Cardiothoracic Disorders Flashcards
first step in asymptomatic pt who has a coin-lesion on CXR found pre-op?
previous previous CXR films for comparison
next step should include CT scan w/ possible CT-guided needle biopsy
symptomatic coin lesion found on CXR and confirmed with CT scan - what next?
bronchoscopy - obtain tissue diagnosis and determine location
lung lesion associated with dental abscess or sinus tract with chest wall involvement
actinomycosis
lung lesion with concentric or homogenous calcification in an endemic area
histoplasmosis
lung lesion with thin-walled cavity often w/ air-fluid level in a pt living in endemic area
coccidiomycosis
lung lesions with associated chronic skin ulcers in an endemic area
blastomycosis
lung lesions in immunocompromised patient, often with meningeal involvement
cryptococcosis
lung lesion that presents as mycetoma with air-crescent sign
aspergillosis
lung lesion that presents with well-defined border with slight lobulations
hamartoma
lung lesion that is adjacent to thickened pleura and comet-tail vessel pattern
round atelectasis
what is the next step in a patient who presents with a stage 1 adenocarcinoma of the lung
thoracotomy
- explore the mediastinum; if no spread outside lung, can proceed with lobectomy
what kind of tx. can you do for a hilar mass that involves a mainstem bronchus?
exploratory thoracotomy
- pneumonectomy will likely be needed for complete removal
what is involved in a pneumonectomy?
- dividing the mainstem bronchus just distal to carina and sewing/stapling it closed
- dividing the pulmonary artery and two pulm. veins
what is involved in a sleeve lobectomy?
- dividing the mainstem bronchus above and below the origin of the right upper lobe bronchus and reattaching the bronchus by suture technique
- blood supply to the unaffected lobes is left in tact
tx. for stage 2 lung cancer
stage 2 - involvement of hilar LN
- tx. is surgical resection but prognosis is worse
pt with lung mass has mediastinal LN positive for mets - stage ?
stage 3 lung cancer
tx. for stage 3 lung cancer
chemotherapy and radiation therapy
- if tumor decreases in size, then can undergo resection
pt with lung cancer has PET scan positive for distant mets - stage? tx?
stage III or IV
- tx. chemo and radiation
what can the Pancoast tumor invade?
lower cords of brachial plexus
subclavian artery
sympathetic ganglia
chest wall
tx. of Pancoast tumor
- irradiation of area over 6 week period
2. surgical resection of involved chest wall and lung
hemoptysis in otherwise healthy young woman with atelectasis….dx?
obstructed bronchus - most likely a bronchial adenoma
two types of “bronchial adenomas”
- carcinoid tumors - usually benign when in lung
2. adenocystic carcinomas - MC in upper airway; invade locally
how can you diagnose bronchial adenoma?
CT scan but ultimately, bronchoscopy w/ biopsy is needed for diagnosis
tx. of bronchial adenoma
lobectomy - with removal of tumor-containing bronchus
an older patient comes in with a pleural effusion…what are you concerned about?
a pleural effusion in an older patient signifies cancer until proven otherwise
what is the next step in diagnosis of a pleural effusion in an old man (w/o CHF)?
thoracentesis and pleural biopsy
only potential tx. of mesothelioma
extrapleural pneumonectomy
- irradiation and chemotherapy are ineffective
what is an extraplural pneumonectomy?
entire lung along with parietal/visceral pleura, pericardium and diaphragm are resected en bloc
tx. for pneumothorax
chest tube (tube thoracostomy)
- polyethylene tube (size 24) w/ a one way-valve (Heimlich valve)
- tube attached to a water-seal type drain
what is the purpose of a water seal in the chest tube?
maintains negative pressure in the pleural space and chest tube so that air and fluids may escape from the chest
how do you tx. persistent or recurrent pneumothorax?
thoracoscopic excision of blebs and pleurodesis (pleural abrasion)
- also used for bilateral spontaneous PTX
pt with pneumonia tx at home with antibiotics improves; she then notes an increased pain in her chest, increased cough and recurrent fever - CXR shows a pleural effusion in the right lung - diagnosis?
empyema
- community - strep pneumo
- hospital - staph or gram negatives
tx. of empyema of lung
- antibiotics
2. chest tube drainage - evacuates pus and re-expands the lung
tx. of empyema that has become loculated (i.e. bc it was not drained early enough)
thoracotomy and decortication (removal of the thick inflammatory tissue trapping the lung)
tx. for pt with three-vessel disease and reduced EF
CABG
MC grafts used in CABG
greater saphenous vein grafts
internal mammary artery grafts - best graft patency
what are the MC reasons of death following cardiac transplantation?
infection - related to immunosuppressive drugs
accerelated coronary atherosclerosis (form of chronic rejection)
histopath findings in achalasia
loss of sm mm. ganglionic cells of Auerbach plexus and neuronal degeneration
what is the proper sequence of diagnostic tests in a patient presenting with dysphagia?
- barium swallow
- endoscopy w/ biopsy
- CT scan
best test for staging of esophageal cancer
endoscopic USG
- assesses wall penetration and can identify adjacent node enlargement
primary tx for cancers of the cervical and upper third of esophagus
chemoradiation therapy
primary tx. of cancers of the middle third of esophagus
neoadjuvant tx. with irradiation and chemo followed by surgical resection
transhiatal esophagectomy
stomach is brought up well into the neck and joined w/ the pharynx
formal esophagectomy (Ivor Lewis procedure)
gastroesophgeal anastomosis in the chest or may be altered to permit anastomosis in the neck
if stomach is used in reconstruction of esophagus after esophagectomy, what other procedure is necessary?
pyloroplasty - to prevent gastric outlet obstruction
tx. of esophageal cancer with distant mets
chemotherapy only
tx. of esophageal cancer in lower 1/3 of esophagus
esophagectomy and proximal gastrectomy with intra-thoracic esophagogastric anastomosis
what tumors arise in the anterior mediastinum?
thymomas - look for sx. of myasthenia gravis teratomas lymphomas - both Hodgkins and NHL germ cell tumors benign dermoid tumors (calcium deposits)
tx. for thymomas (and other tumors other than lymphomas in ant. mediastinum)
surgery (median sternotomy)
MC tumors of middle mediastinum
lymphatic tumors
cysts
bronchogenic cysts
from foregut remnants; found in both lung and mediastinum - benign growths lined by columnar epithelium
what type of cysts have a “water bottle” appearance/
pericardial cysts
tx. of cysts in middle mediastinum
surgical removal w/ posterolateral thoracotomy
MC tumors in posterior mediastinum
neurogenic tumors (MC - neurilemoma) - arise from nerves and nerve sheaths near vertebral bodies and contain both fibrous and neural elements
what test is indicated next if you find a tumor in the posterior mediastinum?
CT scan - to indicate whether tumor is present in spinal canal also
Noise with breathing OUT?
Think asthma
Noise with breathing IN?
Think tracheomalacia
Noise with breathing AND difficulty swallowing?
Think vascular ring
Baby presents with strider and episodes of respiratory distress with crowing respiration during which he assumes a hyperextended position; there is also mild difficulty swallowing
Vascular ring
What diagnostic test(s) do you order if you suspect a vascular ring?
Barium swallow
- will show extrinsic compression from the abnormal vessel
Bronchoscopy
- confirms segmental tracheal compression and R/O tracheomalacia
Tx of vascular ring compressing airway and esophagus
Surgery - dividing smaller of the double aortic arches
12 yo girl found to have a pulmonary flow systolic murmur with a fixed split second heart sound; she has a history of frequent colds and URIs - dx? Test?
Atrial septal defect
Test - echo
Tx of ASD
Closure of defect by open surgery or cardiac catheterization
3 month old baby with failure to thrive has a loud pansystolic murmur best head over left sternal border; chest shows increased pulmonary vascular markings
Ventricular septal defect
- mc in membranous septum
- dx with echo tx with surgery
What type of VSD has good chance to close on its own within first 2-3 years?
Small, restrictive VSD located low in the muscular septum
3 day old premature baby has trouble feeding and pulmonary congestion; on exam she has bound peripheral pulses and a continuous machinery like murmur- shortly thereafter the baby goes into overt heart failure
Patent ductus arteriosus
What are indications for surgical closure of PDA?
Failed indomethacin tx
CHF
Full term babies (intraluminal coils or surgery)
What are characteristics of R–>L SHUNTS
Decreased vascular markings on CXR
Cyanosis
72 yo man with history of angina, SOB and Exertional syncope has a harsh midsystolic murmur best heard at right 2nd intercostal space - dx? Test?
Aortic stenosis
- do echo
When is surgery indicated for aortic stenosis?
Pressure gradient >50 mmHg
First indication of CHF, angina or syncope } symptomatic patients have limited life expectancy
72 yo man with wide pulse pressure, blowing diastolic murmur heard best at right 2nd intercostal space and along left lower sternal border; on echo, there is evidence of beginning LV dilatation - dx? What should you do?
Chronic aortic insufficiency
- tx with aortic valve replacement at first sign of LV dilatation
Tx for acute aortic insufficiency caused by endocarditis
Emergency valve replacement and antibiotics
35 yo lady has dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, cough and hemoptysis progressive for about 5 years; she has atrial fibrillation and a low pitched rumbling diastolic apical heart murmur. At age 15 she has rheumatic fever - dx?
Mitral valve stenosis
- start with echo
Tx of mitral valve stenosis
Surgical repair - mitral commissurotomy or balloon valvuloplasty
55 yo lady has had mitral valve prolapse for many years, she now has developed signs of LHF and atrial fibrillation; she has an apical high pitched holo systolic heart murmur that radiates to the axilla and back
Mitral regurgitation
Tx of mitral valve regurgitation
Surgical repair (annuloplasty) or possibly valve replacement
Candidates for coronary revascularization
- stenosis > 70% in atleast one vessel
- good distal vessels (often bad in smokers and diabetic)
- minimal LV damage (measured by EF)
Cardiac index
CO / BSA
normal = 3 L/ min /m2
How do you interpret PCWP, LAP or LEDV, in the setting of low cardiac index or cardiac output?
0-3- need more fluids (dehydrated)
> 20 - ventricular failure
What is the first step after you find a solitary coin lesion on an XR?
Find a previous CXR to compare
- if same lesion is found on older XR ( one year or more) it is likely not cancer and no further work up is needed for now but follow up with CXR in a few months
What is the management approach to a coin lesion in the lung that was no previously there?
- Sputum cytology and CT scan
- Biopsy
- bronchoscopy if central, percutaneously if peripheral
- if unsuccessful, thoracoscopy with wedge resection
What is the minimal FEV1 to survive pulmonary resection/pneumonectomy?
800 ml
How do you calculate how much FEV1 patient would have after resection of lung?
Take the percent from V/Q scan (%) and multiple it by calculated fev1 during assessment
How do you adequately assess extent of disease in lung cancer ?
CT scan
CT scan plus PET - if status of mediastinal nodes unclear
Endobronchial USG - to same nodes
- do not need to determine fev1 or nodal status in small cell ca. Bc it not treated surgically
