Cardiothoracic Flashcards
What symptoms can be seen with Vascular rings?
(Congenital) Pressure on tracheobronchial tree and esophagus by a ring formed from the aorta and surrounding vessels.
Stridor and episodes of respiratory distress with “crowing” respiration where babies assume hyperextended position (difficulty swallowing).
What should come to mind if only the respiratory symptoms of vascular rings are present?
Trahceomalacia (flaccidity of the tracheal support cartilage which leads to tracheal collapse especially when increased airflow is demanded)
How are vascular rings diagnosed?
Barium swallow showing atypical esophageal compression
Bronchoscopy showing segmental tracheal compression (rules out diffuse tracheomalacia)
What does surgery do in vascular rings?
Divides smaller of the two aortic arches
What is an echocardiogram best used for?
Diagnosing morphologic cardiac abnormalities
What group of congenital conditions are characterized by he presence of a murmur, overloading of the pulmonary circulation, and long-term damage to the pulmonary vasculature?
Left-t-right shunts
What is an Atrial septal defect? When is it usually recognized?
Very minor, low pressure, low volume shunt. Usually recognized in late infancy
What is characteristic of an atrial septal defect?
Faint pulmonary flow systolic murmur and fixed split second heart sound
How is a atrial septal defect diagnosed?
Echocardiogram
How can a atrial septal defect be managed?
Closured can be done surgically or via cardiac catherization
What type of shunt can produce a murmur, but is otherwise asymptomatic?
A small, restrictive ventricular septal defect localized low in the muscular septum. These are likely to close spontaneously within the first 2 or 3 years of life
Where are ventricular septal defects more serious?
High in the membranous septum
What can happen with a ventricular septal defect?
Leads to trouble early on. Failure to thrive within the first few months of life, a loud pansystolic murmur heard at the left sternal border, increased pulmonary vascular makings on CXR,
How are ventricular septal defects managed?
Echocardiogram and surgical closure
Symptoms of patent ductus arteriosus; when does it present? how is it diagnosed?
Bounding peripheral pulses and “machinery-like” heart murmur. Presents on first days of life. Diagnosed by echo
What is the treatment of Patent ductus arteriosus?
For premature babies w/o heart failure: closure with indomethacin.
For those that don’t close, with heart failure or full-term babies: surgical division or embolization with coils
Which are the most common Right-to-left shunts?
- Tetralogy of Fallot (TOF)
2. Transposition of the great vessels (TGV)
What do Right-to-left shunts share?
Murmur, diminished vascular markings in the lung and cyanosis
Signs and symptoms of TOF:
- most common cyanotic anomaly and usually begins at infancy (5-6 years)
- child small for age
- bluish hues in lips and tips of fingers
- -clubbing
- spells of cyanosis relieved by squatting
- systolic ejection murmur at 3rd left intercostal space
- small heart
- diminished pulmonary vascular markings
- right ventricular hypertrophy on EKG
How is TOF diagnosed? Treated?
Diagnosed by Echo, Treated surgically
Signs and symptoms of TGV:
- severe trouble early on
- children are kept alive by VSD, ASD, or patent Ductus but die soon if not fixed
- 1-2 day old with cyanosis
How is TGV diagnosed?
Same as TOF
Signs and symptoms of Aortic stenosis (AS):
- angina and excertional syncopal episodes
- harsh midsystolic murmurat right second intercostal space and left sternal border
When is surgery indicated for AS:
-Valvular replacement when gradient > 50mmHg or at first indication of CHF, angina or syncope
Signs and symptoms of chronic aortic insufficiency (AI):
- wide pulse pressure
- blowing, high pitched diastolic murmur at second intercostal space and left lower sternal border
When is surgery for AI indicated?
- Patients are followed
- Valve replacement at first signs of left ventricular dilation on Echo
Signs and symptoms of acute AI:
- sudden development of heart failure
- new, loud diastolic murmur at right second intercostal space
What is the most common etiology of acute AI? How is it managed?
- Endocarditis in young drug addicts
- Emergency valve replacement is indicated and long-term antibiotics needed (prophylaxis for subacute bacterial endocarditis)
Signs and symptoms of Mitral stenosis (MS):
- dyspnea on exertion
- orthopnea
- paroxysmal nocturnal dyspnea
- cough
- hemoptysis
- low-pitched, rumbling, diastolic apical murmur
- patients become thin and cachectic
- patients develop Afib
What is the most common cause of MS? How is it managed?
- Rheumatic fever years before presentation
- Echo needed for workup
- Valve replacement needed as symptoms become disabling (surgical missurotomy or balloon valvuloplasty)
Signs and symptoms of Mitral regurgitation (MR):
- Excerptional dyspnea
- orthopnea
- Afib
- apical, high-pitched, holosystolic murmur radiating to the axilla and back
What is the most common cause of MR? How is it managed?
- Valvular prolapse
- Same workup and surgical indications as MS
- Valve repair preferred over valve replacement (annuloplasty)
What does the typical patient with coronary disease look like?
Middle-aged sedentary man with hx of smoking, DM2, hypercholesterolemia, family hx of CAD.
Indications for catheterization/ revascularization:
- Progressive, unstable, disabling angina
- One or more vessels with >70% occlusion w a good distal vessel
How is CAD managed:
- Single vessel disease (not Left main or LAD): angioplasty and stent
- Tripple vessel disease: Coronary bypass (Likely from internal mammary artery)
what s important about post-op care of heart surgery patients?
- Cardiac output needs to be optimized
- If low CO then measure pulmonary wedge pressure
- wedge pressure: 0-3 => Need more IV fluids
- wedge pressure: >20 ==> Ventricular failure
Signs and symptoms of chronic constrictive pericarditis:
How is it managed?
- dyspnea on exertion
- hepatomegaly
- ascites
- “square root” sign
- equalization of pressures (RA, RV diastolic, PA diastolic, PCW, LV diastolic)
- Tx with surgical therapy
What does a coin lesion on a CXR mean?
-80% chance of malignant cancer on a patient > 50 years old. Even higher if there’s a hx of smoking.
What is the first thing to do if a coin lesion is seen on a CXR?
-Check an older (1-2 year) CXR. An unchanged lesion is less likely to be cancer.
What tests should be done first when lung cancer is suspected?
- sputum cytology
- CT scan
How is lung cancer diagnosed?
Done in sequence until dx made:
- Cytology
- Bronchoscopy and biopsies (central lesions)
- Percutaneous biopsy (Peripheral lesions)
- Video Assisted Thoracic Surgery and Wedge resection
What determines the specific sequence of diagnostic workup?
- Higher probability of cancer
- Assurance that surgery can be done
- Chances that surgery may be curative
How is small cell cancer of the lung treated?
Chemotherapy and radiation. Surgery only plays a role in non-small cell cancer
How are central lung lesions treated? peripheral lesions?
Central: pneumonectomy
Peripheral: lobectomy
How is operability of lung cancer stablished?
- Residual function after resection.
- minimum FEV1 of 800 mL is needed after resection (Check for FEV1 from each lung and figure out what would remain after surgery)
- Important if clinical findings of like COPD, SOB, are seen
- If <800 mL, do not continue testing: patient is not surgical candidate (Chemo and RT used instead)
What does surgical cure of lung cancer depend on?
Extent of metastases
How can metastases of lung cancer be identified?
- CT scan for nodal metastases, mets to other lung or liver
- CT + PET for actively growing tumor
- Endobronchial ultrasound (invasive) to sample mediastinal nodes
- Hilar mest can be resected with pneumonectomy
- Nodal mets to carina or mediastinum preclude from curative resection
