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Lance Methods > Cardiothoracic Procedures > Flashcards

Cardiothoracic Procedures Flashcards

1
Q

3 cardiac surgery approaches

A

“open” heart surgery
davinci robotic
endovascular

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2
Q

open heart surgery definition

A

any time the chest is opened (sternotomy or thoracotomy)

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3
Q

davinci robotic cardiac surgery definition

A

more laparoscopic rather than open bc small incisions and smaller insufflation is utilized

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4
Q

endovascular cardiac surgery definition

A

possible for valve repair and types of aortic repair

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5
Q

is sternotomy invasive or minimally invasive?

A

invasive

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6
Q

is thoracotomy invasive or minimally invasive?

A

minimally invasive

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7
Q

is davinci invasive or minimally invasive?

A

minimally invasive

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8
Q

is endovascular repair invasive or minimally invasive?

A

minimally invasive

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9
Q

invasive

A

open sternotomy

provides best exposure but most complications

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10
Q

minimally invasive cardiac surgery (MICS)

A

thoracotomy, davinci, endovascular

less common but gaining popularity

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11
Q

3 things specific to minimally invasive cardiac surgery

A

called MICS
double lumen tube must be used
can be off pump or on pump with femoral vessels

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12
Q

two types of aorta surgery

A 
open repair with cross clamps
endovascular repair (minimally invasive)
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13
Q

6 surgical options for CABG

A 
full bypass with arrested or beating heart
partial bypass with beating heart
off pump
sternotomy
thoracotomy
davinci
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14
Q

MICS CABG

A

small thoracotomy incision
typically 1-2 anterior vessels
off pump or on pump with femoral vessels

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15
Q

davinci CABG

A 
function to harvest the LIMA
then thoracotomy is used to sew on graft
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16
Q

hybrid coronary revascularization

A

anterior vessels are bypassed using MICS/thoracotomy
posterior vessels are stented by interventional cardiologist
allows cardiac option for all vessels without sternotomy

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17
Q

what does the hybrid room require?

A

built in fluoroscopy

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18
Q

what procedures will happen in a hybrid room?

A

hybrid coronary revascularization

transcatheter aortic valve replacement (TAVR)((or TAVI))

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19
Q

what two types of surgeons will be in the hybrid room?

A

cardiac surgeon

interventional cardiologist

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20
Q

what is a good premedication for CABG

A

versed– prevent anxiety and tachycardia

CABG pts need more than valve replacement

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21
Q

surgical options for valve repair/replacement 6

A

full bypass with arrested or beating heart
right heart bypass for tricuspid or pulm valve
endovascular or transapical valve replacement (off pump)
sternotomy
thoracotomy
davinci

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22
Q

how do we normally repair stenotic valves?

A

usually replaced

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23
Q

how do we normally repair regurgitant valves?

A

repaired or replaced

repair is more likely for regurg than for stenotic

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24
Q

can you use versed for valve repair/replacement?

A

NO,

these pts need to maintain their preload and afterload

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25
Q

are MICS valve repair/replacement more commonly performed on or off pump?

A

on pump via femoral arteries

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26
Q

endovascular valve repair, what types of patients get this surgery?

A

ONLY pts who dont qualify for open heart surgery

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27
Q

what % of pts with aortic stenosis are considered too high risk for surgery?

A

30-40%

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28
Q

endovascular aortic valve replacement two names

A

TAVR transcatheter aortic valve replacement

TAVI transcatheter aortic valve implantation

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29
Q

endovascular aortic valve replacement catheter/stent pathways 2

A 
femoral artery (more common)
axillary artery
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30
Q

pathway for endovascular mitral valve repair

A

femoral vein
intra-atrial septum
mitral valve

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31
Q

pathway for tricuspid and pulmonic valve repair

A

starts in femoral vein and goes up to valve by passing through right heart

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32
Q

transapical open valve replacement

A

valve replacement that is performed off pump with an open approach

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33
Q

6 risks associated with TAVR

A 
1 stroke & TIA
2 perivalvular leak
3 vascular complications
4 acute kidney injury
5 cardiac conduction abnormalities
6 postoperative bleeding and atrial fibrillation
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34
Q

which is a higher risk of stroke? surgical valve replacement or TAVR

A

TAVR

30 day frequency is 2-6%

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35
Q

what is the % of aortic regurg as high as immediately post TAVR?

A

85%

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36
Q

what is the % of aortic regurg as high as at one year post TAVR?

A

75%

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37
Q

what fraction of patients have more than mild mitral regurg?

A

1/3

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38
Q

what is the most frequent adverse outcome associated with TAVR?

A

vascular complications

perforations, dissection, and/or rupture in arteries used for access

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39
Q

how can you limit vascular complications?

A

use the transapical thoracotomy approach

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40
Q

why is there a risk of acute kidney injury during TAVR?

A

large contrast load used in placing the valve with fluoroscopy

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41
Q

how does cardiac conduction abnormalities happen during TAVR?

A

final prosthesis position impinges conduction system

high incidence of LBBB

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42
Q

what is the incidence of complete heart block in pts that already have RBBB for TAVR surgery?

A

19-22%

could require pacemaker implantation

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43
Q

what TAVR risk is less likely to happen than with open surgical approaches?

A

post op bleeding and a fib

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44
Q

10 steps of anesthetic management for endovascular TAVR

A

1 renal protection
2 stroke prevention
3 lower dose of heparin
4 placement of transvenous pacing leads
5 attaching of external defibrillator pads
6 utilization of TEE
7 amicar administration UNNECESSARY
8 prep to keep heart still during valve deployment
9 hemodynamic goals for typical pt with aortic stenosis
10 continuous postop EKG monitoring for 48 hrs

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45
Q

renal protection steps (because of contrast dye used) TAVR

A

adequate periop volume loading

N-acetylcysteine prior to surgery

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46
Q

stroke prevention steps TAVR

A

dual antiplatelet therapy is started before surgery and continued for 6 months
300-325mg loading dose of aspirin
300mg clopidogrel

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47
Q

what is the goal ACT after heparin dose for TAVR

A

> 250

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48
Q

what are the two reasons that we place pacing leads during a TAVR

A

establish rapid ventricular pacing during valve placement

pace heart in case of complete heart block at end

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49
Q

why do we attach external defibrillator pads on TAVR pts?

A

life threatening arrhythmias can occur in 4% of pts

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50
Q

why do we use TEE during TAVR

A

provides information about results, position and complications of TAVR

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51
Q

what are the two options to keep the heart still during TAVR?

A

RVP rapid ventricular pacing

12 mg adenosine to stop the heart

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52
Q

RVP rate

A

180-220 bpm

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53
Q

what will happen to BP when you keep the heart still during TAVR? treatment?

A

hypotension

-ask surgeon whether or not to treat (usually not bc its short)

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54
Q

how long does valve deployment take?

A

12 seconds

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55
Q

what are the 3 hemodynamic goals for a pt with aortic stenosis

A

preload augmentation
low heart rates (50-70bpm) increase diastolic filling time
maintenance of sinus rhythm

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56
Q

why do you monitor EKG for 48 hr post TAVR?

A

monitors for onset of new rhythm disturbance

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57
Q

in what patients are the pacing wires left in place post op?

A

av block pts to prevent cardiac arrest

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58
Q

what are the two types of surgery to repair thoracic aorta

A

cross clamps with graft (open surgery)

endovascular stent

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59
Q

what is the more common thoracic aorta surgery?

A

endovascular stent

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60
Q

management of endovascular aortic stent

A

no sternotomy/bypass
less heparin
no amicar

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61
Q

aortic root replacement anesthetic plan

A

clamp placed on ascending aorta and treated as traditional bypass with arrested heart

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62
Q

surgical techniques for open ascending aorta repair (you can place cross clamp on ascending aorta)

A

tradition bypass

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63
Q

surgical techniques for open ascending aorta repair (you can NOT place cross clamp on ascending aorta)

A

deep hypothermic circulatory arrest (with or without retro or antegrade cerebral perfusion)
normothermic antegrade cerebral perfusion

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64
Q

what is the problem with descending aorta repair?

A

not possible to perfuse head and lower body with one arterial cannula

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65
Q

what are the bypass options for descending aorta repair?

A 
partial cardiopulmonary bypass
left heart partial bypass
circ arrest (decrease risk of organ dysfunc. and paralysis)
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66
Q

What is the main concern of open descending aorta repair

A

increase the chance of paralysis from inadequate spinal cord perfusion

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67
Q

partial bypass descending aorta repair steps

A

some blood from RA through venous cannula
bypass machine
perfused lower extremities
blood that stays in heart goes through pulm and perfuses the head and upper extremities

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68
Q

Left heart partial bypass

A

some blood removed from LA reservoir cannula
bypass machine
perfuses lower extremities
blood that stays in heart perfuses head and upper extremities

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69
Q

anesthetic concerns for left heart bypass (3)

A 
intensive vigilance to hemodynamics by anesthetist and perfusionist
2 alines (right radial artery and femoral artery)
CVP compared to PA diastolic or wedge to assess filling of ventricles
70
Q

partial left heart bypass pressure too high proximally and low distally do what?

A

flow increased through circuit

71
Q

partial left heart bypass both proximal and distal pressures are low do what?

A

consider vasoconstrictor or fluids

72
Q

partial left heart bypass both proximal and distal pressures are high do what?

A

consider vasodilator

73
Q

anesthetic management for open descending aorta repair (4)

A

place aline in right arm
insert a double lumen tube
prepare cardiac drugs
consider techniques for spinal protection

74
Q

why do we need to place the aline in the right arm for open descending aorta repair?

A

bc the clamp may need to be placed proximal to the left subclavian

75
Q

why do we need a double lumen tube for open descending aorta repair?

A

bc a thoracotomy approach will most likely be used

76
Q

spinal cord protection techniques for open descending aorta repair (4)

A

SSEP/MEP monitoring
Lumbar drain
Steroids (decrease swelling)
Consider Mannitol

77
Q

what does a lumbar drain do?

A

increases spinal cord perfusion pressure

78
Q

spinal cord perfusion pressure equation

A

= MAP- CSF pressure

79
Q

why use mannitol to protect the spine?

A

increases spinal cord perfusion (decreasing CSF production)

improves renal perfusion

80
Q

aortic wrapping procedure description

A

open chest procedure to treat aortic aneurysm
less common
reserved for those concomitant aortic valve replacement and too high risk

81
Q

what are the two ways that heart transplants can be classified as

A

orthotopic heart transplant

heterotopic heart transplant (piggyback)

82
Q

orthotopic heart transplant description and techiques used

A

replaced recipient heart with donor heart

biatrial, bicaval, or total heart transplant

83
Q

heterotopic heart transplant (piggyback)

A

donor heart is placed in right chest next to recipient heart and anastomosed so blood can flow through either or both

84
Q

biatrial heart transplant

A

only ventricles are removed

donor heart attach at midatrial level

85
Q

biatrial heart transplant anastomosis required

A 
4
aorta
pulmonary artery
left atrium
right atrium
86
Q

bicaval heart transplant

A

entire right atrium is removed but the left atrium remains intact

87
Q

bicaval heart transplant anastomosis required

A 
5
SVC
IVC
aorta
pulmonary artery
left atrium
88
Q

total heart transplant

A

removes the entire heart including left atrium

89
Q

total heart transplant anastomosis required

A 
6
aorta
pulmonary artery
SVC
IVC
pulmonary veins (x2)
90
Q

what are the advantages of having less anastomosis (comparing heart transplant techniques)

A

shorter operation times

less anastomotic complications

91
Q

what are the disadvantages to biatrial technique

A 
higher risk of:
post op atrial arrhythmias
atrial enlargement
atrial thrombi
tricuspid valve regurge
92
Q

What heart transplant method gives the best post op function? downfall?

A

total heart transplant

downfall: longer operation times

93
Q

explain normal heart vagus nerve and SA node mechanism

A

presynaptic vagus nerve releases Ach binds to MR on SA node and slows HR (balances to prevent tachy)

94
Q

explain normal heart when atropine/robinul are given

A

atropine/robinul block the MR on the SA node and the Ach does not bind thus the HR increases

95
Q

pt with heart transplant is denervated, what does this mean

A

not connected to sym or parasym nerves
So the SA node does not have the constant vagus nerve input
pt expected to have higher resting HR

96
Q

do atropine/robinul increase the HR in pts with heart transplants?

A

no

97
Q

effect of atropine/robinul on pt with heart transplant

A

will still bind MR on heart but there is no Ach to block so no effect on HR

98
Q

can neostigmine cause bradycardia in patients with heart transplant?

A

yes

bc neostigmine floods the BODY with Ach and that can reach the SA node

99
Q

when can atropine/robinul increase the HR of a pt that had a heart transplant?

A

when the bradycardia was caused by neostigmine

100
Q

do you still give atropine/robinul with neostigmine in pts with heart transplants?

A

yes, you still need to prevent the bradycardia due to neostigmine

101
Q

what happens to the heart when you have HF and pulmonary HTN?

A

right ventricular hypertrophy

this is needed to effectively pump blood into the lungs against higher resistance

102
Q

in pts with HF and pulmonary HTN which ventricle is strong and which is weak?

A

left ventricle weak
right ventricle strong
– left can’t effectively pump blood to body

103
Q

what is the main problem with heart transplants and pumonary HTN

A

you put a normal sized right ventricle that may not be able to pump enough against the high pulm resistance
could have right heart failure

104
Q

what is the heart transplant option for patients with pulmonary HTN?

A

heterotopic heart transplant

2 hearts in pt

105
Q

what do the old heart and the new heart do for the pt after heterotopic heart transplant?

A

old heart strong RV pumps majority through pulm circulation

new heart strong LV pumps majority of blood to body

106
Q

what will happen after time with the heterotopic heart transplant?

A

pulm HTN will resolve and RV will return to normal size and more evenly share load with donor heart

107
Q

implications of denervation (9)

A

1- resting HR >90bpm
2- atropine/robinul administered alone have no effect
3- neostigmine causes bradycardia (antimuscarinics used to counteract)
4- bradycardia must be treated with pacing or beta 1 agonist
5- pt cannot experience angina
6- baroreceptor reflex doesnt work (reflex brady doesnt happen)
7- sympathetic reinnervation within 12 mo for some
8- increase in CO is due to increase SV not increase HR as normal
9- biatrial technique pts will have 2 SA nodes and 2 p waves

108
Q

what are the beta 1 agonists used to treat bradycardia when denervation

A

isoproterenol
dobutamine
epi
NE

109
Q

reinnervation parasym vs sym

A

sym within 12 months for some
para less likely and less pronounced
degree varies and uncertain clinical significance

110
Q

what is the clinical significance of 2 SA nodes

A

original SA node signal cannot cross suture line

thus donor SA node is the only one that effects HR of pt

111
Q

anesthetic management for heart transplant procedure

A

1 PA pressure kept low to prevent right heart failure
2 inotropic support needed more often
3 immunosuppresive therapy implemented
4 beware of hyperkalemia post transplant

112
Q

how often is RV failure an issue with heart transplants?

A

accounts for 20% of early deaths

113
Q

what are strategies to reduce pulmonary artery pressure during heart transplant?

A

hyperventilation
higher FiO2
pulm artery vasodilators
avoidance of acidosis

114
Q

what is methylprednisolone

A

steroid that is used to prevent rejection of transplant

dosed when crossclamp released

115
Q

what are ways to lower plasma K?

A

hyperventilation

116
Q

what is the bypass circuit for heart transplants

A

venous cannulas in SVC and IVC, arterial cannula in aorta

117
Q

transmyocardial laser revascularization (TMLR) or TMR

A

laser creates series of holes in myocardium

relieve angina for pt not eligible for bypass/anginoplasty or have no more grafts

118
Q

what are the two theories for TMR efficacy?

A

1- stimulates angiogenesis (new channels for blood flow)

2- destroyes nerve endings

119
Q

anesthetics considerations for TMR

A

can be used in combination with CABG
when alone uses thoracotomy (double lumen tube)
arrhythmias and decreased CO expected when laser and pressure applied
vasopressors and inotropes need to be available

120
Q

pericardial effusion

A

fluid around the heart

“fluid accumulation in the pericardial cavity”

121
Q

cardiac tamponade

A

when pericardial effusion is big enough to effect cardiac function (decrease EF)

122
Q

what are cardiac tamponade patients at risk for?

A

hypotension
cardiac arrest
especially during induction

123
Q

hemodynamic effects of cardiac tamponade 2

A

1 decreased CO (bc of decreased SV)

2 becks triad

124
Q

what is becks triad

A

hypotension
jugular venous distention
muffled heart tones

125
Q

what are the two treatment options for cardiac tamponade

A 
pericardiocentesis (local or sedation)
pericardial window (general anesthesia)
126
Q

what type of approach is used when the tamponade is an emergency?

A

subxiphoid approach (can be performed under local and sedation if required)

127
Q

what type of tube is used in the subxiphoid approach?

A

single lumen ETT

128
Q

what type of tube is used in the thoracotomy approach?

A

double lumen ETT

129
Q

induction of anesthesia for pericardial window

A

head elevated 45 degrees
propofol avoided (ketamine or etomidate used)
surgeon ready before induction

130
Q

in a patient with cardiac tamponade what does cardiac output depend on? SV or HR?

A

HR because the heart cannot increase SV

bradycardia must be avoided

131
Q

Do you want positive pressure ventilation or spontaneous ventilation during a pericardial window?

A

spontaneous
PPV decreases venous return and CO
awake fiberoptic good option

132
Q

mediastinoscopy

A

visualization of contents of space between lungs (mediastinum) usually for biopsy

133
Q

what is the problem with the scope for mediastinoscopy?

A

ability to compress innominate (brachiocephalic) artery

surgeon not aware need to communicate this

134
Q

what does the innominate artery supply blood to?

A

right arm (subclavian) and right common carotid

135
Q

what patients are at risk for cerebral ischemia with innominate artery compression?

A

pts who have left carotid stenosis

136
Q

aiway management for mediastinoscopy

A

single lumen ETT
no lungs need to be down
Spontaneous ventilation best

137
Q

blood pressure monitors for mediastinoscopy

A

aline in right (know immediately if innominate is compressed)
NIBP left arm for when aline is jacked up

138
Q

what is mandatory for mediastinoscopy?

A

monitor pulse in right arm

139
Q

what is the less common blood pressure monitoring for mediastinoscopy?

A

aline in left arm (monitors continuously)

SpO2 on right (use waveform to watch for compression)

140
Q

what is the primary concern with mediastinal mass?

A

compression of vital structures

141
Q

what vital structures can be compressed by a mediastinal mass?

A

heart
central blood vessels
trachea
bronchi

142
Q

what are the pts with mediastinal mass at risk for during induction

A

airway collapse

cardiovascular collapse

143
Q

what are the signs/symptoms of mediastinal mass?

A

superior vena cava syndrome
pembertons sign
tracheobronchial compression

144
Q

superior vena cava syndrome

A

obstruction to venous return through SVC

145
Q

what is the most common cause of SVC syndrome?

A

malignancy

146
Q

what can obstructed venous return lead to?

A

airway edema
decreased CO
increased ICP
syncope

147
Q

what happens to a persons face during SVC syndrome

A

swelling in face in morning

swelling resolved after being upright all day

148
Q

pembertons sign

A

facial congestion, cyanosis, respiratory distress when raising both arms
shifts mass to cause obstruction

149
Q

what does pembertons sign illustrate about positioning

A

it can cause or alleviate obstruction

150
Q

what patients show pembertons sign?

A

venous obstruction
goiters
mediastinal mass

151
Q

tracheobronchial compression leads to

A

shortness of breath
orthopnea (when lying down)
total airway obstruction
pinch off ETT

152
Q

anesthetic management for mediastinal mass

A

order and review diagnostic tests

153
Q

what diagnostic tests should you order for mediastinal mass?

A

CT
CXR
ECHO
Pulm function test

154
Q

what is the best diagnostic test to assess tracheal compression? at what % of occlusion is there a high risk of complications with GA

A

CT

<50%

155
Q

what is the best diagnostic test to assess compression of the heart

A

ECHO

156
Q

what do the results of diagnostic tests mean for anesthesia?

A

2 or more significant abnormal findings and there is high risk of complications for GA
-wait for tumor to be shrunk

157
Q

intubation technique mediastinoscopy

A

awake fiberoptic intubation in sitting position
premedication limited to antimuscarinics
armored tube

158
Q

armored tube

A

wire coil to prevent kinking or compression

159
Q

inhalation induction for mediastinoscopy

A

may precipitate obstruction

160
Q

routine induction for mediastinoscopy

A

pts that show no clinical or radiological evidence of airway or cardio obstruction

161
Q

ventilation with tracheal compression

A

have plan
if distal to obstruction manual ventilation can be attempted
if unsure about distal or proximal then spontaneous should be maintained

162
Q

what should you do if you are unable to place the ETT distal to the obstruction mediastinoscopy

A

tracheal stent used placed with rigid bronchoscopy or jet ventilation (bronchoscopy should be on standby)

163
Q

jet ventilation

A

high pressure pt can be ventilated through small catheter

“cant intubate, cant ventilate”

164
Q

how do you turn on the jet ventilator

A

push the lever down

165
Q

what position should the patient be in during mediastinoscopy

A

semi upright position to maintain airway and reduce airway edema

166
Q

what should be avoided in order to maintain cerebral perfusion pressure

A

avoid hypotension

obstructed venous drainage can cause increased ICP and compromise CPP

167
Q

where should you place IVs in a person with SVC syndrome?

A

lower extremities

consider preload augmentation

168
Q

what is important to have immediately available during mediastinoscopy?

A

surgical intervention
heart team on standby
groins preped for bypass

169
Q

in what case for mediastinoscopy should the bypass cannulas be placed prior to GA induction

A

all pts with >50% reduction of airway

170
Q

laser lead extraction

A

pacing leads may become infected and need removal
tissues grow around leads
laser sheaths used to remove tissue

171
Q

laser lead extraction precautions

A

aline placed
cardiac team standby
could have severe hypotension and hemorrhage

Lance Methods (2 decks)

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