Cardiothoracic Surgery

Question 1

Vascular Rings

Answer 1

Put pressure on tracheobronchial tree & esophagus
Causes stridor, respiratory distress w/ crowing respiration (hyperextended position)
Difficulty swallowing
Barium swallow shows extrinsic compression from abnormal vessel
Bronchoscopy shows segmental tracheal compression
Surgery divides the smaller of the 2 aortic arches

Question 2

Atrial Septal defect

Answer 2

LT to RT shunt-overloads pulmonary circulation
Minor low pressure, low volume shunt
Typically present in late infancy
Faint pulmonary flow systolic murmur
Fixed split S2
Hx of frequent colds
Dx w/ echocardiogram
Surgical or cath closure

Question 3

Ventricular septal defect

Answer 3

LT to RT shunt-overloads pulmonary circulation
Most common-high in septum, early presentation
Failure to thrive
Pansystolic murmur at LT sternal border
Increased pulmonary markings on CXR
Echo dx and surgical closure
If small & low in septum may spontaneously close

Question 4

Patent ductus arteriosis

Answer 4

LT to RT shunt-overloads pulmonary circulation
Symptomatic in 1st few days of life
Bounding peripheral pulses
Mechanical heart murmur
Echo to dx
In premature infants not in CHF indomethacin close
If full term or in CHF, surgical closure

Question 5

Tetralogy of Fallot

Answer 5

RT to LT shunt- diminished vascular markings in lungs and cyanosis
Most common cyanotic anomaly
Children small for age, blue lips/fingers, clubbing & cyanosis relieved by squatting
Systolic ejection murmur LT 3rd intercostal space
Small heart & EKG signs of RT ventricular hypertrophy
Echo to dx and surgical repair

Question 6

Transposition of Great Vessels

Answer 6

RT to LT shunt- diminished vascular markings in lungs and cyanosis
Severe trouble early on
Kept alive due to ASD, VSD or patent ductus
Suspect in 1-2day old w/ cyanosis & sick sick
Echo to dx complicated surgery to tx

Question 7

Aortic stenosis

Answer 7

Angina & exertional syncopal episodes
Harsh midsystolic murmur at RT 2nd intercostal space and along LT sternal border
Workup w/ echo
Surgical valve replacement if gradient >50mmHg or at 1st indicaiton of CHF, angina or syncope

Question 8

Chronic aortic insufficiency

Answer 8

Wide pulse pressure
Blowing high pitched diastolic murmur best heard at 2nd intercostal space & along LT lower sternal border in full expiration
Medical therapy
Surgery at 1st sign of LT ventricular dilation

Question 9

Acute aortic insufficiency

Answer 9

Due to endocarditis in drug addicts
Suddenly develop CHF & loud diastolic murmur at RT 2nd intercostal space
Emergency valve replacement needed & long term antibiotics
Patients w/ prosthetic valve need antibiotic prophylaxis for subacute bacterial endocarditis

Question 10

Mitral stenosis

Answer 10

Hx of rheumatic fever
DOE, orthopnea, PND, cough, hemoptysis
Low pitch rumbling diastolic apical murmur
Progresses & become thin, cachectic, w A fib
Dx w/ echo
Tx w/ mitral valve repair (annuloplasty) preferred over valve replacement

Question 11

Mitral regurgitation

Answer 11

Most commonly from valvular prolapse
Present w/ DOE, orpthopnea A fib
Apical high pitched holosystolic murmur radiating to axilla & back
Dx w/ echo
Tx w/ mitral valve repair (annuloplasty) preferred over valve replacement

Question 12

Coronary Disease

Answer 12

Typical in middle age sedentary man w/ family hx, hx of smoking, DM2, HLD
Progressive unstable angina main reason for cath
Intervention if 1+ vessel >70% occluded but good distal pulses
Preferably pt has good ventricular fxn
Simpler problems can have angioplasty w stent
More complex problems req surgery
Single vessel not LT main or anterior descending are perfect for angioplasty
Triple vessel dz makes multiple bypass using internal mammary for most important the best

Question 13

Post op care of heart surgery patients

Answer 13

Optimize cardiac output
If CO 5, pulmonary wedge pressure should be monitored (LT atrial pressure)
Low #s (0-3) suggest need for fluids; High numbers suggest ventricular failure

Question 14

Chronic constrictive pericarditis

Answer 14

DOE, hepatomegaly and ascites w/ classic square root sign
Equalization of pressures-RT atrial, RT ventricular diastolic, pulm art diastolic, pulm capillary wedge, & LT ventricular diastolic
Tx w/ surgery

Question 15

Coin lesion of the lung

Answer 15

80% chance of malignancy in people >50; higher if hx of smoking
workup not needed if older CXR shows same lesion same size so always look for older CXR

Question 16

Suspected Cancer of the lung

Answer 16

Workup starts w/ CXR-shows suspicious lesion- coin or infiltrate
If not seen on older CXR, get sputum cytology & CT scan including chest and liver

Question 17

Diagnosis of cancer in the lung

Answer 17

Req bronchoscopy & biopsy for central lesion; percutaneous biopsy for peripheral lesions
If those unsuccessful then video assisted thoracic surgery & wedge resection
Decision based on probability of cancer, assurance that surgery can be done, and chance that surgery may be curative

Question 18

Small cell cancer of the lung

Answer 18

Tx w/ chemo & radiation so no worries for operability

Question 19

Operability of lung cancer

Answer 19

Predicated on residual fxn after resection
Central lesions req pneumonectomy
Peripheral lesions can be removed w/ lobectomy
Minimum FEV1 of 800ml needed
If clinical findings suggest this may be the limiting factor, then pulmonary studies done
Determine FEV1; determine fraction coming from each lung (ventilation-perfusion scan); Figure out what left after pneumonectomy
If <800ml then tx w/ chemo & radiation

Question 20

Potential cure by surgical removal of lung cancer

Answer 20

Depends on extent of mets
Hilar mets can be removed w/ pneumonectomy
Nodal mets at carina or mediastinum precludes curative resection
CT & PET can locate mets in LNs
Endobronchial U/S is more invasive option to sample mediastinal nodes
Cervical mediastinal exploration rarely needed
Mets to other lung or liver seen on CT