAD
risks
procedures

A

Risk
- #1 = smoking
- HTN
- HLD
- DM
- Obestiy
- family history

Managment
GDMT (medications)
PCI: percutaneous cornary intervention (stent placement with IR)
CABG: bypass

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3
Q

Indications for CABG procedure
those with stable CAD
ACS pt.

A

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

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4
Q

CABG
grafts used for where and who

A

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

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5
Q

PCI
- what is it
- primary PCI done when
- delayed PCI done when

A

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

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6
Q

in sum how to determined PCI v CABG

A

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

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7
Q

Aortic Stenosis
etiolgoy
symptoms
PE (murmur)
lead to waht

A

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.

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8
Q

Aortic Insufficiency
etiology
symptoms
PE
complcaitions

A

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)

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9
Q

TAVR proceudre

A

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

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10
Q

SAVR

how to determined who gets SAVR v TAVR

A

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

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11
Q

Mitral Stenosis
etiology
symptoms
PE
complcaitions

surgery

A

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

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12
Q

Mitral Regurguitaion

A

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

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13
Q

determining repair v replace of the mitral valve

A

MV repair recommended for
- most all pt. over replace
- where removal of anatomical bad valve can be repaired and recovery is good

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14
Q

Tricuspid Valve regurg v stenosis

A

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

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15
Q

Pulmonic valve regurg or stenosis

A

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

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16
Q

deciding between tissue and mechanical mitral valves

anticaog. for valves

A

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)

17
Q

Thoracic Aortic Anyuresum
etiology & RF
symptoms

A

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

18
Q

Thoracic Aortic Anyuresum

Surgical Indications

A

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

19
Q

when is the TEVAR used for aortic anyuresums

A

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.

20
Q

Thoracic Aortic Dissection

A

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

21
Q

cardiopulmonary bypass

A
  • 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

22
Q

Complications of Cardiac Surgery

A

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