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Cardiothoracic Surgery Flashcards

1
Q

Primary vessels affected by atherosclerosis

A
  • Proximal LAD
  • Circumflex
  • Right coronary
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2
Q

Outline the pathological process of atherosclerosis

A
  1. Endothelial injury due to risk factors
  2. LDL accumulation leads to intimal thickening and atheroma formation
  3. Platelet adhesion causes microthrombi and release of platelet-derived growth factor
  4. Monocytes/macrophages engulf cholesterol to become foam cells
  5. Further LDL is taken up by macrophages causing release of IL-1 and TNF which stimulates smooth muscle and fibroblast proliferation
  6. Fibroblasts lay down collagen/elastin to mature the plaque
  7. Chronic inflammatory process leads to calcification
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3
Q

What is the role of platelet-derived growth factor in atherosclerosis

A
  • Released from endothelial cells

- Attracts monocytes to area which engulf cholesterol to become foam cells

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4
Q

How are foam cells formed

A

From monocytes and macrophages engulfing cholesterol

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5
Q

What happens to the smooth muscle cells in atherosclerosis

A

Migrate from the media to the intima and transform into secretory cells producing collagen, elastin, chemokines

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6
Q

Symptoms associated with varying degrees of stenosis

A
  • 50% = asymptomatic
  • 75% = exertional angina
  • 90% = angina at rest
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7
Q

Invasive management of stable angina

A
  1. PCI if symptoms difficult to control with medical therapy

2. CABG if anatomy unsuitable for PCI

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8
Q

Invasive management of unstable angina

A
  1. PCI if anticoagulation and nitrates unsuccessful

2. CABG if PCI unsafe

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9
Q

Invasive management of myocardial infarction

A
  1. PCI 1st line

2. CABG rarely used

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10
Q

Advantages of PCI

A
  • Minimally invasive
  • Low morbidity
  • Low immediate complication rate
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11
Q

Disadvantages of PCI

A
  • Unsuitable for left main stem lesions
  • Early re-occlusion and stent thrombosis
  • High rate of symptom recurrence
  • Poorer ‘freedom’ from medication
  • Requires cardiac surgical back up
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12
Q

Advantages of CABG

A
  • Reliable revascularisation
  • Suitable for a wide range of coronary lesions
  • Ability to perform simultaneous procedures e.g. valve replacement
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13
Q

Disadvantages of CABG

A
  • Major procedure
  • Morbidity from sternotomy and conduit harvesting sites
  • Late graft failure (especially if saphenous vein used)
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14
Q

What investigation must be performed prior to cardiac surgery

A

Coronary angiography (for those undergoing CABG and those with risk factors undergoing valve replacement who would benefit from revascularisation at the same time)

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15
Q

Characteristics of Fibrolipid plaques (structure and location within the vessel wall)

A
  • Lipid-rich core
  • Overlying fibrous cap on the luminal surface
  • Tends to spare arteries of the upper limb
  • Between intima and lamina
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16
Q

Outline the 3 microscopic components of atherosclerotic plaques (cells, connective tissues, lipids)

A
  • Cells = mainly vascular smooth muscle cells, macrophages, lymphocytes
  • Connective tissue fibres = collagen, elastin, proteoglycans
  • Lipids = mainly cholesterol and oxidised cholesterol in the form of LDLs
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17
Q

List the risk factors for developing atherosclerosis

A
  • Increasing age
  • Male sex
  • Race
  • Smoking
  • DM
  • Obesity
  • HTN
  • Hyperlipidaemia
  • Family history
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18
Q

How many units of blood should be cross-matched prior to cardiac surgery

A

4 units

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19
Q

Which medications should be stopped 7 days prior to cardiac surgery

A
  • Platelet antagonists (clopi 5 days prior)

- ACE-i due to risk of severe perioperative vasodilatation

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20
Q

What is the role of TOE in cardiac surgery

A
  • Evaluates cardiac wall and valve function

- Checks for air bubbles after closure

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21
Q

Patient position for median sternotomy

A

Supine

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22
Q

Skin prep prior to cardiac surgery

A
  • Prep chest and both groins in case an intra-aortic balloon pump of femoral bypass is required
  • Both arms and legs if harvesting planed
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23
Q

Median sternotomy provides good access to

A
  • Epicardial coronary arteries
  • Ascending aorta
  • Aortic valve
  • Mitral valve
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24
Q

What ligament lies at the top of the midline sternotomy incision

A

Interclavicular ligaments

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25
Q

Describe the median sternotomy incision

A

2cm below the sternal notch to the xiphoid, deepen through the fat with diathermy

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26
Q

What drains may be used at closure of the thorax

A

Under-water drains:

  • Pericardium
  • Left and right pleurae
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27
Q

Immediate complications of midline sternotomy

A

Vessel (e.g. brachiocephalic) or chamber (e.g. right ventricle) injury

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28
Q

Late complications of midline sternotomy

A
  • Sternal dehiscence
  • Sternal osteomyelitis
  • Wire sinuses
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29
Q

How is cardioplegia achieved in CPB

A

Delivers cold blood with high potassium content to arrest the heart

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30
Q

Indications for CABG

A
  • Left main stem stenosis or equivalent (proximal LAD, circumflex)
  • Triple vessel disease
  • Diffuse disease unsuitable fo PCI
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31
Q

What are the physiological conditions created by CPB

A
  • Non-pulsatile flow with mean perfusion pressure of 60mmHg

- Systemic cooling at 30-32 degrees

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32
Q

Why is de-airing performed and where is it usually done

A
  • To prevent air entering the circulation and causing CVA

- Aortic root or LV apex

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33
Q

List the complications of CPB

A
  • Coagulopathy from platelet dysfunction
  • Inflammatory activation and vasodilation
  • CVA
  • Bleeding
  • Cardiogenic shock
  • Cognitive performance impairment
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34
Q

What are the indications for an intra-aortic balloon pump

A
  • Pre-op for poor cardiac output or critical coronary stenosis
  • Post-op when more haemodynamic compromise is seen or anticipated
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35
Q

How is an intra-aortic balloon pump inserted

A

Via the femoral artery in the groin and placed in the descending aorta

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36
Q

Function of intra-aortic balloon pump

A
  • Reduces afterload and therefore myocardial work

- Inflates during diastole to augment maximal diastolic pressure to improve coronary perfusion

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37
Q

What is involved in a standard triple bypass CABG

A
  1. Left internal mammary to the LAD
  2. Portion of long saphenous to the circumflex
  3. Portion of long saphenous to the distal right coronary
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38
Q

Surface anatomy of the long saphenous vein

A
  1. Ankle - vein immediately anterior to medial malleolus
  2. Knee - one hand breadth posterior to medial patellar border
  3. Groin - 1cm medial to midinguinal point
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39
Q

What nerve must you be wary of when harvesting the LIMA

A

Phrenic nerve as it crosses IMA at 1st rib

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40
Q

Why are radial artery grafts becoming more popular as opposed to saphenous grafts

A

Due to the risk of late occlusion with saphenous grafts

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41
Q

What test must be performed prior to radial artery harvesting

A

Allen’s test to ensure adequate ulnar blood flow

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42
Q

What group of people are excluded from radial grafting

A

Those with high functional requirements of the hands

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43
Q

List the immediate complications of CABG

A
  • Bleeding
  • Low cardiac output syndrome
  • MI
  • Neurological complications
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44
Q

List the early complications of CABG

A
  • Pneumonia
  • Sternal infections
  • Leg infections
  • Renal failure
  • Atrial dysrhythmias
  • UGIB and perforation
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45
Q

Late complications of CABG

A

Recurrent stenosis

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46
Q

How is low cardiac output syndrome managed

A
  • Maintenance of sinus rhythm (medically or paced)
  • Optimise preload/afterload (e.g. use Swan-Ganz)
  • Maintain HCT >30%
  • Inotropes
  • Vasodilators to reduce afterload
  • Intra-aortic balloon pump
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47
Q

What nerves must you be wary of when harvesting the radial artery

A
  • Superficial radial nerve

- Lateral antebrachial cutaneous nerve

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48
Q

What nerve must you be wary of when harvesting the long saphenous vein

A

Saphenous nerve (will cause sensory loss over front and medial leg)

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49
Q

Signs and symptoms of sternal infection

A
  • Sternal click on moving
  • Pain
  • Sternal instability
  • Discharge/wound breakdown
  • Movement of wires on CXR
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50
Q

Long term complications of cardiac angioplasty

A

Restenosis

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51
Q

Long term complications of cardiac stenting

A

Stent thrombosis

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52
Q

Criteria for severe aortic stenosis

A
  • Aortic area <1cm^2
  • Jet velocity >4ms
  • Transvalvular pressure >40mmHg
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53
Q

Risk factors for calcific aortic stenosis

A
  • Age
  • Bicuspid valve
  • Rheumatic fever
  • Hypercalcaemia
  • Congenital bicuspid valve
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54
Q

What type of bacteria causes rheumatic fever

A

Group A beta-heamolytic streptococcus

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55
Q

What occurs to the aortic valve in rheumatic fever

A

Fibrosis of the valve with fusion of the commisures

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56
Q

How is the risk of endocarditis reduced pre-operatively

A
  • Dental examination
  • Chest examination
  • Urinalysis
  • Temperature check
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57
Q

Mechanical Vs Bioprosthesis - who receives which

A
  • Young active people without major comorbidity should receive a mechanical valve
  • Elderly patients should receive bioprosthesis
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58
Q

What are the two approaches to TAVI

A
  1. Retrograde transfemoral or subclavian approach

2. Antegrade transapical approach (via left anterolateral mini-thoracotomy)

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59
Q

How does aortic regurgitation typically present

A

Pulmonary venous HTN

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60
Q

Causes of aortic regurgitation

A
  • Rheumatic disease
  • Annuloaortic ectasia (associated with Marfans)
  • Endocarditis
  • Large-vessel vasculitis
  • Acute ‘Type A’ dissection
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61
Q

Indications for treatment in aortic regurgitation

A
  • Chronic = symptomatic patients or those developing LV dilatation
  • Acute = type A aortic dissection is an emergency
62
Q

Which leaflet tends to be affected in mitral regurgitation

A

Larger crescent-shaped posterior leaflet

63
Q

Causes of mitral regurgitation

A
  • Stretched baggy leaflet
  • Chordal rupture
  • Papillary muscle dysfunction
  • Papillary muscle rupture secondary to MI
  • Ventricular dilatation
64
Q

Symptoms of mitral regurgitation

A
  • Atrial dilatation causes AF

- Pulmonary oedema from rising pressure in pulmonary circulation

65
Q

How is mitral regurgitation treated

A

Repair is superior to replacement but this is seldom possible

66
Q

Why is mitral valve repair preferable to replacement

A
  • Patient may avoid warfarin
  • Less prosthetic material to become infected
  • Superior haemodynamics
67
Q

How is the mitral valve accessed on A) first attempt, and B) re-do

A
  • First attempt = median sternotomy

- Re-do = right thoracotomy due to adhesions

68
Q

What coronary artery is at risk during mitral valve surgery

A

Circumflex

69
Q

Most common cause of mitral stenosis

A

Rheumatic fever

70
Q

Consequences of severe mitral stenosis

A
  • Left atrial hypertrophy
  • Pulmonary oedema
  • Eventually right ventricular hypertrophy and secondary tricuspid regurgitation
71
Q

Preferred management of severe mitral stenosis

A

Percutaneous valvotomy

72
Q

List the causes of ejection systolic murmur

A
  • Aortic stenosis
  • Pulmonary stenosis
  • HOCM
  • ASD
  • Fallot’s
73
Q

List the causes of pan-systolic murmur

A
  • Mitral regurgitation
  • Tricuspid regurgitation
  • VSD
74
Q

List the cause of late systolic murmur

A
  • Mitral valve prolapse

- Coarctation of aorta

75
Q

List the causes of early diastolic murmur

A
  • Aortic regurgitation

- Pulmonary regurgitation (Graham-Steel Murmur)

76
Q

List the causes of mid-diastolic murmur

A
  • Mitral stenosis

- Austin-Flint murmur (severe aortic regurgitation)

77
Q

Features of dilated cardiomyopathy

A

Loss of ventricular function and increased ventricular volume

78
Q

Typical cause of restrictive cardiomyopathy

A

Amyloid deposition within the myocardium

79
Q

HOCM inheritance pattern

A

Autosomal dominant

80
Q

Definition of sudden cardiac death

A

Unexpected death from a cardiac cause within an hour of onset of acute symptoms

81
Q

Treatment of HOCM

A
  • Beta blockers and calcium antagonists

- Septal myomectomy to relieve subaortic obstruction

82
Q

CXR features of restrictive pericarditis

A

Calcified cardiac shadow

83
Q

Symptoms of restrictive pericarditis

A
  • Fluid retention due to RHF

- Exerttional dyspnoea

84
Q

Surgical management of restrictive pericarditis

A

Pericardectomy by either median sternotomy or left anterior thoracotomy (must be wary of phrenic nerve)

85
Q

What part of the atrial septa do ASDs develop from

A

Primum and secondum portions

86
Q

Clinical signs of ASD

A
  • Parasternal heave
  • Fixed splitting of the second heart sound
  • Mid-systolic (ejection systolic) flow murmur
87
Q

Symptoms of ASD that indicate need for intervention

A
  • Left-to-right shunt causing pulmonary HTN and exertional dyspnoea
  • AF or HF
  • Paradoxical embolus causing CVA
88
Q

Treatment of ASD

A
  • Percutaneous closure (cardiology)

- Pericardial patch repair

89
Q

What determines the degree of left-to-right shunt in VSD

A

Size of the defect

90
Q

Clinical features of VSD in infants

A
  • Tachypnoea
  • Hepatomegaly
  • Poor feeding/growth
  • Cardiomegaly
  • Biventricular hypertrophy on ECG
91
Q

Clinical features of VSD in older patients

A
  • Systolic murmur

- Non-specific symptoms

92
Q

What is Eisenmenger syndrome

A

Reversal of the left-to-right shunt in VSD secondary to pulmonary HTN

93
Q

Surgical management of VSD

A

Pericardial patch repair

94
Q

Describe a PDA

A

Abnormal presence of a lumen in the ductus arteriosus

95
Q

What is the function of the ductus arteriosus in the fetus

A

Connects pulmonary artery to the arch of aorta which allows fetal blood to bypass the pulmonary circulation

96
Q

What initiates the closure of the ductus arteriosus and how long does it take

A
  • Loss of maternal prostaglandins after birth

- 4 weeks

97
Q

Management of PDA

A
  • NSAIDs may induce closure
  • Percutaenous blockade of the PDA by IR
  • Surgical ligation of the PDA
98
Q

List the anatomical abnormalities that make up Tetralogy of Fallot

A
  1. VSD
  2. Pulmonary stenosis
  3. Over-riding aorta
  4. RV Hypertrophy
99
Q

Describe a Blalock-Taussig shunt

A

Communication is made between the systemic and pulmonary circulations in order to bypass the pulmonary stenosis

100
Q

Definitive surgical management of Tetralogy of Fallot

A
  1. Closure of the surgical shunts
  2. Relief of pulmonary stenosis
  3. Patch repair of VSD
101
Q

Describe an atrial myxoma

A
  • Benign cardiac tumour
  • Pedunculated
  • Most commonly arise from the intra-atrial septum in the left atrium
102
Q

Diagnosis and management of atrial myxoma

A
  • Diagnosed on echo

- Excision is performed via median sternotomy using CPB

103
Q

Describe the histology of small cell lung cancer

A
  • Poorly differentiated small cells (oat cells)
  • High mitotic rate
  • Propensity to secrete neohormonal substances
104
Q

Most common lung cancer

A

Adenocarcinoma

105
Q

Which type of lung cancer is most likely to present in never smokers

A

Adenocarcinoma

106
Q

Criteria for T1 lung disease

A

<=3cm surrounded by lung/visceral pleura, not involving main bronchus

107
Q

Criteria for T2 lung disease

A

> 3 - <=5cm or involvement of main bronchus without carina or invasion of visceral pleura or atelectasis

108
Q

Criteria for T3 lung disease

A

> 5 - <=7cm or tumour of any size that involves the chest wall, pericardium, phrenic nerve, or satellite nodules in the same lobe

109
Q

Criteria for T4 lung disease

A

> 7cm in dimension, or any tumour with invasion of mediastinum, diaphragm, heart, great vessels, RLN, carina, trachea, oesophagus, spine or separate tumour in different lobe of ipsilateral lung

110
Q

What percentage of non-small cell lung cancer patients undergo surgery

111
Q

List the contraindications to lung cancer surgery

A
  • Malignant pleural effusion
  • Stage 3b or 4 disease
  • FEV1 <1.5L
  • Tumour near hilum
  • Vocal cord paralysis
  • SVCO
112
Q

How do you calculate post-op FEV1

A

(Lung segments left after excision / total number of functioning lung segments preoperatively) x Preoperative FEV1 = Estimated postop FEV1

113
Q

Purpose of mediastinoscopy

A

Allows examination and biopsy of the paratracheal, tracheobronchial, and subcarinal nodes

114
Q

Outline the mediastinoscopy procedure

A
  1. 1cm incision above sternal notch and deepen through platysma and strap muscles
  2. Lift thyroid superiorly and divide pretracheal fascia
  3. Ensure visual of right brachiocephalic artery
  4. Find plane between trachea and pretracheal fascia
  5. Insert scope along fascia
115
Q

List the risks associated with mediastinoscopy

A
  • Brachiocephalic artery injury
  • Tracheal injury
  • Oesophageal perforation
  • Minor bleeding from perforation of bronchial artery
  • Major bleeding from biopsy of azygous vein
  • Torrential bleeding from biopsy of aortic arch/pulmonary trunk
  • Injury to left RLN
116
Q

Indications for mediastinoscopy

A

Lymph nodes >1cm on CT

117
Q

How may aortopulmonary nodes be sampled

A

VATS procedure

118
Q

Incision of choice for emergency, resuscitation room procedures for the management of cardiac or thoracic injuries

A

Anterolateral thoracotomy

119
Q

Outline the anterolateral thoracotomy incision

A

Incise from lateral edge of sternum along 5th interspace

be wary of IMA!

120
Q

Incision of choice for elective thoracic procedures

A

Posterolateral thoracotomy

121
Q

What type of ventilation is required for thoracic procedures

A

Single lung ventilation using dual lumen ET tube

122
Q

Indications for pneumonectomy

A

Centrally located tumours or those that impinge the central bronchial tree

123
Q

What is the fate of the space created by pneumonectomy

A

Fills with fluid over 3 months

124
Q

What is a bronchopleural fistula

A

Breakdown of the bronchial stump allows respiratory organisms to enter the space - indicated when the air-fluid level exists beyond its expected time

125
Q

Drain used for pneumonectomy

A

Single basal drain

126
Q

Drain used for lobectomy

A

Basal and apical drain

127
Q

List the causes of cyanotic congenital heart disease

A
  • Tetralogy of Fallot
  • Transposition of the great arteries
  • Tricuspid atresia
  • Pulmonary valve stenosis
128
Q

Outline the management of mesothelioma

A
  • Mostly palliative
  • A select few undergo pleuropneumonectomy
  • Palliative pleurodesis to alleviate SOB and accumulation of fluid
129
Q

What causes SOB in mesothelioma

A

Pleural effusion

130
Q

List the indications for lung transplantation

A
  • COPD in young patients with A1AD
  • CF
  • Fibrosing lung disease
  • Congenital heart disease
131
Q

Donor criteria for lung transplantation

A
  • Age <=55
  • ABO-compatible
  • Clear CXR
  • PaO2>39.9
  • <20 pack year smoking hx
  • Absence of chest trauma
  • No aspiration/sepsis
  • No cardiopulmonary surgery
  • Negative sputum gram stain
  • No purulent secretions on bronchoscopy
132
Q

Who is thoracic aortic aneurysm more likely to occur in

A

Those with connective tissue diseases such as Marfan’s

133
Q

Outline the Crawford classification of thoracic aortic aneurysm

A
  1. Descending aorta from left subclavian to renal
  2. Descending aorta from left subclavian to beyond renal
  3. Distal half of descending thoracic aorta and substantial part of abdominal aorta
  4. Diaphragm to aortic bifurcation
134
Q

Investigations for thoracic aortic aneurysm

A
  • MR angiogram
  • CT
  • TOE
  • Contrast aortography
135
Q

Complications of thoracic aortic aneurysm

A
  • Acute proximal dissection
  • Rupture
  • Peripheral embolism
  • Aortic regurgitation
136
Q

Most likely site of thoracic aortic rupture

A

1cm distal to left subclavian just prior to ligamentum arteriosum

137
Q

CXR changes associated with thoracic aortic rupture

A
  • Widened mediastinum
  • Trachea/oesophagus to right
  • Depression of left main stem bronchus
  • Widened paratracheal stripe
  • Space between aorta and pulmonary artery obliterated
  • Rib fracture/left haemothorax
138
Q

Describe aortic dissection

A

Blood escapes from the aortic lumen via the intimal layer and tracks outside the inner layers of the aortic media to create a false lumen

139
Q

Causes of aortic dissection

A
  • HTN
  • Medial degeneration
  • Aortitis (from syphilis or large-vessel vasculitis)
  • Connective tissue disease
140
Q

Outline the Stanford classification of aortic dissection

A
  • Type A = dissection affecting ascending aorta

- Type B = dissection affecting descending aorta

141
Q

Symptoms of aortic dissection

A
  • Shock
  • Pain
  • Symptoms of end-organ ischaemia (cold legs, paraplegia, oliguria)
142
Q

GOLD standard investigation for aortic dissection

A

Aortography

143
Q

Blood pressure target in aortic dissection

A

Permissive hypotension with SBP 90-100 using infusible beta blockers

144
Q

Management of Stanford A dissection

A

Aortic root repair with synthetic tube graft (may include aortic valve repair also with composite graft)

145
Q

Management of Stanford B dissection

A
  • Medical with BP control

- Surgery reserved for those at risk of rupture or to correct end-organ ischaemia using descending synthetic graft

146
Q

Major complication of Stanford B dissection

A

Spinal cord ischaemia due to occlusion of the vertebral arteries

147
Q

How does blood enter the heart in those with left sided SVC

A

Via coronary sinus

148
Q

Most likely lung segment to be affected in the event of aspiration

A

Superior segment of right inferior lobe

149
Q

Heart rate in those receiving cardiac transplant

A

Sinus tachy as vagus nerve transected

150
Q

Incision used for repair of Type A dissection

A

Median sternotomy

151
Q

Preferred method of extraction of inhaled foreign body

A

Rigid bronchoscopy

The Thorax (5 decks)

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