Cardiothoracic Surgery

Question 1

Vascular rings

Answer 1

2nd aortic arch surrounds trach/esoph=> pressure on both. Stridor + resp distress w/ crowing respiration (baby hyperextended), some difficulty swallowing. IF only resp sx think tracheomalacia. Barium swallow shows extrinsic compression from abnormal vessel. Broncoscope w/ segmental trach compression, rules out tracheomalacia. Surg divides smaller of two aortic arches….

Question 2

Morophologic cardiac anomalies (congen or aquired)

Answer 2

abx prophylaxis for subacute bacterial endocard if risk of bacteremia (dental work). CXR, then echo, then continue

Question 3

Left-to-R shunts

Answer 3

Presence of murmur, overload pulm circulation, long-term damage to pulm vasculature

Question 4

Atrial septal defect

Answer 4

Very minor low pressure low vol shunt. Recog in late infancy, hear faint pulmonary flow systolic murmur and fixed split 2nd heart sound. HIstory of frequent colds, echo is dx, closure surgically or by cardiac cath

Question 5

Small, restrictive ventricular septal defect low in muscular septum

Answer 5

Heart murmur but few other sx. Close spont in first 2-3 years, observation and SBE prophylaxis abx

Question 6

Ventricular septal defects high up in septum

Answer 6

Early trouble, failure to thrive in first few months, loud pansystolic murmur heard at left sternal border, up pulm vasc markings on CXR. Do echo + surgical closure

Question 7

Patent ductus arteriosus

Answer 7

Sx in first few days of life. Bounding peripheral pulses and machinery-like heart murmur. Echo is dx. In preemies not in CHF, close w/ indomethacin. No close, or already in CHF or full term? Surgical division or embolization

Question 8

R-to-L shunts

Answer 8

Murmur, diminished lung vasc markings, cyanosis. All five w/ letter T, three are rare (truncus arteriosis, cyanotic but overloads pulm circulation)

Question 9

Tetralogy of Fallot

Answer 9

VSD, RVH, aortic valve overlapping RV and LV, pulm outflow tract small.
Crippling but allows kids to grow up into infancy. Smallish kids, bluish lip and fingertips, clubbing, cyanosis relieved by squatting. Systolic ejection murmur in L third intercostal space, small heart, dim pulm vasc markings on CXR, EKG w/ RVH. Echo dx, do surgery.

Question 10

Transposition of great vessels

Answer 10

Severe trouble early on- kids kept alive by an ASD, VSD or patent ductus, but die if not corrected. 1-2 day old child w/ cyanosis in depe trouble, do an echo. Mind-boggling surgery!!

Question 11

Aortic stenosis

Answer 11

Angina, exertional syncope. Harsh midsystolic murmur @ R 2nd intercostal space and LSB. Echol, surgical valve replacement if pressure grad > 50 mmHG, or if CHF, angina/syncope start

Question 12

Chronic aortic insufficiency

Answer 12

Wide pulse pressure, blowing, high-pitched diastolic murmu @ 2nd intercostal/LLSB w/ full expiration. Medicla therapy for many years, valve replacement if echo shows LV dilation

Question 13

Acute aortic insuff

Answer 13

Endocarditis cause, seen in young drug addicts, suddenly get CHF and loud diastolic murmur. Emrgency valve replacement + long term abx

Question 14

Mitral stenosis

Answer 14

Rheumatic fever hx, pesents w/ dyspnea on exertion, orhopnea, paroxysmal nocturnal dyspnea, cough, hemoptysis. Low, rumble diastolic apical murmu, pt gets thin, cachectic, atrial fib.
W/u echo, then mitral valve repair w/ surg commissurotomy or ballon valvuloplasty

Question 15

Mitral regurg

Answer 15

Caused by valvular prolapse, get exertional dyspnea, orthop, a-fib, w/ apical high-pitched holosytolic murmu to back/axilla.
W/u same as mitral stenosis (repair better than replacement)

Question 16

Coronary disease

Answer 16

Typical - middle-age lazy man w/ fam hx, smoking, T2DM, hypercholesterolemia. Unstable angina? Do card cath, evaluate for revasc. Intervention if one or more vessels have 70% or greater stenosis and good distal vessel. Better if good ventricle. Simple problem, then better for angioplasty/stent, complex = surgery. Single vessel disease great for angio. Triple vessel great for bypass

Question 17

Postop for heart surgery pt

Answer 17

Optimize cardiac output. If CO way under normal (Ci 3), measure pulm wedge pressure (LAp or LEDP). Low number means give more fluids. High suggest ventricular failure

Question 18

Chronic constrictive pericarditis

Answer 18

Dyspnea on exertion, hepatomeg, ascites, square root sign and equalization of pressures (RA, RV diastolic, PA diastolic, PCW, and LV diastolic) on card cath. Surgery!

Question 19

Coin lesion in lung

Answer 19

80% malignancy if over 50, higher if smoking hx. Avoid w/u if older CXR shows same lesion.

Question 20

Suspected lung cancer

Answer 20

Expensive, invasive w/u. CXR first if sx of cough/hemoptysis. See lesion? Then do sputum cytology and CT scan (chest and liver)

Question 21

Dx of lung cancer

Answer 21

If cytology not dx, do bronchoscopy and biopsy (central lesion), or perc biopsy (peripheral). If that doens’t work, thoracotomy + wedge resection…yikes.
Dep on probabiliyt of cancer- noncalcified lesion, old, smoker, chance of curative surgery (no mets to mediastinal/nodes, lother lung, liver)

Question 22

Small cell cancer lung

Answer 22

Chemo + rads, so don’t need to assess operability/cure chances.

Question 23

Operability of lung cancer

Answer 23

Will there be residual fn post resection (if pneumonectomy is reqd aka central lesion?) For lobectomy, fn not an issue. Need FEV1 of 800 ml- if COPD, SOB, do PFTs. Determine frac of FEV1 from each lungh (v-q scan), figure out what would remain. IF <800, do not continue. Chem + rads

Question 24

Potential cure by surgery for lung cancer?

Answer 24

Dep on mets extent. Can remove hilar mets, but noodal mets at carina or mediastinum preclude cure. CT finds nodal meds, PET helps find active tumor in large nodes. May have to do cervical MS exploration. Mets to other lung/liver also possible