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General Surgery > CARDIO > Flashcards

CARDIO Flashcards

1
Q

RFs for CAD

A

gender (begins to equalize with advanced age) HTN DM age cholesterol smoking family history obesity

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2
Q

Gold standard for Dx of CAD

A

Cardiac catheterization Others: EKG, echo, stress tests, CT angio

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3
Q

“Angiographically significant” finding of cardiac cath

A

Diameter is reduced by > 50%, corresponding to a reduction in cross-sectional area > 75%

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4
Q

Artery of concern in the heart

A

Left anterior descending artery (LAD) “Widow maker”

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5
Q

Who goes to the OR in CAD?

A

Severe angina (CCS class III/IV) Unstable angina Triple vessel dz Left main dz Failed medical therapy Thrombosis, post PTCA or in-stent restenosis Emergently from cath lab (coronary dissection)

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6
Q

CABAG post-MI

A

Postinfarction ventricular septal defect (VSD) Papillary muscle rupture with acute mitral insufficiency LV free wall rupture

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7
Q

Postinfarction ventricular septal defect

A

4-5 days after MI Present with CHF and pulmonary edema and new systolic murmur Need intra-aortic balloon pump (IABP) placed and undergo emergent repair

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8
Q

Papillary muscle rupture with acute mitral insufficiency

A

4-5 days post MI Heart failure, new murmur Prompt valve repair or replacement

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9
Q

LV free wall rupture

A

Cardiogenic shock, often acute tamponade Emergent surgery = 50% successful

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10
Q

CABG

A

Aim to restore flow from aorta to the coronaries distal to obstruction Does NOT rid patient of disease or disease process Uses vascular “conduits” With or without assistance of bypass (“on pump” vs “off pump”)

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11
Q

Benefits of off-pump CABG

A

Less risk of encephalopathy, sternal infection, blood transfusion, and renal failure

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12
Q

Advantages of cardiopulmonary bypass

A

Quiet, bloodless field Better distal anastamoses Still the standard

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13
Q

Disadvantages of cardiopulmonary bypass

A

Increased time in surgery pt must be heparinized then reversed platelet dysfunction (HIT) complications can include hypoperfusion fluid retention CVA Ischemia

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14
Q

Gold standard for conduit

A

Left internal mammary artery to LAD (aka left internal thoracic artery) Others: saphenous vein (for lateral and posterior walls), radial artery

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15
Q

Mechanical Valves

A

Tilting disk and older ball-in-cage designs -Highly durable, require permanent anticoagulation therapy (INR at 2.5 to 3.5 times normal) -Preferable in patients with long life expectancy

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16
Q

Tissue for valve replacement

A

Xenograft (porcine or bovine), homograft (cadaver), or autograft (pulmonic valve) -Less thrombogenic, do not require anticoagulation -More prone to structural failure due to calcification -15-20 years

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17
Q

Aortic Stenosis (AS)

A

Stenosis from thickening, calcification, fusion of aortic leaflets causing LV outflow obstruction Pressure overload of LV leads to LVH Younger patients with congenital bicuspid valves Older– history of rheumatic fever Sx: angina, syncope, CHF Dx: Echo, +/- cardiac cath PE systolic murmur in 2nd R IC space Surgery indicated if symptomatic or based on cross sectional area of valve and gradient across valve

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18
Q

Aortic Valve Incompetence

A

Incompetence of aortic valve, backflow causes LV dilation, LVH Causes: bacterial endocarditis, hx of rheumatic fever, aortic root dilation, bicuspid valve predisposes Dx: echo, cath PE: “Blowing” decrescendo diastolic murmur L sternal border Surgery if symptomatic

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19
Q

Mitral Valve Stenosis (MS)

A

Thickening of mitral leaflets, narrowing of valve, usually due to rheumatic fever Sx: dyspnea (increased LA pressures causing pulmonary edema, afib from dilated LA) Dx: echo/cath PE: diastolic murmur at apex, “rumble,” with opening snap Surgery based on sx/degree of MS

20
Q

Options for surgery in MS

A

percutaneous balloon valvuloplasty open commissurotomy Valve replacement

21
Q

Mitral Valve Regurgitation (MR)

A

Incompetence of mitral valve from prolapse, rheumatic fever, papillary muscle dysfunction (post MI), ruptured chordae, dilation of annulus Dx: Echo/cath PE: holosystolic murmur from apex to axilla Sx: dyspnea, palpitations, fatigue. Late onset. Surgery: based on cath/echo findings

22
Q

Surgical options for MR

A

Flail leaflet mitral repair or ring annuloplasty: for degenerative MR, dilated annulus Mitral replacement (long-standing rheumatic disease)

23
Q

Aortic Dissection

A

Tear in intima which enables blood to flow into the media creating a false lumen Causes: HTN, bicuspid aortic valve, atherosclerotic disease, Marfan’s Presentation: severe chest pain, “tearing” sensation to the back Dx: CXR (widened mediastinum), TEE, CT angio Considered acute if dx within 2 weeks of onset Most common cause of death is rupture

24
Q

Stanford classification (aortic dissection)

A

Type A: ascending aorta Type B: Aorta distal to left subclavian

25
Q

DeBakey Classification (aortic dissection)

A

Type I: Both ascending and descending Type II: Only ascending aorta Type III: Only descending aorta

26
Q

Tx for Aortic dissection

A

Surgery: type A (I & II) Medically: Type B (III) unless complicated or uncontrollable HTN or persistent pain or rupture

27
Q

Crawford Classification (aortic aneurysm)

A

Type I: Proximal descending to proximal abdominal Type II: Proximal descending to infrarenal Type III: Distal descending with abdominal Type IV: Primarily abdominal

28
Q

Descending aortic aneurysm

A

2nd most common Distal to left subclavian artery Fusiform Secondary to arteriosclerosis Surgical repair > 5 cm or rapid growth May be consequence of deceleration injury (ligamentum arteriosus, increased mediastinum width, different BP in UE)

29
Q

Ascending Aortic Aneurysm

A

Cystic medial necrosis Secondary to Marfans, HTN, aging May cause AI, CHF Chest pain worrisome (deep, diffuse, aching) Decision to repair depends on size, presence of AI, associated CHD

30
Q

Aortic arch aneurysm

A

Least common Sx secondary to pain or compression of adjacent structures (dysphagia, dry cough, hoarseness, dyspnea) Fusiform from arteriosclerosis, saccular if syphlitic

31
Q

Thoracic aortic aneurysm: medical management

A

Management based on size and location Medical management: BP control, serial imaging, surveillance, B-blockers

32
Q

Thoracic Aortic Aneurysm: surgical indications

A

Symptoms ascending >5.5 cm in diameter descending >6.5cm in diameter rapid increase in diameter (>1 cm per year) Evidence of dissection Arch and Crawford II have highest morbidity and mortality after repair

33
Q

Arteriosclerotic Obliterans

A

Artheromatous disease similar to coronaries, but peripheral Intimal plaque that partially obstructs and gives “angina” of ischemic limb “Intermittent claudication”– occurs predictably with activity and is relieved within 1-2 mins of rest “Leriche” syndrome– claudication of buttocks and means narrowing higher up in terminal aorta Check in diabetics!

34
Q

Arteriosclerotic Obliterans: Tx

A

Walking program Stop smoking Ideal body weight Optimize diabetic therapy Lipid management Meticulous foot care

35
Q

Leriche’s Syndrome: Tx

A

Aorto-bifemoral or endarterectomy Balloon angioplasty w/wo stent

36
Q

Arteriosclerotic obliterans: surgical tx

A

Balloon angioplasty/stent Surgery: aorta bi-femoral bypass, pem-popliteal bypass, lumbar sympathectomy

37
Q

Carotid Stenosis

A

Narrowing of carotid arteries due to atherosclerosis and accumulation of plaques Stable and asx or source of embolization Sx: transient or permanent focal neuro sx related to ipsilateral retina or cerebral hemisphere

38
Q

Sx of carotid artery stenosis

A

Ipsilateral transient visual obscuration (amaurosis fugax) from retinal ischemia Contralateral weakness or numbness of an arm, a leg, or the face, or a combination Visual field defect Dysarthria In the case of dominant (usually left) hemisphere involvement, aphasia

39
Q

RFs for carotid artery stenosis

A

Similar to those for other types of heart disease: Age Smoking HTN– most important treatable RF for stroke Abnormal lipids or high cholesterol Diet high in sat fat Insulin resistance DM Obesity Sedentary lifestyle FH

40
Q

Dx of carotid artery stenosis

A

Carotid bruit Carotid duplex US (screen) MRA or CTA (diagnostic)

41
Q

Tx of carotid artery stenosis

A

Medically: antiplatelet therapy (90%), antihypertensive therapy, lipid-lowering therapy Weight loss, girth loss Smoking cessation Surgical: Carotid endarterectomy (CEA) is gold standard; Carotid angioplasty and stenting (CAS) is valid alternative

42
Q

“High surgical risk” for endarterectomy: anatomical factors

A

High carotid bifurcation (above C2) Low common carotid artery (below clavicle) Contralateral carotid occlusion Restenosis of ipsilateral prior carotid endarterectomy Previous neck irradiation Prior radical neck dissection Laryngeal nerve palsy Presence of tracheostomy

43
Q

“High surgical risk” for endarterectomy: Physiological factors

A

Age 80+ L ventricular EF

44
Q

Option for patients who are high risk for endarterectomy

A

Carotid Artery Stenting

45
Q

Cardiac surgery post op complications/management

A

Hemodynamic monitoring Pleural effusions Vent dependence/respiratory failure Stroke Pericardial tamponade Afib (25%) Sternal wound infection Post op MI/acute graft closure Early ambulation, deep breathing

General Surgery (8 decks)

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