cardiothoracic surgery

Question 1

why is CABG needed?

Answer 1

usually due to atherosclerosis leading to MI, angina, stroke, TIA, PAD, mesenteric ischaemia

Question 2

how is CABG done?

Answer 2

a graft vessel is taken from usually saphenous vein to bypass a blockage. The machine takes blood from RA or VC, pumps through it and adds O2 and removes CO2 and puts it back into AA. Heparin added to prevent clotting. Cardioplegia is achieved through high concentration potassium and cardioversion or adrenaline used to restore heart beat. Recovery around 3m.

Question 3

what is intimal hyperplasia?

Answer 3

when a vein used in CABG becomes stenosed

Question 4

what are complications of CABG?

Answer 4

death, stroke, infection, AKI, CI, MI, AF

Question 5

what is pericardial effusion?

Answer 5

it is fluid in the pericardial sac - transudate, exudate (inflammation), blood, pus, gas
cardiac tamponade when the intracardial pressure is raised
reduces expansion - reduced CO

Question 6

what are the causes for pericardial effusion?

Answer 6

decreased drainage - transudative - CHF, pulmonary HTN
inflammatory - exudative - infection, AI, injury, uraemia, cancer, medications
acute tamponade - MI, aortic dissection A, trauma

Question 7

how does pericardial effusion present and how is it investigated?

Answer 7

presentation - SOB, CP, fullness, orthopnoea, hiccups, dysphagia, hoarseness, quiet HS, pulsus paradoxus, hypotension, increased JVP, fever, pericardial rub
ix: echo, fluid analysis, bacterial culture, viral PCR, cytology, tumour markers

Question 8

how is pericardial effusion managed?

Answer 8

NSAID, aspirin, colchicine, needle pericardiocentesis, or surgical drainage, pericardial window or pericardiectomy is rare

Question 9

summarise cyanotic heart disease?

Answer 9

right to left shunt - ASD, VSD, PDA, TGA
left>right pressure - Eisenmenger syndrome
complications: arrhythmias, HF, endocarditis, stroke, pulmonary HTN, Eisenmengers

Question 10

summarise ASD?

Answer 10

usually PFO, ostium secundum or primum, dyspnoea, stroke, AF or flutter, mid systolic crescendo decrescendo murmur, fixed split second heart sound
mx: transvenous catheter closure or open heart sx, anticoagulants

Question 11

summarise VSD?

Answer 11

pansystolic murmur over LLSE in 3rd ICS
systolic thrill on palpation
mx: transvenous catheter closure, open heart sx, ABx prophylaxis

Question 12

summarise coarctation of the aorta?

Answer 12

usually around DA, HTN, systolic murmur below left clavicle, BP difference, LV heave, underdeveloped left arm and leg
ix: CT angiography,
mx: emergency surgery at birth if severe, percutaneous balloon angioplasty and stenting, open repair, manage HTN

Question 13

summarise prosthetic heart valves?

Answer 13

usually a midline sternotomy scar
bioprosthetic - porcine - 10y lifespan
mechanical - 20y lifespan - need lifelong warfarin (can be starr edwards, tilting disc or st jude) - clicks replace S1 and S2
can get thrombus, IE and anaemia

Question 14

summarise aortic stenosis?

Answer 14

ejection systolic murmur high pitched, crescendo decrescendo in systole, radiate to carotids, slow rising pulse, exertional syncope, narrow pulse pressure
causes: RHD, idiopathic
mx if severe: transcatheter aortic valve through femoral artery under XR guidance - bioprosthetic

Question 15

summarise mitral regurgitation?

Answer 15

2nd most common
reduced EF, CCF, pansystolic high pitched whistling murmur, 3rd HS
causes: RHD, idiopathic, IE, IHD, CTD

Question 16

what is the main risk of valve replacement?

Answer 16

IE: 2.5% of surgical valve replacements or 1.5% of TAVI
15% mortality
gram +ve cocci such as staph, strep or entero

Question 17

summarise heart and lung transplant?

Answer 17

they mostly come from deceased donors - indications are IHD, cardiomyopathy, CHD, COPD, PF, CF, pulm HTN
variations - single or double lung, heart and lung, heart
lateral thoracotomy scars for lung and midline sternotomy for heart
time between the death and donation is cold ischaemic time - cooled down and operation started immediately as soon as transplant arrives
cardioplegia, bypass, cardioversion
post transplant steroids and immunosuppression
complications - cardiac allograft vasculopathy, primary graft dysfunction, bronchiolitis obliterans syndrome, dehiscence of bronchial anastomases

Question 18

what are the most common types of lung cancer?

Answer 18

non small cell - 80% and small cell - 20%

Question 19

which lung cancer is most likely to have paraneoplastic syndrome?

Answer 19

SCLC - neurosecretory granules

Question 20

how does mesothelioma present?

Answer 20

asbestos link, SOB, cough, reduced weight, clubbing, haemoptysis, pneumonia, paraneoplastic syndromes

Question 21

what is the 2ww criteria for lung cancer?

Answer 21

CXR if >40 with clubbing, lymphadenopathy, recurrent chest infections, increased platelets, lung cancer chest signs
consider if >40 with 2MUS and never smoked or >40 with 1 MUS and smoker - MUS: cough, SOB, fatigue, weight loss, reduced appetite

Question 22

how is lung cancer investigated?

Answer 22

CXR (hilar enlargement, peripheral opacities, pleural effusion, collapse, staging CT, PET CT, bronchoscopy with endobronchial US, histology and biopsy)

Question 23

how is lung cancer managed?

Answer 23

NSCLC: segmentectomy, lobectomy, pneumonectomy, RT
SCLC: chemo and RT
endobronchial treatment with stenting and debulking

Question 24

where does thoracic aortic aneurysm commonly occur?

Answer 24

in the ascending aorta

Question 25

what are the normal values for thoracic aorta?

Answer 25

<4.5cm ascending and <3.5cm descending

Question 26

what is the difference between false and true thoracic AA?

Answer 26

false: two inner layers rupture - blood in outer layer due to trauma
true: all 3 layers intact but dilated

Question 27

what are complications of thoracic aortic aneurysm?

Answer 27

dissection, rupture, aortic regurgitation

Question 28

what is the presentation of rupture?

Answer 28

haematemesis, haemoptysis, cardiac tamponade due to bleeding into mediastinum, back pain, chest pain, collapse, haemodynamic instability, death

Question 29

what are the risk factors and presentation of thoracic aortic aneurysm?

Answer 29

RFs: men, age, smoking, HTN, FHx, marfan/CTD
presentation: chest or back pain, cough, SOB, stridor, hiccups, dysphagia, hoarseness

Question 30

how is thoracic aortic aneurysm investigated/managed?

Answer 30

ix: echo, CT, MRA
mx: stop smoking, diet, exercise, optimise mx of comorbidities, surveillance, thoracic endovascular aortic repair, open surgery

Question 31

what is pneumothorax and what causes it?

Answer 31

it is air in the pleural space which separates the lung from the chest wall
causes: spontaneous, lung pathology, trauma, iatrogenic

Question 32

how is pneumothorax investigated and managed?

Answer 32

ix: CXR, CT thorax
mx: <2cm and asymptomatic: conservative - f/u in 2-4w
>2cm - aspiration and reassessment
if fails twice - chest drain in triangle of safety
pleurodesis or pleurectomy if required
tension - large bore cannula in 2nd ics MCL then chest drain