Cardiothoracic Surgery Flashcards
What is a coin lesion?
Solitary pulmonary nodule on CXR; DDx primary lung cancer, granuloma (TB or fungi), hamartoma, metastatic cancers
How do you manage a coin lesion?
First thing is always to get an older CXR for comparison studies. If suspicious, sputum cytology and CT scan.
If indeterminate, resection is indicated
Likely metastatic if there are multiple lesions (vs solitary lesion is more likely lung cancer)
What are the signs of a benign coin lesion?
Calcification = granuloma Bull's-eye shape or popcorn shape = hamartoma Air-crescent sign = aspergilloma Southwest region = coccidiomycosis Ohio river valley = histoplasmosis
How do you manage lung cancer?
First thing is always CXR –> if suspicious, then sputum cytology and CT scan –> if still suspicious, bronchoscopy and mediastinoscopy with biopsy
What is NSCLC Tx?
Stage I: local Stage II: hilar LN Stage III: distal LN Stage IV: metastatic cancer If stage I/II: first get spirometry and V/Q scans to see if patient is a surgical candidate, then do pneumonectomy or sleeve lobectomy Stage III/IV: chemotherapy and radiation
What is the surgical contraindication for NSCLC?
FEV1 <800 mL, mediastinal LN involvement, distal metastases
What is SCLC staging and treatment?
Limited stage involves ipsilateral lung only, extensive stage involves contralateral lung
Tx is chemotherapy and radiation
What is a Pancoast tumor?
Superior sulcus tumor at the apex of the lung, presents as Horner syndrome (ipsilateral ptosis, miosis, anhidrosis, flushing due to loss of sympathetic tone) because the tumor invades the superior cervical ganglia
Treated by irradiation followed by surgical resection
What is a bronchial adenoma?
Tumors that arise from within the bronchi and cause obstruction; MC lung cancer in a nonsmoker under 30 y/o, Sx are hemoptysis and atelectasis, Dx CT scan and bronchoscopy
Tx: lobectomy is curative
What is mesothelioma? (Dx, Px and Tx?)
Cancer arising from pleural mesothelium, shipyards and asbestos exposure are risk factors.
Dx: CT scan shows thick pleural walls
Px: Not responsive to medical therapy, <1 year to live without surgery
Tx: extrapleural pneumonectomy is curative, but high rate of morbidity and mortality
What is a pleural effusion? (with DDx and management)
Fluid build-up in pleural space, cancer in older patient until proven otherwise;
DDx CHF, bronchogenic carcinoma, mesothelioma, empyema, pneumonia, TB effusions
Management: get thoracentesis and culture pleural fluid, pleural biopsy
What is a spontaneous pneumothorax?
Rupture of apical blebs in healthy young people causes sudden chest pain and dyspnea; tx is thoracostomy on water-seal drainage
How do you treat recurrent/persistent pneumothorax?
Indicated for thorascopic excision of belbs, and pleurodesis causing pleural adhesions
What is an empyema?
Collection of pus within pleural cavity; presents with cough, fever, chest pain, and pleural effusion on CT scan; MCC is staph aureus
How do you treat an empyema?
Initiate appropriate antibiotics, insert a chest tube, evacuate pus collection, then re-expand the lung
What is unstable angina?
Progressive ischemia of myocardium resulting in increasing angina at rest and an ischemic EKG pattern
How do you manage unstable angina?
Cardiac catheter and evaluate for potential revascularization, tx bypass or angioplasty
What is an abnormal ejection fraction?
SV/EDV; normal EF is 67%, EF <35% is high-risk for operative MI
What is coronary artery disease?
Blockage of coronary arteries, high risk of sudden death due to ventricular arrhythmias, Tx bypass or angioplasty
What is three-vessel disease?
Blockage of LAD/RCA/LCX
What is a coronary artery bypass?
open via median sternotomy, isolate internal thoracic artery or greater saphenous vein, put on bypass and stop the heart, sew grafts to arteries, restart the heart and close up
What is a coronary angioplasty?
Insertion of stent to prolong patency of clogged coronary arteries, 33% rate of restenosis in one year
What is cardioplegia solution?
Solution used to stop heart mid-diastole to protect it from ischemia and provide a motionless field; often used with hypothermia to prolong time of safe ischemia (up to 2.5 hours)
What is off-bypass coronary surgery?
Grafting of ITA or GSV to coronary arteries without bypass in order to avoid complications of bypass, reserved for high-risk patients
What is dilated cardiomyopathy?
Dilation of myocardium causing systolic dysfunction leading to progressive dyspnea and fatigue, often preceded by viral URI.
Beta blockers will improve heart function, but heart transplant is indicated
What is constrictive pericarditis?
Presents as dyspena, hepatomegaly, and ascites due to diastolic failure
Dx cardiac cath shows “square root sign”, tx is surgical correction
What are the symptoms of aortic stenosis?
Angina, dyspnea, syncope, and high risk of sudden death; dx is harsh mid-systolic murmur
MCC is congenital bicuspid valve with dystrophic calcification, tx valve replacement when symptomatic
What are the symptoms of aortic regurgitation?
Loud, blowing diastolic murmur and bounding pulses; if chronic–> valve replacement when symptomatic
if acute–> emergent valve replacement and long-term abx
What are the symptoms of mitral stenosis?
Presents as dyspnea and fatigue, caused by rheumatic fever, results in cor pulmonale (RVH+PH) and AFib; Tx is valve repair or replacement
What are the symptoms of mitral regurgitation?
Presents as dyspnea and fatigue, caused by MVP, high pitched holosystolic murmur
Tx: annuloplasty or valve replacement
When are you concerned about mitral prolapse?
Eccentric closure of mitral leaflets; common in women, precedes severe disease in men
What is on the differential for an anterior mediastinal mass?
thymomas, lymphomas, teratomas, and other metastatic germ cell neoplasms
How does a thymoma present?
Often presents with progressive muscle weakness secondary to myasthenia gravis
Tx is surgical removal via median sternotomy
What is on the differential for a middle mediastinal mass?
lymphomas, bronchogenic cysts, pericardial cysts
What is a bronchogenic cyst?
Develops from foregut remnants, treat with surgical removal via thoracotomy
What is on the differential for a posterior mediastinal mass?
Neurogenic tumors, neurilemoma is the MCC
What is a neurilemoma?
Dumbbell-shaped tumor found adjacent to vertebral bodies, develops from nerves and nerve sheathes, tx is surgical removal via thoracotomy
